Posted on April 15, 2026

EHR Templates Improve Colonoscopy Surveillance Accuracy

Timothy Yen, MD

Assistant Professor, Loma Linda University Health, Loma Linda, CA

This article reviews Atlas SJ, et al. A randomized controlled trial to improve the accuracy of follow-up surveillance time intervals in the electronic health record after a colonoscopy for colorectal cancer screening. Am J Gastroenterol. 2026 Feb 1;121(2):432-440.

Access this article in The American Journal of Gastroenterology

Correspondence to Timothy Yen MD, Associate Editor. Email: EBGI@gi.org

Keywords: cancer screening; colorectal cancer; colonoscopy; surveillance; cluster randomized trial

STRUCTURED ABSTRACTQuestion: Does the use of a colonoscopy surveillance template improve concordance with the colonoscopy surveillance interval in the electronic health record?

Design: Single-center unblinded pragmatic randomized controlled trial.

Setting: Academic medical center.

Patients: Patients were aged 45-75 years who were undergoing colonoscopy for screening or surveillance. They excluded those with colon cancer, inflammatory bowel disease, hereditary colorectal cancer syndromes, and those who only had a diagnostic indication for their colonoscopy. They also excluded endoscopists who were involved in an initial pilot phase, who rarely performed colonoscopies, or who no longer worked at the institution.

Intervention: Electronic health record (EHR) template consisting of a drop-down menu of surveillance interval options that would automatically update the reminder EHR surveillance interval for the patient. The control arm was not offered the EHR template until after the study period. The intervention was implemented through a training session and reminder emails.

Outcomes: Agreement between endoscopist-documented and EHR reminder surveillance interval. If a range was recommended by the endoscopist, the shortest end of the range was used. Secondary outcomes included subgroup analyses among patients with a specific numeric interval (rather than a range) and among patients with a polypectomy.

Data Analysis: Primary analysis was intention to treat using logistic regression models with generalized generating equations to account for clustering within endoscopists. They also performed a modified intention to treat analysis that limited the number of colonoscopies to 200 per endoscopist to balance differences in volume among endoscopists, as well as a model adjusted for patient race, insurance, colonoscopic indication, bowel preparation quality, and pathology result.

Funding: Risk Management Foundation of the Harvard Medical Institutions.

Results: Among 2,365 intervention patients and 1,422 control patients performed by 43 endoscopists, patients were a median age of 60 and mostly White with commercial insurance. Colonoscopies were done mostly for screening or adenoma surveillance with good to excellent bowel preparation quality; 63% had a polypectomy, 3% had an advanced-histology polyp, and 18% had a polyp ≥10 mm in size. There was adequate balance between arms. Sixty one percent of patients were sent a letter (63% intervention vs 57% control).

For the primary outcome, there was higher agreement in the intervention arm (92%) compared to 76% in the control arm (P < 0.001), which remained after adjusting for patient and colonoscopy factors. This difference remained in the subgroup analysis in patients recommended a specific numeric surveillance interval (95% vs 81%, P <0.001) and patients who underwent polypectomy (94% vs 77%), P < 0.001). There was no difference among patients with no polypectomy or biopsy (82% vs 69%, P = 0.22). In the modified intention-to-treat analysis, results were similar (93% vs 76%, P < 0.001). Approximately half of endoscopists in the intervention arm found the template easy to use.

COMMENTARY

Why Is This Important?
Inbox management, including follow-up and communication of pathology results, is a major contributor to clinician burnout as a necessary but burdensome, time-consuming, and uncompensated task.1 Although guideline-concordant management of polyp surveillance can reduce the risk of developing colorectal cancer,2 our guidelines in the United States are relatively convoluted compared to other countries,3,4 and can lead to inconsistences in care over the course of years of follow-up.

Key Study Findings

Templates were overall effective at updating the EHR reminder interval for primary care providers, and approximately half of endoscopist found it easy to use in their clinical workflow for return of results after colonoscopy. This demonstrates that such an intervention is feasible to implement, and can ease effective communication of polyp surveillance intervals from endoscopists to primary care providers.

Caution
This study did not examine agreement of recommended surveillance intervals with multi-society task force polyp surveillance guidelines,5 which is the more clinically relevant metric that has more direct impact on colorectal cancer prevention. This is a particularly important outcome for each healthcare system given there is likely substantial variability between institutions depending on endoscopist practice, documentation workflow, and quality monitoring.6 Therefore, each institution must examine this in order to ensure that the EHR reminder is updated with a clinically appropriate interval.7

My Practice
From a practical standpoint, I find that engaging adequate IT support in a timely fashion is highly dependent on institutional prioritization of quality or operational goals and complexity of the EHR intervention. Even as a clinical informaticist, implementation of division-level interventions is often more feasible on a relatively quick timeline. However, when an intervention may impact a wider audience, it is then critical to engage relevant stakeholders before approaching IT. For example, the authors’ intervention may require support from primary care and possibly population health/hospital leadership to implement at other institutions, as demonstrated in this study.

For Future Research
With the growth of artificial intelligence/large language models in the clinical space, the use of automated EHR surveillance systems may be a more impactful and sustainable intervention for ensuring adherence to a variety of guidelines.8,9

Conflict of Interest
No conflicts of interest.

REFERENCES

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  2.  Akbar F, Mark G, Warton EMet al. Physicians’ electronic inbox work patterns and factors associated with high inbox work duration. J Am Med Inform Assoc. 2021;28:923-930.
  3. Lieberman D, Gupta S. Does colon polyp surveillance improve patient outcomes? Gastroenterology. 2020;158:436-440.
  4.  Hassan C, Antonelli G, Dumonceau JMet al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2020 Endoscopy. 2020;52:687-700.
  5. Gupta S, Lieberman D, Anderson JC, et al. Recommendations for follow-up after colonoscopy and polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2020;158:1131-1153.e1135.
  6. Rosas US, Pan JY, Sundaram Vet al. Adherence to recommendations for repeat surveillance after publication of new postpolypectomy guidelines Gastro Hep Adv. 2023;2:132-143.
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  9. Wu L, Shi C, Li Jet al. . Development and evaluation of a surveillance system for follow-up after colorectal polypectomy JAMA Netw Open. 2023;6:e2334822.