Colorectal screening worklist, synthetic demonstration
About this demo
This is the weekly worklist I would build from a health center’s nightly coded file and go through with its outreach staff. It supports the routine. The calls, the kits and the navigation are done by people, in the site’s own systems.
Every figure on this page describes the same 30 invented patients, a synthetic single-site panel built to show the routine. The share of positive stool tests is higher than a real panel would have, so the follow-up queue has something to show. Nothing here connects to an EHR, and no message is ever sent.
If you have one minute, do these three things
- Read the top row of the Follow-up view. One patient is 194 days past a positive stool test, already past the 180-day mark in the draft COF-E specification (the follow-up measure NCQA has added to HEDIS). Most EHRs have no screen that shows you this.
- Press “Record colonoscopy as done” for that patient. The change appears right beside the button: the follow-up rate rises, the backlog shrinks, and the median days to colonoscopy goes up, because a long-delayed case has closed. Undo puts it back.
- Open the Equity view. It shows follow-up by preferred language with the counts behind each percentage. With groups this small, one patient moves the gap a long way.
Why the follow-up step is where most people are lost
24-75%
of positive stool tests actually get a follow-up colonoscopy, a gap so wide that NCQA has added a dedicated HEDIS measure for it (COF-E, new for MY2027: colonoscopy after a positive test, ages 45–75; 180 days in the draft specification).1
~2×
higher colorectal-cancer mortality among people with a positive test who never completed a follow-up colonoscopy, hazard ratio 2.03.2 An association, not a measured causal effect.
12 months
is the danger line: beyond it, the odds of any colorectal cancer are 2.25× and of advanced-stage disease 3.22× those of a colonoscopy done within a month.3 Sooner is better.
What the worklist does, and what it does not
This is what the first pilot would run. Everything here is illustrative; nothing is deployed.
Open until done
Most registries mark screening “done” at the stool test. This list keeps a positive test open until the colonoscopy is done, and counts the days, in line with the follow-up measure NCQA has added to HEDIS (COF-E, MY2027).1
Three plain rules
Days overdue, days since a positive test, prior no-shows. Anyone on staff can see why a patient is where they are. No model, no score.
Staff pick the action
Language and known barriers sit beside each name. They never change the order. The outreach staff and I choose the next step: a mailed kit, a call in the patient’s language, help booking, or a ride.4
One nightly file
The pilot runs on a 19-column coded export. Nothing is written back into the EHR. Deeper integration is roadmap, and only after a validated pilot.
Follow-up by language
The Equity view shows who is finishing and who is not, by preferred language, with the counts behind each percentage, so the routine never quietly widens a gap.
How it would work in production
A first pilot needs two things: a file that gets your data in, and data rules that keep it safe. The third card is roadmap and is not part of the first pilot.
01 · Feeding data in
One nightly file from your IT team
- The whole ask: a nightly coded export (CSV) of the overdue registry and results, 19 columns, dates as day counts.
- Mapping (patient code, screening status, last result, contact preference, barriers) is a one-time setup with your IT lead. After that it runs on a schedule.
- Roadmap, after a validated pilot: FHIR Bulk Data for panels and results, a SMART-on-FHIR view inside the EHR, and actions written back as FHIR Communication or Task resources. None of this is part of the first pilot.
Effort for your team: the one-time mapping, then nothing. Keeping the list current from the file is my job.
The exact file a site would send, 19 columns
| patient_id | Site-generated code. The key that links it to a patient stays at the site. No name, MRN, DOB, address or phone leaves your system. |
| birth_year | Year only — enough to apply the 45–75 window of the follow-up measure (COF-E, HEDIS MY2027). |
| sex, preferred_language | Reporting and outreach-channel matching. |
| zip3 | First three digits only, per the HIPAA Safe Harbor rule. |
| payer_type | Coded category, not a policy number. |
| screening_status | overdue | fit_negative | fit_positive | colonoscopy_completed |
| days_overdue | Days since the patient became due. The first ranking rule. |
| days_since_last_fit, last_fit_result | Days since the most recent stool test, and its result. A day count, not a date. |
| days_since_positive_fit | Starts the COF-E clock and is the second ranking rule. The single most important field. A day count, not a date. |
| colonoscopy_status, days_to_colonoscopy | open | scheduled | completed, and days from the positive test to the colonoscopy. Closes the cascade. |
| prior_no_shows_24mo | Count. The third ranking rule. |
| portal_active, preferred_contact | Which channel actually reaches this person. |
| sdoh_flags | Pipe-separated: transport | language | food | housing | cost. Optional. |
| pcp_id, site_id | Panel attribution for multi-provider or multi-site reporting. |
02 · Data rules & security (HIPAA)
A coded file, and the key stays with you
- Phase 1, coded data only, inside the site: the 19-column file lands in a restricted folder on the site’s own secure storage, and I work in it through an account the site issues. Nothing is copied to HSREP. Dates arrive as day counts, and the key that links codes to patients never leaves the site. The evaluator receives a separate de-identified extract under its own agreement with the site.
- Agreements decided before launch: HSREP is not meant to handle names, record numbers or full dates, and outreach runs in the site’s own systems, by its own staff. Whether the coded file, and HSREP’s work beside staff, needs a business associate agreement, a limited data set or another arrangement is for the site’s privacy officer and counsel to determine, and the sender, transfer route, storage, access and deletion of the phase-1 file are written down and signed off by the site before the first export.
- Later phases (FHIR ingest, write-back, any hosted tool) move to a HIPAA-eligible cloud under a signed BAA, with encryption in transit (TLS 1.2+) and at rest (AES-256), role-based access with SSO/MFA, and full audit logging.
- Minimum-necessary access throughout; no PHI in analytics, or in this demo.
- Access reviews, breach monitoring, and a documented incident-response plan; aligns with the HIPAA Security Rule (and 42 CFR Part 2 where behavioral data applies).
Rollout: (1) flat-file pilot at one site → (2) deeper EHR integration → (3) more sites, and a model only if it beats the rules. Each step waits on an evaluation.
03 · Roadmap, after a validated pilot
Predict, prioritize, explain, never decide
- Not in the first pilot. The pilot runs on the three rules above. A model is considered only after the pilot is evaluated, only if it beats the rules, and only under the site’s governance and a BAA.
- Predicts non-completion for each overdue patient, and, via an uplift model, which one action most changes their odds, not just who is high-risk.
- Explainable by design: every score decomposes to its drivers (SHAP), shown per patient. Logistic-regression baseline → gradient boosting.
- Human-in-the-loop: the model ranks and suggests; staff and CHWs decide and act. No autonomous clinical decisions.
- Guardrails: fairness-audited (the equity gap is a monitored metric), no protected attributes as direct features, and drift monitoring on live performance.
Signals that would sharpen it: prior colonoscopy history, insurance follow-up cost-sharing, comorbidity burden, transportation access, appointment-slot availability, portal engagement, area deprivation index, and prior FIT-kit return behavior.
Sources
- NCQA. Follow-Up After Positive Colorectal Cancer Non-Invasive Screening Test (COF-E), draft public-comment specification: colonoscopy within 180 days of a positive stool-based test, ages 45–85 (strata 45–75 and 76–85). NCQA’s MY2027 announcement (updated 30 September 2026) lists COF-E as a new measure for ages 45–75; the final technical specification is to be checked before any formal alignment is claimed. The published literature puts follow-up completion between 24% and 75%; NCQA’s own field testing found plan-level rates of 21.7% to 37.5% at 180 days.
- Zorzi M, et al. Non-compliance with colonoscopy after a positive faecal immunochemical test, and colorectal cancer mortality. Gut 2022;71(3):561-567. doi:10.1136/gutjnl-2020-322192. Hazard ratio 2.03 (95% CI 1.68-2.44) for colorectal-cancer death among non-compliers. Observational; a published critique (Winters & Ford, Gut 2023;72(9):1799-1800) argues immortal-time bias may inflate the estimate.
- Corley DA, et al. Association between time to colonoscopy after a positive fecal test result and risk of colorectal cancer and cancer stage at diagnosis. JAMA 2017;317(16):1631-1641. 70,124 Kaiser Permanente patients across Northern and Southern California: beyond 12 months, the odds of any colorectal cancer were 2.25 and of advanced-stage disease 3.22, against colonoscopy within one month. The study measures incidence and stage, not mortality. Summary.
- Centralized patient navigation shortens time-to-colonoscopy and raises follow-up completion after a positive FIT (randomized and pragmatic trials in safety-net settings). Community Preventive Services Task Force recommends mailed-FIT outreach and patient navigation.
- Nadel MR, et al. Variations in screening quality in a federal colorectal cancer screening program for the uninsured. Prev Chronic Dis 2019;16:180452. doi:10.5888/pcd16.180452. CDC’s Colorectal Cancer Control Program set a quality indicator of 80% of positive stool tests followed by colonoscopy within 90 days; the 180-day mark reflects the more lenient US Multi-Society Task Force guidance.
A demonstration of the Prevention Adoption Initiative (an HSREP initiative in development). Synthetic data; no real patients, no PHI, no EHR connection. Positive-FIT share is amplified for illustration; a real panel would surface these from hundreds of screened patients. Illustrative only. One figure on this page was corrected on 3 August 2026; the record is in the corrections log.