Impacting Cancer Disparities with a Community Outreach and Patient Navigation Database

Cleveland, home to a 50% minority population and one of the poorest large cities in the U.S., has a cancer death rate 1.5 times the national average. Nearly 20 years ago, the Cleveland Clinic Cancer Center initiated a program to support under-resourced communities through outreach, education, and navigation for cancer screenings and HPV vaccines. The Cancer Navigation (CancerNav) database was developed to enhance these efforts and extend our reach.

The Cleveland Clinic Information Technology team developed CancerNav with input from cancer center leaders and outreach staff. This HIPAA-compliant database serves as an electronic medical record system, resource toolkit, and reporting platform, aimed at reducing patient barriers to cancer screening. Although separate from the health system's electronic medical record, Epic, CancerNav integrates data with Epic to keep providers informed of patient screening history and results.

CancerNav helps the outreach team identify patients for follow-up from events and referrals and notifies patient navigators to connect with them. Navigators track daily interactions, screenings, and diagnostic testing. If a patient begins treatment, navigators ensure and document a smooth handoff to care coordinators at the cancer center of the patient's choice (our health system or another in Cleveland). Patient navigators can also set reminders to follow up with specific patients. Data collection, ongoing since 2009, documents patient demographics, screenings, results, and navigation calls. The team addresses barriers like finances, transportation, and language using tools like financial aid, Uber health rides, and translation services. These records ensure consistent care for patients at high risk for late-stage cancer diagnosis.

CancerNav enables our outreach program to systematically address cancer disparities. Navigators document patient interactions, track and overcome barriers, and use reminders to facilitate screenings. Monthly and annual analyses of screening referrals by zip code help strategically allocate resources and support program expansion.