DAY 1: Electronic Care Pathway Improves Screening of Patients at High Risk for Hepatic Fibrosis

Use of a clinical pathway integrated into the electronic health record (EHR) in combination with provider education improved screening for metabolic dysfunction-associated steatohepatitis (MASH) at an academic primary care clinic, according to an analysis presented at the 2025 Annual Scientific Meeting of the American College of Gastroenterology in Phoenix, Arizona.

Lead author Brendan McQuillen, MD, noted that, while residents’ awareness and willingness to implement the fibrosis screening guidelines improved significantly over 6 months following the implementation of the pilot program, the clinical pathway, which remains a work in progress, has not yet gained widespread traction in the primary care clinic.

Guidelines currently recommend the use of noninvasive testing such as the Fibrosis-4 (FIB-4) score in primary care to assess the risk for advanced hepatic fibrosis. This strategy is particularly important for patients with metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease (NAFLD), which has continued to increase in prevalence among individuals with metabolic risk factors. However, the implementation of the screening guidelines in real-world settings remains suboptimal.

At the Rush University Medical Center, in Chicago, Illinois, McQuillen and colleagues set out to optimize a screening algorithm for advanced hepatic fibrosis by incorporating a care pathway into the EPIC EHR system used by residents in a primary care clinic. The pathway consisted of a series of silent best-practice advisories within the HER. Residents also received structured education on MASH pathophysiology and screening guidelines, and learned about using the pathway.

“The system was designed to automatically calculate a FIB-4 [index] in any patient with a charted diagnosis of type 2 diabetes mellitus,” McQuillen said during an interview. “This is something that is only active in the resident clinics, so the attending primary care clinics and the hepatology clinics don’t have access to this pathway yet. It will take any laboratory results that are available within the past year and use them to calculate a FIB-4 [index]. If results are not available, it will prompt the residents to order the appropriate laboratory tests to calculate it. It will pop up as a prompt saying that the patient is at risk for MASH and will recommend hepatic fibrosis screening, allowing residents to place the orders [in the system].” The pathway was designed to suggest subsequent management depending on the patient’s initial fibrosis score, including elastography, blood-based Enhanced Liver Fibrosis (ELF) testing, and referral for hepatology consultations.

A total of 1,047 patients were screened for fibrosis over 6 months with the use of the electronic care pathway. However, the rates of referrals for secondary testing and hepatology consultations were low. Although structured resident education resulted in a significant improvement in awareness and knowledge of noninvasive screening strategies, the pathway was not used as expected by residents. “The problem is that it is not a pop-up,” McQuillen explained. “It appears in the clinical reminders section, which is buried with screening tests and vaccinations, so residents actually have to go in and click on these [recommendations] to advance the pathway.” 

Visibility and patient complexity were identified as the main barriers to the routine use of the pathway.

“What we can see with these data is that the pathway is really effective for capturing those patients who need screening and can actually calculate the initial FIB-4, but once we get to the secondary testing and the hepatology referral, the amount of interaction with the pathway is very low,” McQuillen noted. “Every month, we are getting only a couple of patients who are getting secondary testing or a hepatology referral. Part of it is because these data [were collected] only over 6 months and we haven’t followed up with a lot of patients yet. Our goal is to eventually incorporate it into all of the other RUSH primary care clinics and the hepatology clinic. My job as a resident has been to try to increase awareness among the other residents and to foster more [frequent] use.”