Trial Outcomes & Findings for Facilitators and Barriers to Cancer Screening: Stakeholder Perspectives on Implementation (NCT NCT04683744)

Last Updated: 2025-01-31

Results Overview

Semi-structured interviews with health system leadership, providers and staff conducted every 3-4 months to discuss facilitators and barriers to implementing decision aids, provider notification, and personal risk calculation using an EHR to promote cancer screening.

Recruitment status

COMPLETED

Target enrollment

82 participants

Primary outcome timeframe

2 years

Results posted on

2025-01-31

Participant Flow

Healthcare system: we used snowball sampling to identify leadership, providers, and clinical staff involved in cancer screening, primary care and prevention. We interviewed 20 key informants in January-July 2021 and re-interviewed 11 of them in January-March 2022. Patients: we interviewed patients (screened and not screened) who were due for breast, cervical, colorectal, or lung cancer screening in April-July 2020. Interviews were conducted from August 2021 through February 2022.

One patient that was consented, enrolled, and interviewed was removed from the study after review of data by PI and key research members concluded that the patient had undergone a diagnostic rather than screening procedure.

Participant milestones

Participant milestones
Measure	Healthcare System Leadership, Providers, and Staff Leadership, providers, and staff at the study team's affiliated health systems. Semi-structured interviews-Health system: The interview guide will consist of questions to elicit thoughts from health system leadership, providers, and staff about implementing decision aids, provider notifications, and cancer risk assessments in their health center or healthcare system. The questions may be specific to colorectal cancer screening or more generally about other cancer screenings. The investigators may also ask questions about cancer screening initiatives their health center or healthcare system engaged in during the COVID-19 pandemic.	Not Screened Patients Patients who had a least one primary care visit during the past 24 months at the study team's affiliated health care systems, were due for breast, cervical, colorectal, or lung cancer screening in April-July 2020, and did NOT complete the screening they were selected for at time of interview. Semi-structured interviews-Patients: The interview guide will consist of questions to elicit the patients thoughts about getting preventive healthcare during the COVID-19 pandemic, including perception of risk, barriers to getting healthcare, and information needed for decision making.	Screened Patients Patients who had at least one primary care visit during the past 24 months at the study team's affiliated health care systems, were due for breast, cervical, colorectal, or lung cancer screening in April-July 2020 and did completed the screening they were selected for at time of interview. Semi-structured interviews-Patients: The interview guide will consist of questions to elicit the patients thoughts about getting preventive healthcare during the COVID-19 pandemic, including perception of risk, barriers to getting healthcare, and information needed for decision making.
Overall Study STARTED	20	29	33
Overall Study Interview #1	20	29	33
Overall Study Interview #2	11	0	0
Overall Study COMPLETED	20	29	32
Overall Study NOT COMPLETED	0	0	1

Reasons for withdrawal

Reasons for withdrawal
Measure	Healthcare System Leadership, Providers, and Staff Leadership, providers, and staff at the study team's affiliated health systems. Semi-structured interviews-Health system: The interview guide will consist of questions to elicit thoughts from health system leadership, providers, and staff about implementing decision aids, provider notifications, and cancer risk assessments in their health center or healthcare system. The questions may be specific to colorectal cancer screening or more generally about other cancer screenings. The investigators may also ask questions about cancer screening initiatives their health center or healthcare system engaged in during the COVID-19 pandemic.	Not Screened Patients Patients who had a least one primary care visit during the past 24 months at the study team's affiliated health care systems, were due for breast, cervical, colorectal, or lung cancer screening in April-July 2020, and did NOT complete the screening they were selected for at time of interview. Semi-structured interviews-Patients: The interview guide will consist of questions to elicit the patients thoughts about getting preventive healthcare during the COVID-19 pandemic, including perception of risk, barriers to getting healthcare, and information needed for decision making.	Screened Patients Patients who had at least one primary care visit during the past 24 months at the study team's affiliated health care systems, were due for breast, cervical, colorectal, or lung cancer screening in April-July 2020 and did completed the screening they were selected for at time of interview. Semi-structured interviews-Patients: The interview guide will consist of questions to elicit the patients thoughts about getting preventive healthcare during the COVID-19 pandemic, including perception of risk, barriers to getting healthcare, and information needed for decision making.
Overall Study withdrawn (determined not eligible after enrollment)	0	0	1

Baseline Characteristics

Demographic-age data for health system participants was not collected at baseline.

Baseline characteristics by cohort

PRIMARY outcome

Timeframe: 2 years

Population: The initial sample of 8 interviewees identified 12 additional stakeholders, allowing us to "snowball" our sample to complete interviews with 20 participants including primary care providers, nurses, medical assistants, quality and clinic managers, and cancer screening program managers.

Outcome measures

Outcome measures
Measure	Healthcare System Leadership, Providers, and Staff n=20 Participants Leadership, providers, and staff at the study team's affiliated health systems. Semi-structured interviews-Health system: The interview guide will consist of questions to elicit thoughts from health system leadership, providers, and staff about implementing decision aids, provider notifications, and cancer risk assessments in their health center or healthcare system. The questions may be specific to colorectal cancer screening or more generally about other cancer screenings. The investigators may also ask questions about cancer screening initiatives their health center or healthcare system engaged in during the COVID-19 pandemic.	Screened Patients Patients who had at least one primary care visit during the past 24 months at the study team's affiliated health care systems, were due for breast, cervical, colorectal, or lung cancer screening in April-July 2020 and did complete the screening they were selected for at time of interview. Semi-structured interviews-Patients: The interview guide will consist of questions to elicit the patients thoughts about getting preventive healthcare during the COVID-19 pandemic, including perception of risk, barriers to getting healthcare, and information needed for decision making.
Facilitators and Barriers to Implementing Decision Aids, Provider Notifications, and Personal Risk Calculation Using an Electronic Health Record (EHR) to Promote Colorectal Cancer Screening. Themes: Facilitators identified	6 Themes	—
Facilitators and Barriers to Implementing Decision Aids, Provider Notifications, and Personal Risk Calculation Using an Electronic Health Record (EHR) to Promote Colorectal Cancer Screening. Themes: Barriers identified	8 Themes	—

PRIMARY outcome

Timeframe: 9 months

Population: 20 leaders, managers, and providers were interviewed in January-July 2021, and 11 were re-interviewed in January-March 2022. We identified five emergent, overarching themes of the impact of COVID-19 pandemic on cancer screening and preventive care services across two healthcare organizations and across the time frame of the COVID-19 pandemic (2020-2022).

Semi-structured interviews with health system leadership, providers, and staff from the study team's affiliated health systems about their perceptions of the impact of COVID-19 on primary care and cancer screening.

Outcome measures

Outcome measures
Measure	Healthcare System Leadership, Providers, and Staff n=20 Participants Leadership, providers, and staff at the study team's affiliated health systems. Semi-structured interviews-Health system: The interview guide will consist of questions to elicit thoughts from health system leadership, providers, and staff about implementing decision aids, provider notifications, and cancer risk assessments in their health center or healthcare system. The questions may be specific to colorectal cancer screening or more generally about other cancer screenings. The investigators may also ask questions about cancer screening initiatives their health center or healthcare system engaged in during the COVID-19 pandemic.	Screened Patients Patients who had at least one primary care visit during the past 24 months at the study team's affiliated health care systems, were due for breast, cervical, colorectal, or lung cancer screening in April-July 2020 and did complete the screening they were selected for at time of interview. Semi-structured interviews-Patients: The interview guide will consist of questions to elicit the patients thoughts about getting preventive healthcare during the COVID-19 pandemic, including perception of risk, barriers to getting healthcare, and information needed for decision making.
Challenges and Facilitators of Effective Cancer Screening and Prevention in Primary Care During the COVID-19 Pandemic Among Leadership, Providers, and Staff.	5 Themes	—

PRIMARY outcome

Timeframe: 6 months

Population: We interviewed 32 patients who completed screening in 2020 and 29 patients who did not complete the relevant screening test from April 2020 to the date of the interview.

Semi-structured interviews with primary care patients who were due for either breast, cervical, colorectal, or lung cancer screening between April-July 2020 at the study teams affiliate health systems. The interview guide contained questions to explore the patients' understanding, attitudes, and beliefs about getting preventive healthcare during the COVID-19 pandemic, including perception of risk, barriers to getting preventive and other (non-screening) healthcare, and information needed for decision making.

Outcome measures

Outcome measures
Measure	Healthcare System Leadership, Providers, and Staff n=29 Participants Leadership, providers, and staff at the study team's affiliated health systems. Semi-structured interviews-Health system: The interview guide will consist of questions to elicit thoughts from health system leadership, providers, and staff about implementing decision aids, provider notifications, and cancer risk assessments in their health center or healthcare system. The questions may be specific to colorectal cancer screening or more generally about other cancer screenings. The investigators may also ask questions about cancer screening initiatives their health center or healthcare system engaged in during the COVID-19 pandemic.	Screened Patients n=32 Participants Patients who had at least one primary care visit during the past 24 months at the study team's affiliated health care systems, were due for breast, cervical, colorectal, or lung cancer screening in April-July 2020 and did complete the screening they were selected for at time of interview. Semi-structured interviews-Patients: The interview guide will consist of questions to elicit the patients thoughts about getting preventive healthcare during the COVID-19 pandemic, including perception of risk, barriers to getting healthcare, and information needed for decision making.
Number of Themes Identified by Patients That Influenced Decisions to Engage in Cancer Screening and Other Healthcare Services, and What Information Was Needed for Making Healthcare Decisions During the COVID-19 Pandemic. Cancer Screening	3 Themes	3 Themes
Number of Themes Identified by Patients That Influenced Decisions to Engage in Cancer Screening and Other Healthcare Services, and What Information Was Needed for Making Healthcare Decisions During the COVID-19 Pandemic. Other Healthcare Services (non-screening)	4 Themes	4 Themes
Number of Themes Identified by Patients That Influenced Decisions to Engage in Cancer Screening and Other Healthcare Services, and What Information Was Needed for Making Healthcare Decisions During the COVID-19 Pandemic. Health Information	3 Themes	3 Themes

Adverse Events

Healthcare System Leadership, Providers, and Staff

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

Not Screened Patients

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

Screened Patients

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

Serious adverse events

Adverse event data not reported

Other adverse events

Adverse event data not reported

Additional Information

Dr. Peter H. Schwartz

Indiana University

Phone: 317-278-4037

Email: [email protected]

Results disclosure agreements

Principal investigator is a sponsor employee
Publication restrictions are in place

Measure	Not Screened Patients n=29 Participants Patients who were due for cancer screening (breast, cervical, colorectal or lung cancer) between April-July 2020, however had not completed the screening they were selected for at time of interview.	Screened Patients n=32 Participants Patients who were due for cancer screening (breast, cervical, colorectal or lung cancer) between April-July 2020 and had completed the screening they were selected for at time of interview.	Health System Participants n=20 Participants Leadership, providers, and clinical staff involved in cancer screening, primary care, and prevention at two affiliated health systems.	Total n=81 Participants Total of all reporting groups
Age, Continuous	56.1 years STANDARD_DEVIATION 15.1 • n=29 Participants • Demographic-age data for health system participants was not collected at baseline.	56.2 years STANDARD_DEVIATION 14.5 • n=32 Participants • Demographic-age data for health system participants was not collected at baseline.	—	56.1 years STANDARD_DEVIATION 14.7 • n=61 Participants • Demographic-age data for health system participants was not collected at baseline.
Sex/Gender, Customized Female	24 Participants n=29 Participants • Demographic-sex/gender data for health system participants was not collected at baseline.	23 Participants n=32 Participants • Demographic-sex/gender data for health system participants was not collected at baseline.	—	47 Participants n=61 Participants • Demographic-sex/gender data for health system participants was not collected at baseline.
Sex/Gender, Customized Male	4 Participants n=29 Participants • Demographic-sex/gender data for health system participants was not collected at baseline.	9 Participants n=32 Participants • Demographic-sex/gender data for health system participants was not collected at baseline.	—	13 Participants n=61 Participants • Demographic-sex/gender data for health system participants was not collected at baseline.
Sex/Gender, Customized Other	1 Participants n=29 Participants • Demographic-sex/gender data for health system participants was not collected at baseline.	0 Participants n=32 Participants • Demographic-sex/gender data for health system participants was not collected at baseline.	—	1 Participants n=61 Participants • Demographic-sex/gender data for health system participants was not collected at baseline.
Race/Ethnicity, Customized White	17 Participants n=29 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.	16 Participants n=32 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.	—	33 Participants n=61 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.
Race/Ethnicity, Customized Black or African American	11 Participants n=29 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.	13 Participants n=32 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.	—	24 Participants n=61 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.
Race/Ethnicity, Customized Other	1 Participants n=29 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.	3 Participants n=32 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.	—	4 Participants n=61 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.
Race/Ethnicity, Customized Hispanic/Latino	0 Participants n=29 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.	0 Participants n=32 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.	—	0 Participants n=61 Participants • Demographic-race and ethnicity data for Health system participants was not collected at baseline.
Living Situation Never Married	7 Participants n=29 Participants • Living situation data will not be collected for health system participants.	9 Participants n=32 Participants • Living situation data will not be collected for health system participants.	—	16 Participants n=61 Participants • Living situation data will not be collected for health system participants.
Living Situation Married/Living with a Partner	14 Participants n=29 Participants • Living situation data will not be collected for health system participants.	13 Participants n=32 Participants • Living situation data will not be collected for health system participants.	—	27 Participants n=61 Participants • Living situation data will not be collected for health system participants.
Living Situation Divorced	3 Participants n=29 Participants • Living situation data will not be collected for health system participants.	4 Participants n=32 Participants • Living situation data will not be collected for health system participants.	—	7 Participants n=61 Participants • Living situation data will not be collected for health system participants.
Living Situation Separated	0 Participants n=29 Participants • Living situation data will not be collected for health system participants.	1 Participants n=32 Participants • Living situation data will not be collected for health system participants.	—	1 Participants n=61 Participants • Living situation data will not be collected for health system participants.
Living Situation Widowed	5 Participants n=29 Participants • Living situation data will not be collected for health system participants.	5 Participants n=32 Participants • Living situation data will not be collected for health system participants.	—	10 Participants n=61 Participants • Living situation data will not be collected for health system participants.
Highest Level of Education Less than high school diploma	2 Participants n=29 Participants • Education level will not be collected for health system participants.	3 Participants n=32 Participants • Education level will not be collected for health system participants.	—	5 Participants n=61 Participants • Education level will not be collected for health system participants.
Highest Level of Education High school graduate/GED	12 Participants n=29 Participants • Education level will not be collected for health system participants.	7 Participants n=32 Participants • Education level will not be collected for health system participants.	—	19 Participants n=61 Participants • Education level will not be collected for health system participants.
Highest Level of Education Some college/technical or trade school	7 Participants n=29 Participants • Education level will not be collected for health system participants.	10 Participants n=32 Participants • Education level will not be collected for health system participants.	—	17 Participants n=61 Participants • Education level will not be collected for health system participants.
Highest Level of Education Associate degree	0 Participants n=29 Participants • Education level will not be collected for health system participants.	4 Participants n=32 Participants • Education level will not be collected for health system participants.	—	4 Participants n=61 Participants • Education level will not be collected for health system participants.
Highest Level of Education Bachelor's degree	6 Participants n=29 Participants • Education level will not be collected for health system participants.	7 Participants n=32 Participants • Education level will not be collected for health system participants.	—	13 Participants n=61 Participants • Education level will not be collected for health system participants.
Highest Level of Education Professional or graduate degree	2 Participants n=29 Participants • Education level will not be collected for health system participants.	1 Participants n=32 Participants • Education level will not be collected for health system participants.	—	3 Participants n=61 Participants • Education level will not be collected for health system participants.
Employment Status Unemployed/retired	21 Participants n=29 Participants • Employment status data will not be collected from health system participants.	16 Participants n=32 Participants • Employment status data will not be collected from health system participants.	—	37 Participants n=61 Participants • Employment status data will not be collected from health system participants.
Employment Status Employed Full-time	6 Participants n=29 Participants • Employment status data will not be collected from health system participants.	9 Participants n=32 Participants • Employment status data will not be collected from health system participants.	—	15 Participants n=61 Participants • Employment status data will not be collected from health system participants.
Employment Status Employed Part-time	2 Participants n=29 Participants • Employment status data will not be collected from health system participants.	6 Participants n=32 Participants • Employment status data will not be collected from health system participants.	—	8 Participants n=61 Participants • Employment status data will not be collected from health system participants.
Employment Status Unknown	0 Participants n=29 Participants • Employment status data will not be collected from health system participants.	1 Participants n=32 Participants • Employment status data will not be collected from health system participants.	—	1 Participants n=61 Participants • Employment status data will not be collected from health system participants.
Subjective Health Status Excellent	1 Participants n=29 Participants • Subject Health Status data will not be collected from health system participants.	1 Participants n=32 Participants • Subject Health Status data will not be collected from health system participants.	—	2 Participants n=61 Participants • Subject Health Status data will not be collected from health system participants.
Subjective Health Status Very good	3 Participants n=29 Participants • Subject Health Status data will not be collected from health system participants.	6 Participants n=32 Participants • Subject Health Status data will not be collected from health system participants.	—	9 Participants n=61 Participants • Subject Health Status data will not be collected from health system participants.
Subjective Health Status Good	14 Participants n=29 Participants • Subject Health Status data will not be collected from health system participants.	16 Participants n=32 Participants • Subject Health Status data will not be collected from health system participants.	—	30 Participants n=61 Participants • Subject Health Status data will not be collected from health system participants.
Subjective Health Status Fair	7 Participants n=29 Participants • Subject Health Status data will not be collected from health system participants.	7 Participants n=32 Participants • Subject Health Status data will not be collected from health system participants.	—	14 Participants n=61 Participants • Subject Health Status data will not be collected from health system participants.
Subjective Health Status Poor	4 Participants n=29 Participants • Subject Health Status data will not be collected from health system participants.	2 Participants n=32 Participants • Subject Health Status data will not be collected from health system participants.	—	6 Participants n=61 Participants • Subject Health Status data will not be collected from health system participants.
Subjective Income Are comfortable	7 Participants n=29 Participants • Subjective Income data will not be collected from health system participants.	15 Participants n=32 Participants • Subjective Income data will not be collected from health system participants.	—	22 Participants n=61 Participants • Subjective Income data will not be collected from health system participants.
Subjective Income Have just enough to make ends meet	14 Participants n=29 Participants • Subjective Income data will not be collected from health system participants.	14 Participants n=32 Participants • Subjective Income data will not be collected from health system participants.	—	28 Participants n=61 Participants • Subjective Income data will not be collected from health system participants.
Subjective Income Do NOT have enough to make ends meet	7 Participants n=29 Participants • Subjective Income data will not be collected from health system participants.	3 Participants n=32 Participants • Subjective Income data will not be collected from health system participants.	—	10 Participants n=61 Participants • Subjective Income data will not be collected from health system participants.
Subjective Income Unknown	1 Participants n=29 Participants • Subjective Income data will not be collected from health system participants.	0 Participants n=32 Participants • Subjective Income data will not be collected from health system participants.	—	1 Participants n=61 Participants • Subjective Income data will not be collected from health system participants.
Difficulty Understanding Written Information Always	2 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	0 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	2 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Difficulty Understanding Written Information Often	0 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	1 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	1 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Difficulty Understanding Written Information Sometimes	7 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	8 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	15 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Difficulty Understanding Written Information Occasionally	7 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	5 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	12 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Difficulty Understanding Written Information Never	13 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	18 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	31 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Confidence Filling Out Medical Forms Extremely	15 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	21 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	36 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Confidence Filling Out Medical Forms Quite a bit	5 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	5 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	10 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Confidence Filling Out Medical Forms Somewhat	4 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	4 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	8 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Confidence Filling Out Medical Forms A little bit	1 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	1 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	2 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Confidence Filling Out Medical Forms Not at all	4 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	1 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	5 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Have Help Reading Hospital Materials Always	2 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	0 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	2 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Have Help Reading Hospital Materials Often	2 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	2 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	4 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Have Help Reading Hospital Materials Sometimes	4 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	4 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	8 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Have Help Reading Hospital Materials Occasionally	7 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	6 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	13 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Have Help Reading Hospital Materials Never	14 Participants n=29 Participants • Health literacy data will not be collected from health system participants.	20 Participants n=32 Participants • Health literacy data will not be collected from health system participants.	—	34 Participants n=61 Participants • Health literacy data will not be collected from health system participants.
Health System Roles Leadership/Administration	—	—	9 Participants n=20 Participants • Health system role data was only collected from health system participants.	9 Participants n=20 Participants • Health system role data was only collected from health system participants.
Health System Roles Provider (MD, DO, APP)	—	—	5 Participants n=20 Participants • Health system role data was only collected from health system participants.	5 Participants n=20 Participants • Health system role data was only collected from health system participants.
Health System Roles Clinical Support (MA, RN)	—	—	6 Participants n=20 Participants • Health system role data was only collected from health system participants.	6 Participants n=20 Participants • Health system role data was only collected from health system participants.