Implementation of a Collaborative HIV and Hepatitis C Screening Program in Appalachian Urgent Care Settings

Abstract

IntroductionWith the current hepatitis C (HCV) epidemic in the Appalachian region and the risk of human immunodeficiency virus (HIV) co-infection, there is a need for increased secondary prevention efforts. The purpose of this study was to implement routine HIV and HCV screenings in the urgent care setting through the use of an electronic medical record (EMR) to increase a provider’s likelihood of testing eligible patients.MethodsFrom June 2017 through May 2018, EMR-based HIV and HCV screenings were implemented in three emergency department-affiliated urgent care settings: a local urgent care walk-in clinic; a university-based student health services center; and an urgent care setting located within a multi-specialty clinic. EMR best practice alerts (BPA) were developed based on Centers for Disease Control and Prevention (CDC) guidelines and populated on registered patients who qualified to receive HIV and/or HCV testing. Patients were excluded from the study if they chose to opt out from testing or the provider deemed it clinically inappropriate. Upon notification of a positive HIV and/or HCV test result through the EMR, patient navigators (PNs) were responsible for linking patients to their first medical appointment.ResultsFrom June 2017 through May 2018, 48,531 patients presented to the three urgent care clinics. Out of 27,230 eligible patients, 1,972 patients (7.2%) agreed to be screened for HIV; for HCV, out of 6,509 eligible patients, 1,895 (29.1%) agreed to be screened. Thirty-one patients (1.6%) screened antibody-positive for HCV, with three being ribonucleic acid confirmed positives. No patients in either setting were confirmed positive for HIV; however, two initially screened HIV-positive. PNs were able to link 17 HCV antibody-positive patients (55%) to their first appointment, with the remainder having a scheduled future appointment.ConclusionIntroducing an EMR-based screening program is an effective method to identify and screen eligible patients for HIV and HCV in Appalachian urgent care settings where universal screenings are not routinely implemented.

Centers for Disease Control and Prevention Recommendations for Hepatitis C Testing: The Need to Adopt Universal Screening in an Appalachian Emergency Department

“…16 Through this grant, the EMR was programmed to identify patients for both screening models by triggering a BPA for emergency physicians and advanced practice providers (APPs) to address during the ED visit. 15 The HCV screening was provided at no cost to the patient through the program. Gilead Sciences, Inc., did not have an influence on generation of the manuscript or the design of this study.…”

“…One study found that an EMR best-practice alert (BPA) led to ED providers initiating HCV screenings more often. 15 Further, upon receiving notification of an HCV Ab+ result, the EMR would trigger an automatic reflex to HCV confirmatory testing, thereby removing the task of additional order placement from the provider. 15 Therefore, the ED could be a crucial location for infectious disease-related screenings.…”

“…15 Further, upon receiving notification of an HCV Ab+ result, the EMR would trigger an automatic reflex to HCV confirmatory testing, thereby removing the task of additional order placement from the provider. 15 Therefore, the ED could be a crucial location for infectious disease-related screenings. The purpose of this study was to evaluate characteristics of HCV Ab+ and RNA-confirmed-positive patients identified via two different screening models that were implemented in an Appalachian ED: risk-based and universal screenings.…”

Using the Electronic Medical Record to Increase Testing for HIV and Hepatitis C Virus in An Appalachian Emergency Department

“…Upon presentation of the BPA, providers and nursing staff could select from the following options if they decided to not order screening: "Will Assess," "Not Clinically Appropriate," and "Patient Refused." [22] When providers chose "Will Assess," the BPA would continue to appear until orders were placed or another option was chosen; however, a hard stop was not employed and charts could be closed without an acceptance or rejection of the order.…”

“…As a result of this feedback, we moved the location of the BPA to occur upon opening the orders tab of the patient's chart; this was the preferred location by our providers and proved to be the most logical option during the course of care. If no orders were placed, the BPA would not be triggered.Second, the EMR was programmed to appear based on specified risk factors as outlined by the CDC and modified based on age [20][21][22]. For the BPA to trigger, specified risk factors must be populated in searchable areas of the EMR-for example, the problem list or past medical history tabs.…”