Using an electronic health record alert to prompt blood-borne virus testing in primary care

Abstract

Background: Late diagnosis of HIV, hepatitis B (HBV) and hepatitis C (HCV) remains relatively common in the UK and many people who present late have missed opportunities for testing in primary care. The objective was to assess the effectiveness and acceptance of a prototype application (BBV_TP1), embedded in a primary care electronic health record (EHR), to increase real-time blood-borne virus (BBV) testing.Methods: This prospective cohort study assessed BBV_TP1 in 14 general practices in North East England, in comparison with 54 similar practices in 2019. Rates of HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) testing in practices were measured before and after the application was activated. Patient and clinician acceptance of the technology was assessed by surveys.Results: In the 6 months following the intervention, HIV testing rates increased 555% and combined HBV/HCV testing rates increased 362%. No significant differences were observed for any BBV testing rates in the nonintervention practices over the same period. Monthly testing rates declined towards baseline after initial increases. Clinician's perceptions of the prompt system were positive, with average additional time required for BBV test discussion in consultations estimated at 2 min. The patient survey also showed high acceptance of the technology. Conclusion:This pilot study demonstrated that BBV_TP1 increased BBV testing rates in primary care via targeted screening, although testing rates subsequently fell whilst the application remained active. Such systems can potentially reduce late diagnoses, while having high acceptance by clinicians and patients. Larger studies with longer follow-up are needed to demonstrate efficacy and cost-effectiveness.

Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review

“…This particular prompt, compared with other prompts, was considered simple to understand and easy to manage The prompt in the context of the consultation - Most discussed blood tests and submitted an order with the patient present. Some GPs ordered the test after the patient had left and were faced with the dilemma of whether to bring the patient back to discuss HIV testing - Many hospital-based and general practice HCWs felt the prompt was too late in the ordering process and disrupts the consultation, potentially opening up a new topic, causing irritation Perception Impact on time: Mixed views Driving perception: Either: - no mention of time - prompt causes test to be ordered after consultation - disruptive if prompt comes too late in the ordering process - potentially opens up a new topic right at the end of the consultation Chadwick et al 2021 [ 100 , 101 ] UK To evaluate a prototype application designed to prompt in real-time, BBV testing in previously untested higher risk individuals attending primary care Condition of focus : Blood-borne viruses Setting : General practice Tool : CDS to identify patients at risk of blood-borne viruses - Embedded/linked with EMR: Yes - Interruptive alert: Yes - User-driven: Clinician - Risk score: Yes Prospective cohort study Number of 'hard prompts' and clinicians' responses BBV tests ordered Survey of GPs Clinicians’ perceptions of the prompt system were positive with average additional time required for BBV test discussion in consultations estimated at 2 min Nineteen percent of clinicians reported having to make an additional appointment after a BBV test prompt because of insufficient time during a consultation and 15% had to make an additional appointment to discuss test results Free-text answers stressed the lack of time available Median additional consultation time varied from 0.25 min when the clinician ignored the prompt to 2 min when the prompt was accepted or declined Perception Impact on time: Increase Driving perception: limited time during consultations Chima et al 2019 [ 102 ] UK To summarise existing evidence on the effects of eCDSTs on decision making for cancer diagnosis in primary care, and determine factors that influence their successful implementation Condition of focus: Cancer Setting : General practice Tool : Range of CDS tools to support cancer diagnosis - Embedded/linked with EMR: Range - Interruptive alert: Range - User-driven: Range - Risk score: Range Systematic review …”

Workload And Workflow Implications Associated With The Use Of Electronic Clinical Decision Support Tools Used By Health Professionals In General Practice: A Scoping Review

“…121 Some studies (n = 10) mentioned 'alert fatigue' indicating that eCDS tools designed to support health professionals can increase the number of on-screen alerts, leading to a high chance of them being missed or ignored. 15,35,38,97,112,117,[122][123][124][125] None of these studies reported a decrease in consultation duration.…”

“…Twenty-three of these reported the impact on 'work ow', regarding how eCDS tools altered the usual order in which patient-related tasks were carried out. 33,35,38,57,61,62,64,80,86,89,97,102,104,105,108,[113][114][115][116][117][118][119][120] Five referred to the impact of using eCDS tools on the trajectory of dialogue with patients, to the extent that follow-up appointments were arranged to avoid consultations running late. 35,72,114,115,118 One of these mentioned clinicians' concerns about 'taking time away' from other waiting patients, expressed as a barrier to the implementation of eCDS systems.…”

“…33,35,38,57,61,62,64,80,86,89,97,102,104,105,108,[113][114][115][116][117][118][119][120] Five referred to the impact of using eCDS tools on the trajectory of dialogue with patients, to the extent that follow-up appointments were arranged to avoid consultations running late. 35,72,114,115,118 One of these mentioned clinicians' concerns about 'taking time away' from other waiting patients, expressed as a barrier to the implementation of eCDS systems. 121 Some studies (n = 10) mentioned 'alert fatigue' indicating that eCDS tools designed to support health professionals can increase the number of on-screen alerts, leading to a high chance of them being missed or ignored.…”

“…Among the 36 studies that indicated a perceived increase in consultation duration, the most commonly highlighted concerns related to existing time pressures and lack of time during a consultation for clinicians to interact with eCDS tools and/or to carry out resultant recommended actions. 16,[26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] A prevalent view was that workload was 'already heavy' and that using eCDS tools would inevitably add burden. 36,38,39,[41][42][43][44][45][46][47][48] In the case of one tool to support delivery of preventive care through review of patients' lifestyle factors, the sense of lack of time for preventive care in general drove the view towards the tool increasing consultation duration.…”