HCV Screenings Spike after Prompt in Electronic Health Record

DECEMBER 12, 2017
Kenneth Bender
Monica Konerman, MDMonica Konerman, MD
A best practice advisory (BPA) displayed in the electronic health record (EHR) of baby boomer patients in a multi-site healthcare system prompted a 5-fold increase of screening for hepatitis C virus (HCV) in the population that, according to the Centers for Disease Control and Prevention (CDC), has a 5-fold higher prevalence of HCV than other age groups.

Low screening rates for baby boomers in clinical practice have been noted in multiple studies, in spite of the CDC’s and US Preventive Services Task Force’s recommendation years ago, Monica Konerman, MD, Gastroenterologist and Clinical Lecturer, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, told MD Magazine.

Konerman’s health center has similarly reported low screening rates for the age population.

“In conversation with our primary care physicians (PCPs) and our population health team that works with design of our electronic health record, the idea arose to build a best practice advisory for primary care clinics to help remind clinicians about the need to screen, and to make it easier for PCPs to quickly complete the screening," Konerman said.

The BPA is displayed on the EHR of any patient seen in the primary clinic who was born between 1945 and 1965, lacked a prior EHR diagnosis code for HCV infection, and lacked documented HCV antibody testing after 2009.  If the patient accepts screening, the BPA then pre-populates a "smart set" of orders for HCV-antibody and reflex HCV RNA test, which the PCP can acknowledge with or without ordering during that patient visit.

Konerman and colleagues credit the BPA for eliminating the burden on the PCP for remembering the need for HCV screening in this population and verifying whether there has already been a screening or diagnosis. The BPA was also designed with awareness of "alert fatigue" that can occur from multiple displays occurring within time-constrained patient visits.

"We elected to not make the alert a 'hard stop' for the clinic encounters and to not have the BPA fire at each subsequent visit until it was addressed, based on PCP feedback and in order to prevent impeding workflow," researchers wrote.

Patient educational flyers on HCV screening in baby boomers were also posted in the primary care clinics, and educational material was provided within the electronic patient portal.  After a 3-month pilot trial of the BPA and related materials, however, there was anxiety noted among some patients receiving the materials in advance of their appointment. 

In subsequently implementing the program across all (13) primary care clinics, these materials were held until the visit to allow PCPs to address questions and concerns as they arose.

Konerman and colleagues reported that HCV screening in the one year following implementation of the BPA rose to 72% of targeted patients, a 5-fold increase from the year preceding the program. This substantial increase appeared as an even more dramatic spike, as there had only been 7.6% of baby boomer patients screened in the 6 months preceding the program.

"We attribute the high success rate to the design of the EHR prompt," Konerman said. "It made it easy and fast for PCPs to be able to complete the screening."

The increase in screening occurred across demographics in this age-group, in contrast to previous screening patterns. The researchers had found previous screening more often in male patients, in African-American and Asian patients, and in those with Medicaid or Medicare coverage.

"These discrepant screening rates have been shown previously and in part reflect perceived varying prevalence rates of HCV infection among different patient cohorts," Konerman and colleagues observed. "Of note, these practice variations disappeared once the BPA implementation had been in place for 1 year, with screening rates being driven by baby boomer status and not by other demographic, insurance, or practice setting variables."

After laboratory confirmation of HCV infection, 100% of patients were referred to specialty care.  In the first six months of the BPA program, 87% had been seen by a specialist and 67% of these patients were treated with direct acting antivirals (DAAs).  Although the BPA program was clearly successful in facilitating identification and treatment of more patients with HCV, Konerman emphasized the need for continued improvement.

"Once patients are newly diagnosed, there still remains a gap in terms of number of patients referred and those who attend their specialty clinic visit," Konerman said. "There are then still patients lost to follow-up or patients with active issues that pose challenges to treatment, such as ongoing substance abuse, etc. 

Though insurance coverage for HCV therapies has improved, Konerman said there are still patients “who are unable to get the medications approved and cannot pay out of pocket due to high cost.”

The effect of a best practice advisory  in electronic health records on the rate of HCV screening was reported in the December issue of Hepatology.

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