Enhancing HIV Testing Practices: Routinizing

Testing through Electronic Medical Record (EMR)

Technology

Ann K Avery, MDMetroHealth Medical Center

Cleveland, Ohio

Setting• Urban safety net hospital and affiliated

community health centers in Cleveland, Ohio

• Comprehensive electronic medical records (EMR) since 1999

• Largest provider of Ryan White funded HIV care in area.

Background• Capacity-building grant from the AIDS

Funding Collaborative (AFC)o Evaluation of electronic medical records

(EMR) to establish testing trendso Develop provider educationo Increase HIV testing by maximizing use of

EPIC (EMR system)

Cleveland Department of Public Health

Initial Approach - Education• Large and small group education

o Increase knowledge of new recommendations

o Increase comfort with topico Collect information on real and perceived

barriers for providers

Evaluation• Reviewed HIV tests performed prior to CDC

recommendations (from 2002-2007)• Analyzed clinical encounters (for 2008-

YTD2011) to define missed opportunities for HIV testingo Tested on encounter o Test resulto Tested previouslyo Demographics

HIV Testing & Diagnosis:MHMC, 2002-2007

HIV TestsNewly

Diagnosed Cases

Positivity

2002 6927 72 1.0%2003 7092 59 0.8%2004 7626 62 0.8%2005 7751 51 0.7%2006* 8042 60 0.7%2007 9155 48 0.5%

*CDC Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings were revised in September 2006.

Lab Orders/Results Analysis, MHMC

Missed Opportunity

A patient encounter with a healthcare provider for any health issue — regardless

of risk factors or contact with any other provider — where HIV testing was notperformed during the visit and had not

been previously performed.

HIV Testing by Encounter Type: MHMC, 2008-2009

186306

121711

3674

57748

3173

183309

115866

4046

60069

33280

50000

100000

150000

200000

Total Encounters Never Ever "Missed

Opportunities"

Got Their Status Knew Their Status

Got Retested

2008 2009

Avery and Del Toro, IDSA 2010 abstract #1062 2010

64%

32%

Only 2% 1.8%

Missed Opportunities among Outpatients

HIV Testing Trends: MHMC 2008-2009

• Repeat testing is commono May be due to known risk factors

• Gender & race disparitieso Women are more likely to have been

previously tested Routine prenatal screening

o 80% of men have never been tested for HIV

New and Improved Education• Seize the Opportunity: Why Routine HIV

Testing is Importanto Increase knowledge of recommendations

and HIV statistics Identifying missed opportunities Department-specific performance measures Update on Ohio Revised Code & MHS policy

o Improve communication skills and comfort Strategies on how to apply HIV testing into

clinical practice

Electronic Reminder• Health Maintenance tab revised to

include HIV testingo Reminder to test if status unknowno Mostly used in outpatient settingo Went “live” in July 2010

0

50

100

150

200

250

300

Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011

Repeat Testers

First Time Testers

Testing patterns since 2010

Inpatient Testing

Testing patterns since 2010

0

500

1000

1500

2000

2500

3000

3500

4000

Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011

Repeat Testers

First Time Testers

Outpatient testing

Missed Opportunities outpatients 1st Quarter 2010 vs 1st Quarter 2011

Males

P value < .001 for all matched age groups except 13-19 y/o

Missed Opportunities outpatients 1st Quarter 2010 vs 1st Quarter 2011

0102030405060708090

100

13-19 20-24 25-29 30-39 40-49 50-59 60-64

Q1 2010

Q1 2011

Females

P value < .001 for all matched groups 25 and older

New DiagnosesConfirmed New Case

False Positive

2008 15 (7 males) 7

2009 15 (6 males) 7

2010 21 (17 males) 13

2011 (1st

Qtr only) 9 (8 males) 1

ConclusionsAn electronic medical record based prompt

quickly and effectively improved the integration of HIV testing into ambulatory care practices.

Utilization of the health maintenance tool was essential for the success of this intervention.

Acknowledgements• Michelle Del Toro, MPH, MALS• Peter Greco, MD• David Kaelber, MD, PhD, MPH• Aleese Caron, PhD

• Laureen Tews Harbert, MPH

Thank You.

Questions?