Electronic Health Record Prompt Improves HCV Screenings

The results of a new study show that when a best practice advisory (BPA) displayed in the electronic health record (EHR) of patients in the baby boomer generation, it prompted a 5-fold increase in screening for hepatitis C virus (HCV) in this population, which 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 Contagion^®’s sister publication, MD Magazine.

Dr. Konerman’s health center has also reported low screening rates for this 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 BPA 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," Dr. 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 the HCV-antibody and reflex HCV RNA test, which the PCP can acknowledge with or without ordering during that patient visit.

Dr. Konerman and her 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 an 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," the investigators wrote in the study.

Dr. Konerman and her colleagues reported that HCV screening in the 1 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.

After laboratory confirmation of HCV infection, 100% of patients were referred to specialty care. In the first 6 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, Dr. Konerman emphasized the need for continued improvement.

"Once patients are newly diagnosed, there still remains a gap in terms of the number of patients referred and those who attend their specialty clinic visit," Dr. 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, she said there are still patients “who are unable to get the medications approved and cannot pay out of pocket due to high cost.”

A previous version of this article appeared on MD Magazine.com.