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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?