Electronic Health Records in HIV Screening and Prevention

The federal government had made millions available in funding for electronic health records (EHR) in the outpatient and inpatient setting. The use of such records is supposed to reduce errors, improve care coordination between clinicians and across healthcare settings, and improve quality. They are also often linked to personal health records (PHR), patient portals that give patients access to test results, medical records, screening recommendations, and health-related education.

Now hospitals, clinics, and researchers are investigating how both can be used to improve HIV screening and outcomes.

“The EHR and PHR offer great opportunities in HIV,” said D. Keith McInnes, ScD,research assistant professor at Boston University School of Public Health and research health scientist at the Center for Health Quality Outcomes and Economic Research at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Massachusetts. He and his colleagues conducted focus groups to assess perceptions of an automated reminder system about HIV screening, involving 12 patients and 15 physicians. All generally thought that such emails would motivate them to consider screening.

As one patient said, ““They’re not telling you [you have to be tested for HIV]. They’re putting it in your mind saying.. . . “Have you ever thought about getting HIV testing?” It’s non-offensive. You’re not prying. But it gets you thinking. Something like that might work.”

Although several of those surveyed expressed concern about privacy issues, particularly if the reminders come through a personal email system, one said that if the emailed message simply directed patients to the secure PHR for information, he didn’t see a problem. A 549-patient survey  regarding confidentiality around HIV disease in electronic records found widespread acceptance of sharing HIV-related patient data through health information exchanges (systems that “speak” to each other across provider settings).

Physician concerns centered on the increased workload they perceived the reminders would trigger, including more phone calls and time spent explaining the program, and extra appointments. However, patients didn’t say they would rush to contact their doctor. Instead, they suggested that linking the reminder to online information could actually save the doctor time otherwise spent explaining the test.

On the inpatient side, two studies suggest that integrating screening reminders into the EHR could improve screening rates. In one, researchers found that while most of the 37 internal medicine residents from Lenox Hill Hospital in New York City surveyed knew that state law required that all inpatients be screened for HIV, just 9.1% of 95 patients they’d seen had been offered or received screening.

Half of the residents didn’t know that written consent wasn’t required, and a third didn’t know how to order the rapid screening test. Nearly 80%, however, said that adding an HIV screening option to the EHR would increase their rate of screening. The hospital has since added the automated screening reminder, although no results are available yet on its effectiveness.¹ 

In another study, this one conducted at the University of Chicago medical center where verbal-only consent is required for HIV testing, just a quarter of clinicians reported always or usually performing routine testing in the inpatient setting, with 38% saying that they only sometimes or never conducted HIV tests on patients with risk factors for the virus. The most common barriers were competing priorities and forgetting to order the test, although 54% of physicians said that electronic reminders through the EHR, which are available at the hospital, did help.² 

Electronic health records also hold significant potential for improving the quality of care that HIV-positive patients receive. Two studies presented at the 2012 Infectious Diseases Society of America meeting in October found inpatient prescription medication error rates of 50% in HIV-positive patients, likely because most HIV care is provided on the outpatient basis and inpatient pharmacists and clinicians may not be as familiar with the most recent medications, dosages, and treatment guidelines.^3,4

However, if the patient’s medications were maintained in an outpatient EHR that the hospital could access, error rates plunged-93% in one study. The direct cost of those errors also fell 85%. ⁴

The PHR can also improve adherence to antiretroviral therapy. A study from Dr. McInnes published in the January 2013 online issue of AIDS Behavior  found that patients who used the PHR had at least a 90% adherence rate, far higher than the 26% rate identified in a recent large study of factors in nonadherence to HIV treatment.  

In Louisiana, which ranks fifth in AIDS rates in the US, a secure bidirectional public health information exchange links statewide public health surveillance data with EHR data to alert clinicians with HIV-infected patients about those who have not received HIV care for more than 12 months. Analysis of outcomes for HIV patients in the Louisiana health information exchange showed that it identified 345 patients between 2009 and 2011. After the physicians were notified, 82% received at least one CD4 or HIV viral load test. The study also found strong patient acceptance for sharing such information.

One challenge with integrating HIV information into the PHR, said Dr. McInnes, is training patients to use it. Those who are not comfortable with computers, or who have problems with the medical language they encounter when lab results and progress notes are available via the PHR, may avoid it entirely. Thus, he said, “we need  very careful and aggressive outreach for those who are not comfortable with computers or who have low health literacy.” To do otherwise, he added, means to write off about a fourth of those with or at risk of HIV.

References:

REFERENCES

1. Yehuda M,

et al.

A Missed Opportunity: Identifying Barriers to Inpatient HIV Screening. Paper presented at: Infectious Diseases Society of American annual meeting; 2012; San Diego. Yehuda M, et al. A Missed Opportunity: Identifying Barriers to Inpatient HIV Screening. Paper presented at: Infectious Diseases Society of American annual meeting; 2012; San Diego.

2. Bares S,

et al.

Knowledge, Attitudes, and Ordering Patterns for Routine HIV Screening Among Resident Physicians at an Urban Medical Center. Paper presented at: Infectious Diseases Society of American annual meeting; 2012; San Diego.

3. Neuner EA,

et al.

Antiretroviral Medication Errors in Hospitalized Patients with HIV Infection. Paper presented at: Infectious Diseases Society of American annual meeting; 2012; San Diego.

4. Lee J,

et al.

Reducing Antiretroviral Medication Errors Utilizing an Electronic Medical Record in Hospitalized HIV-Positive Patients. Paper presented at: Infectious Diseases Society of American annual meeting; 2012; San Diego.