Intermountain Healthcare

Improving Sexually Transmitted Infection Testing in a Large Urgent Care Network

Project Lead: Allan M. Seibert, MD

Project AIM(s):

1. Evaluate a recently implemented multi-modal intervention to improve sexually transmitted
   infection testing, diagnoses, and follow-up in the urgent care centers of a large vertically
   integrated healthcare organization. This evaluation will assess testing rates for gonorrhea (GC), chlamydia (CT), HIV, and syphilis, time to anti-retroviral initiation for individuals identified as newly positive for HIV, and a limited qualitative assessment of the intervention via clinician interviews.
2. Improve upon the multi-modal initiative with the addition of a real-time electronic decision
   support tool (i.e., interactive dashboard) to guide HIV, syphilis, and GC/CT testing.

Narrative Description:

Intermountain Healthcare (IH) is a large vertically integrated healthcare network in the mountain west, predominantly in Utah. IH operates a network of 35 UC clinics across the state. These UC clinics have the same electronic health record (EHR) across all sites, are staffed predominantly by physicians, are from one medical group (no private practice clinicians staff the UC clinics), and report to an IH system leader. These UC clinics serve a young patient population and STI testing is commonly performed. Of all UC visits between July 2018 – December 2021, the monthly percentage of all encounters with a GC/CT test ranged between 0.63% (399/62,866 March 2020) - 1.59% (568/35,687 January 2021). Of those with a GC/CT test, the average percentage of those who also underwent HIV testing was 25.2% (12.9-34.5%).

The average percentage of encounters with GC/CT testing and HIV and syphilis testing was 22.2%. Although national standards are not available, CDC guidelines for STI testing suggest these metrics can be significantly improved. Importantly, the state of Utah has the lowest percentage of adults 18-64 years-old ever tested for HIV (26.5%). Utah also has the lowest percentage of individuals tested for HIV in the previous 12 months (6.5%). Increasing HIV
testing in the state of Utah is of the utmost importance.

In 2020, to improve testing rates of STIs in our UC centers, we performed qualitative interviews with UC clinicians to evaluate barriers and limitations to STI testing. Thirteen UC providers (APPs and MDs) from across the IH service area were interviewed in an open-ended format to assess barriers and explore possible solutions. Based on our qualitative work, we designed and implemented a multi-modal intervention to improve STI testing rates, diagnoses,
and follow-up in our UC sites in 2020-2021. The intervention included:

1. Clinician education: We created a STI diagnosis and treatment algorithm based on CDC recommendations. It was distributed across sites and multiple system-wide lectures were performed emphasizing recommendations.
2. EHR improvements: A “PowerPlan” was created to improve testing accuracy and ordering the most appropriate test. A PowerPlan is an EHR, Cerner based, tool that consolidates testing options into an interactive dashboard on one screen to allow clinicians to easily, quickly, and accurately order STI labs and treatments.
3. Automatic HIV referral: All patients with a laboratory diagnosis of HIV were reviewed by an Infectious Diseases (ID) physician within 48 hours, completes a rapid assessment of the chart, speaks with the patient, provides initial education, and ensures the patient is seen in clinic within 7 days.

We generated, validated, maintained, and will continue to maintain interactive dashboards that include testing and co-testing rates for gonorrhea (GC), chlamydia (CT), HIV, and Syphilis for the Emergency Department (ED) and Urgent Care (UC) systems of Intermountain Health (IH). The purpose of our grant initiative was to expand to include the IH ED system after ED stakeholders learned of our efforts in the IH UC system. 

 As part of our first aim evaluating the previously implemented intervention to improve sexually transmitted infection (STI) testing, these dashboards for both the ED and UC system allow examination of site-specific testing rates and testing rates by age group, race, ethnicity, gender, and preferred language categories. We were able to characterize the time to ID Physician contact and anti-retroviral initiation for individuals newly identified as living with HIV in ambulatory environments (UC, ED, primary care, and subspecialty ambulatory care clinics). Limited qualitative assessment of the intervention with service line leaders and clinicians continues. With multidisciplinary input we developed and implemented a real-time electronic decision support tool to guide HIV co-testing for patients in the ED and UC environments who were undergoing STI testing but whose HIV status was unknown and an HIV test had not been ordered. 

All patients newly identified as living with HIV or with indeterminate test results were successfully contacted by an ID Physician within 24 hours of test results being available, usually in 6-12 hours. In-network patients were generally able to be seen by an HIV Physician and initiate antiretroviral therapy in less than 7 business days.

Patient education materials in English and Spanish along with Provider education materials and our Results Callback script were developed. While we on the ID team ultimately assumed responsibility to engage patients newly identified as living with HIV in the ED and UC environments, some patients continue to be identified in other ambulatory care environments (i.e. Internal Medicine, Family Medicine, OB/GYN clinics) where the ordering provider remains responsible for disclosing the HIV diagnosis. We reach out to these ordering providers and coach them as desired in disclosing a new HIV diagnosis via our Results Callback script. These documents were designed with input from patients, medical writers, Infectious Diseases, UC, and ED providers and executive input.

We observed an increase in appropriate HIV co-testing across the UC and ED centers of our health system during the period in which our electronic decision support tool was active. In the seven months since our HIV co-test alert has been live at various sites over 350 appropriate HIV co-tests have been ordered via alert engagement in patients undergoing testing for other STIs. While no tests ordered as a result of alert engagement have been positive, our ID physician engagement program has provided clarity, education, reassurance, and rapid contact for patients newly identified as living with HIV and those who have indeterminate results and require additional testing. This program has also served as a venue to provide academic detailing to UC, ED, OB/GYN, and other ambulatory providers in our health system.

We hope to refine our co-test alert in the future by: omitting patients receiving pre-exposure prophylaxis who routinely undergo HIV testing and unnecessarily trigger the co-test alert, offering rapid fingerstick testing for patients who defer a blood draw with the understanding that positive results would require an HIV Ag/Ab test, and broadening the time frame that triggers the alert if unnecessary repeat testing is being performed or if the HIV incidence is found to be sufficiently low such that broad focused screening efforts are not cost-effective in our health system.

Further study is needed to understand differences in co-testing practices and alert engagement rates across different ED and UC sites and patient gender, race, ethnicity, and language categories. It is not yet clear if the disparities identified represent inequitable care. Substantial opportunity remains to increase HIV co-testing in UC and ED GC/CT encounters across our system among all patients. 

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

• Patient delayed or unable to access care
• Information gathering
• Information integration
• Information interpretation
• Establishing an explanation (diagnosis)

Root causes/causative factors addressed by the intervention

• Workflow (includes testing, follow-up, and referrals)
• Health information sharing and accessibility via health IT
• Diagnostic patient safety culture
• Identifying/investigation/sharing diagnostic errors 
• Cognitive biases including premature closure
• Knowledge gaps/inexperience
• Other (describe)

Setting of the diagnostic quality improvement intervention

• Ambulatory medical care setting (e.g., clinic, office, urgent care)
• Emergency department