Clinical reminder might assist physicians in deciding when to offer HIV testing

Created through collaborative effort at VA hospital

Investigators have developed a clinical reminder that provides clinicians with a simple guide to when it’s important to offer HIV testing to patients.

"This has been a collaborative effort that has come out of the Veteran Administration’s strategic health care group in Washington," says Matthew B. Goetz, MD, chief of infectious diseases at the VA Greater Los Angeles Healthcare System in Los Angeles, CA. Goetz also is a professor of clinical medicine at the David Geffen School of Medicine at the University of California Los Angeles.

"The method takes advantage of the electronic record and uses electronic reminders to prompt clinicians to apply appropriate care to at-risk patients," Goetz explains.

The electronic record provides electronic access to lab records and patient risk factors, and it is used to screen for a variety of diseases, including recent adaptations for HIV, sexually-transmitted diseases (STDs), substance abuse, and hepatitis C infection, Goetz says.

"It’s not an entirely perfect screening method because there are some risk factors and behaviors that are not captured by an electronic record, in part because patients don’t always acknowledge their behaviors," Goetz says. "But clinicians in the day-to-day practice are sufficiently busy that they don’t have the ability to screen patients themselves for risk factors."

The system works this way: clinicians enter progress notes on the computer and look to see if there are any clinical reminders that need to be addressed for that particular patient, Goetz says.

"They have reminders for diabetes care, hypertension care, screening for cancer, amongst many other items," Goetz says.

"We adapted it for HIV care and the reminder software goes into the patient’s database, saying the patient is known to be infected with hepatitis C, for example," Goetz explains. "When the clinician clicks on the reminder box, it says, This patient has a risk factor for HIV infection.’"

Then the clinician can click on the link to see what the risk factor is, Goetz adds.

"The reminder instructs the provider how to counsel and test the person for HIV, and it’s all consistent with the VA and federal regulations regarding voluntary nature of HIV testing," Goetz says.

Typically the entire screening process takes 2 to 3 minutes, although if patients ask a lot of questions it could take longer, Goetz says.

"And there are providers who have to give everything a lengthy explanation," Goetz says.

"The template gives the provider an algorithm to follow to appropriately counsel the person and get informed consent for testing, and it gives the provider an opportunity to see if the patient has been tested outside the VA and then to enter the results into the system," Goetz says.

Pilot testing of the system took place in Los Angeles and San Diego, using a network personal computer system in which a computer is in every exam room, so physicians can look at it while examining patients, Goetz says.

"The computer is like our right hand," Goetz says. "And I believe the VA has the most advanced medical records system in the country, if not internationally."

The software includes hyperlinks to instructions, including hospital policy and details, and it provides various scenarios for every suggestion, he says.

For instance, when the screen window says the patient has a risk factor, it also provides 4 different responses as to how to satisfy the request for HIV testing, Goetz says.

"If the patient indicates he wishes to undergo HIV testing, then the instructions say how to fill out the HIV consent form, and the form goes through detail on the meaning of the HIV test, confidentiality and care for patients who have HIV," Goetz explains.

There are technical instructions regarding the test, and the physician can order the test electronically and then have the blood drawn, he says.

"There’s another project going on where we’re looking at patients’ acceptance of rapid HIV testing, and we’re looking at procedural matters so it could be implemented in an effective way," Goetz says. "Interim data is favorable, and we anticipate implementing rapid testing in our facility."

Research about the use of the electronic screening method has shown that it is cost effective down to a prevalence rate of about 0.5 percent, and it is effective even to a prevalence rate of 0.1 percent if you consider the impact of HIV testing and HIV therapy on subsequent HIV transmission, Goetz says.

"Across the VA as a whole, we believe our HIV prevalence is 1 percent," Goetz says.

"We don’t recommend that all veterans are screened because we don’t have enough evidence that it’s cost effective," Goetz notes. "We’re trying to demonstrate in this population that this is a process that can be incorporated into standard clinical practice."

Since the screening method has sufficiently small impact on physician work flow and it has a high yield in terms of new diagnoses of HIV, investigators are hopeful that if it’s successful they’ll move to the next step of using the screening system routinely, Goetz says.

One of the reasons such a screening tool is needed is because physicians tend to believe HIV testing is special and that they aren’t qualified to screen for HIV unless they are trained experts, Goetz says.

"We’re trying to change the paradigm for doing this and show HIV testing as a normative behavior, just as testing for hepatitis C and testing for syphilis and hepatitis B," he says. "One does not need to stigmatize the patient or stereotype the interaction."

So in addition to providing an electronic tool, it’s important to educate clinicians about HIV testing and how to have a dialogue with patients in which HIV risk and HIV testing are discussed, Goetz says.

"We have our study staff go down to the clinic and talk with doctors," Goetz says. "We don’t have a fully-developed process at this time, but we’re trying to determine what educational materials providers need and how to customize those materials to different levels."

Eventually, there might be enough societal acceptance of HIV infection that it will become normalized, and the screening process will become routine and very brief, Goetz says.

"We’ve talked with other VA facilities that are interested in adopting our model," Goetz says. "No one outside the VA has contacted me, but there are lessons that would be of interest to other integrated health care management groups and others with electronic medical records because the overall model is streamlining HIV testing to make it part of the standard of care of patients."