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Decision Support for STD Screening via Tablet

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Ashley Scarborough of the California STD/HIV Prevention Training Center, describes the development of a tablet-based risk assessment app built for STD/HIV providers to improve STD screening rates. …

Ashley Scarborough of the California STD/HIV Prevention Training Center, describes the development of a tablet-based risk assessment app built for STD/HIV providers to improve STD screening rates. Presented at YTH Live 2014 session "Apps for Sexual Health: Lessons Learned in Development."

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  • 1. Smarter than your Smartphone: Clinical Decision Support for STD Screening via Tablet- Based Sexual History Application (TaSHA) Ashley Scarborough, MPH Special Projects Coordinator California STD/HIV Prevention Training Center April 6-8, 2014 San Francisco, CA Annual Conference on Youth + Tech + Health  
  • 2. Background • Who  we  are:  California  STD/HIV  Preven5on  Training  Center   (CA  PTC)-­‐Part  of  a  na5onal  network  of  training  centers  created   in  partnership  with  universi5es/health  departments   • What  do  we  do:    Provide  training  and  technical  assistance  to   increase  knowledge  and  skills  of  health  professionals  around   sexual/reproduc5ve  health   • Who  funds  us:  Centers  for  Disease  Control  and  Preven5on     www.stdhivtraining.org      
  • 3. Sometimes you see a problem and you think there is an easy way for technology to fix that problem…. Those  aren’t  my  famous  last  words,  but  it  felt  like   it  at  5mes…   1.  Outline  of  the  problem     2.  Introducing  TaSHA   3.  Barriers  to  Implementa5on     4.      Comparison  to  Paper-­‐based  Sexual  History   5.        Lessons  We’re  Learning                
  • 4. Do Providers Ask About Risk? 0 10 20 30 40 50 60 70 80 90 100 %ofProvidersWho AssessedSTDRisk Private Physicians Tao AIDS 2003 Primary Care Providers Bull STD 1999 Non-ID trained Physicians Duffus CID 2003 ID trained Physicians Duffus CID 2003 HIV Care Providers Metsch AJPH 2004
  • 5. So What? If we don’t know about people’s sexual practices, how can we adequately screen them? Missed infections, that’s what. Image  credit:  Phil  Harvey      
  • 6. Proportion of CT and GC infections MISSED if screening only urine/urethral site in Gay, Bisexual and other Men who Have Sex with Men Chlamydia   Gonorrhea   Marcus  et  al,  STD  Oct  2011;  38:  922-­‐4     N=3398  asymptoma5c  MSM   San  Francisco,  2008-­‐2009  
  • 7. Introducing: TaSHA
  • 8. Tablet-based Sexual History App Patient Survey Plain Language 6th grade reading level se habla español non-judgmental Come see me for a Demo…. Provider Report Summary STD testing recommendations Education and counseling recommendations Tablet-Based Sexual History Application
  • 9. Provider Report (AKA Clinical Decision Support) Sugges7ons  for  educa7on  and  counseling  “conversa7on  starters”   Summary  of  pa7ent’s  answers   Recommenda7ons  for  STD  tes7ng     according  to  na5onal  guidelines      
  • 10. Strategic Use of Time In 10 HIV+ MSM or MSMW: Average time 2 min. 50 sec. Target Patient Feedback Q: ‘Was anything confusing?’ A: ‘No, it was easy.’ Q: ‘Would you use this in a real life doctor visit?’ A: ‘Yes.’ ‘I prefer it to paper. Paper is boring Follows national guidelines and utilizes significant input from STD experts What do we know about TaSHA?
  • 11. An Adaptable Health Assessment App from v Apex Education Existing platform for iPad tailored for our purposes App is available to clinics via licensing agreement The platform has had tremendous success with school-based health centers in New Mexico and Coloradowww.apexeduca5on.org  |  www.apexapps.org   Apex  Educa?on:  Evalua?on  that  works.  Programs  that  work.  
  • 12. 1. Not a clear path for implementing mobile technology into clinic systems 2. Multiple parties involved: CA PTC; App Developer; Target Organization (TO) Staff; TO IT department; TO Legal department and HIPAA compliance 3. Implementation Fatigue a. Staff Turnover b. ACA c. Transitioning to EHR d. Billing Codes Barriers to Implementation
  • 13. 1. We just printed them out and delivered.... 2. The tool was easily piloted with limited involvement of IT departments or HIPAA considerations… 3. There is data to report for the intervention period of 6/13-9/13 190 surveys collected out of 394 patients seen = 48% Statistically significant increases in screening for gonorrhea and chlamydia in all three sites (throat, rectum, and urine) 8.5% increase (p=.01) in the throat 8.8% increase (p=.003) in the throat and rectum 4.7% increase (p=.03) Note: The Sexual History isn’t meant to increase screening, but drive screening decisions to reflect actual sexual behaviors and risk of patients. Comparison to a Paper-based Sexual History
  • 14. Lessons We’re Learning
  • 15. Hands down: The only reason we’re still in the game is the providers who’ve bought- in and are willing to address each barrier; one step at a time. Business case: Emphasize your tool’s capacity to save time and or money. For the Patients: Find a common cause here. People absolutely deserve quality, evidence-based sexual health care. Champion!
  • 16. There isn’t a history to build on. Develop a language that clearly explains the intervention (Hints: very thorough; very patient; abstain from assumptions!!) Do NOT gloss over components that address privacy and data security. Have a stash of work-arounds up your sleeve. Communication!
  • 17. Sample Data Flow Diagram HIPAA  Compliant  Server   De-­‐iden5fied    
  • 18. Other settings may prove less barrier ridden…some ideas we’ve seen, heard of or had… Patient driven v. Provider driven. Example: http://www.stdwizard.org/ Intake tool with decision support for non-medical staff; such as case workers or patient navigators. Expanded for HIV negative populations….HIV testing and PrEP candidates We’re attached to the CDS for Providers, but….
  • 19. Ashley Scarborough, MPH Ashley.Scarborough@ucsf.edu Thank You and Good Luck Out There!!!