1. Enhancing HIV Testing
Practices: Routinizing
Testing through Electronic
Medical Record (EMR)
Technology
Ann K Avery, MD
MetroHealth Medical Center
Cleveland, Ohio

2. 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.

3. Background
• Capacity-building grant from the AIDS
Funding Collaborative (AFC)
o Evaluation of electronic medical records
(EMR) to establish testing trends
o Develop provider education
o Increase HIV testing by maximizing use of
EPIC (EMR system)

4. Cleveland Department of Public Health

5. Initial Approach - Education
• Large and small group education
o Increase knowledge of new
recommendations
o Increase comfort with topic
o Collect information on real and perceived
barriers for providers

6. Evaluation
• Reviewed HIV tests performed prior to CDC
recommendations (from 2002-2007)
• Analyzed clinical encounters (for 2008-
YTD2011) to define missed opportunities for
HIV testing
o Tested on encounter
o Test result
o Tested previously
o Demographics

7. HIV Testing & Diagnosis:
MHMC, 2002-2007
Newly
HIV Tests Diagnosed Positivity
6927 72 1.0%
Cases
7092 59 0.8%
2002
7626 62 0.8%
2003
7751 51 0.7%
2004
8042 60 0.7%
2005
9155 48 0.5%
2006*
2007
*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

8. 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 not
performed during the visit and had not
been previously performed.

9. HIV Testing by Encounter Type:
MHMC, 2008-2009
200000 186306 183309
121711
115866
150000
57748 60069
100000
Only 2% 1.8%
50000 64%
3674 4046 3173 3328
32%
Total Encounters Never Ever Got Their Status Knew Their Got Retested
0
"Missed Status
Opportunities"
2008 2009
Avery and Del Toro, IDSA 2010 abstract #1062 2010

10. Missed Opportunities among
Outpatients

11. HIV Testing Trends:
MHMC 2008-2009
• Repeat testing is common
o May be due to known risk factors
• Gender & race disparities
o Women are more likely to have been
previously tested
 Routine prenatal screening
o 80% of men have never been tested for HIV

12. New and Improved Education
• Seize the Opportunity: Why Routine HIV
Testing is Important
o 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

13. Electronic Reminder
• Health Maintenance tab revised to
include HIV testing
o Reminder to test if status unknown
o Mostly used in outpatient setting
o Went “live” in July 2010

17. Testing patterns since 2010
Inpatient Testing
300
250
200
150 Repeat Testers
First Time Testers
100
50
0
Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011

18. Testing patterns since 2010
Outpatient testing
4000
3500
3000
2500
2000
Repeat Testers
1500
First Time Testers
1000
500
0
Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011

19. Missed Opportunities outpatients
1st Quarter 2010 vs 1st Quarter 2011
Males
P value < .001 for all matched age groups except 13-19 y/o

20. Missed Opportunities outpatients
1st Quarter 2010 vs 1st Quarter 2011
100
90 Females
80
70
60
50 Q1 2010
40 Q1 2011
30
20
10
0
13-19 20-24 25-29 30-39 40-49 50-59 60-64
P value < .001 for all matched groups 25 and older

21. New Diagnoses
Confirmed False
New Case Positive
2008 15 (7 males) 7
2009 15 (6 males) 7
2010 21 (17 males) 13
2011 (1st 9 (8 males) 1
Qtr only)

22. Conclusions
An 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.

23. Acknowledgements
• Michelle Del Toro, MPH, MALS
• Peter Greco, MD
• David Kaelber, MD, PhD, MPH
• Aleese Caron, PhD
• Laureen Tews Harbert, MPH

24. Thank You.
Questions?