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."

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.

13. 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

14. 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

15. Lessons We’re Learning

16. 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!

17. 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!

18. Sample Data Flow Diagram
HIPAA
Compliant
Server
De-­‐iden5fied

19. 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….

21. Ashley Scarborough, MPH
Ashley.Scarborough@ucsf.edu
Thank You and Good Luck Out There!!!