The prevalence of hepatitis C virus (HCV) among the Birth Cohort (BC) born during 1945-1965 is five times higher than adults born in other years. Though there is a productive discussion about effective linkage to care strategies for this population, healthcare systems are failing to adequately screen eligible patients. Identifying system-wide gaps in adherence to federal screening recommendations is paramount to uncovering the full burden of disease and planning a course toward HCV Elimination.
Beginning July 2015, MedStar Health (MSH) activated a clinical decision support (CDSS) Electronic Health Record (EHR) prompt. Eligible BC patients were neither previously HCV tested nor positive. The prompt was triggered at primary care visits only upon clicking the ‘View All Protocols’ (VAP) button. It contained seven discrete, actionable options, each traceable and monitored to determine system-wide adherence to HCV BC testing recommendations. A qualitative analysis is presented.
Between 7/1/2015 and 6/30/2016, 77,575 patients were identified as eligible. Testing occurred at 133 primary care sites by 470 providers across MSH. Providers clicked the VAP button for 29,668 (38%) eligible patients seen, accessed the HCV CDSS prompt for 21,675 patients (28% of total denominator; 73% of clicked VAPs), and took an action within the prompt for 20,528 (26% of total; 95% of prompts accessed). Of these: 6,768 patients (9% of total denominator; 33% of prompt actions) were HCV tested, 4,426 patients (5%; 22%) were not screened [1807 (41%) declined, 39 (1%) had a history of HCV positivity, 1912 (43%) previously screened negative, 349 (8%) deferred, and for 319 (7%) it was not indicated]; there were 9,334 actions (45%) that were unaccountable, these were likely printing an HCV handout. There were 1,356 additional tests conducted outside of the CDSS prompt, for a total of 8,124 tests.
Adherence to BC recommendations was low at approximately 11% (8,124/75,305). It is concerning that 62% of providers did not access the VAP. Next steps will provide targeted education to PCPs and a health maintenance dashboard in a new EHR; consideration will be given to implementing standing orders. Barriers to HCoC initiation are evident, and exemplify the observation that only 50% of those infected are ever tested. Creating and implementing new best practices with supporting policy changes are essential if Elimination of HCV is to be a realistic possibility.