1.Briefly describe the current approach to measuring and supporting the care team in HIV testing and follow up in your organization.

In our clinical content in athenaPractice, there are CDS tools that alert the provider whether or not the patient should have an HIV screening or for routine testing in the general population. This is in the adult preventative care form and other forms such as the prenatal clinical content. It is always on the flow sheets to see the results if the HIV test was completed. There are order sets that allow individual providers to check one box for STI testing, which includes HIV, Hep-B, Hep-C, gonorrhea, chlamydia and syphilis.

2. Talk about the process you would have to engage in to design and get care team buy in for the design of content and interfaces to support HIV testing and follow up guidelines and workflow improvements.

It would be interesting to design a new workflow where during intake the care team screens the patient for diabetes, HIV, etc. This could include standing orders that automatically order the HIV test to be a part of bloodwork that is being requested. Nursing staff in addition to the provider is then in the workflow ordering the tests. There may also be Point of Care testing for HIV or the regular testing completed by the intake person. This would be additional responsibility placed on those care team members, but then it reduces the burden on the provider (especially as this is then routine, and the provider may be occupied with other more urgent screenings). We should be making HIV testing as one of the routine processes.

3. Identify the team, including titles, who would work on this project from the clinical and technical sides. Who are the technical leads? Are there any external vendors? Clinical SMEs and users? Other leaders/champions?

Dr. Timothy Long (Clinical SME/User), the Director of Nursing, HIV Care Team, Medical Assistants, and Lab Director.

For most of the technical components, that would be AllianceChicago staff (Clinical Informatics). At the health center, it would be the EMR manager who would ensure the order was created correctly for the SME user to utilize in-house.

4. Discuss your technical path to implement new tools or significant improvements to your EHR/pop health tools to support HIV testing and follow up. Include approvals, costs, impacts, testing, vendor involvement if any. If there are unanswered questions you need to answer, OK to list here.

The technical path involved the following milestones:

• Discovery: Reviewed the existing HIV testing clinical decision support technical programming logic against the USPSTF clinical guidance recommendations
• Design: Created prototypes of an updated HIV testing clinical decision support technical logic and user interface design.
• Development: Updated HIV testing clinical decision support technical programming logic.
• Testing: Tested the technical updates
• Deployment: Deployed the updated HIV testing clinical decision support to EHR clinical content subscribers. Created electronic wraparound support materials for marketing and communication, to reinforce best-practices of HIV testing clinical decision support available in the EHR and highlighting the technical updates deployed to Health Centers.

These stages of our technical path – Discovery, Design, Development, Testing, and Deployment – are indicative of our standard informatics processes for health IT software solutions, based on healthcare user experience best-practices.  Stakeholders involved included internal AllianceChicago clinical, implementation, and technical Subject Matter Experts, as well as external Health Center clinical Subject Matter Experts.  This team of cross-functional expertise enabled the translation of the USPSTF recommendations into real-world CDS solutions and workflow recommendations.  These stakeholders were informed and engaged at each stage, to ensure the project was on course and approving next steps for the overall jobs-to-be-done.

1. 1. Do you have a portal where you can use FHIR applications inside your EHR? Yes: https://mydata.athenahealth.com/home

1. 1. Do you have a CDS engine to build content in your EHR? 

Yes – clinical decision support (CDS) can be built within the EHR application we use, involving product-specific programming capabilities enabled by the vendor. In addition, we have experience in CDS development integration projects where we connect the EHR to CDS engines outside the EHR application, for real-time referencing of outside CDS guidance while the user is within the EHR experience.

1.Briefly describe the current approach to measuring and supporting the care team in HIV testing and follow up in your organization.

• Part of “care guidelines” a one-time check box for patients 18-65 years old – serves as a reminder for providers to perform HIV testing when they are seeing the patient 
• Results are scored in a program – “Relevant” – where providers can see the percent of patients in their panel who have been tested, as well as the list of patients who have not been tested from their panel. 
• Patients are assigned to a provider panel – based on who they have seen for the last three encounters.  

2. Talk about the process you would have to engage in to design and get care team buy in for the design of content and interfaces to support HIV testing and follow up guidelines and workflow improvements.

• • A Weitzman initiative was started four years ago – to make HIV testing mandatory at least 1 time for individuals 18-65 years old.  
  • Need for ongoing training with STI testing and management, considerations for PrEP  
  • Some of these trainings – occur during “Lunch and Learn” sessions and Operational Meetings 
  • As company is set to transition to EPIC – new workflows and teams are being created to set up new guidelines and templates 

4. Discuss your technical path to implement new tools or significant improvements to your EHR/pop health tools to support HIV testing and follow up. Include approvals, costs, impacts, testing, vendor involvement if any. If there are unanswered questions you need to answer, OK to list here.

A. Do you have a portal where you can use FHIR applications inside your EHR? 

• With our current Nextgen we do NOT have the FHIR technical capabilities to do this. We are working with EPIC on this as part of our Implementation workflow analysis.

B. Do you have a CDS engine to build content in your EHR? 

• We are working with EPIC on this as part of our Implementation workflow analysis 

1.Briefly describe the current approach to measuring and supporting the care team in HIV testing and follow up in your organization.

Monthly reports are distributed that aggregate the number of tests completed as well as HIV positive tests.  The reports are stratified by different demographics (e.g., age, race, ethnicity, gender, etc.).  

Care teams conduct daily huddles for patients seen that day.  The huddles review any clinical services that a patient is due for (e.g., HIV test, depression screen, etc.)   The huddle forms are accessible in the patient’s charts.

2. Talk about the process you would have to engage in to design and get care team buy in for the design of content and interfaces to support HIV testing and follow up guidelines and workflow improvements.

We have several workgroup and team meetings that provide an opportunity to discuss workflow improvements.   There is a weekly clinical computing meeting that consists of clinical and technical staff.  Additionally, we have a monthly HIV meeting where clinical issues and workflows are discussed.

4. Discuss your technical path to implement new tools or significant improvements to your EHR/pop health tools to support HIV testing and follow up. Include approvals, costs, impacts, testing, vendor involvement if any. If there are unanswered questions you need to answer, OK to list here.

• Any changes to our EHR include an approval process by both clinical and technical leads.  Depending on the complexity, this may require external vendor support.  The costs associated with this can vary from a few hundred dollars to a few thousand dollars.  
• Changes to ancillary products (e.g., population management tool) to our EHR, require conversations with external vendors. The modifications require commitment by the vendor as well as prioritization within their work queue. Costs associated with changes varies.

Do you have a portal where you can use FHIR applications inside your EHR?

• Yes, we currently have other FHIR applications integrated with our EHR

Do you have a CDS engine to build content in your EHR?

• Yes, but not a very sophisticate rules engine

1. Briefly describe the current approach to measuring and supporting the care team in HIV testing and follow up in your organization.

The current approach to supporting the care team in HIV testing is  – Best Practice Advisory (BPA) Prompts. We have an established multidisciplinary network of HIV providers in primary care, developing comprehensive program for HIV prevention with PrEP

2. Talk about the process you would have to engage in to design and get care team buy in for the design of content and interfaces to support HIV testing and follow up guidelines and workflow improvements.

Meeting with primary care quality improvement (QI) committee – Describing the problem ( showing data about relative low testing rate)

Making BPA more user friendly – Discuss BPA modification or other types of CDS à get feedback from the committee 

Talking to IT Team for adult ambulatory EPIC care – discussing feasibility and modifications

4. Discuss your technical path to implement new tools or significant improvements to your EHR/pop health tools to support HIV testing and follow up. Include approvals, costs, impacts, testing, vendor involvement if any. If there are unanswered questions you need to answer, OK to list here.

IT/EPIC Ticket/request à reviewed in Adult Medicine IT request prioritization meetings - prioritized and assigned to analysts for final approval by Matt Berger, MD 

1. Do you have a portal where you can use FHIR applications inside your EHR? – Not Known
2. Do you have a CDS engine to build content in your EHR? - Yes