Evolving STD Clinic Practice How Hot is Cool?

1. Evolving STD Clinic PracticeHow Hot is Cool? Kees Rietmeijer, MD, PhD Denver Public Health Department and Colorado School of Public Health University of Colorado Denver Contact: kees.rietmeijer@dhha.org

2. Resources www.denverstdclinic.org

3. Resources www.cdc.goc/std/treatment

4. Resources www.denverptc.org

5. Resources www.stdpreventiononline.org

6. GYT2009 STD Awareness Monthwww.gyt09.org

7. GYT2009 STD Awareness Monthwww.gyt09.org

8. Topics • Express / Fast-Track Visit System • Electronic Medical Record • Online Results • Normalizing HIV testing • EPT implementation • Counseling • Safe in the City • InSpot • Iwantthekit • Text Messaging for results and reminders

9. Express / Fast-TrackClinic Visits

10. Express / Fast Track Visits • Purpose • To enhance clinic efficiency and patient satisfaction through a process by which qualifying patients are offered a testing-only, no-exam visit

11. Express / Fast Track Visits • Who is eligible? • Asymptomatic patients regardless of • Demographics • Risk or contact status • Sexual preference

12. Express / Fast Track Visits • How is it done? • All patients go through triage after registration • Triage staff determines eligibility • Patients can opt for comprehensive visit if they desire regardless of eligibility for express visit • Patients are discouraged to opt for express visit if symptomatic, but are not denied

13. Express / Fast Track Visits • What is done? • HIV rapid test (unless opt-out) • RPR • CT and GC NAAT • Males: urine • Females: self-obtained vaginal swab • Gonorrhea cultures among at-risk MSM • Anal swab • Pharyngeal swab

14. Shamos et al. Sex Transm Dis 2008;35:336-340.

15. Shamos et al. Sex Transm Dis 2008;35:336-340.

16. Time & Motion Study • N = 751 • 182 Express • 569 Comprehensive • Wait time until triage • 30 (28 – 35) minutes • Triage • 2 (1 – 22) minutes Shamos et al. Sex Transm Dis 2008;35:336-340.

17. Time & Motion Study • Median visit duration men • Comprehensive: 85 • Express: 52 minutes • Reduction: 39% • Media visit duration women • Comprehensive: 105 • Express: 46 • Reduction: 56% Shamos et al. Sex Transm Dis 2008;35:336-340.

19. Return

20. HealthDoc:The DMHC Electronic Medical Record

21. DMHC Electronic Medical Record • Implemented in March 2005 to replace an outdate medical record system that was based on scannable forms and had been in existence since 1988 • Built from a public health perspective • For example allows automatic reporting to state health department for reportable infections • Not focused on billing

22. DMHC Electronic Medical Record • Combines • registration system • electronic form document system • rules engine to ensure accurate and appropriately coded information • web portal interface • interface with the Denver Health patient registration (Siemens Invision) • interface with the Sunquest laboratory system • multiple inbound/outbound interfaces with the State Health Department. 

23. DMHC Electronic Medical Record Java-based application  • two application servers • a Siemens Rules Engine server • a Biztalk server • an OPENLink interface engine • a Microsoft SQL database server • An FTP server for transmitting encrypted data to/from State Health • a Crystal Report application for reporting, and clinical form data stored in XML. 

24. Stockholm, September 3 1967: 5:00 AM

25. Transfer to Electronic Medical Record System Denver, March 14 2005, 8:00 AM

26. HealthDoc: Advantages • All STI services in one system • DMHC • Jail services • Title X Family Planning • HIV counseling and testing • Yes, it does PEMS! • Outreach testing • Bath House testing program • Reproductive Health for Young Adults (ReHYA) • Special testing events

27. HealthDoc: Advantages • Data Exchange • (partially) integrated with lab database • Electronic transfer of data between DMHC and state health department • PEMS data • HIV (WB and NAAT) results • RPR results • Automatic reporting of reportable infections • Easy abstraction and transfer of data to other parties: • STD Surveillance Network (SSuN)

28. HealthDoc: Advantages • Relatively flexible • Many changes and updates can be performed in-house at low cost • Data quality • Internal error checking system • Cost-effective • Has reduced clerical data input and associated risk for errors • Easily accommodates innovations • Online results • Automatic text messaging

29. HealthDoc: Disadvantages • Steep learning curve, especially among staff not accustomed to electronic interfaces and data entry • Potentially distracting from provider-patient interaction

30. Return

31. Providing STD Test ResultsOnline

32. Results Online • How it works • Program started June 2008 • Originally, patients opted in and had to create their own (strong) password (opt-in) • Since December 2008, patients are given a login code and a predetermined password (opt-out) • Results available online after 5 days

36. Providing Test Results OnlineLessons Learned • Proportion of patients receiving results online • Opt-in Phase: 25% • Opt-out Phase: 50% • No net increase or decrease of patients receiving results • Substantial savings in clerical time spent on answering phone calls

37. Wanted!! • Partnerships with clinics to evaluate the use of the Internet interface for their clinics

38. Return

39. Normalizing HIV Testing

40. Denver Metro Health Clinic • Largest STD clinic and HIV testing facility in Rocky Mountain region • Provides: • confidential HIV testing in the STD clinic • confidential and anonymous testing in the HIV counseling and testing site integrated in the clinic • In 2006: • ~16,000 visits • 11,300 HIV tests • 119 HIV diagnoses: ~50% of new HIV infections in the Denver Metro area; ~30% in Colorado.

41. HIV Testing at Denver STD ClinicBefore November 2003 • General consent for all procedures and testing, except HIV testing, obtained at registration • HIV testing offered by clinician during the clinic visit, based on risk assessment • Blood drawn for syphilis and HIV (if accepted) testing during the clinic visit • HIV test used: standard EIA

42. HIV Testing at Denver STD ClinicAfter November 2003 • November 2003: Rapid HIV testing (OraQuick) offered • First as optional alternative to standard EIA • Routine after July, 2004 • May 2004: Change in testing logistics • March 2005: Introduction electronic medical record and switch from opt-in to opt-out HIV testing

43. HIV Testing at Denver STD ClinicChange in Testing Logistics • To avoid adding another 20 minutes to the visit, prior to clinic encounter: • Draw RPR blood before clinician sees patient • Offer HIV testing routinely • Obtain additional consent • Use RPR blood draw to collect extra tube for rapid HIV test

44. Evaluation • HIV testing acceptance and HIV test positivity was evaluated for 4 time periods: • Period 1: The year before introduction of rapid testing • December 2002 – November 2003 • Period 2: The 6 months following introduction or rapid testing, before logistical adjustment in the clinic and discontinuation of the standard test • December 2003 – May 2004 • Period 3: The 10 months following logistical adjustment, but before introduction of the electronic medical record and opt-out testing • June 2004 – March 2005 • Period 4: The 6 months following opt-out testing • April 2005 – September 2005

45. Evaluation • Inclusion/Exclusion criteria • New problem visits • RPR performed • Previously known HIV+ excluded • Main outcome: HIV/RPR ratio • RPR used as the gold standard of routine testing

46. Impacts of Rapid Testing Denver Metro Health Clinic Percentage of patients who received their positive test results: Before: After: 66% 100%

47. HIV/RPR Ratio and HIV Positivity Rate by Period January 2005 - October 2006 0.96 1.00 0.92 1.5% HIV(+) Rate 0.86 (HIV:RPR) Ratio 0.79 0.80 0.8% 0.7% 0.6% 0.5% 0.60 0.0% Period I: Jan 2003 - Period II: Dec 2003 - Period III: Jun 2004 - Period IV: Apr 2005 - Nov 2003 May 2004 Mar 2005 Oct 2006 HIV:RPR Ratio Period HIV+ Rate

48. Return

49. Expedited Partner TherapyThe DMHC Experience

50. EPT Legal Status in Colorado • No legal impediments to provide EPT • EPT specifically endorsed by: • Colorado State Board of Medical Examiners • Policy 40-10, issued 5/10/2001 • “It is the position of the Colorado Board of Medical Examiners that the public risk of untreated sexually transmitted infection is greater than the risk of complications from prescribing in this less than ideal setting” • Colorado State Board of Pharmacy • Policy 40-4, issued 7/19/2007 • “It is the position of the Colorado Pharmacy Board that the public risk of untreated sexually transmitted infection is greater than the risk of complications from dispensing in this less than ideal setting”