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Innovations in STD Clinic Practice

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  1. Innovations in STD Clinic Practice Kees Rietmeijer, MD, PhD 2011 STD Update Indianapolis, April 20, 2011

  2. GYT2011 STD Awareness Monthwww.gytnow.org

  3. Resources www.denverstdclinic.org

  4. Resources www.cdc.goc/std/treatment/2010

  5. Resources www.denverptc.org

  6. Resources www.stdpreventiononline.org

  7. Why STD Clinics Matter

  8. Proportion of STIs Reported from STI Clinics Golden and Kerndt. Sex Transm Dis 2010;37:264-265

  9. Origin of STI Case Reports by GenderCity and County of Denver - 2009 Denver Metro Health Clinic Men Women % % Chlamydia 46 13 Gonorrhea 54 20 Early syphilis 24 12 Rietmeijer and Mettenbrink. Sex Transm Dis 2010;37:591

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

  11. Express / Fast-TrackClinic Visits

  12. 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

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

  14. 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

  15. 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

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

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

  18. 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.

  19. 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.

  20. Return

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

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

  23. HealthDoc:The DMHC Electronic Medical Record

  24. DMHC Electronic Medical Record • Implemented in March 2005 to replace an outdated 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

  25. 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. 

  26. 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. 

  27. 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

  28. 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)

  29. 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

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

  31. Return

  32. Providing STD Test ResultsOnline

  33. 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

  34. 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

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

  36. Return

  37. Normalizing HIV Testing

  38. 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.

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

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