title: Unintended adverse consequences of electronic health record introduction to a mature universal HIV screening program.
abstract: Early HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55,054 patients presented before, and 50,576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline (p < 0.0001), leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.
authors.affiliation: a Department of Emergency Medicine , University of Pennsylvania , Philadelphia , PA , USA.
authors.forename: Laura N
authors.initials: LN
authors.lastname: Medford-Davis
authors.affiliation: b Department of Medicine, Section of Emergency Medicine , Baylor College of Medicine , Houston , TX , USA.
authors.forename: Katharine
authors.initials: K
authors.lastname: Yang
authors.affiliation: c Harris Health System , Houston , TX , USA.
authors.forename: Siavash
authors.initials: S
authors.lastname: Pasalar
authors.affiliation: b Department of Medicine, Section of Emergency Medicine , Baylor College of Medicine , Houston , TX , USA.|c Harris Health System , Houston , TX , USA.
authors.forename: M Tyson
authors.initials: MT
authors.lastname: Pillow
authors.affiliation: c Harris Health System , Houston , TX , USA.
authors.forename: Nancy P
authors.initials: NP
authors.lastname: Miertschin
authors.affiliation: b Department of Medicine, Section of Emergency Medicine , Baylor College of Medicine , Houston , TX , USA.|c Harris Health System , Houston , TX , USA.
authors.forename: William F
authors.initials: WF
authors.lastname: Peacock
authors.affiliation: c Harris Health System , Houston , TX , USA.|d Department of Medicine, Sections of Infectious Diseases and Health Services Research , Baylor College of Medicine , Houston , TX , USA.|e Center for Innovations in Quality, Effectiveness and Safety , Michael E. DeBakey VA Medical Center , Houston , TX , USA.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Giordano
authors.affiliation: b Department of Medicine, Section of Emergency Medicine , Baylor College of Medicine , Houston , TX , USA.|c Harris Health System , Houston , TX , USA.
authors.forename: Shkelzen
authors.initials: S
authors.lastname: Hoxhaj
mesh_terms: D000328:Adult; D057286:Electronic Health Records; D004636:Emergency Service, Hospital; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000517:prevention & control; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D016730:Program Development; D015397:Program Evaluation / Q000379:methods*; D011634:Public Health; D012189:Retrospective Studies; D014481:United States; D014505:Urban Population
keywords: AIDS; Electronic health record; HIV; health IT; prevention; public health; screening