EHR advisory improves infection screening in patients with autoimmune, rheumatic diseases
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Key takeaways:
- The automated EHR advisory improved screening for diseases including tuberculosis, hepatitis B and hepatitis C.
- Researchers will continue to improve the advisory for use outside of rheumatology.
An automated best practice advisory within the electronic health record can improve infectious disease screening in patients with autoimmune and rheumatic conditions, according to data published in Arthritis Care & Research.
“Initiating a [biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD)] in patients with unknown preexisting latent tuberculosis (TB), hepatitis B virus (HBV), or hepatitis C virus (HCV) infection can lead to significant morbidity and mortality,” Hailey Baker, MD, MS, of the Yale New Haven Health System, in Connecticut, and colleagues wrote. “Adverse outcomes can be prevented by appropriate screening and treatment of underlying infection prior to initiation of, or concurrently along with, b/tsDMARD therapy.”
To investigate whether the use of an automated best practice advisory within the EHR could improve patient outcomes and screening for infectious diseases, Baker and colleagues analyzed patient data from the Yale New Haven Health System. Included patients were aged 18 years or older, had at least one visit to the health system’s rheumatology practice between Oct. 1, 2017, and March 3, 2022, and were either DMARD-naïve or were swapping from one DMARD to another.
When prescribing a new biologic or targeted synthetic DMARD, providers received an automated best practice advisory through the EHR that detailed the patient’s most recent results for hepatitis B, hepatitis C and TB. This advisory was created by “professional information technology specialists,” and was trained using clinician collaboration, the researchers wrote. Throughout its development, Baker and colleagues assessed and altered the advisory’s design and functionality to improve accuracy. The researchers also collected feedback for the advisory from associated staff members.
The study included a total of 711 patients enrolled prior to the initiation of the advisory, and 257 patients after initiation. According to the researchers, the advisory was associated with statistically significant improvements in screenings for TB (from 66% to 82%; P ≤ .001), hepatitis C virus (60% to 79%; P ≤ .001), hepatitis B core antibody (32% to 51%; P ≤ .001) and hepatitis B surface antigen (51% to 70%; P ≤ .001).
“Given our institutional directive for universal screening, we chose to screen broadly and refine the [best practice advisory (BPA)] if future data emerge to inform better practice,” Baker and colleagues wrote. “While we considered patient safety our primary objective, the cost effectiveness of screening all patients remains unclear, and a potential future direction. Overall, our study showed that a BPA can significantly improve screening for infectious diseases prior to initiation of new b/tsDMARDs and potentially reduce screening discrepancies in an efficient manner.”
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
Screening for infections before initiating biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) is recommended by numerous national and international societies. However, a study involving 2,027 patients prescribed new biologics, published in 2019, revealed suboptimal adherence to these guidelines. Only 62% of patients were screened for latent tuberculosis (TB), 42% for hepatitis B virus (HBV), and 33% for hepatitis C virus (HCV). Shockingly, merely 26% of patients underwent appropriate screening for all three infections.
The American College of Rheumatology advises TB screening (QuantiFERON or PPD) within 12 months prior to starting b/tsDMARDs for all rheumatoid arthritis patients. Although the ACR recommends treatment and monitoring for HBV and HCV in RA patients, it does not provide clear guidelines for screening these diseases before initiating b/tsDMARDs.
Electronic health records (EHRs) have the potential to enhance adherence to clinical practice guidelines by incorporating computerized decision support systems (CDSS). These tools, widely recognized in the literature, significantly improve patient safety, diagnostic support clinical management, administrative functions, and cost containment.
A specific type of CDSS, the best practice advisory (BPA), can be integrated into EHR systems. BPAs enable a swift review of current laboratory results and facilitate easy ordering of tests. Notably, studies in rheumatology have demonstrated a direct link between the implementation of CDSS in EHRs and improvements in RA productivity, quality metrics and clinician efficiencies.
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