Streamlined System Doubles Screening Rates for Hepatitis

A new study indicates that hepatitis C virus (HCV) screening rates can be significantly improved with a simple change in computer settings. The randomized clinical trial conducted at the Perelman School of Medicine at the University of Pennsylvania made HCV screening a default order for patients who met guidelines at 2 different hospitals and compared it with a system that required physicians to use extra steps to order a screening. When HCV screening was the made the default, screenings increased from 42% to approximately 80%, according to the study published in JAMA Network Open.

“We expected there to be an increase in ordering, but not to this magnitude, since we were comparing the default order to a pop-up alert that already existed in the electronic health record,” said Shivan Mehta, MD, associate chief innovation officer at Penn Medicine and assistant professor of Gastroenterology, said in a press release. “The default order reduced effort by the clinicians by aligning the preferred choice with existing workflows while also reducing the number of clicks.”

Mehta added that screening is recommended because many patients may be unaware they are infected and the new generation of antiviral treatments can produce a sustained response versus HCV infection in more than 95% of patients.

Despite these recommendations, screening rates have remained low. To encourage physicians to order HCV screening for more patients, the study investigators tried to streamline the process to require fewer clicks and less cognitive load.

At the outset of the study at a pair of Penn Medicine hospitals in mid-2020, there was an existing system that alerted physicians to increase HCV screeening orders via a pop-up alert in the electronic health record (EHR) when a patient was recommended for a screening. The physician would then need to click to add in a screening order.

Under the new system, a patient recommended for screening already had the order in their EHR admission order-set, and the physician only needed to click to nix the screening.

Out of more than 7500 patient encounters, approximately 4400 patients were evaluated under the pre-existing alert system and approximately 3200 under the no-click default system. Beyond the doubled screening rate in the no-click system, patients who had the screening ordered and subsequently followed through with it jumped from 42% among those in the older system having a screening compared with 80% in the streamlined no-click system.

“Alert fatigue likely contributes to the high rates of clinician burnout in the US,” said co-lead author Mitesh Patel, MD, associate professor of Medicine at Penn and vice president for Clinical Transformation at Ascension, in a press release. “This simple intervention both improved clinician workflow and identified patients who can receive treatment for hepatitis C sooner than they might have had the system not been in place.”

The study authors said the results prompt consideration for this system in other clinical areas for which a streamlined approach may have a benefit.

“Our study shows that there are opportunities to leverage nudges in the electronic health record to improve health outcomes, while maintaining physician autonomy,” Mehta said in the release.