Identifying Gaps and Best Practices for HIV/STI Screenings Using Nationally Standardized Data in the Indian Health Service Electronic Health Record (EHR)

Background: The Indian Health Service (IHS) provides healthcare to approximately 1.2 American Indian/Alaska Native patients in 34 states.  According to CDC, chlamydia rates among American Indians/Alaska Natives are elevated at 776.5/100,000.

Objectives: Assess, monitor, and improve annual chlamydia screening rates among women 15-24.  The Indian Health Service defined a national indicator for chlamydia and STI screening (follow-up comprehensive STI screening for patients with an STI diagnosis).

Methods: National indicators were defined and integrated into the IHS electronic health record (EHR) to provide passive reporting of facility-specific screening data. A local chart audit was conducted to validate the measures.

Results: National chlamydia screening coverage scores among federal sites (n=65) was 26% (range 0%-42%).  A local chart audit showed that of 103 women without screening, 69% had received a pregnancy test and 74% had received a urine test in the past 12 months.  Subsequent site visits have shown some screening underreporting due to coding issues or screenings via tribal programs that are not recorded in the IHS EHR.  For STI screening in federal sites, the median screening score was 31% (range 0%-67%).  A chart audit showed that among 140 STI patients, 90 (74%) required follow up screening, of whom only 29 (32%) were screened.  However, 95% of missed opportunities consisted of women diagnosed with chlamydia who did not receive an HIV test.

Conclusions: The national screening indicators allow for effective monitoring across the large network of rural and urban IHS facilities.  

Implications for Programs, Policy, and Research: Chart audits have found opportunities to improve national indicator logic for improved specificity and as well as reduce missed screening opportunities.  National electronic clinical reminders for chlamydia and STI screening to identify eligible and past due clients for testing have been designed and can be deployed and locally modified as needed in any IHS facility.