Barriers to STD Surveillance in Urgent Care and Federally Qualified Health Centers in Baltimore City

Background: Surveillance data, though largely limited to confirmed diagnoses, are critical to understanding the impact of gonorrhea and chlamydia. Syndromic treatment (based on symptoms, without diagnostic test results) of these infections could compromise the accuracy of surveillance. To assess the extent of syndromic treatment, a chart review project of all federally qualified health and urgent care centers in an urban area was initiated.  The purpose of this presentation is to present the barriers encountered when attempting to collect data on patient symptoms, exam findings, diagnostic tests, diagnosis and treatment.

Methods: Two urgent care centers and 25 federally qualified health centers (FQHCs) were sent letters from the Baltimore City Health Department (BCHD) notifying them of the need to review clinic records to obtain de-identified data on the frequency of screening and types of treatments prescribed for gonorrhea and chlamydia.  Patients were included if they were aged 15 years and older, visited the clinic between December 1, 2012 and May 31, 2013, and received a diagnosis of: gonorrhea, chlamydia, cervicitis, lymphogranuloma venereum, pelvic inflammatory disease, prostatitis, urethritis, or vaginitis. Records (N=504) were reviewed by BCHD nurses and entered into an electronic database on a portable tablet.

Results: All of the FQHCs gave BCHD staff access to review records; both urgent centers refused. Electronic medical records (EMRs) were used at all sites. Incomplete documentation related to assessment, diagnosis, and treatment was evident in multiple clinic sites.  Patient symptoms and risk behaviors were not clearly documented. In multiple charts there was no evidence of a complete genitourinary physical assessment. Diagnostic testing methods and specimen site were often unclear. Type of medication and dose used to treat was frequently missing from the chart.

Conclusions: Obtaining accurate patient information on STI incidence and treatment from EMRs at urgent care centers and FQHCs proved to be difficult.