recommendations all likely play a role in why providers
do not offer these screening tests. 39, 40, 41
EMR health maintenance alerts have also been
shown to be underused in clinical practice, potentially
somewhat limiting the effectiveness of our intervention. 41 From the patient perspective, stigmas associated
with these two diseases, cost concerns, fear of a positive
result, and suspicion of the healthcare system are noted
barriers to accepting screening. 42, 43, 44
Using an EMR alert such as this has potential
Hepatitis C Screening Results Pre- and Post-Alert
SMG 1.7% 36.2%
WB 5.6% 40.0%
STP 10.5% 47.7%
IG 4.1% 10.4%
UAC 9.2% 51.8%
HIV Screening Per Practice Location
Male 1.1% 40.1%
Female 0.8% 47.8%
Caucasian 0.7% 43.1%
Black or African-American 4.2% 52.7%
Asian 2.5% 56.2%
Hispanic 0.9% 49.4%
Other 4.7% 47.8%
N/A 1.6% 45.1%
Total Screened 1.0% 44.0%
Demographic Pre-Flag Post-Flag
Clinic Pre-Flag Post-Flag
SMG 0.4% 43.1%
WB 0.9% 49.5%
STP 2.3% 50.0%
IG 0.2% 7.0%
UAC 3.2% 50.6%
Hepatitis C Screening Per Practice Location
Clinic Pre-Flag Post-Flag
drawbacks as well. Alert fatigue may diminish its
effectiveness, and one could appropriately wonder if a
provider might rely on an EMR alert instead of employ-
ing risk-specific screening when appropriate.
Our study had a number of limitations. The primary
limitation was that we assumed a patient’s diagnosis
code of routine health maintenance implied randomized
onetime screening per USPSTF and CDC recommendations. However, it is possible that providers identified
risk factors during the routine health maintenance
(RHM) visit that prompted screening. Given the large
volume of patients seen in this study, it was not practical
to evaluate each patient’s reason for being screened, or
not to be screened, for HIV or hepatitis C.
Additionally, we were unable to account for
patients who were not screened because they had been
screened in the past, but were outside of our system.
We felt that confounders such as this would be equally
distributed across the pre- and post-flag groups owing
to the large number of patients in this study. Future
studies should include specific evaluation of how
race and gender impact generalized screening recommendations and to what prevalence level the screening
recommendations should apply.
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