New EMR-Based Tools Improve Hepatitis Screening in Various Care Settings

New diagnostic tools used to identify hepatitis C virus (HCV) and hepatitis B virus (HBV) utilize simple questionnaires and emergency medical records (EMR) to alert physicians in both primary care and high-volume care settings about patients at risk for viral hepatitis infection or reactivation. The results of these studies were presented at the American Association for the Study of Liver Diseases’ The Liver Meeting, held November 8 to 12, 2019, in Boston, Massachusetts.

Better diagnostic methods are needed to meet the goal of eliminating hepatitis globally. Some of the current hepatitis research is focused on developing and evaluating new tools for identifying HBV and HCV infection in different care settings. Questionnaires and EMR-based alerts may increase diagnoses of viral hepatitis in primary care settings, and automated EMR-based screening protocols may effectively link patients to treatment pathways in high-volume settings. In vulnerable patients receiving immunosuppressive therapies, an “alert ordering system” was valuable in early detection of HBV reactivation.

One new diagnostic approach is called the Camden and Islington Viral Hepatitis Identification Tool (CIHVIT), which utilizes a questionnaire designed to identify risk factors for HBV and HCV and a computer algorithm to identify codes associated with risk factors that were linked to the EMRs of existing patients.¹

CIHVIT was administered to new patients registering at all primary care practices in 2 London boroughs or at opportunistic visits. One year postimplementation, the number of patients who were tested for HBV and HCV infection increased by 78.5%, from 8520 to 15,210. Identification of HBV cases increased by greater than 2-fold, from 68 to 142, while the number of HCV diagnoses increased from 131 to 168. The primary risk factor for HBV and HCV infection was country of birth; other risk factors included being a relative of infected patients and having tattoos. Although the introduction of CIHVIT increased case detection 2.5-fold in the year it launched into practice, the researchers found that the number of secondary care referrals was relatively low.

Another group of researchers implemented an automated HBV and HCV screening protocol in the emergency department of a suburban New Jersey community hospital screen.² This program utilized EMR alerts and assessed eligibility criteria for screening, including year of birth (1945 to 1965) or history of HBV-endemic country of birth. If bloodwork was indicated as a part of care, hepatitis C antibody with reflex to HCV-RNA or hepatitis B surface antigen was automatically added to lab orders.

EMR alerts notified nursing of viral hepatitis tests and reactive results, and a patient navigator was tasked to facilitate improved linkage to care. The patient navigator was responsible for providing patient education and scheduling the patient for follow-up evaluation at a primary care practice with internists trained in viral hepatitis care.

After 13 months, results of this study demonstrated that 10,900 patients were tested for HCV and 9500 were tested for HBV through the emergency department screening program. Hepatitis C antibody was found positive in 363 (3.3%) cases, of which 118 (1.1%) were confirmed by an HCV-RNA test. Of the 118 confirmed cases of HCV, 74 (63%) patients were linked to care. Trained primary care physicians initiated HCV therapy for 25 patients. Hepatitis B antibody was found positive in 114 (1.2%) of cases, with 74 (65%) linked to care; 66 HBV patients were evaluated by trained primary care physicians. Researchers suggest EMR-based screening programs can significantly scale up efforts to identify hepatitis infection in high-volume settings and utilize frontline primary care providers to provide hepatitis care.

An EMR-based alert system can be valuable for promoting hepatitis screening but also for the prevention and diagnosis of HBV reactivation in vulnerable patients, such as those receiving systematic chemotherapy or immunosuppressive therapy. Researchers at Nagoya City University Hospital developed the “alert ordering system” in which physicians administered medication (injected or oral) to induce HBV reactivation in cases identified through an EMR-based alert system.³ A high-sensitive hepatitis B surface antigen assay in combination with the HBV-DNA test was performed in response to the alerts in order to identify, observe, and treat reactivation.

During the study period, 4 patients receiving systematic chemotherapy or immunosuppressive therapy were positive for hepatitis B surface antigens and were treated. In addition, 137 patients receiving these therapies were found positive for hepatitis B surface antibodies or hepatitis B core antigen antibodies and diagnosed with resolved HBV infection. These patients were observed with monitoring HBV-DNA test in which 11 (8.0%) were diagnosed with HBV reactivation and were treated immediately. Hepatitis B surface antigens were further detected in 8 of the 11 patients. The researchers suggest the “alert ordering system” was effective for the early diagnosis of HBV reactivation and for timely treatment with nucleos(t)ide analogues.

References

1. Cococcia S, Srivastava A, Rhodes F, et al. A new clinical database tool to improve identification of hepatitis B and C viruses in the primary care setting. Poster presented at: American Association for the Study of Liver Diseases: The Liver Meeting; November 8-12, 2019; Boston, MA. Abstract 0532.

2. Wang SH, Xu B, Brogden R, et al. An integrated viral hepatitis program: from emergency department screening to primary care practice for care and cure. Poster presented at: American Association for the Study of Liver Diseases: The Liver Meeting; November 8-12, 2019; Boston, MA. Abstract 0972.

3. Inoue T, Korenaga M, Kusumoto S, Shinkai N, Goto T. Clinical usefulness of the electronic medical record-base “alert system” designed to prevent hepatitis B virus reactivation combined with HBV-DNA test and a high-sensitive hepatitis B surface antigen assay. Poster presented at: American Association for the Study of Liver Diseases: The Liver Meeting; November 8-12, 2019; Boston, MA. Abstract 0940.