Implementation of Electronic Health Screening in Primary Care to Improve STI Testing

STIs, particularly chlamydia and gonorrhea, significantly impact adolescents, who often miss the Centers for Disease Control and Prevention (CDC)-recommended annual screenings. The St. Louis metropolitan area has one of the highest STI rates in the United States and the St. Louis Children’s Hospital (SLCH) Emergency Department (ED) frequently treats at-risk adolescents. To address unique barriers, such as concerns about disclosing sexual activity, SLCH implemented the Adolescent Questionnaire on Sexuality (AQS) in their ED, which increased STI screening and treatment among all adolescents. The AQS, integrated with the Epic electronic health record (EHR), assesses STI risk for adolescents aged 15-21 regardless of visit purpose, allowing patients to opt-in for testing. The questionnaire responses and test recommendations are immediately integrated into the EHR for review by physicians and nurses. To further increase STI screening in this population, researchers adapted and implemented the AQS in primary care pediatric practices.

The specific aims of the research were as follows:

• Adapt an electronic STI risk assessment tool and clinical workflows for implementation in pediatric clinics.
• Implement an electronic STI risk assessment tool in multiple pediatric clinics and assess for changes in STI testing and treatment.

Researchers used the Consolidated Framework for Implementation Research (CFIR) to understand the pediatric primary care environment and identify barriers and facilitators for implementing evidence-based adolescent sexual health programs. The study involved two stages: first, researchers conducted semi-structured qualitative interviews with physicians, nurses, adolescent patients, and their parents to gather beliefs about STI screening and testing. Based on this feedback, researchers adapted the AQS from its original use in the ED to pediatric primary care by updating the language and removing non-essential questions. They then implemented the AQS and obtained qualitative and quantitative feedback using the System Usability Scale (SUS), a validated tool to measure technology usability. Patients using the AQS answered questions about their sexual history, an integrated decision rule displayed any recommended STI testing on-screen, and patients electronically opted-in for testing. Responses and recommendations were integrated in real-time into the EHR.

Researchers found that nearly all participants agreed upon the need for increased STI testing for adolescents in the pediatric primary care setting. They observed a higher uptake of the AQS in participating pediatric practices than in the ED, with over two thirds of eligible adolescents completing it. Participants rated the AQS very highly for usability, with a median score of 92.5 on the SUS (scores of 68 or higher indicate above-average usability). Despite concerns about confidentiality, adolescents were comfortable with the AQS, and healthcare providers believed it encouraged more honest responses. Although adolescents were generally open to screening for STI risk factors, their willingness to undergo recommended STI testing was low and varied significantly across participating practices. Some practices saw fewer than 10 percent agreeing to testing, while in others, more than 30 percent consented. While these figures show an overall increase in STI testing rates because the participating practices did not routinely offer such testing before this study, they also reveal that most adolescents declined testing despite recommendations, often perceiving themselves as not at risk. Finally, despite the high AQS uptake, no new STIs were detected among eligible participants. This study provided valuable insights into reducing the high rate of STIs in adolescents and enhancing the use of technology in clinical care.