Goetz MB et al. 2008 "Implementing and evaluating a regional strategy to improve testing rates in VA patients at risk for HIV, utilizing the QUERI process as a guiding framework: QUERI series."

Goetz MB, Bowman C, Hoang T, et al. Implementing and evaluating a regional strategy to improve testing rates in VA patients at risk for HIV, utilizing the QUERI process as a guiding framework: QUERI Series. Implement Sci 2008;3:16.
"Background: We describe how we used the framework of the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) to develop a program to improve rates of diagnostic testing for the Human Immunodeficiency Virus (HIV). This venture was prompted by the observation by the CDC that 25% of HIV-infected patients do not know their diagnosis - a point of substantial importance to the VA, which is the largest provider of HIV care in the United States.
Methods: Following the QUERI steps (or process), we evaluated: 1) whether undiagnosed HIV infection is a high-risk, high-volume clinical issue within the VA, 2) whether there are evidence-based recommendations for HIV testing, 3) whether there are gaps in the performance of VA HIV testing, and 4) the barriers and facilitators to improving current practice in the VA. Based on our findings, we developed and initiated a QUERI step 4/phase 1 pilot project using the precepts of the Chronic Care Model. Our improvement strategy relies upon electronic clinical reminders to provide decision support; audit/feedback as a clinical information system, and appropriate changes in delivery system design. These activities are complemented by academic detailing and social marketing interventions to achieve provider activation.
Results: Our preliminary formative evaluation indicates the need to ensure leadership and team buy-in, address facility-specific barriers, refine the reminder, and address factors that contribute to inter-clinic variances in HIV testing rates. Preliminary unadjusted data from the first seven months of our program show 3-5 fold increases in the proportion of at-risk patients who are offered HIV testing at the VA sites (stations) where the pilot project has been undertaken; no change was seen at control stations.
Discussion: This project demonstrates the early success of the application of the QUERI process to the development of a program to improve HIV testing rates. Preliminary unadjusted results show that the coordinated use of audit/feedback, provider activation, and organizational change can increase HIV testing rates for at-risk patients. We are refining our program prior to extending our work to a small-scale, multi-site evaluation (QUERI step 4/phase 2). We also plan to evaluate the durability/sustainability of the intervention effect, the costs of HIV testing, and the number of newly identified HIV-infected patients. Ultimately, we will evaluate this program in other geographically dispersed stations (QUERI step 4/phases 3 and 4)."
To develop a program to improve rates of diagnostic testing for HIV using electronic clinical reminders, audit/feedback, and appropriate changes in delivery system design.
Tools Used
Type Clinic
Primary care
Urban and suburban
Other Information
The implementation facilities provide care to 37,000-80,000 veterans per year. With one exception, facilities consisted of "an inpatient center plus one or more geographically dispersed sub-stations in which primary care and specialty services ... were provided."
Type of Health IT
Electronic health records (EHR)
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
The electronic clinical reminders are a real-time system identifying "veterans at higher than average risk for HIV infection and [encouraging] providers to offer HIV testing." The reminder is triggered by prior evidence of hepatitis infection, "illicit drug use, sexually transmitted diseases, homelessness and/or documented risk factors for hepatitis C." The audit-feedback system informs providers of "group performance with regard to screening rates."
Workflow-Related Findings
"Reminders require customization to the needs of providers. We have found that providers benefit from having ready access to the specific factor(s) that trigger the HIV Testing Clinical Reminder for an individual patient. In addition, it is important that the factors that trigger the Reminder be as closely linked to actual risks of HIV infection as possible. In this regard, we have found that the triggers for a diagnosis of homelessness are sufficiently non-specific (i.e., loss of housing for a few days) as not to warrant inclusion in the reminder."
"Providers would like the reminder to clearly indicate what specific factor(s) triggered the HIV Testing Clinical Reminder, so that they can better counsel patients as to why HIV testing is relevant to the veteran's circumstances."
"Providers perceive the layout of the reminder to be unduly complicated."
Study Design
Pre-postintervention (no control group)
Study Participants
The study participants included providers and patients at several Veterans Administration facilities.