Embracing Technology to Self Register Clients and Deliver STI Clinic Negative Results

State: NY Type: Promising Practice Year: 2015

Rockland County is located approximately 30 miles north of New York City on the west side of the Hudson River. Geographically, the county of 115,000 acres contains more than 35,000 acres of preserved open space and parkland. Rockland continues to experience steady population growth in the past several years within its five towns and 19 villages, driven by the major forces of natural increase and net migration. The Rockland County population in 2010 was 311,687. The County population is approximately 72% White, 12.2% Black, 16.3% Hispanic, and 6.1% Asian (US Census, 2012). Sexually transmitted infections (STDs/STIs) are rising dramatically in Rockland County. Although rates of chlamydia and gonorrhea have been increasing for years, the recent increase is worrisome. Chlamydia cases increased 43% from 2008 to 2011 and for gonorrhea; the increase was 72% during the same time period. The increase in STIs is seen across all neighborhoods, all socio-economic strata, and varied age groups. But much of the burden is being borne by teenagers and young adults. In 2006, 1 in every 111 females in Rockland County ages 15-19 was diagnosed with chlamydia, but by 2011, 1 in 63 females in that age group was discovered with chlamydia. Even more troubling is the fact that up to half of the cases of chlamydia goes undiagnosed. Chlamydia and gonorrhea cases are continuing to increase at an alarming rate. In 2011, the rates of chlamydia increased 29% from the previous year and 43% from 2008 levels; for gonorrhea, the increase was 26% and 72%, respectively for the above years. RCDOH offers free and confidential clinical diagnosis and treatment of sexually transmitted diseases available two times a week on a walk-in basis. HIV counseling and partner notification services are available prior to receiving clinic services. A physician, public health nurse, and disease specialists staff this clinic. There are on average over 2000 visits to the RCDOH STI clinic each year.  RCDOH implemented a secured automated Patient Contact technology solution. Patient registration occurred through the use of a Kiosk where the patient self enrolled and received a confidential login sent on a HIPAA secured network to their smartphone device. Once clinical laboratory results were available, the RCDOH staff entered negative test results into the secure provider system and sent a text message to the patient informing them to log into their portal to retrieve their negative results. Any positive results are never sent through the system. Instead the patient receives a generic message informing them to contact the RCDOH to schedule an in person appointment for the next clinic. From September 2013-September 2014, 721 patients self registered using the kiosk system with an average of 50 registering per month of the implementation period.   The objectives were met as the number of revisits to the clinic were reduced significantly.  Prior to the practice, 25% of patient interactions at the STD clinic were for obtaining test results.  This changed to 8.75% for the one year of utilizing this practice. This has improved the staff time and clinic efficiency.  In addition, each month an average of 60 patients received their test results via email or text through the patient messaging system.  The specific factor that lead to the success of this practice centered around the use of a self registration kiosk.  Other agencies that utilize similar technology solutions require the enrollment to occur with the assistance of a staff member (eg. nurse, physician or clerical staff).  The RCDOH decided to minimize potential work flow barriers and instead provided clear signage with additional reminders by the staff to the patient of the option to receive their results through their smartphone by self registering using the kiosk. The public health impact was a reduction in unnecessary clinic visits, the seamless integration of technological advances in discreet HIPAA compliant patient messaging for negative results notification and improvement in work flow by minimizing the time spent contacting and notifying patients.
The RCDOH identified that approximately 25.6% of our patient encounters in STI clinic were for the sole purpose of receiving test results from a previous visit over the period of 01/2011-08/2013. Additionally the clinic had an average of 181 patient encounters per month during the same time frame.   With over 2000 visits to the STI clinic a year, all patients using the STI clinic were the target population.   All patients were reached during the time period for implementation.  Those that were comfortable using their smartphone technology availed themselves of the opportunity to self register and receive secure patient messaging of negative results from the RCDOH. In the past, there was little to be done to improve the efficiency of negative test reporting as they needed to be communicated in person as the most secure methodology.  This practice is better in that it minimizes the need for a patient to revisit the clinic only for the receipt of a negative result a week later from testing.   The use of the self enrolling kiosk is a new concept in the field of public health as all other electronic messaging requires a staff mediated approach. The Sexually Transmitted Infection Clinic at Rockland County has a unique system for reporting results to patients. The literature does not show a comparable approach or an evaluation of a comparable approach. There have been programs in place where patients are notified via cell phone or text message, but the message is sent by a person, not a system. It is shown that most clinic patients have a cell phone (Labacher & Mitchell, 2013; Tripathi et al., 2012). Receiving results by text message allows the receiver to be able to process the information and develop a response; it also eliminates any facial expressions or tones used by the clinician that could be portrayed negatively (Labacher & Mitchell, 2013). It was shown in a genitourinary medicine (GUM) clinic that patients who received their results by text message were diagnosed faster and treated sooner than patients who were told to call the clinic or go back in for results. The median time from test to treatment for patients who received a text message was 9 days (range of 4-27) and for patients who did not receive a text message was 15 days (range of 7-35). The text messages had three possible messages: All your results are negative, Please ring the clinic, or Please come back to the clinic (Menon-Johansson, McNaught, Mandalia, & Sullivan, 2006). This was the closest program found to the Rockland County clinic. Although no similar program was found, the literature does show that a text message to report screening results can save staff time and increase the timeliness for a patient to be treated (Menon-Johansson, McNaught, Mandalia, & Sullivan, 2006; Tripathi et al., 2012). Tripathi et al. suggest that a software system that automatically messages screening results could reduce costs and quickly provide results; this could lead to a reduced time to treatment and transmission (Tripathi et al., 2012).   Labacher, L. & Mitchell, C. (2013). Talk or text to Tell? How Young Adults in Canada and South Africa Prefer to Receive STI Results, Counseling, and Treatment Updates in a Wireless World. Journal of Health Communication, 18, 1465-1476. doi: 10.1080/10810730.2013.798379 Menon-Johansson, A.S., McNaught, F., Mandalia, S., Sullivan, A.K. (2006). Texting Decreases the Time to Treatment for Genital Chlamydia trachomatis Infection. Sexually transmitted Infections, 82, 49-51. doi: 10.1136/sti.2004.014381 Tripathi, A., et al. (2012). Delivering Laboratory Results by Text Message and E-Mail: A Survey of Factors Associated with Conceptual Acceptability Among STD Clinic Attendees. Telemedicine and E-Health, 18, 500-506. doi: 10.1089/tmj.2011.0251
The goal of the practice was to increase the efficiency of the RCDOH STI clinic operation by reducing the need for all patients to return to our facility in person in order to receive their STI testing results.  This was implemented by working with a health technology company to use their Chexout program.  As this was an internal practice with external implications and public benefit, the RCDOH Division of Epidemiology and Public Health Planning met with its Divisions of Patient Services, Division of Communicable Disease Control and Prevention, and Administration to discuss the feasibility of the practice and identify the best methodology for implementation.  This was where the work flow process raised and the solution created to develop a kiosk self registering approach for the practice.  Additionally, the practice proposal was presented to the Rockland County Public Health Priorities (PHP) Steering Committee.  This is a private-public partnership formed in May 1997. Committee participants include more than twenty representatives of educational institutions, health care providers, health-related organizations, community service organizations, governmental agencies, faith-based organizations, consumers, and the business community. The committee is chaired and coordinated by the Rockland County Department of Health. Its mission is the coordination and collaboration of resources to address local unmet public health needs in order to promote health, improve access to health care and prevent disease and disability in Rockland County.   The Committee responded favorably to the practice proposal. The start up costs associated with this practice were nominal.  The Chexout program was free for the first year with a $900 cost to the RCDOH in year two.  There were no costs associated with the number of patients enrolling and utilizing the system for accessing their secured patient records.
We set out to increase the efficiency of our clinic operation by reducing the need for all patients to return to our facility in person in order to receive their STI testing results. Using the patient log sheet database, which captured demographic information as well as the visit type, and testing information, we were able to evaluate the change in policy had on our monthly census and services delivered. Primary source patient data was collected by the Division of Epidemiology and Public Health Practice to review and analyze the indicators of interest.  Historically our log data had shown that approximately 25.6% of our patient encounters in clinic were for the sole purpose of receiving test results from a previous visit over the period of 01/2011-08/2013. Additionally the clinic had an average of 181 patient encounters per month during the same time frame. After instituting the practice in September 2013, the number of patient encounters dropped down to an average of 118 visits per month (09/2013-09/2014), and the percentage of those being revisits to obtain test results has dropped to 8.75% monthly. This significant reduction in patient traffic is obviously a benefit to our clients and to the quality of care we can deliver.  Using the data provided  from the CheXout database, we have also been able to show that each month an average of 60 patients receive their test results via email or text thanks to the self enrollment system. A literature review was performed to obtain comparison data. The literature does not show a comparable approach or an evaluation of a comparable approach.  There were no practice modifications made as a result of the data findings.  
There were valuable lessons learned in relation to this practice.  The implementation of the kiosk to lessen the impact on staff work flow time was a marked success.   Despite the diverse client base, the common thread of adopting smartphone technology was embraced and within the first month there was a significant reduction in revisits for obtaining negative test results. A formal cost benefit analysis has not been fully performed however the evidence from the reduction of revisits from 25% prior to the practice implementation to 8.75% after the practice implementation and the over 700 patients that have self enrolled provides some basis anecdotally proving a benefit to such implementation at a local health department level. There is sufficient commitment to continue and sustain the practice by the Administration and staff at the RCDOH.  Steps are also being taken to implement the practice at the RCDOH Family Planning Clinic as well.
Model Practices brochure|E-Mail from NACCHO|NACCHO website|NACCHO Exchange|NACCHO Connect