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The American Journal of Managed Care December 2016
Getting From Here to There: Health IT Needs for Population Health
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Building Health IT Capacity to Improve HIV Infection Health Outcomes
Hannah Rettler, MPH; R. Monina Klevens, DDS, MPH; Gillian Haney, MPH; Liisa Randall, PhD; Alfred DeMaria, MD; and Johanna Goderre, MPH
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US Hospital Engagement in Core Domains of Interoperability
A. Jay Holmgren, BA; Vaishali Patel, PhD; Dustin Charles, MPH; and Julia Adler-Milstein, PhD

Building Health IT Capacity to Improve HIV Infection Health Outcomes

Hannah Rettler, MPH; R. Monina Klevens, DDS, MPH; Gillian Haney, MPH; Liisa Randall, PhD; Alfred DeMaria, MD; and Johanna Goderre, MPH
Massachusetts is integrating HIV surveillance and leveraging electronic health record clinical data into their electronic disease case management system to enhance monitoring the HIV continuum of care.
In community health centers in which HIV medical care is integrated fully into primary medical care, it is difficult to assess whether HIV medical management (eg, medication adherence) was addressed based on EHR data (ICD-9 and ICD-10-CM codes on problem lists; ICD-9 and ICD-10-CM codes and or procedure codes used in conjunction with clinic visits). Unless a viral load was ordered or an antiretroviral prescription was generated, it is difficult to define the primary reason for the clinical encounter. HIV medical care is changing rapidly, and for stable patients, guidelines have changed8 and many clinicians are choosing to order viral loads annually or even less frequently, and may be renewing antiretroviral prescriptions without viral load testing. This change in practice results in clinical visits that do not involve viral load orders or ARV prescriptions less valuable in predicting medication adherence or ongoing viral suppression.

A related challenge to identifying a clinic visit relevant for HIV medical care is the “missed visit” issue, which is the indicator that clinics are using to generate out-of-care line lists. Missed visits are another indicator of care retention; a missed visit is not always captured in the EHR, but rather in a separate practice management or appointment system that is not interoperable with the EHR. Additionally, even when identifying a missed visit is possible, it has been difficult to define whether that missed visit was HIV-related.

Unforeseen transition to a new EHR vendor. Several community health centers were transitioning to a different EHR during the project. Prior to the transition, the mapping of local codes had been completed between their original EHR reporting portal and its gateway to MAVEN. With the transition to their new EHR systems, the time- and resource-intensive process of building a map between the EHR and MAVEN needs to be repeated. This mapping challenge will almost certainly arise again in the case of an upgrade or update to an existing EHR system that may affect the way certain data are documented, as well as for additional EHR transitions in the future.

HIV screening to identify undiagnosed infection. In the context of a primary care setting, and particularly in a multidisciplinary community health center (eg, dental, optical, medical, social services), there are only certain types of encounters appropriate for HIV infection screening. Clinics develop their own local coding for various encounter types, related to organizational factors, grant-funded programs, agency-specific quality improvement initiatives, reporting needs, and other factors. Relative to identifying clinical encounters where HIV screening might be reasonably assumed to be feasible and/or desirable to perform, Massachusetts observed that all local codes must be mapped to characterize the “clinical encounter.” Some health centers identified “HIV testing” as an encounter type because they have a dedicated HIV testing program, while others implemented certain HIV screening in the context of their dental services provided in an “oral health” encounter. Each community health center had to have their unique codes for various encounter types in which screening might take place mapped into 1 “medical visit” category.

Other challenges in identifying HIV-related care. Additional information that may flag a visit as HIV-related is often found in the clinician notes or other free-text entries. At present, text notes cannot easily be extracted to populate a structured field in MAVEN, and data structure changes may not always be the best or most feasible answer to these problems. Direction, consensus, and standardized practice in data entry, as well as use and encoding of information, must be supported at the clinical level. 


Based on our experience with the pilot project, we offer 3 recommendations for health departments interested in a similar approach to enhancing their health IT for HIV surveillance, case management and quality assurance:

Communication. Early identification of what is, and is not, available in the EHR system(s)—particularly where multiple systems and clinics are involved—is highly recommended. All project partners should agree on the goals of data capture and flow to establish feasibility and an appropriate timeline for implementation. Explicit communication about standardized data definitions and entry expectations at the clinic level is imperative to capturing robust and useful data.

Site selection. Start with only a few sites that use the same EHR vendor and version to become familiar with the system structure and data capture.

Acknowledge and address the current lack of standardization. Uniform standards for electronic case reporting that can be the basis for industry standards for EHRs is highly desirable. Similar to Meaningful Use requirements, EHR vendors should be able to incorporate state and local reporting requirements in the design, structure, and functionality of their EHRs.

Conclusions and Next Steps

The ability to electronically extract key variables from clinical records and integrate the data with public health surveillance and case management systems has implications for many other infectious diseases, and potentially for chronic diseases, as well. A successful electronic system built to extract care information would facilitate public health monitoring and action related to a care continuum for other infections, such as hepatitis C.9

Our next steps will include the full implementation of this pilot project and expansion of ESPnet to other facilities offering HIV care. We will further explore HIV reporting requirements and collaborate with other public health jurisdictions toward the development of a standard for EHR vendors and compliance agencies, such as the Office of the National Coordinator for Health IT. We will continue to work with clinical partners in refining the system and utilization of data collected.

Consolidation of the data elements necessary to monitor the HIV care continuum will provide opportunities for enhancement of public health services and response. EHR data will augment efficient oversight of the HIV care continuum. With enhanced health IT infrastructure, we hope to facilitate engagement and retention in HIV care to maximize the benefits and contribute to prevention.

Author Affiliations: Massachusetts Department of Public Health, Bureau of Infectious Disease and Lab Science  (AD, GH, RMK, HR, LR), Boston, MA; Agency for Healthcare Research and Quality (JLGJ), Rockville, MD.

Source of Funding: This publication was made possible by grant number H97HA27536 from HHS, Health Resources and Services Administration (HRSA), HIV/AIDS Bureau’s Special Projects of National Significance Program. The views expressed in this article are those of the authors and no official endorsement by the HRSA, HHS, or the federal government is intended or should be inferred.

Author Disclosures: Ms Goderre Jones was the HRSA project officer for this project. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AD, JLGJ, GH, RMK, HR, LR); acquisition of data (GH, HR, LR); analysis and interpretation of data (GH, HR, LR); drafting of the manuscript (AD, RMK, HR); critical revision of the manuscript for important intellectual content (AD, JLGJ, GH, RMK, HR, LR); obtaining funding (GH, LR); administrative, technical, or logistic support (AD, JLGJ, GH, RMK, LR, HR); and supervision (GH, LR).

Address Correspondence to: Hannah Rettler, MPH, Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences, 305 South St, Jamaica Plain, MA 02130. E-mail:

1. HIV/AIDS care continuum. website. Updated March 6, 2015. Accessed October 28, 2016.

2. Massachusetts HIV care continuum. Massachusetts Department of Public Health website. March 1, 2016. Accessed November 15, 2016.

3. Part F: Special Projects of National Significance (SPNS) Program. Health Resources and Services Administration website. Accessed October 28, 2016.

4. Troppy S, Haney G, Cocoros N, Cranston K, DeMaria A Jr. Infectious disease surveillance in the 21st century: an integrated web-based surveillance and case management system. Public Health Rep. 2014;129(2):132-138.

5. Lazarus R, Klompas M, Campion FX, et al. Electronic support for public health: validated case finding and reporting for notifiable diseases using electronic medical data. J Am Med Inform Assoc. 2009;16(1):18-24. doi: 10.1197/jamia.M2848.

6. Human immunodeficiency virus (HIV) infection: screening. US Preventive Services Task Force website. Published April 2013. Accessed November 15, 2016.

7. HIV/AIDS Bureau performance measures. Health Resources & Services Administration website. Updated January 2015. Accessed November 15, 2016.

8. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. AIDSinfo website. Updated July 14, 2016. Accessed October 28, 2016.

9. Wyles DL, Sulkowski MS, Dieterich D. Management of hepatitis C/HIV coinfection in the era of highly effective hepatitis C virus direct-acting antiviral therapy. Clin Infect Dis. 2016;63(suppl 1):S3-S11. doi: 10.1093/cid/ciw219. 
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