Before further discussing specific implementation considerations, it is helpful to visualize how the eCR process may integrate with clinical workflow. The figure below diagrams one hypothetical STI eCR workflow. For practical considerations, we assume that a patient receives STI testing and subsequent treatment in an ambulatory setting. The case detection logic and eCR process are amenable to various types of clinical settings; however, those settings and workflows may present a different set of facilitators and barriers to eCR implementation.

While there are many other steps needed to support the delivery of clinical care, this workflow diagram emphasizes only those steps relevant to eCR. Variations across EHR systems and implementations may produce alternative workflows.

Sample of an eCR workflow

The steps with the label “A” in the figure below represent three possible options where patient data may satisfy the eCR case detection logic and initiate the creation of the eICR. Note that while the data reflected in Step 15 could also satisfy the eCR case detection logic, excluding it may help to prevent subsequent unrelated encounters (e.g., an orthopedic office visit for a broken ankle) documented in the same EHR system from generating superfluous eICRs. This is one example of the decisions implementing organizations will need to consider after conducting their own business analysis.

Implementation guidance available to date does not specify any time delay between case detection, building the eICR and sending the eICR to public health. Assuming that an organization implements eCR in a manner where these three events occur instantaneously, it is possible to build the eICR and sent it to public health before the patient has received STI treatment, which may require the patient to physically return to the clinic, pick up a prescription from a pharmacy, or both.

While STI treatment may be given preemptively in some circumstances, it is common for several days to pass before a patient receives treatment following a positive STI laboratory result. Public health helps to ensure that patients receive appropriate treatment. Therefore, it is the authors’ understanding that the eICR is intended to include treatment information related to the condition(s) being reported.

This potential discrepancy between the timing of case detection and that of STI treatment entry into the EHR may necessitate future modifications to the case detection logic. (Recall from Table 1 that treatment codes do not send a case report under the current case detection logic.)  Alternatively, this discrepancy could be addressed by imposing a time delay between case detection and building the eICR, taking into account jurisdictional reporting requirements.

Sample STI eCR workflow for a reportable case of chlamydia or gonorrhea (click to expand)

Note: Steps are numbered for convenient reference but may not necessarily represent the chronological order of events.

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