Clinical decision support (CDS) is a tool for providing medical professionals and patients with access to the most current guidelines and recommendations to inform the delivery of patient care. Best practices for STI recommendations shift regularly to accommodate the newest science—for example, to reflect the rise of antibiotic-resistant gonorrhea (GC) infections. The adoption of electronic health records (EHRs) and the use of standards has allowed for implementation of automated real time CDS solutions that place the most up-to-date recommendations in the hands of clinicians at the time of care. CDS solutions can come in many forms such as alerts, questionnaires, forms, specialized order sets or links to recommended guidelines.

PHII CDS pilot

In collaboration with the Division of Sexually Transmitted Disease Prevention (DSTDP) and the Division of HIV Prevention at the CDC, PHII coordinated a project to test the feasibility, usability and acceptance of a CDS solution aimed at increasing provider adherence to public health guidelines for treating gonorrhea (GC), encouraging human immunodeficiency virus (HIV) screening and raising awareness of pre-exposure prophylaxis (PrEP) prescriptions in clinical settings. The goal was to create an electronic health record (EHR)-agnostic, standards-based CDS application that could be integrated into clinical workflows for real-world validation.

PHII enlisted the support of Lantana Consulting to prepare initial documentation, Elimu Informatics to design, build and test the solution and Seidel Analytics to provide evaluation support. Three clinical partners actively contributed to the CDS solution design including:

• Mass General Brigham
• Northwestern Medicine
• Yale New Haven Health.

The collaboratively developed CDS design included an open-source application that when integrated into a health system’s EHR prompted the appearance of alerts with treatment recommendations related to GC treatment for both presumptive treatment and laboratory-confirmed scenarios based on patient factors such as weight, allergy and potential for pregnancy. The recommendations included additional information about HIV screening and PrEP education when appropriate.

A pilot with Yale New Haven Health ran at first with the recommendations appearing in the background under “silent mode” from August 2023 through February 2024 and then in the live environment for 15 weeks between February and May 2024. The specific code set and knowledge artifacts for the CDS design used in this pilot can be found below. It is important to note that the CDS solution implemented a subset of the recommendations in the CDC guidelines for GC treatment, HIV screening and PrEP education and does not reflect the complete set of recommendations in the guidelines.

Background of previous CDS work

The recent CDS pilot work was built on a strong foundation laid by several years of multi-partner planning and piloting. In 2019, PHII developed a proof of concept design for a GC CDS tool within a clinical workflow in partnership with Apervita, AllianceChicago and Brigham and Women’s Hospital. In 2020, OCHIN and Codman Square joined the partnership to assist in designing and testing an Epic-native CDS solution that includes a sexual history data capture form, a best practice advisory, an enhanced order set and a documentation template. A pilot of this CDS solution ran for 12 weeks in the live production environment at Codman Square between August and November 2021. The results of the pilot can be found in a published manuscript “Clinical Decision Support System for Guidelines-Based Treatment of Gonococcal Infections, Screening for HIV, and Prescription of Pre-Exposure Prophylaxis: Design and Implementation Study” in the Journal of Medical Internet Research.