Step 2: Initiating standard screening protocols
Identifying who to screen for what infection(s) and when is a critical consideration for how to implement an effective routine screening program. Emergency departments continue to face challenges with individual biases about sexual health and infectious disease, both from patients and the clinical staff. This sense of vulnerability, compounded by socialized stereotypes and stigma, makes testing consent conversations emotional and complex. Implementing an opt-out approach to screening can help simplify these conversations and normalize screening as a standard of care.
Guidance from the EHR, including automated orders and reminders, as well as straightforward, demographic-based routine screening criterion have proven to be effective tools for increasing screening and are time and energy savers for a busy care team. Patients feel more comfortable if routine screening is offered as a clinical standard of care, and they feel seen and heard by health care professionals.
Critical considerations at this stage
- The more complex the criteria, the harder it is to reliably execute routine screening
- Screening conversations can take time while moving through the EHR, making the interaction less personal and more transactional
- Implicit bias carried by care team staff members
- Lack of EHR support and optimized structure for routine screening
- Relying on clinicians to remember to screen for all diseases without alerts or reminders
- Testing is seen as a financial liability, at odds with the emergency department’s business model
- Time constraint of patient encounters
Strategies you can implement
- 1. Implement the “opt-out” approach
Training health care professionals and appropriate staff to implement opt-out language helps normalize routine screening as standard of care. Opt-out screening reduces the subjectivity of the decision on behalf of the patient where consent is not legally required.
Related resources
- Explanation of opt-out screening approach for HIV: This resource link from the CDC provides an explanation of an opt-out approach to screening and why it is effective at increasing screening.
- Sample opt out script for clinicians during HIV screening encounter: Pages 4-5 of the Guidance for Delivering HIV Pre-Test and Post-Test Results resource from the Reproductive Health National Training Center outlines samples scripts that clinicians can use when conducting an opt-out approach to HIV screening.
- Discussion Guide: Using normalizing and opt-out language for chlamydia and gonorrhea: This resource from the Reproductive Health National Training Center is designed to build the confidence of clinic staff to use normalizing and opt-out language for chlamydia and gonorrhea screening.
- State Laws that address High-Impact HIV Prevention Efforts: This resource from the CDC is a summary of state specific laws on a minor’s autonomous consent for HIV and/STI services, and laws that address HIV prevention efforts.
- 2. Stick to sex-positive messaging
Equipping care team members with training and resources on sex-positive and non-judgmental messaging about risk, transmission, treatment, outcomes, and benefits of screening can help overcome initial patient refusal.
Related resources
Care team resources to help health care providers educate patients on the importance of sexual health: These tools from the National Coalition for Sexual Health can help health care providers and clinical staff cultivate a clinical environment that delivers inclusive, patient-centered, and accessible sexual health services for all patients.
- Inclusive Sexual Health Services: Practical Guidelines for Providers & Clinics
- Sexual Health and Your Patients: A Provider’s Guide
- Compendium of Sexual & Reproductive Health Resources for Healthcare Providers
Care team training on LGBTQ, transgender and gender nonconforming essentials: The AMA Ed Hub offers a series of training modules developed by Howard Brown Health, SAGECare, The Fenway Institute and more that can help provide education to your care team on sex-positive and gender appropriate language and methods to incorporate best practices into your organization.
- 3. Implement automated EHR reminders, prompts and orders to increase screening
EHRs that automatically flag patients in need of screening as well as EHR reminders to initiate screening takes the pressure off the health care professional to remember who to screen. Alerts can automatically prepopulate test orders, further reducing the clinician’s responsibilities. Auto-orders in the EHR that are connected to the patient identification algorithms for routine screening will reduce time in the EHR and additional steps for clinicians. Positive and indeterminant results can also be linked to auto-orders for confirmatory testing.
Related resources
- Clinical Decision Support System to Increase HIV Screening: This webpage outlines Community Preventative Services Task Force (CPSTF) recommendations and considerations for implementation of clinical decision support systems, which evidence shows increases HIV screening both for the general population as well as those at higher risk for HIV infection.
- Tips to Leverage Your Electronic Health Record to Implement Opt-Out HIV: This resource from Health Information Technology Evaluation and Quality Center outlines best practices and strategies for implementing opt-out HIV screening in your organization using the electronic health record.
- 4. Align infectious disease control with organization’s goals
Presenting the health and cost-benefit analysis of diagnosing diseases early versus treating disease progression can help establish infectious disease control as a strategic imperative in a health setting and gain access to timesaving resources.
Related resources
- HIV Cost-effectiveness: This resource from the CDC provides a basic guide to the cost-effectiveness analysis of prevention interventions for HIV infection and AIDS and help prevention program staff and planners become more familiar with potential uses of economic evaluation.
- Integrating Routine HIV Screening Into Clinical Practice (PDF): This resource from the CDC outlines the clinical benefits of early HIV diagnosis and treatment.
- Overview of Cost, Reimbursement, and Cost-Effectiveness Considerations for Hepatitis C Treatment Regimens: This webpage outlines the cost-effectiveness of HCV treatment and care with a section specifically dedicated to the cost effectiveness of screening for HCV.
Related videos
Implement the “opt-out” approach
Douglas White, MD from Alameda Health System's Highland Hospital shares tips on implementing opt-out notifications in an emergency department setting
Stick to sex-positive, status-neutral messaging
Jason Zucker, MD, provides an overview of the importance of using sex-positive messaging to help increase screening for HIV and STIs
Implement automated EHR reminders, prompts and orders to increase screening
Carmen Burrell, DO, shares West Virginia University's approach to optimizing EHR alerts when implementing opt-out screening in the emergency department.
Align infectious disease control with organization’s goals
Jason Zucker, MD, highlights how universal HIV screening has been shown to be cost effective in numerous settings and models, while also removing stigma associated with testing leading to earlier diagnosis, treatment, and reduced transmission
Download the toolkit
Next steps
The toolkit is organized across the screening continuum and offers helpful resources and best practices for the emergency department care team.
Disclaimer: This page contains resources supplied by third party organizations. Inclusion of these materials on this page does not imply endorsement of these resources or corresponding organization.
