Health IT and telemedicine are important tools to help early diagnosis and treatment of a growing problem in the U.S. – hepatitis C virus (HCV) infection. The Centers for Disease Control and Prevention (CDC) launched a new pilot program to help use telemedicine to fight HCV, develop new treatment tools, and get them in the hands of providers to try and stem the tide of HCV infections. The pilot program is prompting the Office of the National Coordinator (ONC) — in collaboration with the American Medical Association (AMA) — to create new HCV clinical quality measures (CQMs) and clinical decision support (CDS) tools to help fight this deadly disease.

In a nutshell, CDC, ONC, and AMA are identifying what works to treat HCV infections by creating new electronic clinical decision support mechanisms and then trying to scale them up in rural areas that need the most help.

Approximately three million patients live with HCV infection in the United States. HCV patients are at risk for developing cirrhosis and hepatocellular carcinoma (HCC) (the fastest growing cause of cancer-related deaths in the United States), both of which can lead to end-stage liver disease and liver failure.

The Scope of the Problem

• Annual health-care costs for HCV-infected persons are five-fold higher than those for other patients.
• From 1999-2007, the number of HCV-associated deaths increased by 50 percent; this percentage is predicted to grow in the absence of interventions to improve diagnosis and treatment.
• National surveys and observation cohort studies indicate that only 50 percent of HCV-infected persons in the United States have been tested for HCV; of these, 32 to 38 percent are referred for care, 7 to 11 percent are treated, and just 5 to 6 percent are cured.

The low proportions of HCV-infected persons who are tested, treated, and cured reflect gaps in health care delivery at every stage of the HCV care cascade (i.e., testing, care, treatment, and cure).

CDC’s Division of Viral Hepatitis (DVH) has increased HCV testing and linking to care and treatment. They are targeting patients who experience barriers to care because they live in remote areas with limited access to medical specialists who know how to treat HCV. The lack of provider expertise in HCV treatment and limited access to specialists pose significant barriers to achieving the substantial public health benefits of HCV testing, care, and treatment.

The Pilot Program

With an eye toward tackling these challenges, CDC funded programs in Arizona and Utah to implement Project ECHO, a telemedicine approach to shore up primary care capacity for treatment of HCV in areas with a shortage of HCV specialists. Weekly videoconferencing enables primary care providers to collaborate with specialists and present patients with HCV infection. These sessions promote the active exchange of clinical information, spur advice and lead to mentoring situations that help inform patient-management practices.

The Results

Sixty-six primary care clinicians, predominantly from rural settings, received training through this program. Nearly all (93 percent) of the clinicians had no prior experience in the care and treatment of HCV infection. Through Project ECHO, approximately 46 percent of all patients presented received antiviral treatment, suggesting that Project ECHO is an effective model that can be used to expand primary care capacity to treat HCV infection, especially among underserved populations.

To further expand treatment capacity and improve the HCV care cascade, DVH is collaborating with ONC and the AMA to develop a clinical quality improvement infrastructure for HCV screening and referral to treatment. The project is using health IT to identify CQMs for testing, link them to care, validate the developed measures, and develop corresponding CDS tools. The hope is to facilitate not only measurement of provider performance but improvement in access to care for underserved and other populations facing barriers to HCV testing, care, and treatment.

CDS is a powerful tool that, when effectively applied, can help improve care and health outcomes by providing up-to-date guidelines and other information to members of the care team to help inform critical decisions. The ‘CDS 5 Rights’ describe how CDS can help improve care, stating that effective CDS should provide:

1. The right information (evidence-based guidelines, response to clinical need)
2. To the right people (entire care team – including the patient)
3. In the right medium (e.g., electronic health record, mobile device, patient portals)
4. In the right format (order sets, flow-sheets, dashboards, patient lists)
5. At the right times (during the office visit, preparation for an office visit)

The CDS tools developed will be in the Health Level 7 (HL7) Clinical Decision Support Knowledge Artifact Implementations Draft Standard for Trial Use (DSTU), a consensus-balloted standard developed by the ONC-convened Health eDecisions Standards & Interoperability Framework Initiative. This standard, which provides a platform-neutral way to express CDS logic, enables broad dissemination of the most current guideline-based CDS interventions and lowers the cost of implementing them, as individual providers no longer are required to develop their own standard.

Population health applications

Another requirement for these programs is to link public health and clinical care data systems to track the implementation of these interventions and the number of persons tested and cured of HCV. Developing electronic clinical quality improvement tools, such as linked CDS and eCQMs, gives providers the tools necessary to identify patients most in need, improve care, and efficiently evaluate the impact of their quality improvement efforts to support and sustain improved delivery of care. With the health IT infrastructure linking the activities of coalition partners, the goals of the projects are to test and cure 10,000 persons with hepatitis C.

With support from CDC, communities are being encouraged to form coalitions of primary care, academic centers, and public health officials to implement a package of interventions to expand access to HCV testing and treatment. Guided by the experiences from these two projects, the interventions will include models of care, performance measures, and clinical decision support tools.

The lessons learned from these projects will help other communities fight the epidemic of hepatitis C.