Enhancing Electronic Health Systems to End Transmission of Chronic Hepatitis B During COVID‐19: A Collaborative Approach

Abbreviations

CBC

complete blood cell count

CDC

Centers for Disease Control and Prevention

CHB

chronic hepatitis B

CMP

complete metabolic panel

COVID‐19

coronavirus disease 2019

EHR

electronic health record

END B

ending the transmission of the HBV from the prenatal period throughout the lifespan

FHx

family history

HALO

Health and Life Organization

HBcAb

hepatitis B core antibody total

HBeAb

hepatitis B e antibody

HBeAg

hepatitis B e antigen

HBIg

hepatitis B immune globulin

HBsAb

hepatitis B surface antibody

HBsAg

hepatitis B surface antigen

HBV

hepatitis B virus

ICD

International Classification of Diseases

INR

international normalized ratio

MA

medical assistant

PCP

primary care provider

Q

quarter

TDF

tenofovir disoproxil fumarate

Tx

transplant

US

ultrasound

USPSTF

US Preventive Services Task Forces

UV

viral load

Y

year

The essential elements to eliminate hepatitis B virus (HBV) transmission include preventing perinatal HBV transmission, HBV vaccination of newborn and youth, and screening of at‐risk adults with linkage to care for those who may be chronically infected. These components are the premise of our federally funded “END B” program: “Ending the transmission of the HBV from the prenatal period throughout the lifespan.” The purpose of this paper is to describe how we have built on our prior work and report our preliminary results that have been enabled by electronic health system enhancement, as well as describe the impact of coronavirus disease 2019 (COVID‐19) and our response during the implementation of END B.

Chronic hepatitis B (CHB) may affect up to 2.4 million persons in the United States, and about 59% of foreign‐born persons living with CHB in 2018 emigrated from Asia. ¹ Because Asian Americans experience the highest prevalence of past or present HBV infection, 10 times greater (21.1% compared with 2.1%) than non‐Hispanic whites, ² we chose to focus our CHB prevention efforts on Asian Americans.

Context for END B

The UC Davis team has conducted randomized controlled studies documenting statistically significant increases in screenings with electronic clinical decision prompts for HBV testing. ³ , ⁴ These studies revealed how electronic health record (EHR) enhancement together with bilingual/bicultural health care workers outreach increased HBV screenings of underserved populations.

END B provides the opportunity for applying these lessons learned to changing routine practice in community health clinics. First, we partnered with the Health and Life Organization (HALO), a Federally Qualified Health Center Look‐Alike, the largest health care provider to Asian Americans in Sacramento County, serving more than 9000 Asian Americans, particularly those born in intermediate‐ to high‐risk areas as defined by the Centers for Disease Control and Prevention (CDC). Of HALO’s six clinics, four offer both primary and prenatal care. All HALO clinics use Intelligent Medical Software (Meditab Software Inc., Sacramento, CA), which is a state‐of‐the‐art, fully customizable EHR. Second, we partnered with the Sacramento County Division of Public Health because of their commitment to preventing perinatal HBV transmission. Third, we enlisted the California Primary Care Association to oversee and evaluate the program.

Conduct of END B Interventions

The hallmark of END B is using EHR enhancement to increase screening for CHB, which has been instituted in two phases: (1) universal screening of pregnant women, regardless of race or ethnicity; and (2) high‐risk patient screening, particularly among those born in CDC‐defined HBV‐endemic areas. The workflow for HBV screening is summarized in Fig. 1. To synergize with END B activities, we have held “Academies” (in‐services) to train HALO medical assistants (MAs) on using the enhanced EHR and patient‐centered HBV educational workshops (Table 1).

FIG 1.

Pregnancy and “high‐risk” hepatitis B screening workflow.

TABLE 1.

Interventions Used to End the Transmission of Hepatitis B

Intervention	Description
EHR enhancement	Hepatitis B order set that is triggered by pregnancy diagnosis EHR‐based registry to identify “high‐risk” patients Custom reports tailored to identifying HBsAg‐positive patients and pertinent demographic information
Case Navigator	Bilingual and bicultural Hmong/English to provide culturally competent care Ensures that HBsAg‐positive patients are linked to care of hepatologist Works with care providers to ensure that HBsAg‐positive mothers and their babies receive standard of care to prevent HBV transmission
MA training academy	Regular instruction of MAs regarding the burden of HBV and importance of HBV screening among “high‐risk” patients Formal EHR training to properly identify “high‐risk” patients and enter the information accurately into the EHR
HBV education workshops for patients	Bilingual and bicultural Hmong/English HBV instruction Introduce the importance of HBV to patients to overcome barriers to screening “Storytelling” by patients living with HBV to remove stigma and encourage screening

Due to the COVID‐19 pandemic, a shelter‐in‐place order was issued in Sacramento County on March 19, 2020. From March to April 2020, HALO clinics saw a decrease of patient encounters by 70% across its health services. HALO did not have telehealth services in place before the pandemic. Bolstered by extramural funding, telehealth services were initiated and by July/August 2020. Patient encounters then began to increase toward baseline levels. HALO interventions were therefore adapted to conform to social distancing protocols.

Universal screening of pregnant women has received a Grade A recommendation from the US Preventive Services Task Forces (USPSTF). ⁵ To screen these women, we created an electronic hepatitis B order set containing orders for hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb) total, and hepatitis B surface antibody (HBsAb). This series is automatically ordered when medical staff (MAs or primary care providers [PCPs]) enter an International Classification of Diseases (ICD)‐10 code for pregnancy into the EHR. The HBV order set will not trigger for patients who have already had these tests in the past 9 months.

High‐risk patient screening has received a Grade B recommendation from the USPSTF and is a non‐copay preventive service provided by HALO. ⁶ Prior to the COVID‐19 pandemic, electronic alerts were used to prompt testing for foreign‐born patients from endemic areas who presented in person to clinic. The COVID‐19 pandemic decreased in‐person visits, and this workflow was modified. We developed an EHR‐based registry of high‐risk patients (primarily Asian Americans) encompassing all HALO clinics. Beginning in October 2020, we started ordering hepatitis B testing using this registry and informing patients of awaiting laboratory tests by mail. This system was designed to enable completion of hepatitis B testing without being physically present in the clinic.

Because the primary goal of END B is to spare the next generation from CHB, we have used an English/Hmong bilingual Case Navigator to longitudinally follow each patient found to be HBsAg positive. For pregnant women, if HBV viral load (VL) at 28 weeks is ≥200,000 IU/mL, the mother will be started on tenofovir 300 mg/day to prevent transmission to the newborn. Tenofovir will be stopped at time of breastfeeding, and mothers will be monitored for treatment reinitiation as medically indicated. Newborns will also be given hepatitis B immune globulin and hepatitis B vaccination at birth. ⁷ All patients found to be HBsAg positive will be linked to the care of a hepatologist to receive standard of care for CHB. ⁸ For patients found to be susceptible to HBV, bulk EHR clinical reminders to vaccinate have been sent to their PCPs.

Interim Results and Future Directions

The results of cumulative testing (July 2019 to March 2021) for HBV at HALO are summarized in Table 2. Regarding universal screening of pregnant women for HBV, 345 patients have been tested to date, and 4 have been found to be HBsAg positive (1.1% prevalence rate). All of these patients have been linked to the care of a hepatologist (Fig. 2). As a result of early adoption of telehealth services at HALO, completion of HBV testing among pregnant women at HALO has remained only slightly below prepandemic levels.

TABLE 2.

END B Cumulative Testing to Date: July 2019 through March 2021

Population	Y1 Q1	Y1 Q2	Y1 Q3	Y1 Q4*	Y2 Q1	Y2 Q2 †	Y2 Q3	Total
Obstetrical HBsAg+	– ‡	0	2	2	0	0	0	4
Obstetrical tested	– ‡	61	69	58	55	49	53	345
							Prevalence	1.1%
Asian American HBsAg+	– ‡	– ‡	2	1	2	10	9	24
Asian American tested	– ‡	– ‡	42	26	36	78	87	269
							Prevalence	8.9%

^*COVID‐19 shelter‐in‐place declared on March 19, 2020.

^† Registry‐based testing of “high‐risk” patients (nonpregnant Asian Americans) begins.

^‡ Start‐up phase; no actual testing was performed.

FIG 2.

Care cascade of hepatitis B‐positive patients. Linked to care: patient has seen hepatology in clinic (in person or virtually). Engaged in care: patient has had hepatic function panel, hepatitis B e antigen, hepatitis B e antibody, and hepatitis B VL completed. Retained in care: patient has seen hepatologist twice. Treatment eligible: eligible for hepatitis B antiviral therapy based on standard of care. ⁸ Antivirals: patients has been prescribed appropriate antiviral therapy for HBV.

High‐risk patient (nonpregnant Asian Americans) testing also experienced a decrease in completed testing during the pandemic. In response to this, we developed an EHR‐based registry of high‐risk patients across all HALO clinics, which has led to a large increase in the number of tests completed and new HBV cases detected. For example, 19 new HBV diagnoses were found in the past 6 months compared with 3 in the 6 months prior to initiating registry‐based testing (Table 2). The overall prevalence rate of HBV among tested high‐risk patients is 8.9%. This high prevalence is due to the fact that 12 of the 24 Asian Americans positive for CHB are of Hmong/Laotian descent. In our previous analysis of Asian origin groups in Sacramento County, the Hmong had the highest CHB prevalence and experienced the most health disparities. ⁹ , ¹⁰ Due to the new influx of positive cases, many have not yet been linked to care, but our Case Navigator is working in earnest to expedite the referral process (Fig. 2).

As a proof of concept, our hepatitis B elimination program END B shows what hepatitis B elimination can look like when digital tools are harnessed to combat a pandemic. By applying what we learn through partnerships, deploying bilingual/bicultural case navigation, and expanding the role of EHR, while facing the challenges of COVID‐19, we can personalize health care to screen appropriate patients. It is our expectation that END B could be a transferable model for HBV elimination nationally.