Enhancing electronic Health systems to end transmission of Chronic Hepatitis B During COviD- 19: a Collaborative approach
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Original Article
Enhancing Electronic Health Systems
to End Transmission of Chronic
Hepatitis B During COVID-19: A
Collaborative Approach
Eric Chak, M.D., M.P.H.,* Fresnia Vu,† Julie Dang, Ph.D., M.P.H.,‡
Ulissa Smith, M.P.H.,§ Susan Stewart, Ph.D.,¶ Karman Tam, M.P.H.,**
Amy Beste-Fong, R.N.,** Breanna Phelps,†† Ian Johnson, M.D.,†
Miguel Suarez, M.D.,† Mary Pat Pauly, M.D.,‡‡ and
Moon S. Chen, Jr., Ph.D., M.P.H.§§
The essential elements to eliminate hepatitis B virus screening of at-risk adults with linkage to care for those
(HBV) transmission include preventing perinatal HBV who may be chronically infected. These components are
transmission, HBV vaccination of newborn and youth, and the premise of our federally funded “END B” program:
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.
From the * Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento, CA; † Sacramento Community
Clinics, Health and Life Organization, Inc., Sacramento, CA; ‡ Department of Public Health Sciences, UC Davis School of Medicine,
Sacramento, CA; § Office of Community Outreach and Engagement, UC Davis Comprehensive Cancer Center, Sacramento, CA;
¶
Division of Biostatistics, UC Davis Department of Public Health Sciences, Sacramento, CA; ** Sacramento County Department of
Health Services, Division of Public Health, Sacramento, CA; †† Meditab Software Inc, Sacramento, CA; ‡‡ California Primary Care
Association, Sacramento, CA; and §§ Division of Hematology and Oncology, UC Davis School of Medicine, Sacramento, CA.
The work described in this paper was funded in part by grant CPIMP191176 (“END B”) from the Office of Minority Health, US
Department of Health and Human Services and by grant A18-2016-001 from the Bristol-Meyers Squibb Foundation, “UC Davis-
HALO Collaborative.”
Potential conflict of interest: Nothing to report.
Received July 22, 2020; accepted May 25, 2021.
View this article online at wileyonlinelibrary.com
© 2021 by the American Association for the Study of Liver Diseases
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| Clinical Liver Disease, VOL 17, NO 6, JUNE 2021 An Official Learning Resource of AASLDOriginal Article Ending Transmission of Chronic Hepatitis B Chak et al.
“Ending the transmission of the HBV from the prenatal two phases: (1) universal screening of pregnant women,
period throughout the lifespan.” The purpose of this regardless of race or ethnicity; and (2) high-risk patient
paper is to describe how we have built on our prior work screening, particularly among those born in CDC-defined
and report our preliminary results that have been enabled HBV-endemic areas. The workflow for HBV screening is
by electronic health system enhancement, as well as de- summarized in Fig. 1. To synergize with END B activities,
scribe the impact of coronavirus disease 2019 (COVID-19) we have held “Academies” (in- services) to train HALO
and our response during the implementation of END B. medical assistants (MAs) on using the enhanced EHR and
patient-centered HBV educational workshops (Table 1).
Chronic hepatitis B (CHB) may affect up to 2.4 million
persons in the United States, and about 59% of foreign- Due to the COVID-19 pandemic, a shelter-in-place order
born persons living with CHB in 2018 emigrated from was issued in Sacramento County on March 19, 2020.
Asia.1 Because Asian Americans experience the highest From March to April 2020, HALO clinics saw a decrease
prevalence of past or present HBV infection, 10 times of patient encounters by 70% across its health services.
greater (21.1% compared with 2.1%) than non-Hispanic HALO did not have telehealth services in place before the
whites,2 we chose to focus our CHB prevention efforts on pandemic. Bolstered by extramural funding, telehealth
Asian Americans. 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
CONTEXT FOR END B
social distancing protocols.
The UC Davis team has conducted randomized con-
Universal screening of pregnant women has received a
trolled studies documenting statistically significant in-
Grade A recommendation from the US Preventive Services
creases in screenings with electronic clinical decision
Task Forces (USPSTF).5 To screen these women, we cre-
prompts for HBV testing.3,4 These studies revealed how
ated an electronic hepatitis B order set containing orders
electronic health record (EHR) enhancement together with
for hepatitis B surface antigen (HBsAg), hepatitis B core
bilingual/bicultural health care workers outreach increased
antibody (HBcAb) total, and hepatitis B surface antibody
HBV screenings of underserved populations.
(HBsAb). This series is automatically ordered when med-
END B provides the opportunity for applying these les- ical staff (MAs or primary care providers [PCPs]) enter an
sons learned to changing routine practice in community International Classification of Diseases (ICD)-10 code for
health clinics. First, we partnered with the Health and Life pregnancy into the EHR. The HBV order set will not trigger
Organization (HALO), a Federally Qualified Health Center for patients who have already had these tests in the past
Look-Alike, the largest health care provider to Asian 9 months.
Americans in Sacramento County, serving more than 9000
High-risk patient screening has received a Grade B rec-
Asian Americans, particularly those born in intermediate-
ommendation from the USPSTF and is a non-copay pre-
to high-risk areas as defined by the Centers for Disease
ventive service provided by HALO.6 Prior to the COVID-19
Control and Prevention (CDC). Of HALO’s six clinics, four
pandemic, electronic alerts were used to prompt testing
offer both primary and prenatal care. All HALO clinics
for foreign-born patients from endemic areas who pre-
use Intelligent Medical Software (Meditab Software Inc.,
sented in person to clinic. The COVID-19 pandemic de-
Sacramento, CA), which is a state-of-the-art, fully custom-
creased in-person visits, and this workflow was modified.
izable EHR. Second, we partnered with the Sacramento
We developed an EHR-based registry of high-risk patients
County Division of Public Health because of their commit-
(primarily Asian Americans) encompassing all HALO clin-
ment to preventing perinatal HBV transmission. Third, we
ics. Beginning in October 2020, we started ordering hep-
enlisted the California Primary Care Association to oversee
atitis B testing using this registry and informing patients
and evaluate the program.
of awaiting laboratory tests by mail. This system was de-
signed to enable completion of hepatitis B testing without
CONDUCT OF END B INTERVENTIONS being physically present in the clinic.
The hallmark of END B is using EHR enhancement to Because the primary goal of END B is to spare the next
increase screening for CHB, which has been instituted in generation from CHB, we have used an English/Hmong
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| Clinical Liver Disease, VOL 17, NO 6, JUNE 2021 An Official Learning Resource of AASLDOriginal Article Ending Transmission of Chronic Hepatitis B Chak et al.
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 1. Hepatitis B order set that is triggered by pregnancy diagnosis
2. EHR-based registry to identify “high-risk” patients
3. Custom reports tailored to identifying HBsAg-positive patients and pertinent demographic information
Case Navigator 1. Bilingual and bicultural Hmong/English to provide culturally competent care
2. Ensures that HBsAg-positive patients are linked to care of hepatologist
3. Works with care providers to ensure that HBsAg-positive mothers and their babies receive standard of care to prevent
HBV transmission
MA training academy 1. Regular instruction of MAs regarding the burden of HBV and importance of HBV screening among “high-risk” patients
2. Formal EHR training to properly identify “high-risk” patients and enter the information accurately into the EHR
HBV education workshops for patients 1. Bilingual and bicultural Hmong/English HBV instruction
2. Introduce the importance of HBV to patients to overcome barriers to screening
3. “Storytelling” by patients living with HBV to remove stigma and encourage screening
bilingual Case Navigator to longitudinally follow each pa- positive will be linked to the care of a hepatologist to re-
tient found to be HBsAg positive. For pregnant women, ceive standard of care for CHB.8 For patients found to be
if HBV viral load (VL) at 28 weeks is ≥200,000 IU/mL, the susceptible to HBV, bulk EHR clinical reminders to vacci-
mother will be started on tenofovir 300 mg/day to prevent nate have been sent to their PCPs.
transmission to the newborn. Tenofovir will be stopped at
time of breastfeeding, and mothers will be monitored for
INTERIM RESULTS AND FUTURE DIRECTIONS
treatment reinitiation as medically indicated. Newborns
will also be given hepatitis B immune globulin and hepati- The results of cumulative testing (July 2019 to March
tis B vaccination at birth.7 All patients found to be HBsAg 2021) for HBV at HALO are summarized in Table 2.
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| Clinical Liver Disease, VOL 17, NO 6, JUNE 2021 An Official Learning Resource of AASLDOriginal Article Ending Transmission of Chronic Hepatitis B Chak et al.
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.
Regarding universal screening of pregnant women for HBV, example, 19 new HBV diagnoses were found in the past
345 patients have been tested to date, and 4 have been 6 months compared with 3 in the 6 months prior to ini-
found to be HBsAg positive (1.1% prevalence rate). All of tiating registry-based testing (Table 2). The overall preva-
these patients have been linked to the care of a hepatolo- lence rate of HBV among tested high-risk patients is 8.9%.
gist (Fig. 2). As a result of early adoption of telehealth ser- This high prevalence is due to the fact that 12 of the 24
vices at HALO, completion of HBV testing among pregnant Asian Americans positive for CHB are of Hmong/Laotian
women at HALO has remained only slightly below prepan- descent. In our previous analysis of Asian origin groups
demic levels. in Sacramento County, the Hmong had the highest CHB
prevalence and experienced the most health disparities.9,10
High-risk patient (nonpregnant Asian Americans) test- Due to the new influx of positive cases, many have not yet
ing also experienced a decrease in completed testing been linked to care, but our Case Navigator is working in
during the pandemic. In response to this, we developed earnest to expedite the referral process (Fig. 2).
an EHR-based registry of high-risk patients across all HALO
clinics, which has led to a large increase in the number As a proof of concept, our hepatitis B elimination pro-
of tests completed and new HBV cases detected. For gram END B shows what hepatitis B elimination can look
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| Clinical Liver Disease, VOL 17, NO 6, JUNE 2021 An Official Learning Resource of AASLDOriginal Article Ending Transmission of Chronic Hepatitis B Chak et al.
like when digital tools are harnessed to combat a pandemic. 4) Chen MS, Fang DM, Stewart SL, et al. Increasing hepatitis B screening
for Hmong adults: results from a randomized controlled community-
By applying what we learn through partnerships, deploy-
based study. Cancer Epidemiol Biomarkers Prev 2013;22:782-791.
ing bilingual/bicultural case navigation, and expanding the
role of EHR, while facing the challenges of COVID-19, we 5) Owens DK, Davidson KW, Krist AH, et al. Screening for hepati-
can personalize health care to screen appropriate patients. tis B virus infection in pregnant women: US Preventive Services
Task Force Reaffirmation Recommendation Statement. JAMA
It is our expectation that END B could be a transferable
2019;322:349-354.
model for HBV elimination nationally.
6) LeFevre ML; USPSTF. Screening for hepatitis B virus infection in non-
CORRESPONDENCE pregnant adolescents and adults: U.S. Preventive Services Task Force
recommendation statement. Ann Intern Med 2014;161:58-66.
Eric Chak, M.D., M.P.H., Division of Gastroenterology and Hepatology,
UC Davis School of Medicine, 4150 V Street, Suite 3500, Sacramento,
7) Jourdain G, Ngo-Giang-Huong N, Harrison L, et al. Tenofovir versus
CA 95817. E-mail: echak@ucdavis.edu
placebo to prevent perinatal transmission of hepatitis B. N Engl J
REFERENCES Med 2018;378:911-923.
1) Wong RJ, Brosgart CL, Welch S, et al. An updated assessment of 8) Terrault NA, Bzowej NH, Chang KM, et al.; American Association
chronic hepatitis B prevalence among foreign-born persons living for the Study of Liver Diseases. AASLD guidelines for treatment of
in the United States. Hepatology. Published online March 3, 2021. chronic hepatitis B. Hepatology 2016;63:261-283.
Available at: https://doi.org/10.1002/hep.31782
9) Stewart SL, Dang JH, Torok NJ, et al. Patterns and co-occurrence
2) Kruszon-Moran D, Paulose-Ram R, Martin CB, et al. Prevalence and of risk factors for hepatocellular carcinoma in four Asian American
trends in hepatitis B virus infection in the united states, 2015–2018. communities: a cross-sectional study. BMJ Open 2019;9:e026409.
NCHS Data Brief, no. 326. Hyattsville, MD: National Center for
Health Statistics; 2020. 10) Wang T, Liu YU, Letran D, et al. Healthcare Disparities Identified
Between Hmong and Other Asian Origin Groups Living with
3) Chak E, Li CS, Chen MS Jr, et al. Electronic health record alerts en- Chronic Hepatitis B Infection in Sacramento County 2014-2017. J
hance mass screening for chronic hepatitis B. Sci Rep 2020;10:19153. Community Health 2020;45:412-418.
428
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