Predictive analytics and clinical decision support to improve PREP prescribing in community health centers (PREDICT) - rates of new HIV infections are high, and uptake of preexposure prophylaxis…

Predictive analytics and clinical decision support to improve PREP prescribing in community health centers (PREDICT) - rates of new HIV infections are high, and uptake of preexposure prophylaxis (PREP) low, in populations served by community health centers (CHCS) in the US. Healthcare providers in CHCS could play a critical role in increasing PREP prescribing. However, providers face barriers to PREP prescribing, such as difficulty identifying candidates for PREP, discomfort discussing sexual behavior, and lack of familiarity with PREP care. We have found that providers are enthusiastic about the potential benefits of decision support tools to mitigate these barriers to PREP provision, and that patients would find such tools acceptable if implemented sensitively. We previously showed that data from electronic health records (EHRS) can be used to identify patients at increased risk of HIV acquisition in two large, general practice healthcare systems. In our formative R34 research, we expanded on this approach in a safety-net setting, incorporating strategies to support not only identification of PREP candidates but also PREP discussions and prescribing. In a national network of CHCS serving 6.2 million patients in 46 states (OCHIN), we used machine learning with EHR data to identify patients at increased risk for incident HIV diagnosis (area under the curve 0.84). Using stakeholder-engaged qualitative methods, we then built an EHR-based decision support tool that uses our prediction model to prompt PREP discussions with patients likely to benefit. The tool features a suite of resources to support initial PREP prescribing, including suggested language for patient-centered discussions; information about PREP indications, formulations, and dosing; laboratory order sets; diagnosis codes; and automated clinical notes. We piloted this tool at 3 CHCS, establishing feasibility and acceptability. We now propose predictive analytics and clinical decision support to improve PREP prescribing in community health centers (PREDICT) to evaluate the impact of our tool on PREP provision in OCHIN CHCS. Our specific aims are to 1) expand and refine the decision support tool to facilitate PREP follow-up care, and therefore patients' persistence on PREP; 2) quantify the impact of the decision support tool on PREP initiation and persistence in a pragmatic stepped-wedge trial across 16 CHCS; and 3) identify patient populations with whom providers are less inclined to discuss PREP when prompted to do so, and explore facilitators and barriers to selection of patients for PREP discussions. We will engage an advisory group of patients from OCHIN CHCS in tool expansion, refinement, and implementation. This project is innovative in its use of predictive analytics and decision support to improve PREP provision in safety-net settings. The research is significant because IT has the potential to facilitate large increases in PREP utilization using highly scalable tools. Our intervention addresses NIH priorities, aligns with the federal ending the HIV epidemic initiative, and could become a best practice for how CHCS and other healthcare systems support PREP care delivery.