Time is of the Essence: Clinical Decision Support for the Treatment of Syphilis Positive

Pregnant Women

Hanna Kristina C. Sahagon

School of Nursing, University of San Diego

HCI 552– Electronic Medical Record Systems

Dr. Cynthia Reed

May 13, 2021

Executive Summary

Congenital Syphilis rates in the United States have increased by 261% between 2013 and

2018. Miscarriage, stillbirth, and early infant death are all exacerbated by congenital syphilis.

Lifelong physical and neurological effects can also occur as a result of congenital syphilis.

However, congenital syphilis can be prevented if a penicillin treatment is given to pregnant

mothers 30 or more days before their due date. Currently, women in the United States are being

screened for syphilis, but there is a lack of follow-up of the penicillin treatment when pregnant

women test positive for syphilis. This has prompted the Chula Vista Women’s Clinic to

implement a clinical decision support (CDS) within their Electronic Medical Record (EMR)

system. Specifically, they will add an automated order set, which will prompt providers to order

the penicillin or alternative treatment upon a positive syphilis diagnosis. The project will take

approximately 3 months to complete, and it will cost the organization $66,000.00. The project

will be evaluated by determining the number of times the order set was used, the number of

syphilis positive patients given a timely penicillin treatment, and the number of syphilis positive

patients who had a baby without congenital syphilis. The project will be evaluated after 12

months, and it will have yearly evaluations.

Introduction

When syphilis positive pregnant women are not properly treated, they risk infecting their

unborn fetuses with congenital syphilis (Kimball et al, 2021). The risk of miscarriage, stillbirth,

and early infant death are all exacerbated by congenital syphilis (Kimball et al, 2021). When

Mother-to-Child transmission (MTCT) of syphilis occurs, there is also an increased risk for

lifelong physical and neurological problems (Kimball et al, 2021). Transmission can occur at any

stage of maternal syphilis infection, but it is more likely during primary and secondary syphilis,

where transmission likelihood is close to 100% (Warren et al, 2018). In the past decade, the

United States has witnessed a dramatic increase in infants born with congenital syphilis (Kimball

et al, 2021).

Between 2013 and 2018, the incidence of congenital syphilis increased by 261%

(Kimball et al, 2021). Congenital syphilis rates often mirror the rates of primary and secondary

syphilis among women of reproductive age, and this rate has also nearly doubled in the past

decade (Warren et al, 2018). Many states have implemented the current evidence-based practice

(EVP) recommendation by the Centers for Disease Control and Prevention (CDC) and United

States Preventative Task Force (USPTF) (Kimball et al, 2021). The USPTF recommends

screening for syphilis at the first prenatal appointment (USPTF, 2018). Currently, 45 states

require syphilis testing at the first prenatal visit or soon after (Warren et al, 2018).

Because of the increased amount of syphilis screening at early pregnancy, syphilis

positive women are often aware of their current disease status (Kimball et al, 2018). However,

there is a lag that exists between the diagnosis of syphilis and the treatment of syphilis in

pregnant women (Kimball et al, 2018). The current recommendations states that the penicillin-
based regimen must be initiated approximately 30 days before delivery (Kimball et al, 2018).

When this treatment is delayed or not given to the pregnant mother, the risk of vertical

transmission to the fetus increases (Kimball et al, 2018). 31% of congenital syphilis cases were

attributed to a lack of preventative care, even if the mother was timely diagnosed with syphilis

(Kimball et al, 2018).

Clinical Decision Support (CDS) can help increase clinical adherence to the current CDC

guidelines for syphilis positive pregnant women. Clinicians are often expected to learn and

implement new clinical guidelines, but there is often a lack of adherence to new guidelines and

care pathways (Sutton et al, 2020). When looking at congenital syphilis, it appears that there is a

disconnect between the maternal diagnosis and follow-up treatment (Kimball et al, 2020). CDS

will address this disconnect by prompting providers to provide the necessary maternal treatment

to prevent congenital syphilis.

The Chula Vista Women’s Clinic located in Chula Vista, San Diego is especially

concerned about the drastic increase in congenital syphilis cases. The clinic specializes in

women’s health, and they also treat pregnant women. They see about 50-70 patients each day,

and their patients are from primarily low to middle income households. Most of their patients are

insured by Medi-Cal or by the Centers for Medicaid and Medicare Services (CMS). The staff of

the clinic includes 2 Medical Doctors (MDs), 3 Nurse Practitioners (NPs), 4 Registered Nurses

(RNs), 5 Medical Assistants (MAs), 1 Office Manager/Scheduler, 1 Receptionist, 2 in the Billing

Department, and 1 contracted IT administrator.

Proposed Method

The CDS will target timely treatment of syphilis during pregnancy using automated

orders. Using automated order sets have shown to improve medical practice and reduce medical

errors. Order suggestions have shown to increase adherence to clinical guidelines (Overhage et

al, 1997). Overhage et al found that 50% of providers that were sent suggested orders after

certain tests or medications were ordered were more likely to adhere to clinical guidelines

compared to the 20% in the control group (1997). Automated order sets can be used to remind

providers that the penicillin treatment must follow after a diagnosis of maternal syphilis. The

suggested order set will prompt the provider to prescribe penicillin or an alternative treatment

based on the patient’s current diagnosis status. The driver of this CDS is to increase quality and

promote patient safety amongst pregnant women who were diagnosed with syphilis.

EMR Look and Feel

The optimal point in the workflow will be during an MD or NP’s encounter with a

syphilis positive pregnant patient (see Appendix A for workflow diagram). During an encounter

with a pregnant patient, the EMR will be doing work in the background to ensure the patient has

been previously tested for syphilis. If the patient does not have a syphilis test in their EMR

record, the CDS will alert the provider to order a syphilis test for the patient. Once the syphilis

test is ordered, a RN will draw the patient’s blood and take the sample to processing. Because the

syphilis test is a point of care test and results can be returned instantaneously, the provider will

then continue on with the patient encounter. If the test result is positive or if the patient has a

previously positive test, then MD or NP will then be alerted that a penicillin treatment or similar

medication (if the patient is allergic to penicillin) should be added to the patient’s orders. The
alert for the automated order will appear as a pop-up, and it will be a red box that will alert the

MD or NP that the patient is more than 30 days away from her due date and a penicillin

treatment should be added (see Appendix B for screen captures of EMR). The provider will have

the option to order the penicillin treatment or ignore the pop-up. If the provider chooses to use

the automated order set, they will be taken directly to the orders screen, where they will see the

penicillin or similar treatment order appear at the top (see Appendix B for screen captures of

EMR). Before leaving the clinic, a RN will administer the penicillin or alternative treatment.

Boolean Logic

The Boolean statements below indicate when the CDS will be triggered. However, it

should be noted that the CDS will only be triggered when an NP or MD has an encounter with a

pregnant patient.

 If patient has taken a syphilis test AND patient is syphilis positive AND has no previous

order for penicillin or related treatment, then CDS is triggered.

 If patient has taken a syphilis test AND patient is syphilis positive AND has no previous

order for penicillin or related treatment AND is allergic to penicillin, then CDS triggered

but alternative medications will be suggested instead.

 If patient is has taken a syphilis test AND is syphilis positive AND has record of

penicillin treatment, then CDS is not triggered.

 If patient has taken a syphilis test AND is syphilis positive AND has record of related

medication treatment (but is not penicillin due to their known drug allergies), then CDS

is not triggered.

 If patient has taken a syphilis test AND is syphilis negative, then CDS is not triggered.
Implementation Plan

The target user group of the CDS will be the MDs and the NPs since they are the only

providers that can prescribe medication.

Planning

In order to implement this new CDS, the clinic hired a Project Manager (PM) who will

oversee the implementation of the new CDS. 1 NP and 2 RNs have also agreed to be on the

implementation team as they are interested in eventually having leadership roles within their

organization. The NP catalogued the current workflow when a syphilis positive patient is

identified. The implementation team also did a Gemba Walk to watch how the MDs and NPs

currently prescribe the penicillin treatment for syphilis positive pregnant patients. Upon analysis

of the current state workflow and their observations from the Gemba Walk, the team created the

future state workflow (see Appendix A for workflow diagram). During this stage, the team

decided that the project will take approximately 3 months to complete.

Building/Testing

The clinic’s EMR vendor, DrChrono, has offered to build the new CDS into the existing

EMR. The implementation team decided this would be the best option considering the technical

limitations of the current staff. DrChrono has graciously offered to do all the testing as well. The

DrChrono staff will work directly with the contracted IT Administrator to ensure the clinic’s

hardware can handle the EMR updates. The clinic already has portable tablets for every staff

member and computers in each examination room so they decided there would be no need to

purchase additional devices. The training afternoon, mentioned in more detail in the next section,

was announced to all members of the staff. The scheduler was made aware to not schedule any

appointments at 3:00 p.m. or later on the day of staff training.

Training

The implementation team decided it would be best for the clinic to close starting at 3:00

p.m. to do a training afternoon with the 2 MDs and 3 NPs. Because the build will be developed

by DrChrono, a DrChrono trainer will be teaching the clinical staff about the new feature. The

implementation team also presented on why this change is important for the clinic so that the

MDs and NPs understood why it is important for this EMR change to take place. Training will

only take one afternoon.

Go-Live

Immediately after the clinical staff are trained, the new EMR features will go-live

overnight at 11:59 p.m. that same day. After training the MDs and NPs, the DrChrono on-site

staff and the implementation team will stay at the clinic to ensure the process of updating the

EMR goes smoothly. The implementation team believed this would produce the best results

because only a few staff members will be affected by the change. Since the change only effects a

small portion of the EMR, it is believed an immediate go-live after training would help the

providers adjust more easily to the new changes. The DrChrono staff stayed at the clinic for 1

day after GoLive to ensure that the EMR updates were successful and to assist the MDs and NPs

with any troubleshooting.

Post Go-Live

After Go-Live, the implementation team will conduct a post implementation survey with

the NPs and MDs to see how they thought the Go-Live day went. This survey will occur

approximately 2 weeks after Go-Live so that the thoughts about the implementation process are

still fresh in the MDs’ and NPs’ memories. The implementation team will also evaluate any of
the “issues” reported list to see if any were directly related to the congenital syphilis EMR

feature.

Budget

Item Cost Justification

Project Manager Salary
(3 months)
DrChrono: Special EMR
Feature Build
DrChrono: Trainer and Go-
Live Support person
Payroll for Implementation
Team
Total
$25,000.00 The project manager is needed to lead the
implementation team and execute the entire
CDS implementation.
$30,000.00 The clinic does not have an informaticist who
can build new EMR features for them. They
must contract their EMR vendor to build the
CDS rule for them.
$6,000.00 The trainer will ensure the MDs and NPs know
how to use the new EMR features. The Go-Live
support person will ensure the updates are
installed correctly and offer Go-Live support on
the day of implementation.
$5,000.00 Overtime pay for the 1 NP and 2 RNs who will
stay at the clinic after hours when the DrChrono
staff installs the updates.
$66,000.00

Timeline

The project will take 3 months to complete. During month 1, the implementation team

will meet to do all the planning for the project. During month 2, DrChrono will also be contacted

to build the EMR feature, and it will take them approximately 1 month to complete the entire

build. During month 3, DrChrono will test the new features with the existing interface, and the

implementation team will continue to plan the training afternoon. At the end of month 3, the

trainer will conduct the training for the MDs and NPs, and as mentioned in the implementation

plan, Go-Live will occur that same day at 11:59 p.m.

Monitoring and Evaluation

The first evaluation of the CDS will be done 12 months after Go-Live day. The reason

the implementation team decided the first evaluation would occur 12 months after Go-Live is

because the average pregnancy is 9 months. They wanted to ensure that the data collected about

the CDS was reflective of patients who saw the providers throughout the course of their entire

pregnancy. The CDS will be evaluated based on the following indicators:

1. For syphilis positive pregnant patients, the number of times the providers ordered the

suggested order set, including non-penicillin medications for patients who were allergic

to penicillin. This metric will be considered successful if it occurs 75% +1 during the

evaluation period.

2. For syphilis positive pregnant patients, the number of patients treated more than 30 days

before their expected due date. This metric will be considered successful if it occurs 80%

+1 during the evaluation period.

3. For syphilis positive pregnant patients, number of syphilis positive patients whose babies

were born without congenital syphilis. This metric will be considered successful if it

occurs 90% +1 during the evaluation period.

The evaluation results will be compared to the status quo data, which will be collected on

the day before Go-Live. This data will be pulled from the existing patient charts in the EMR.

After the initial evaluation, the CDS will be evaluated once a year.
 References

Kimball, A., Miele, K., Bowen, V., Torrone, E., & Kreisel, K. (2021). National and Regional

Congenital Syphilis Prevention Opportunities — United States, 2018. Section on

Neonatal-Perinatal Medicine Program. doi:10.1542/peds.147.3_meetingabstract.717

Warren, H. P., Cramer, R., Kidd, S., & Leichliter, J. S. (2018). State Requirements for Prenatal

Syphilis Screening in the United States, 2016. Maternal and Child Health Journal, 22(9),

1227-1232. doi:10.1007/s10995-018-2592-0

Final Recommendation Statement: Syphilis Infection in Pregnant Women: Screening: United

States Preventive Services Taskforce. (2018, September 04.

https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatem

entFinal/syphilis-infection-in-pregnancy-screening

Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I.

(2020). An overview of clinical decision support systems: Benefits, risks, and strategies

for success. Npj Digital Medicine, 3(1). doi:10.1038/s41746-020-0221-y

Overhage, J. M., Tierney, W. M., Zhou, X., & Mcdonald, C. J. (1997). A Randomized Trial of

"Corollary Orders" to Prevent Errors of Omission. Journal of the American Medical

Informatics Association, 4(5), 364-375. doi:10.1136/jamia.1997.0040364

 Appendix A

Note. The above figure is the future state workflow for the use of the congenital syphilis order

set.
 Appendix B

Note. The first screen capture shows the alert given to clinicians when the CDS is triggered. The

second screen captures shows the automated penicillin order in the patient’s orders tab.