As reports of gonorrhea (GC) and chlamydia (CT) increase across the United States1 without a similar increase in funding for sexually transmitted disease (STD) control,2 health departments need affordable solutions to improve local prevention efforts. Many STD clinics, including those in North Carolina, rely on staff time to call patients testing positive for GC or CT to notify them of results and schedule treatment. Text messaging and e-mail communication is ubiquitous and immediate,3 and has been used to provide a variety of health interventions.4 Electronic messaging (text message or e-mail) has been used successfully in other STD clinics to inform patients of their results quickly while simultaneously reducing the amount of staff time spent calling patients with results.5–7 Chexout, a software designed to notify patients of available test results using electronic messaging, was implemented in the Durham County STD clinic in North Carolina in 2018 to facilitate GC and CT result notification. The Durham STD Clinic also incorporated partner notification and 3-month rescreening reminders into the electronic messaging provided by Chexout. To assess patient opinions about these services, we conducted a short survey with patients that opted in and opted out of receiving electronic messaging.
In March 2018, the Durham County Department of Public Health STD clinic integrated the Chexout Result Notification package into clinic procedures for patients that tested for GC or CT. Clinic staff worked with Chexout programmers to tailor the software to the preferences of the STD clinic, and to interface with the clinic's electronic medical record (EMR) system. Upon arrival, clinic patients can “opt-in” to be notified of their GC and CT results via Chexout using text message or e-mail or “opt-out” to notification by phone, which was the standard method of providing positive result notification in Durham. Under the opt-out notification method, patients testing negative for GC and CT were not notified of their results unless they called the clinic.
Text/e-mail notifications for all opt-in patients, regardless of their test result, included a link to the secure Chexout-sponsored patient portal where they could view their results. If the patient tested positive and had not received presumptive therapy, the text/e-mail also included the clinic phone number for the patient to call and schedule a treatment appointment: “Your lab results are available: (Chexout portal website). To schedule an appointment, call (clinic phone number).” The text/e-mail included no mention of specific STDs or laboratory results. Within the Chexout portal, we developed four services for patients testing positive for GC or CT. First, we included a link to the health department website with information about local GC/CT treatment options, tips for notifying partners, information about reinfections, and the importance of rescreening in 3 months. Second, we provided unique code words that infected patients could give to partners for prioritization at the STD clinic (and allow us to link them confidentially within their EMRs). Third, infected patients could provide contact information (cell phone or email address) for partners in a secure online form if they wanted health department staff to notify their partners anonymously. Finally, we incorporated a 3-month reminder text/e-mail that said, “A check-up is a good idea even if you feel fine” and linked patients to the portal where they could find local resources for CT/GC rescreening.
For both opt-in and opt-out patient populations, we attempted to interview every other patient requesting GC and CT testing between May and June 2018 (a 50% random sample) to assess patient opinions about electronic messaging services for STD care. The responses from opt-out patients helped elucidate barriers to implementing electronic messaging in our patient population. We attempted to contact patients up to 5 times to conduct a 5-minute telephone survey. Responses were entered into a password-protected Access database and analyzed using SAS version 9.4 (Cary, NC). We compared responses by opt-in status and GC/CT positivity using χ2 tests or Fisher exact test when numbers were small for categorical variables and Wilcoxon rank sum tests for continuous variables. This evaluation of a public health program was considered exempt by the University of North Carolina Institutional Review Board.
In total, 634 patients requested GC/CT testing from the STD clinic (530 opt-in and 104 opt-out) between May and June 2018. We randomly sampled 50% of each group (N = 317; 265 opt-in and 52 opt-out) to call for the follow-up survey: 48 (15.1%) refused to participate (39 [14.7%] opt-in, 9 [17.2%] opt-out), 126 (39.7%) could not be reached (113 [42.6%] opt-in, 13 [25.0%] opt-out), and 143 (45.1%) were interviewed (113 [42.6%] opt-in, 30 [57.7%] opt-out). Compared with surveyed opt-out patients, opt-in patients were more likely to be female (57.5% vs. 33.3%; P = 0.02) and were younger (median: 27 vs. 37 years, P = 0.002) (Table 1).
Over three quarters of surveyed opt-in patients were notified that their results were available to view on the patient portal via text message (78.8%); most opt-in patients reported that they viewed their results in the Chexout patient portal (86.7%). Opt-in patients found result notification via text/e-mail satisfactory (99.0%) and easy to use (92.9%). Eleven patients remarked that they preferred electronic result notification to “playing phone tag” with clinic staff to obtain results (standard/opt-out notification method). Nine opt-in patients with negative results noted the added benefit of being able to take screenshots of their results to show partners. Most opt-in patients (87.4%) were not worried that another person would see the text/e-mail notification. The most commonly reported complaints about text/e-mail result notification were desires to have other STD results (e.g., syphilis, HIV) included in the portal (n = 6) and concerns about confidentiality (n = 3) (Table 1).
Opt-out patients listed multiple reasons for declining text/e-mail notification, including concerns for privacy (56.7%), not being technologically savvy (30.0%), and not wanting “more text messages or e-mails” (6.7%) (Table 1). Over half of opt-out patients shared a cell phone with another person (56.7%) and 63% shared an e-mail address with another person. Among opt-out patients, 40% (n = 12) reported that they never learned their results since the clinic does not typically notify patients with negative test results.
Both opt-in and opt-out patients said they would prefer to tell their partners themselves if they had positive test results (opt-in = 88.5%; opt-out = 76.7%). Most of the 21 opt-in patients who tested positive for GC or CT read the information in the portal about treatment and partner notification (61.9%), but only 42.9% (n = 9) clicked the website link with additional local STD resources. Less than one third of infected opt-in patients saw the partner code word (n = 6; 28.6%) and only 2 gave the code word to their partners.
Compared with opt-out patients, a higher proportion of opt-in patients were willing to receive a reminder from the clinic to rescreen for GC/CT after 3 months (66.4% vs. 20.0%; P < 0.0001). Among patients willing to be reminded to rescreen, 64.0% of opt-in patient preferred a reminder via text message, and 66.7% of opt-out patients wanted to be reminded with a phone call (Table 1). Respondents thought the reminder message should be “vague” and not mention STDs specifically. Most respondents that did not want a reminder message stated they test regularly.
We found that electronic messaging was an acceptable modality for GC/CT result notification and rescreening reminders among persons seeking STD services, particularly among younger patients. Most clinic attendees preferred result notification via text message or e-mail to a phone call; these patients found the system easy to use and liked the convenience of viewing their results on their personal devices. Clinic patients that preferred a phone call from the clinic were generally older and reported more concerns about privacy surrounding electronic notification than opt-in patients. Allowing for multiple methods for notification may empower patients by providing information in a format that patients find most accessible, which in turn may encourage increased STD screening.
Interventions capitalizing on existing technology could improve STD care and prevention services. In our sample, only one respondent (3.3%) opted out of electronic result notification because they had neither a cell phone nor an e-mail address to receive messages. Previously, text messages and e-mails have been used successfully to notify patients of their STD results,5–8 provide general STD information,9,10 and remind STD patients about appointments and rescreening.11,12 Similar to the results from our survey, patient acceptability of these services in previous studies may depend on test positivity, age, and gender.8,13–15 However, opt-in patients in our sample overwhelmingly found text/e-mail notification to be satisfactory, and several patients preferred it to notification via phone calls.
The high volume of GC/CT patients across the United States often times prohibits health departments from providing formal partner notification services. We developed online partner notification resources, including the code word in Chexout. However, this resource was infrequently used by survey respondents, possibly because this process was confusing or not visually engaging. Improved efforts to develop practical and appealing partner notification strategies using current technologies are necessary for effective notification and treatment of sex partners potentially exposed to GC or CT.
We did not assess changes to clinic staff workload in this analysis. Under Chexout, staff no longer need to notify every patient; however, some staff time is still needed to ensure that local customizations work as intended and patients view their results and are treated, if positive. Patients that did not check the patient portal need to be contacted by clinic staff. By eliminating patients that can easily navigate clinic and treatment processes from staff workload, increased attention can be focused on the presumably harder to reach patient population.
Health departments constantly search for improvements to STD services that are both inexpensive and impactful. Increasingly, people rely on personal electronic devices to access information, including healthcare information. Leveraging this existing technology can enhance the flow of information between the STD clinic and the patient and ultimately improve patient care.
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