Medical Record Auditing for Hepatitis C

• The target population will depend on your practice type, location, patient demographic
• You can choose to be specific or more general in your search, depending on the type of patients you are trying to reach
• Will you be searching electronic medical records or paper-based records?
• You may have several different target populations; it can be useful to prioritise these populations in order of urgency, so you don’t have an overwhelming workload. Make sure all involved in the audit at a service level understand the inclusion and exclusion criteria.
• Examples of populations could include:
  • People with a positive hepatitis c antibody test
  • People who have had a hepatitis C RNA test in the past
  • People who inject drugs
  • People on opioid agonist therapy (OAT)
  • People who were born or who have lived in a high prevalence country
  • People who have had blood transfusions in countries where transfused blood is not screened for hepatitis
  • Or a specific age cohort, amongst other populations.
• It is important to remember that there may be some limitations in what information you can get from your Practice Management Software
• You may have to think creatively about your search terms and target population to create your list of people for follow up

Identify your patients 

• Familiarise yourself with the search functions of the software used in your practice. 
• Develop a register of patients to be recalled. A register is effectively a list so simple spreadsheet would suffice.
• It may be useful to review pathology results to identify people for recall. Practice Management Software search functions often have limited capacity to extract pathology results. Consider approaching the pathology providers who service your clinic as they may be able to provide patients level data on investigations and results
• There are data extraction systems, usually available from a third party. These are very useful for practice level data to measure outcomes.

Defining your search terms

• Common search terms:

1. People with a diagnosis of hepatitis C (to find people who have been diagnosed but not yet treated) (searching up ‘Hepatitis C’ or ‘HCV’ or ‘Viral Hepatitis’ when doing a Conditions/Diagnosis/Clinical Items report)
2. People with a positive hepatitis c antibody test (this may be tricky and there are a lot of factors– search up ‘Hepatitis’ when searching up in an Investigations’ report, then crosschecking whether results are a) reviewed b) unreviewed c) ordered but not received d) results received but not matched to a patient)
3. People who have a positive hepatitis C RNA test (ribonucleic acid amplification test) (this may be tricky and there are a lot of confounding factors– search up ‘Hepatitis’ when searching up in an Investigations’ report, then crosschecking whether results are a) reviewed b) unreviewed c) ordered but not received d) results received but not matched to a patient)
4. People who have a history of injecting drug use (searching up injecting drug use (IDU)/former IDU, polysubstance abuse/substance use/methamphetamine/ heroin/opioid use/ketamine when doing a Conditions/Diagnosis/Clinical Items report)
5. People currently on Opioid Agonist Therapy (searching up ‘Methadone’,  ‘Buprenorphine’, ‘Sublocade®’ ‘Buvidal®’ or other opioid agonist therapies when doing a ‘Medications’ report – making sure you capture those prescribed at the service and those prescribed elsewhere but then recorded in their Medication History.
6. Children of people with hepatitis C (when you have made a register of clients with ‘Hepatitis C’ then there may be a way to filter by ‘Dependents’
7. People born or who have lived in a country with high hepatitis C prevalence
8. People in an age range cohort
9. People who have had blood transfusions in countries where transfused blood is not screened for hepatitis C
10. People who have had medical/dental procedures in countries that may have inadequate sterilisation
11. People who have received unsterile tattoos or body art
12. People with high liver enzymes
13. People with a history of incarceration (independent risk factor in Australia)
14. People who have been prescribed treatment for hepatitis C (to recall for SVR/look for reinfection)

• Practice management software search functions can be limited in what they are able to search for. You may have to rethink your target population in creative ways so you can search for them.
• You may need to change your search terms to increase or decrease the number of patients identified, based on your clinic’s capacity to follow these patients up

Helpful resources:

• What does the evidence say?
• Resources, tools, proforma 

• Add patient specific detail to your list/register. Consider including details such as:
  • Age
  • Indigenous status
  • Cultural background
  • Hepatitis C antibody result
  • Hepatitis C RNA result
  • Hepatitis C genotype (no longer needed in some locations)
  • APRI score (AST to Platelet Ratio index – freely available calculators are available that use the AST and platelet results to estimate the likelihood of cirrhosis)
  • FIB 4 Score (uses a combination of patient age, platelet count, AST and ALT to help estimate the amount of scarring in the liver)
  • Fibroscan score (liver elastography where available)
  • Previous treatment
  • SVR12

• Use your clinical judgement to decide the most appropriate care to offer the patient. It may be:
  • Screening for hepatitis c infection according to risk factors. If you haven’t seen the patient in many years following up to see if the patient has been treated for HCV
  • Treatment of hepatitis C due to known infection
  • Follow up to ascertain SVR12
  • Testing or treatment for reinfection
  • Referral or management of advanced liver disease
  • Hepatocellular carcinoma (HCC) surveillance

• Use existing systems within your practice to recall the client you have identified
• Consider SMS, email phone or letter to contact the patient to offer an appointment
• Leave a message at the patient’s pharmacy (or shelter or outreach worker) to call or come to the clinic
• Add a reminder in the client’s file to flag what needs to be discussed/offered at next visit.

Systems and Training

• It is ideal to develop a sustainable system within your practice that is not dependent on a single person.
• Ensure the whole team – doctors, nurses and support staff are aware of the process and have adequate training.
• Consider training in:
  • Hepatitis C clinical management
  • Stigma and Discrimination
  • Cultural awareness
  • The use of clinical software and coding clinical entries
  • The use of data extraction software
• Consider sharing success stories at clinical meetings or team building days to create champions in the clinic

Role allocation

• Allocate who will do the work to recall the patients you have identified. It is important to have role allocation when conducting recalls of patients into your clinic and to ensure that the staff who have been tasked with conducting this task have time, skills and capacity to do so.

Managing the workload

• Organizing protected time away from usual duties for staff to conduct the recall can be helpful to ensure it can be done
• Assess the amount of follow-up to be done vs the staff capacity. You may need to scale your search terms up or down to make sure the workload remains manageable.

Communication

• It is vital that the whole team is aware of the process – from the person conducting the search, right through to the clinician who is ordering tests, prescribing treatment, or having a conversation with the patient

 Clinical capacity

• Can your practice provide the care? Do all GPs and nurses in the clinic know how to manage someone with hepatitis C? Make sure that you have the clinical capacity to provide the follow-up care

Helpful resources:

• Toronto Community Hep C Program Peer Manual 
• The Hepatitis C Trust Resources  
• Resources, tools, proforma

Review the findings of the audit and identify the opportunities for quality improvement, using the findings to guide next steps. Summarising the findings is critical given disorganised or unnecessary data may result in an inability to use the results to enable change.

Reflect on how you will present the findings, summarising the data in a way which will be most impactful.

Helpful resources:

• What does the evidence say?
• Resources, tools, proforma 

Organizing protected time away from usual duties for staff to conduct the recall can be helpful to ensure it can all be done. Assess the amount of follow up to be done vs the staff capacity. You may need to scale your search terms up or down to make sure the workload remains manageable. 

Clear role allocation for the different tasks involved. Who will conduct the recall for the clients you have identified. It is important to have role allocation when conducting recalls of patients into your clinic and to ensure that the staff who have been tasked with conducting this task have time, skills and capacity to do so. 

Ensure staff have access to education and training as well as resources that ensure they have the skills and knowledge to provide care.  

Can your practice provide the care? Do all GPs and nurses in the clinic know how to manage someone with hepatitis C? Make sure that you have the clinical capacity to provide the follow-up care required.  

In some regions, government agencies, departments of health, health networks or national/state peak bodies will provide additional funding to clinics to conduct a quality improvement program.  

It is worth looking into what financial incentives are available to your clinic before undertaking your project.  

Utilise global best practice examples from services who have successfully implemented and undertaken auditing projects for hepatitis C as an evidence based to demonstrate efficacy.