JMIR Publications

ABSTRACT

Background:

Electronic health record-based clinical decision support (CDS) tools can facilitate sexual risk assessments and support HIV pre-exposure prophylaxis (PrEP) prescribing by prompting clinicians to document sexual risk factors. Nevertheless, clinician experiences with CDS tools to facilitate PrEP prescribing following implementation in primary care is poorly understood.

Objective:

To describe primary care clinicians’ experiences with CDS tools implemented in urban community health clinics to improve sexual health assessment and PrEP prescribing.

Methods:

We surveyed primary care clinicians from 12 urban community health clinics in North Texas using a 12-item questionnaire assessing awareness, use, perceived barriers and facilitators, and usefulness following implementation of a CDS tool including a sexual history questionnaire and PrEP advisory alert. Survey questions were adapted from a prior study that used constructs from the Consolidated Framework for Implementation Research and the Acceptability, Appropriateness, and Feasibility of Intervention Measures to assess clinicians’ perceptions and contextual factors influencing implementation. We collected data via REDCap from July 8 to 29, 2024. We analyzed closed-ended questions using descriptive statistics and evaluated open-ended responses using content analysis. Participants who completed the survey were entered into a drawing for a gift card incentive.

Results:

Our study population comprised 33 clinicians (12% of 284 eligible), of whom 61% were physicians, 30% were nurse practitioners, 88% were older than 30 years, 70% were female, and 58% were non-Hispanic White. Fewer than half were aware of the updated sexual history questionnaire. Clinicians who used the sexual history questionnaire reported that the questionnaire was important to implement (67%), helpful for identifying PrEP candidates (60%), and appropriate for primary care (60%). In contrast, clinicians had concerns about increases in patient interaction time (60%) and workflow fit (47%). Most clinicians agreed that the PrEP advisory alert was appropriate for primary care (78%) and supported guideline-concordant care (73%), but only 40% agreed that the alert fit within the workflow and 53% had concerns about patient interaction time. Qualitative analysis (n = 10) identified themes of workflow disruption and time burden, alert fatigue, provider discomfort, limited understanding of tool functionality, and perceived usefulness for identifying patients at increased HIV risk.

Conclusions:

Clinicians described the CDS tool as appropriate, evidence-based, and valuable for identifying at-risk patients, but uptake was hindered by workflow disruption, time-related barriers, alert fatigue, discomfort with content, and limited understanding of tool functionality. These formative insights underscore the importance of eliciting clinician feedback to address concerns and enhance functionality of CDS tools. In addition, the low response proportion, despite reminders and incentives, emphasizes the need for pragmatic alternatives to collecting meaningful clinician feedback.