As emergency medicine and infectious disease physicians, we often see patients with chlamydia, gonorrhea, and other sexually transmitted infections (STIs). Diagnosing and treating these diseases is generally straightforward. What isn’t straightforward — and is often frustrating and impossible — is treating the person at the other end of the two-way street that makes up an STI.
Treating partners should be easier to do than it is. But it is blocked in large part by the electronic health records used in most health systems and by health insurance policies.
Cases of chlamydia and gonorrhea are close to the highest they have been in the past decade. According to new data from the Centers for Disease Control and Prevention (CDC), even during the Covid-19 pandemic there were 2.4 million cases of STIs in 2020, and case of gonorrhea increased 10% between 2019 and 2020. Mirroring the stark racial disparities witnessed with Covid-19, there is a staggeringly unequal burden of sexually transmitted infections (STIs).
Untreated gonorrhea and chlamydia are particularly harmful to women. They can lead to serious pelvic infections, increase the risk of HIV, cause infertility, and threaten the health of newborn babies.
After a decade of declining budgets for local health departments followed by a pandemic-related reduction in sexual health clinics and other services, the funding situation has only gotten worse. Across the country, health departments do not have the capacity to provide contact tracing to identify the partners of patients diagnosed with chlamydia, and only in select cases have that capability for gonorrhea. People with sexually transmitted infections are now spilling over to the de facto safety net — emergency departments — which have experienced a three-fold increase in the share of reported gonorrhea and chlamydia cases reported to the CDC from 2010 to 2018.
One way to combine treatment and prevention is with a practice known as expedited partner therapy, which has been around for years but is unused because of several practice barriers. This harm-reduction strategy makes it possible to treat partners of patients diagnosed with STIs without requiring them to come in for visits. It has been recommended by the CDC for the past 16 years. It’s also legal or potentially allowable in all U.S. states, and has been shown to reduce the rate of repeat STIs. Since California started offering expedited partner therapy more than a decade ago, no severe adverse effects have been reported. So, if expedited partner therapy is effective and safe, what is stopping physicians from using it?
Partner therapy is designed so the patient being treated does not need to share the partner’s name. But an electronic prescription cannot be sent to an unnamed person, and it is impossible to bill insurance for the service.
As we write this, most major health systems do not provide a way for physicians to electronically prescribe expedited partner therapy. One reason is that the most-used electronic health record, has still not created an electronic prescription pathway to enable partners to receive STI treatment. Thirty-four states have current or future laws requiring that all prescriptions to be sent electronically, so the lack of an electronic pathway effectively shuts down using expedited partner therapy when paper prescriptions aren’t available. Despite being aware of this issue, the failure to have prescribing options for expedited partner therapy in all electronic health record systems may reflect the medical system’s prioritization of direct patient care over public health needs.
Insurance barriers further hinder the provision of take-home medication kits for the partner. These include pre-dosed medicines, informational materials, and clinic contacts for the partner. But because health insurance in most states won’t cover medicines meant for anyone other than the insured individual, there is no one to pay for these kits. Some clinics have received specially allocated governmental grants for family planning or public funds to help pay for expedited partner therapy, but many of those whose partners need this therapy are being diagnosed and treated in settings that have no such funding.
Innovative workarounds are being developed. The Institute for Family Health in New York City has devised workflows in its electronic health record to prescribe to anonymous profiles, allowing patients or their partners to pick up the treatment straight from retail pharmacies. In California, recent policy changes to Medicaid plans allow low-income patients to use their own insurance to pay for partner prescription. Emergency clinicians affiliated with Colorado’s UCHealth will hand write prescriptions for partners. Clinicians at the University of Michigan and Johns Hopkins health systems are able to print prescriptions using regular printer paper through specific health record orders designed to support partner therapy.
More such efforts are needed. Or, better yet, the health systems, electronic health record vendors, and insurers that are entrusted with caring for patients and communities must step up to the plate and devise simple solutions to expedited partner therapy and help quell the rising tide of sexually transmitted infections.
Rachel Solnick is an emergency medicine physician, health services researcher, and assistant professor of emergency medicine at Icahn School of Medicine at Mount Sinai. Jason Zucker is an adult and pediatric infectious diseases physician, assistant medical director of the New York City STD Prevention and Training Center, and an assistant professor of medicine at the Columbia University Irving Medical Center.
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