CAN ADAPTIVE ELECTRONIC MEDICAL RECORD (EMR) TECHNOLOGY BE USED TO DEVELOP A SCREENING AND TREATMENT PATHWAY FOR PATIENTS WITH HEPATITIS C VIRUS IN ALBERTA?

UNDERSTANDING THE EPIDEMIOLOGY AND RISK FACTORS OF HCV

• Hepatitis C Virus (HCV) is a high morbidity and mortality disease identified by the World Health Organization (WHO) as one of the Top 10 eradicable diseases, globally. Disease complexity is compounded due to latency. It presents acutely and at end stages. World-wide about 71 million people have chronic HCV with a large portion being undiagnosed and untreated (refs: 1). In Canada, approximately 50% to 75% of patients with chronic HCV are unaware of their diagnosis (ref: 2).

See Figure 1

As per peer-reviewed literature, HCV patients present with common criteria:

• Given the asymptomatic nature of new infections, patients are (often) only diagnosed at late stage with severe liver damage such as cirrhosis (ref: 3).
• Presentation is frequent in high-risk populations with highest cases numbers for specific marginalized populations. Health Canada (2025)4 statistics estimate that \~22% of intravenous drug users have a corollary diagnosis of HCV.
• Barriers to access for the patient population include stigma, discrimination, lack of transportation and unstable housing/ homelessness; all of these prevent high-risk individuals from accessing healthcare and testing (ref: 5, 6)
• Recent data suggests knowledge gaps for community caregivers. Providers have insufficient knowledge of risk factors resulting in low screening rates. In one national study (ref; 7), 73% of primary care physicians reported seeing five or fewer HCV patients in a year.

See Figure 2

HEPATITIS C PREVALENCE IN ALBERTA

• Research on HCV prevalence suggests about \~19,000 HCV positive patients province wide in 2024 (ref: 10); rates declined sharply since the 90s due to the introduction of antivirals. The literature notes a lower HCV prevalence (5 per 1000 persons) in Calgary compared to Edmonton (8 per 1000 persons) (refs: 10, 11).  There may be pockets of higher prevalence with Indigenous communities, both on reserves (7.4 per 1000), and off reserves (12.3 per 1000) (refs: 11, 12).
• In 2024, Brahmania et al., undertook research to map hot spots of HCV in Alberta. Using updated heat mapping, “hot zones” of untreated HCV infection were identified (i.e. lab serology data).

See Figure 3

• In Alberta, there is not a standardized pathway to identify (or screen for) HCV patients in the community.  This is the next step for better linkage to specialist care and increased treatability of an eradicable disease.

PROJECT PURPOSE

• Project purpose is to build and implement a screening pathway for south Calgary HCV patients using data in the EMR. The pathway proactively flags HCV + patients with the goal of improving the "cascade of care," reducing the number of undiagnosed patients or those “lost to follow-up.”
• An electronic evidence- based screening tool was built in 4 major EMRs in 87 community clinics in south Calgary. Based on clinical risk factors, the screening tool searched for, and identified untreated patients with HCV Ab+, lost to follow-up or lacked documented cure.
• This study evaluates the feasibility of EMR- based triggers to improve identification, re-engagement, and referral to specialty care.
• This research is ongoing; provincial spread and scale is planned to build an HCV screening pathway for Alberta. Work is in partnership with Primary Care Networks (PCNs) in Edmonton and Calgary with the intention of engaging rural sites in Summer 2026.

METHODS   This is a multi-part observational cohort study using the EMR data of patients in the south Calgary catchment (approximately 385,000 patients, 87 family medicine clinics and 381 family physicians).    Phase I: Meta-Analysis Research

1. A meta-analysis was completed to identify evidence- based screening criteria identified in the peer- reviewed literature 
2. A comprehensive search was conducted in the databases CINHAL, EmBase, PsychInfo, PubMed, Web of Science and grey literature from 2020 to present. Search terms combined keywords: ‘HCV positive’, ‘screening’, ‘clinical pathway(s)’, ‘primary care’, ‘intervention’, ‘family medicine’, ‘community medicine’
3. Parameters were patients 18 years + (b. year 2007 or earlier), HCV + identified by serology; exclusions were case studies, single subject designs (see “Evidence Binder” for full report)

Phase 2: Cohort Collection

1. Survey was administered to determine which clinics held HCV patients; distributed to physicians (n = 327) in the south Calgary catchment via a communication portal in South Calgary Primary Care Network (SCPCN), hard copy and QR code on a poster
2. The response rate was 33.7%; n= 111 community physicians reported 50 HCV + (or query +) patients in their panel

Phase 3: Data Extraction and Analysis

1. Following receipt of consent, chart data was extracted (n=50) and multi-variate statistical analysis was completed
2. The extract was retrieved from the EMRs types Aviva, CHR, MedAccess and Accuro; data included key patient demographics and clinical information
3. T-tests (p< 0.05) and odds ratios (OR) compared the identified screening criteria for HCV + (query +) patients and the HCV negative patients. This identified the criteria most effective in predicting early screening for a clinical pathway

ANALYSIS AND LIMITATIONS

ANALYSIS The HCV + results show a clear concentration of cases within specific behavioral and social risk groups rather than even distribution across the population.

• Most HCV + cases are male (OR = 1.72, p < 0.047) suggesting a gender imbalance that reflects different exposure patterns rather than biological susceptibility
• The data shows strong clustering around substance use (OR = 308.6, p< 0.0001) and alcohol abuse (OR = 6.14, p< 0.0001); nearly all heavy drinkers (n = 35/37) are current users (OR = 1.13, p = 0.0378) indicating an ongoing behavioral risk factor
• Drug use categories form the strongest association (OR = 308.6, p < 0.0001) which may be consistent with blood-borne transmission linked to needle sharing and unsafe practices. In contrast, prior blood transfusion exposure accounts for a smaller share of positives (n = 17/ 50, 34%), albeit it is still statistically significant (OR = 3.25, p < 0.0004). This suggests, in this cohort, medical exposure routes are important, but behavioral transmission routes may be still more influential
• Socioeconomic risk patterns suggest that HCV + is tied to overlapping vulnerability factors rather than any single variable alone
• Trends worth noting are ‘Presently Employed’ was significant (OR = 2.54, p < 0.003), education levels skew toward high school (OR = 8.49, p < 0.0001) or below and incarceration history (OR = 1.79, p = 0.04) suggesting a patient who is marginalized but still functional in society
• Race data (OR = 0.71, p = 0.139) cannot be reliably interpreted as most entries are unlisted. This weakens demographic conclusions and highlights a data quality limitation

LIMITATIONS

• The sample size (n=50) is a noteworthy limitation. The cohort shows some variables approaching statistical significance, larger samples may clarify the importance of these risk factors.
• Chart documentation is inconsistent; key word searches were binary. The sample size may be expanded applying synonym searches
• The sample of HCV + patients (n=50) were all attached to a family doctor.  Any patients who do not have a family doctor and HCV + are not captured here study

CONCLUSIONS, REAL LIFE APPLICATIONS AND EXTENSION

CONCLUSIONS

• My hypothesis was correct: an evidence-based EMR-enabled pathway can proactively identify HCV + (or query +) patients in the community. This suggests an efficacious and effective screening pathway supports early identification, expeditious linkage to specialist care and reduces loss to follow-up
• Key data descriptors are past/ present lifestyle factors like incarceration (OR = 1.79), completion of an Audit C alcohol test (OR = 6.14), IV drug use (OR = 308.6), stratified by drug type, and patient history of receiving blood/ blood products (OR = 3.25)
• Apart from sex (male OR = 1.72) the impact of sociodemographic factors (education levels, age) is less clear. Race may be a factor with ‘white’ (OR = 1.39) or ‘other’ (OR = 11.88) show increased risk.  It may be informative for ‘race – other’ to be stratified for Indigenous 11, 12 patients as the literature records higher HCV +

REAL LIFE APPLICATIONS

• This research suggests prevention/ treatment focus less on broad population screening and more on targeted intervention in high-risk groups; programming that expands addiction treatment access, harm-reduction strategies, stable housing, employment support, and routine screening in correctional and recovery settings may produce material reductions in new infections numbers and long-term liver disease outcomes

• This data suggests early behavioral intervention matters as many heavy drinkers are “present” rather than “past”; risk appears connected to long exposure histories meaning earlier prevention may reduce later disease burden

• Research supports a public health approach combining medical care with social and behavioral support systems; drivers of infection are connected to life circumstances and risk environments, not just individual medical events

EXTENSION: This research supports implementation of an HCV screening pathway because (refs 14-17):

1. Proactive\, early detection\, reduced mortality

• Early diagnosis of HCV means less invasive treatments later (i.e. transplant) with fewer side effects

2. Standardization of care (refs: 15\, 17\, 18)

• Consistent evidence-based practices managing HCV patients, regardless of care provider type (i.e. NP, FP, PA)

3. Streamlined triage/ referrals to specialists (refs: 15\, 18\, 19)

• Defines when to refer to specialists, reduces wait for urgent HCV cases

4. Efficient workflows (refs: 15\, 16)

• Automated management low-risk HCV cases, allows community physicians to high-risk complex patients, reduced admin burden/ errors

5. Improved documentation (refs: 14\, 17\, 18)

• Requisite documentation areas made clear

6. Reduced health care costs (refs: 15\, 17\, 19)

• Early intervention is cheaper than later stage more expensive treatments (i.e. transplant)

7. Equity of access to care (refs: 16\, 18\, 19)

• Patient screening is subject to stigma, bias, geographic/ social barriers

See Figure 4

REFERENCES

1. WHO, Global Hepatitis Report 2024, Global hepatitis report 2024: action for access in low- and middle-income countries
2. Public Health Agency of Canada, “CATIE Fact Sheet: The Epidemiology of Hepatitis C in Canada,” fs-epi-hcv-en-10-2025.pdf
3. Brahmania M, et al., HCV Re-Link: Developing and evaluating tailored methods to improve linkage to care for patients with HCV in Alberta, Canada Department of Medicine: Division of Gastroenterology and Hepatology, University of Calgary & University of Alberta, 2024
4. Hepatitis C in Canada: Surveillance Report, Hepatitis C in Canada: 2021 surveillance data update - Canada.ca, updated in July 2025
5. CDC Clinical Overview of Hepatitis C, Clinical Overview of Hepatitis C | Hepatitis C | CDC
6. EASL Practice Guidelines, EASL Recommendations for the Study of Hepatitis C, Journal of Hepatology 2020 vol. 73 pg. 1170–1218
7. Canadian Task Force for Preventative Health Care: Guidelines for Primary Care, Hepatitis C Clinician Summary – Canadian Task Force on Preventive Health Care
8. Thomas DL, Seeff LB. Natural history of hepatitis C. Clin Liver Dis. 2005;9:383-98
9. Hofer H, Watkins-Riedel T, Janata O, et al. Spontaneous viral clearance in patients with acute hepatitis C can be predicted by repeated measurements of serum viral load. Hepatology. 2003; 37:60-4
10. Gill S, Rizwan S, et al., The effect of spatial variation in linkage to care and treatment rates among patients with Hepatitis C: A Canadian population-based study. Canadian Liver Journal. 2024; 11: 447-58
11. Gitau Z, Suarez-Ariza C et al., Epidemiology of Hepatitis C in Alberta, Saskatchewan, and Manitoba compared to Canada. Journal of Infection and Public Health. 19 (2026) 1031–48.,
12. Dunn K, Wardman D et al., Epidemiology of Chronic Hepatitis C in First Nations Populations in Canadian Prairie Provinces. Pathogens 2025 14 693-708.
13. Ha S, S Totten et al., Hepatitis C in Canada and the importance of Risk-based Screening. Can Commun Dis Rep. 2016 Mar 3;42(3):57–62.
14. CDC Clinical Screening and Diagnosis for Hepatitis C https://www.cdc.gov/hepatitis-c/hcp/diagnosis-testing/index.html
15. Sarkeala T Introduction to cancer screening: balancing benefits with potential harms European Journal of Public Health 35 (4) 2025
16. Iagorri N, E Spackman Assessing the value of Screening Tools: reviewing the challenges and opportunities 39 (17) 2018
17. Alberta Health Services Clinical Pathways and Specialty Access   https://www.specialistlink.ca/clinical-pathways-and-specialty-access
18. Weidland D Why Use Pathways rather than Clinical Practice Guidelines? 174 (6) 12 592-595
19. Hepatitis C Elimination Pathway Roadmap Ontario Full Report  https://endhepc.ca/roadmap/

ACKNOWLEGEMENTS ●       Dr. Mayur Brahmania, MD, MPH, Calgary Liver Unit, Faculty of Medicine, University of Calgary ●       Ms. Linh Tran, South Calgary Primary Care Network ●       Mr. Jati Pujol, South Calgary Primary Care Network   Special thanks to the family physicians and health care professionals in south Calgary who participated in (and continue to participate in) this research study.