EHR template boosts childhood TB risk screening but testing gaps remain

Tuberculosis remains a concern in U.S. pediatric care because identifying and treating latent tuberculosis infection (LTBI) prevents future disease, yet many children with risk factors are missed. To better understand where children fall out of the care process, researchers led by Julia Fink used electronic health record (EHR) data to follow the full LTBI care cascade in a real-world primary care setting. The team examined well-child and adolescent visits at a federally qualified health center in Northern California from 2014 to 2020, capturing 18,681 visits from 10,409 children. The median age in the group was 6.9 years. In 2014 the clinic added a TB risk factor question to the progress note template and the investigators tracked whether that EHR prompt changed practice over time. By using routinely collected EHR information, the study aimed to measure screening, testing, diagnosis, and follow-up steps so that gaps in care could be identified and addressed using tools already available to clinicians.

The team constructed an LTBI care cascade that followed patients from initial risk factor screening through testing and treatment, and they used multivariable logistic regression to identify factors associated with completion of each step. Data came from well-child and adolescent visits between 2014 and 2020. Overall, 90% of visits completed a TB risk factor screening, and the addition of a question in the progress note template significantly increased screening over time. Despite high screening, only 20% of children who had a documented TB risk factor had testing ordered; however, that testing rate rose from 7% early in the study period to 33% by the end. Among those who were tested, 4% had a positive result, and most of those children completed the next steps in care. Age-related differences were identified: children under 5 years old were more likely to receive risk factor screening than older children, but they were less likely to be tested after a positive screen.

These findings show that simple EHR-based changes can increase routine screening for TB risk in pediatric primary care, but screening alone does not ensure testing and diagnosis. High screening rates are encouraging, yet the gap between identifying risk and ordering a test means some children with LTBI may remain undiagnosed and untreated. The study supports using the EHR not only to prompt clinicians to ask about risk factors but also to monitor downstream actions—such as ordering tests and completing follow-up—so clinics can target where patients fall out of the cascade. Because previous efforts to map the pediatric LTBI care cascade were incomplete, this full EHR-based assessment helps pinpoint opportunities to close the loop: implementing and refining EHR templates, tracking testing completion, and focusing on younger children who are screened but less often tested. Overall, the research suggests scalable, low-cost EHR tools could improve detection and management of LTBI in children if matched with systems to ensure testing and treatment follow-through.