The Design Process of a Digital Patient Decision Tool to Increase Sexually Transmitted Infection Testing in the Emergency Department.

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Published in final edited form as: Sex Transm Dis. 2025 Jun 4;52(8):462–469. doi: 10.1097/OLQ.0000000000002166 The Design Process of a Digital Patient Decision Tool to Increase Sexually Transmitted Infection Testing in the Emergency Department Lauren S Chernick 1, 2 , Talia Adler 1 , Jaciara N De Souza 1 , Christina N Franqui 1 , Lisa-Pierre Tchoungui 1 , Anna Caselli 3 , Ariel Tyndell 3 , Renato Castilho 3, * , Marc A Probst 1 , Delivette Castor 4, 5 , Jason Zucker 4, 6 Author information Article notes Copyright and License information 1 Department of Emergency Medicine, 3959 Broadway, CHN 1-116, Columbia University Medical Center, NY, NY, United States 2 Department of Population and Family Health, Mailman School of Public Health, Columbia University Medical Center, 60 Haven Ave, NY, NY, 10032, United States 3 Modus Agency, 3003 Purchase St., Unit 159, Purchase, NY 1057 4 Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, 622 West 168th Street, New York, NY 10032, USA 5 Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, USA 6 Department of Pediatrics, Columbia University Medical Center, NY, NY, United States * There is no terminal degree to report. ✉ Corresponding author: Lauren Chernick MD MS, Division of Pediatric Emergency Medicine, Department of Emergency Medicine, 3959 Broadway, CHN 1-116, Columbia University Medical Center, NY, NY, United States. Lc2243@columbia.edu Issue date 2025 Aug 1. PMC Copyright notice PMCID: PMC12245585  NIHMSID: NIHMS2070916  PMID: 40464392 The publisher's version of this article is available at Sex Transm Dis Abstract Background: Adolescents and young adults (AYA) frequently use the emergency department (ED) and admit to infrequent contraceptive use, increasing their risk of sexually transmitted infections (STIs). This study aimed to design STIckER (STI Check in the ER), a user-informed digital patient decision aid aiming to increase shared decision-making (SDM) around genitourinary and extra-genital STIs testing among AYA ED patients. Methods: This two-center study followed a multi-phased approach. In phase 1, we defined our health condition, target audience, and health decision, and organized a multi-disciplinary steering group. Through a series of design workshops, we created a low-fidelity prototype. In phase 2, we conducted semi-structured interviews with AYA ED patients and ED healthcare providers (HCPs) to understand values and preferences around STI testing and decision-aid implementation. Interviews were recorded and analyzed using rapid qualitative analysis techniques. Data from interviews led to a final high-fidelity prototype. Results: Interviews with 19 AYA ED patients suggested interest in participating in the decision for STI testing and have emotions about getting results. Interviews with 15 ED HCPs highlighted that SDM matches clinical practice, interventions should not increase cognitive load, and sexual health interventions are more complex when parents are involved. Both groups were receptive to non-judgmental sexual health interventions that promote privacy and eliminate testing stigma. Conclusion: The STIckER decision aid was designed using an iterative process that involved user testing and integrating feedback, leading to a digital tool that could promote equitable STI testing built specifically for the complex ED setting. Keywords: sexual health, sexually transmitted infections, mobile health, emergency department, adolescent health, gonorrhea, chlamydia, digital health Short summary: STIckER (STI Check in the Emergency Room) is a user-informed, theory-based digital decision aid designed to increase equitable screening for sexually transmitted infections among adolescents and young adults. INTRODUCTION Adolescents and young adults (AYA) continue to bear a disproportionate burden of sexually transmitted infections (STIs), with nearly half of all reported cases of chlamydia, gonorrhea, and syphilis occurring among individuals aged 15–24 years. 1 STIs can lead to serious health complications, including pelvic inflammatory disease, chronic pelvic pain, infertility, and urethral fistulas or peri-rectal abscesses. 2 – 4 Beyond individual health, STIs impose substantial economic burdens on healthcare systems and society. Infections like chlamydia and gonorrhea are readily treatable, highlighting an urgent need for strategies that effectively address disparities and reduce the STI burden among AYA. 5 The emergency department (ED) visit represents a unique opportunity to improve STI testing. Each year, over 17 million AYA seek care in the ED, with the majority coming from underserved communities where the ED often serves as their primary source of healthcare. 6 , 7 AYA ED patients frequently report infrequent condom use, contributing to STI prevalence rates ranging from 6–21%. 8 – 12 Despite this, STI screening in the ED remains suboptimal. Providers often do not routinely take sexual health histories, and extragenital STI testing is rarely conducted, with fewer than 5% of patients presenting with extragenital complaints receiving appropriate testing. 13 Barriers such as limited time, lack of privacy, parental presence, and the need to maintain patient flow further hinder comprehensive sexual health care in the ED. 14 To address these gaps, targeted strategies are needed to improve STI screening and detection in this setting, particularly for infections like chlamydia and gonorrhea that are commonly overlooked. An STI-focused patient decision aid using a shared decision-making (SDM) approach represents an innovative, practical, and patient-centered opportunity to enhance STI screening 15 . For asymptomatic AYA patients, the decision to test or not test for an STI in the ED can be considered a reasonable choice, particularly for those with primary care providers or recent STI testing. Decision aids are tools designed to facilitate SDM by educating patients, clarifying values and risk perceptions, and encouraging active participation in care decisions. Even in the fast-paced ED environment, decision aids can positively impact patient knowledge, decision-making quality, and clinical outcomes. 16 The goal of our multi-disciplinary team was to develop a digital STI screening decision aid designed to facilitate STI screening (for chlamydia and gonorrhea) in the ED using SDM principles. In this manuscript, we describe the phased approach taken to design STIckER ( STI Ch eck in the E mergency R oom), a digital tool aimed at increasing STI testing among AYA in the ED setting. METHODS Overview of study design Figure 1 displays the phases followed to create STIckER. Phases were informed by the International Patient Decision Aid Standards (IPDAS) and incorporated the constructs of SDM and of human-centered design (HCD). 17 , 18 Figure 1. Open in a new tab Phases of STIckeR design and development. PHASE 1 Described health condition and target population Our work has explored reasons for condomless sex and the barriers and facilitators to using contraceptives. 8 , 9 We also explored preferences for sexual health interventions in the ED, specifically building and testing user-informed apps and texting programs to promote sexual health among ED patients. 19 , 20 This led directly to the development of this intervention with a focus on how to improve chlamydia and gonorrhea testing among AYA. Steering group We formed a multi-disciplinary core team consisting of ED physicians (2), an implementation scientist (1), an infectious disease expert (1), and three user-design experts. Advisory input regarding the content and design was collected from several other sources including (1) a local HIV Prevention Community Advisory Board (CAB) which is comprised of youth and parents from the local community and has experience informing researchers of community concerns as well as local parents and (2) iterative feedback from adult and pediatric ED providers during departmental research meetings. Decision that needs to be considered and the conceptual model ED patients report wanting to be actively involved in clinical decisions, and the decision to test for a urinary, rectal, or oral STI in the ED is often driven by personal values and preferences and can benefit from SDM conversations. 21 The decision to test for an STI may not only base itself in one’s personal “risk” but other factors such as comfort in ED-based testing, relationship with one’s outpatient provider, and understanding of STI transmission. This led to our conceptual model ( Figure 2 ), which was inspired by the SDM model inspired by Elwyn et al. 22 , 23 We envisioned the STICKER decision aid serving as the initiator and facilitator of the SDM process. Through the process of deliberation using an SDM approach, a patient would engage with the provider around the clinical decision, thereby increasing their knowledge and selecting an option most aligned with their values and preferences. This process, if properly performed, would lead to decreased decisional conflict and increased trust in their provider, which could, in turn, lead to an increase in STI testing, when indicated. Figure 2. Open in a new tab The theoretical model of STIckER and the behavioral and psychological constructs it aims to affect. Co-design workshops To address decisional needs around STI testing, we conducted three virtual 1–2 hour participatory co-design workshops. Workshop 1 focused on understanding the AYA users, capturing their current experience and defining the target problem. The group used individual ideation (individuals contributed ideas silently and independently) and affinity mapping (discussion, sorting and grouping) to generate key audience attributes and develop proto-personas. A second workshop focused on capturing the existing experience of STI testing in the ED, leveraging ethnographic methods (observation and photos within actual ED settings) to continue to build empathy and understanding into the design process. We developed journey maps showing key steps to the process and highlighting when and where STIckER might be applied during the ED visit. This led to an individual experience map of how one might interact with STIckER based on their persona. Personas and journey maps were then refined for use in Workshop 3. The third workshop focused on ideation of the ideal experience–also known as “the happy path”. This simplified journey map considered each persona’s preferences and mindset to envision the best possible experience with a STI testing tool and the information required, and in what order. In order to test our assumptions, a low-fidelity prototype was designed using the tool Figma ® . 24 During these workshops, medical experts created the content for the decision aid. PHASE 2 Alpha testing aimed to iteratively revise the STIckER low-fidelity prototype via feedback from its end users, AYA ED patients and ED HCPs. Using an observational rapid qualitative design, we conducted two rounds of semi-structured interviews with round 1 focusing on the content, clarity, and experience with SDM, and round 2 focusing on usability testing. AYA Participants Study population and procedures We conducted interviews across pediatric and adult urban academic EDs. Research coordinators recruited ED patients aged 14–24 years old and sexually active in the prior 6 months. We excluded patients who were too ill and cognitively impaired per the treating HCPs. Interviews were conducted in English only with the expectation that future iterations of STIckER would be in Spanish. Research coordinators screened potentially eligible AYA patients. Eligible patients were enrolled with verbal informed consent. Our IRB approved the protocol with a waiver of parental consent for participants under age 18 years. Participants completed a brief questionnaire regarding demographics, use of medical care, sexual practices, and prior STI testing. A research coordinator audio-recorded interviews privately in the patient’s room. Participants received a $10 gift card. The interview guide for AYA users first focused on past experiences with SDM and prior STI testing. Then questions explored values and preferences around STI testing and what it looks and feels like to be “heard” by their HCP. Next, when shown a tablet with an early version of the STIckER prototype, participants performed the “think aloud” method in which participants describe what they are thinking, seeing, and trying to do as they navigate the app. The interview guide contained probes focused on comprehensibility, content, and personal relevance. Lastly, questions focused on the implementation of STIckER during the ED visit. Health care providers Study population and procedures We recruited ED HCPs via emails to attending physicians, nurses, and advanced care practitioners inviting them to participate in the research study. All HCP participants were enrolled with verbal informed consent and completed a brief demographic questionnaire. A member of the research team conducted interviews over video and documented memos. HCPs received a $40 gift card. The interview guide for HCP first focused on the STIckER app itself. Utilizing the “think aloud” method, HCPs were given a real-time link to the app on Zoom, and the screen was shared. As they navigated the app, they described what they saw, thought, and did, paying attention to the final infographic, which is the only part of the app that HCPs would see during patient engagement. We recorded users’ feedback to highlight problems. The final phase of the interview focused on ED implementation including questions focused on when and where STIckER should be initiated within the visit. Data analysis Our analysis was conducted in two steps. During our interview phase, after every 3–4 interviews, we met as a steering group and discussed findings using memos as a guide, allowing us to iterate on the app in real-time. After the interview phase, we analyzed our interviews using a rapid qualitative analytic approach. 25 , 26 First, we chose domains from the interview guide and organized them into two types of summary templates, one for AYA users and one for HCPs. Next, team members used the templates to summarize one AYA and one HCP transcript to ensure that the domains were identifiable in the data and that team members were consistently capturing domains. Once we established consistency by reviewing aloud excerpts from select transcripts, each team member summarized three transcripts and the team discussed and reconciled the findings over three meetings. Then remaining interviews were divided and each team member individually summarized transcripts by inserting bullet points with corresponding quotes into each summary statement. Bullet points from the summary templates were then placed in two larger matrices, one for AYA users (stratified by age 14–19 and 20–24 years) and the other for HCP (stratified by adult and pediatric providers). Six team members discussed final matrices to generate emerging themes. RESULTS Phase 1 After building a theoretical model portraying the intersection of our behavioral constructs, we created personas to simulate a real STIckER experience that included detailing feelings and perceptions about STI testing. We then mapped each persona onto a journey map of that person’s experience using STIckER during the ED visit. Figure 3 represents an example. Figure 3. Open in a new tab One key audience persona, summarizing thoughts and feelings about the STIckER app. Images provided by Modus Associates LLC. Phase 2 AYA users We interviewed 19 AYA users with a mean age of 19.2 years. Sexual and gender identity varied from heterosexual (11; 58%) to bisexual (6; 32%). Most identified as female (12; 63%), with one being gender non-conforming. Race and ethnicity also varied from black (5; 26%) to “unsure or I don’t want to answer” (10; 53%), with 13 identifying as Hispanic. Over half had STI testing in the prior year (12; 63%). Table 1 summarizes elicited themes and exemplary quotes. Table 1. Themes and exemplary quotes from adolescents and young adults as well as health care providers. Themes were organized within two domains: STI testing in the ED and Design and Implemention. Category Theme Exemplary Quote Adolescent and young adult STI Testing in the ED AYA are open to STI testing but rarely does anyone offer it to them. I mean every time, when I go for a doctor’s check, they just be like -- they always ask me if I’m sexually active. I just answer, yes, and that’s it. They don’t ask me if I wanted to get tested. (Male, age 19) Waiting for and getting STI results can be emotional. When I found out [was positive for an STI] I was actually pissed, very, very pissed, because the person that I had sexual intercourse with should have told me that they had something. And when the doctors told me-- I can’t really explain, like, I was really upset. (Female, age 18) AYA want to be involved in the decision of why they should be tested for an STI. I guess like, I don’t know. I think being heard is like if you’re not just a number, I guess, in the system. That they acknowledge you and your desires to be tested. (Male, age 21) An intervention like STIckER is important, easy to use, and non-judgmental. I think it’s very helpful because a lot of the stuff I like obviously learned in health when I was younger, but a lot of stuff I didn’t know that you don’t always have symptoms, which is like --- and so it’s like important to get tested. (Female, age 19) Design and Implementation I value getting information about how to optimize my sexual health in an easy and non-judgmental way. I feel like it’s something like this that more people could see and that’s kind of easier to use and a little bit more informative would be great, especially on a college campus where people go a little crazy. (Male, age 20) Privacy is important especially when collecting information on sensitive topics like sexual health. I think, especially with something that a lot of people would be more uncomfortable about, like STIs and stuff, being able to do it in the privacy of your own phone would be great. (Male, age 20) The ED is a great place for STI testing but there may be more than one “right time” for STIckER. I feel like anytime really. I feel like there’s no wrong time. Yeah, I feel like anytime really would be fine. (Female, age 19) Healthcare providers STI Testing in the ED Incorporating SDM into STIckER matches HCP clinical practice. I think shared decision making is, is great, because it allows the patient the feeling that they are involved in the discussion, and they’re not being forced to do something. (Pediatric ED Attending, age 46) STIckER can support privacy and take out the stigma of STI testing. Someone is much more willing to read stuff on their phone privately than they are to be like, yes, I’m sexually active with 14 partners, and all of these things. I think, also potentially, and I don’t know if it needs to be directly stated, but somehow your answers will not be shared directly with the provider, but rather the results. As you know, sometimes people don’t want to say I am bisexual, I have male and female partners, and I’ve had 10 new sexual partners and these are -- they kind of just want to know like yes, I want to be tested. (Physician assistant, age 28) STIckER would be well received by AYA because it meets adolescents where they are. “Teenagers will come in and, like, just want a pregnancy test or like STI testing, and they may go around, asking it for that in different ways. But like, that’s basically what they’re looking for, and so, it’s a great place [the ED] to do it, because I think a lot of them too, like don’t necessarily have a good primary care doctor that they go to, like on a regular basis with this stuff.” (Registered nurse, age 40) Design and Implementation Implementing STIckER may be trickier with certain patient populations like adolescents with parents. I think it’s trickier when you’re talking to a teenager. If I had 15-year-old and then I’m asking this 15-year-old kid about can I do a rectal swab? It just feels more invasive to me. Whereas it’s like a 25-year-old, I’m like, drop your pants, that kind of thing. (Emergency medicine attending, age 39) Interventions will be favored when they decrease HCP cognitive load. You know, in the ER, things are very like you have limited time with limited resources and lots of patients. So, what’s nice about this app is that it provides a lot of education, and so when it comes to shared making decision conversation, the patient is already semi-informed, and not to take that away from the provider, but it’s easier to have a conversation with someone who is informed. (Physician assistant, age 28) Collecting urine is an easier ask than drawing blood but HIV and syphilis testing is important. So, I could see like a low healthcare literate person would get this app, would see this, would do the testing and think they’ve been tested for STIs they’re done, right, whereas they haven’t been. They haven’t been tested for HIV, syphilis, Trichomonas, all the other STIs. (Pediatric Emergency Medicine attending, age 46) Open in a new tab AYA are open to STI testing but are rarely offered any. While older patients recounted more STI testing experiences, younger participants, despite being sexually active, recalled rarely being tested and explained how this was similar for their friends. Several explained how HCPs might ask if they had sex in the past, but then did not offer testing nor an explanation of why testing may or may not be necessary. AYA were open to testing, admitting to an uncertainty “on their mind.” As one AYA explained, “I mean, I’m really fine that I haven’t been tested, but…what if I do have something…it is good to know if you’re clean or not.” Patients wanted to know when and how to be tested, wanting testing to be simple with a quick turnaround time as “people got places to be.” Waiting for and getting STI results can be emotional. For those who experienced STI testing, many recalled the encounter as “scary.” Some admitted to never finding out the test results and assuming they were negative; others talked about waiting “until I got the call” and how that wait time negatively impacted their experience. When patients felt uncertain about the testing outcome, this made the wait time more uncomfortable and sometimes affected their decision to accept treatment. For example, an AYA explained how they received testing and “didn’t find out [results] to a week later.” By that time, they felt as though they no longer had an infection so did not take the medication despite testing positive. AYA want to be involved in the decision around STI testing. Patients valued providers who truly were “listening.” They liked feeling respected with their concerns validated so they felt part of the decision-making process. One patient explained how she wanted “to know what’s going on…instead of just kind of having it happen to me.” Patients preferred when they and their provider “both have to come to the same consensus for something to happen.” They liked when the decision to test was personalized and reasons for and against were explained, leading to a decision that “we both agree on.” Particularly they did not want to feel “rushed.” One AYA negatively reflected on feeling “rushed” and how “I couldn’t even gather myself.” An intervention like STIckER is important, easy and non-judgmental. There was an overall positive response to the app, with patients calling it “valuable,” providing important, practical information about STIs including reasons for and how testing is performed. They also felt the app would normalize testing and that it was better than filling out a form or having to say things out loud. Many highlighted a willingness to share it with friends. Participants also found the app simple to use, the content helpful, and the length and language appropriate. There was, however, a desire to be able to access the information more easily, to search for more information if needed, and have the ability to provide more personal information directly into the app. Privacy is important to AYA especially when collecting information on sensitive topics like sexual health. There was a sense that an app on a personal device rather than a hospital-owned device provides a level of confidentiality that is appreciated for “embarrassing” topics leading to more honest responses. While many AYA felt the app was private, some youth worried about interacting with the app in front of parents and preferred a more private space to complete the process. The ED is a great place for STI testing, but there may be more than one “right time” for STIckER. There was a wide spectrum of when participants wanted to engage with STIckER during the ED visit. While some felt there was no wrong time for using STIckER to encourage a testing discussion, others felt that it was best to do it in the waiting room or examination room. These conversations could occur at a variety of times ranging from before or after provider assessment. Healthcare providers We interviewed 15 HCPs with a mean age of 42 years and average years of work experience of 8, including 5 adult ED attending physicians, 5 pediatric ED attending physicians, 3 physician assistants, 1 nurse practitioner, and 1 registered nurse. Half identified as female (7; 47%). Race varied from white (9; 60%), black (1; 7%), and Asian (3; 20%) with all HCPs identified as non-Hispanic. Table 1 also displays HCP themes and quotes. Incorporating SDM into STIckER matches HCP clinical practice. HCPs saw SDM as a way to explain risks and benefits by “supporting whichever way [the patients] decide, giving research to back up each side, but not giving my own opinion.” Conversations using SDM were explained as those that weighed options to understand the pros and cons, ultimately leading to the “least amount of harm and the greatest benefit” for the patient. Another HCP explained how using SDM has to be truly shared to be real-- “you have to be 50/50 on shared decision-making, right? … if you are not comfortable with the alternate decision, that’s not shared anymore.” STIckER would be well received by AYA because it meets adolescents where they are. HCPs viewed AYA patients as a population who would benefit from ED-based STI testing as many of them “rely heavily on the emergency room compared to going to their primary medical doctor.” Testing for STIs in the ED is “better to just do now and have it done.” STIckER is also tailored to each patient. Those AYA who were deemed “medium” risk for an STI were led through a series of SDM modules so the patient could “make the decision for themselves….part of the informed consent mentality.” And those that needed testing but did not choose testing pushed the HCP to “probe a little bit more deeply and see if there’s a fear that it might be positive or nervousness about what it might entail or embarrassment or kind of what the barrier is, and if that’s something that we can… work through…” STIckER can support privacy and take out the stigma of STI testing. HCPs viewed STIckER as a way to take “the awkwardness out of the discussion.” Patients would be able to answer sensitive questions without having to “verbalize it, because I think it’s easier for people to say yes and no, without having to, like answer the question, you know, are you having rectal sex?” This fear might be heightened with patients who may not want their provider to know the answers to these sensitive questions and recommended that only results, not answers be shared. One provider explained-- “Sometimes people don’t want to say I am bisexual, I have male and female partners, and I’ve had 10 new sexual partners… -- they kind of just want to know like yes, I want to be tested.” In addition, it was noted that the advertisement of STIckER needed to be sensitive to the idea that sexual behavior is a private topic. As one HCP explained, “There might be a stigma if you have a poster that’s like scan this to assess for if you want to be treated for STIs. … I even see patients who will make up a triage complaint that’s completely unrelated to why they’re there, even though the only reason they’re there is STI testing.” Implementing STIckER may be trickier with certain patient populations like adolescents with parents. Testing adolescents was considered more complicated than adults. “If I see a patient who’s an adult, who … screened positive, and it says, oh, it’s red on the rectal, I’m like, oh, would you be interested in doing some screening for STIs? But for adolescents, it would be harder to say especially with parents present.” “It’s very easy for a parent to look over their shoulder. It would also be hard to advertise STIckER in a way that aligned with the kid-friendly environment of the ED.” “You can’t just really put a QR code randomly in front of a Disney picture… some other parent happens to sit there… scans it, just out of curiosity, then…what am I doing here?” Interventions will be favored when they decrease HCP cognitive load. Caring for patients in the chaotic environment of the ED was viewed as stressful; an app was deemed as more “efficient then doing the whole conversation” they gravitated toward interventions that “facilitated discussion” and were “succinct but also thorough.” Any intervention should not “add time to a provider’s day,” as they did not have the capacity to have long, educational conversations with patients. Examples were given on how to facilitate STI testing beyond the STIckER app. These included prepackaged bags with the testing swabs, electronic medical record reminders to use the app, or color coding the app to match the colors of the swabs. Collecting urine is an easier task than drawing blood, but HIV and syphilis testing is important. One HCP explained how “obtaining a urine sample is very [non]invasive… you’re already obtaining a urine pregnancy…A lot of times when they hear STI testing then they immediately think it’s going to be blood work. That’s why they’re like, ‘No I don’t need it. I don’t think I have it.’” Blood testing also put a burden “on nursing time… it’s like one more thing that takes a lot longer…You have to move them to the area where they can do a venipuncture.” However, several providers worried that STIckER was not enough, noting that if a patient was vulnerable to an oral, rectal, or urinary STI, they were also vulnerable to syphilis and HIV. The final STIckER prototype Figure 4a and 4b provide examples of the final prototype of the web-based app. Content spans five sections: 1) STI education, 2) a validated sexual health assessment to stratifying for the need for oral, urinary, or rectal STI testing, 3) decision-making modules including weighing values and preferences, and a 4) final infographic screen for the provider alerting to testing need and prompts to facilitate a SDM conversation. Figure 4a and 4b. Open in a new tab Example screenshots of the final STIckER prototype. DISCUSSION In this manuscript, we present the multi-phased process of designing a user-informed, theory-based STI screening tool. Findings from our interviews highlighted views about decision aids in general and specifically regarding STI testing in the ED. Consistent with other studies, patients were interested in STI testing but felt it was not routinely offered. 27 , 28 Similar to prior work, if offered, patients expressed a strong desire for it to be offered in a private and nonjudgmental way. 29 They also wanted to be actively involved in the decision-making process and receive clear, comprehensive information about the testing procedures and their implications, mentioning the emotional impact of waiting for results and the need for timely and sensitive communication. 29 These findings are consistent with research recognizing the importance of adolescence as a stage of growing autonomy. Our phased design methodology models that process in a way that incorporates their feedback that can make them feel heard. Elicited themes from ED HCPs along with their suggestions for how to implement STIckER highlighted important considerations. Although patient decision aids have been shown to be compatible with providers’ workflow, implementing interventions in the ED can be challenging. 30 Adding the layer of adolescent consent for a sexual health study creates complexity around how to implement such interventions while respecting patient privacy around parents. The suggestions of the HCPs, such as the timing of the introduction of the app and how successful interventions would not increase cognitive load, can be applied to other sensitive health interventions, such as those pertaining to substance use or violence prevention. While a QR code as a vehicle for app delivery is scalable and understood by users, where to place that QR code in the ED can be tricky, as referenced by a HCP who recognized the contrast of being a child-friendly hospital and the controversary of providing sexual healthcare. More information is needed from a system’s standpoint including feedback of hospital administrators on how best to weave the QR code into the journey map and in actual practice. Nevertheless, given that EDs care for underserved populations not seeking healthcare elsewhere, tools to better identify AYA patients who might benefit from sensitive health interventions are valuable. In conclusion, STIckER offers an educational tool that could enhance STI testing rates in the ED by aligning with the values and preferences of both groups. While our ongoing pilot testing using a randomized trial is underway, the potential success of STIckER hinges on its uptake by patients and careful integration into the ED workflow. Additional future directions should consider how best to later incorporate blood testing for HIV and syphilis into the intervention. Funding: Research reported in this publication was supported by the National Institute of Allergy and Infectious Diseases (NIAID) under Award Number R21AI168958. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This publication was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant Number UL1TR001873. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Abbreviations: STI sexually transmitted infection STIckER STI check in the Emergency Room ED emergency department SDM shared-decision making AYA adolescent and young adult HCP health care provider PI Principle Investigator EMR Electronic Medical Record Footnotes Conflicts of Interest: All authors have nothing to disclose. Trial Registration : N/A References 1. 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