Point of care experience with pneumococcal and influenza vaccine
documentation among persons aged ?65 years: High refusal rates and missing
Elisha Brownfield MDa,*, Justin E. Marsden BSa, Patty J. Iverson MAa, Yumin Zhao PhDa,
Patrick D. Mauldin PhDb, William P. Moran MDa
aDivision of General Internal Medicine and Geriatrics, College of Medicine, Medical University of South Carolina, Charleston, SC
bCollege of Pharmacy, Medical University of South Carolina, Charleston, SC
Electronic medical record
Missed opportunities to vaccinate and refusal of vaccine by patients have hindered the achievement of
national health care goals. The meaningful use of electronic medical records should improve vaccination
rates, but few studies have examined the content of these records. In our vaccine intervention program
using an electronic record with physician prompts, paper prompts, and nursing standing orders, we were
unable to achieve national vaccine goals, due in large part to missing information and patient refusal.
Copyright ? 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.
Community-acquired pneumonia (CAP) and influenza remain
leading causes of hospitalization and death in the United States for
persons aged ?65 years.1Although safe and effective vaccines are
widely available, influenza vaccination (IV) and pneumococcal
vaccination (PV) of noninstitutionalized persons aged ?65 remains
below the 90% targetfor Healthy People 2020,2and these rateshave
changed little in recent years.3Medicare covers both vaccines, and
both the Joint Commission and the Centers for Medicare and
Medicaid Services consider these vaccinations quality measures.
Payers tie reimbursement to vaccination for patients hospitalized
Missed health system opportunities, attitudes and beliefs of
to low vaccination rates. Refusal rates for these vaccines are high,
particularly among African-Americans.5Patient recall of PV status
among elderly persons has limited accuracy, notably for vaccines
have resulted in improved vaccination rates,7and meaningful use
of electronic medical record (EMR) systems has been postulated
to improve vaccination tracking and facilitate the implementation
of organized medical care, although the actual impact has been
disappointing to date.8,9Information in EMRs must be accurate
for both patient care and practice reimbursement; however, few
studies have evaluated the information contained in EMRs. We
implemented a brief vaccination intervention and found a high rate
of patient refusal and missing physician-level data for PV and IV
METHODS AND RESULTS
Between September 28, 2010, and December 13, 2010, a total of
825 community-dwelling patients aged ?65 years presented for
care at the Medical University of South Carolina’s Internal Medicine
Resident Clinic in Charleston (69.2% females, 78.7% African-
American, 20.2% Caucasian). The vaccination intervention program
described is part of a larger study approved by our Institutional
Review Board (Aging Q3; Reynolds Foundation Grant). During the
rollout of an intervention, the Aging Q3design emphasizes combi-
nations of intervention strategies to enhance effectiveness,
including lectures, brief point of care education (ie, academic
detailing), point-of-care cues, EMR prompts, and decision support.
Before the physician visit, paper prompts directed nurses to
determine current IV and PV status and administer vaccine to
eligible, consenting patients in accordance with standing orders.
All vaccines administered by nursing staff were electronically
recorded, and physicians documented vaccine status with the
prompted response “done,” “refused,” or “done elsewhere” as part
of the EMR note used by all physicians throughout the study for
* Address correspondence to Elisha Brownfield, MD, General Internal Medicine
and Geriatrics, Medical University of South Carolina, 135 Rutledge Ave, Suite 1252,
Charleston, SC 29425-0591.
E-mail address: firstname.lastname@example.org (E. Brownfield).
Supported by a grant from the Donald W. Reynolds Foundation.
Conflict of interest: None to report.
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0196-6553/$36.00 - Copyright ? 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
American Journal of Infection Control 40 (2012) 672-4
encounter documentation. This answer was not required for
completion of the note.
Of the 825 patients, 527 (63.9%) had electronic documentation
of PV during the preceding 10-year period, and 158 (19.2%) had no
information regarding PV status recorded by a physician. Another
140 patients (17.0%) had physician-documented eligibility for the
vaccine; 69 of these (49.3%) were vaccinated at the time of the visit,
66 (47.1%) refused, and 5 (3.6%) reported previous administration of
vaccine outside of our institution. Findings for IV revealed missing
vaccination status data in the electronic physician clinic note for
212 of 825 patients (25.7%). Of the remaining 613 patients, 525
(85.6%) were vaccinated at the time of the visit, 87 (14.2%) refused,
and 1 (0.2%) reported administration elsewhere (Fig 1).
The determination of vaccine eligibility in a target population is
crucial for any vaccine program, and the use of EMRs may signifi-
cantly improve this process. Even though our intervention included
the use of an established EMR in conjunction with paper prompts
and standing vaccination orders, we encountered high rates of
missing data over the 3-month study period. All patient electronic
visit templates included vaccination status data fields, but the
physician user did not complete these in a significant number of
encounters. Nursing administration of vaccine by standing order
was documented independently, and so patients with missing data
did not receive the vaccine at the time of the visit. Some patients
declined to answer questions about vaccination, had the vaccine
elsewhere, or refused an offered vaccine.
Our overall vaccination rates appear low, especially for PV,
with only 69 of the 825 patients receiving the vaccine at the
time of the visit, yet the majority of patients had recorded
vaccination within 10 years of the visit. Our overall documented
PV rate for these patients was 72.2% (596/825), which is similar
to the national average. As expected, the percentage of patients
eligible for yearly vaccination was significantly higher for IV
than for PV, yet only 63.6% of these patients received the vaccine
during the study period. Among the patients with recorded data,
refusal rates for vaccination were high, 47.1% of patients docu-
mented as eligible for PV and 14.2% of those eligible for IV.
These refusal rates may be even higher, given that some of the
patients with missing information might have refused vaccina-
tion. When taking patient refusal and recalled vaccination done
outside of our institution into account, our documented rates
(done, refused, done elsewhere) rise to 74.3% for IV and 80.8%
Required completion of the vaccination questions in the EMR,
surveillance of records for missing data, and review of pharmacy
data might result in more complete documentation of vaccination
status. Of these potential interventions, required completion of the
EMR may be the most feasible, given that few physician practices
have the resources required for office data surveillance or phar-
macy record review. Although documentation of vaccine adminis-
tration is considered the gold standard, the availability of vaccine
across multiple health care settings, lack of a centralized medical
record, and the nature of PV status, which may be current >20
years after administration, make its achievement a daunting
The use of an established EMR, paper prompts with standing
orders for vaccination, and physician prompts were not sufficient
to improve internally documented IV and PV rates to meet
national goals. The meaningful use of EMRs may be difficult to
achieve, particularly for health interventions that may have been
applied appropriately in the past, such as PV, and the input of such
data by health care providers should be monitored to ensure
accuracy. Further studies of the ambulatory system and EMR use
may be needed to fully understand the limited functioning of such
Fig 1. Documentation of vaccination in 825 ambulatory patients aged ?65 measured over a 3-month period. (A) Documented status of pneumococcal vaccination. (B) Documented
status of influenza vaccination.
E. Brownfield et al. / American Journal of Infection Control 40 (2012) 672-4
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