Impact of Electronic Health Record-Based Alerts on Influenza Vaccination for Children With Asthma

Pediatric Generalist Research Group, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
PEDIATRICS (Impact Factor: 5.47). 08/2009; 124(1):159-69. DOI: 10.1542/peds.2008-2823
Source: PubMed


The goal was to assess the impact of influenza vaccine clinical alerts on missed opportunities for vaccination and on overall influenza immunization rates for children and adolescents with asthma.
A prospective, cluster-randomized trial of 20 primary care sites was conducted between October 1, 2006, and March 31, 2007. At intervention sites, electronic health record-based clinical alerts for influenza vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. The proportion of captured immunization opportunities at visits and overall rates of complete vaccination for patients at intervention and control sites were compared with those for the previous year, after standardization for relevant covariates. The study had >80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices.
A total of 23 418 visits and 11 919 children were included in the study year and 21 422 visits and 10 667 children in the previous year. The majority of children were male, 5 to 9 years of age, and privately insured. With standardization for selected covariates, captured vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, a 0.3% greater improvement. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. The 4 practices with the greatest increases in rates (>or=11%) were all in the intervention group. Vaccine receipt was more common among children who had been vaccinated previously, with increasing numbers of visits, with care early in the season, and at preventive versus acute care visits.
Clinical alerts were associated with only modest improvements in influenza vaccination rates.

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    • "Such interventions have been termed "reminder/recall" (RR) measures, and methods include automated or personal telephone calls, postcards, letters, and text messages to patients [9-13]. RR interventions can also be directed at immunization providers using processes such as reminders attached by nurses or receptionists to patient charts and, with the growth of electronic medical records (EMRs) and registries, through computerized alerts [14,15]. Regardless of whom the RR systems are targeting, they have been demonstrated to increase vaccine coverage by 5-20% [16-18]. "
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    ABSTRACT: Background Although many studies have demonstrated the benefits of reminder/recall (RR) measures to address patient under-immunization and improve immunization coverage, they are not widely implemented by healthcare providers. We identified providers’ perceived barriers to their use from existing literature. Methods We conducted a systematic review of relevant articles published in English between January 1990 and July 2011 that examined the perceptions of healthcare providers regarding barriers to tracking patient immunization history and implementing RR interventions. We searched MEDLINE, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Academic Search Premier, and PsychINFO. Additional strategies included hand-searching the references of pertinent articles and related reviews, and searching keywords in Google Scholar and Google. Results Ten articles were included; all described populations in the United States, and examined perceptions of family physicians, pediatricians, and other immunization staff. All articles were of moderate-high methodological quality; the majority (n=7) employed survey methodology. The most frequently described barriers involved the perceived human and financial resources associated with implementing an RR intervention, as well as low confidence in the accuracy of patient immunization records, given the lack of data sharing between multiple immunization providers. Changes to staff workflow, lack of appropriate electronic patient-tracking functionalities, and uncertainty regarding the success of RR interventions were also viewed as barriers to their adoption. Conclusions Although transitioning to electronic immunization records and registries should facilitate the implementation of RR interventions, numerous perceived barriers must still be overcome before the full benefits of these methods can be realized.
    BMC Medical Informatics and Decision Making 12/2012; 12(1):145. DOI:10.1186/1472-6947-12-145 · 1.83 Impact Factor
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    • "Fifty-nine percent (32/54) of CCDSSs were integrated with electronic medical records [2,3,14-18,21-23,25,26,28,29,31-40,42-44,46,48,49,51,53-55,60-64,67,73,74,76,79], and 17% (8/47) were also integrated with computerized physician order entry systems [22,29,36,38,46,48,49,53,60,61]. Fifty-three percent (25/47) automatically obtained data needed to give recommendations from electronic medical records [2,3,18,21-23,25,28,34-36,38,40,46,48,49,51,53-55,60-64,67,73,74,76,79]; 36% (17/47) relied on practitioners to enter the data [2,3,14-17,23,30,39,41,45,48,49,52-58,67-69,72,75]; and 26% (12/47) used research staff for this purpose [18,24,36,41,47,50,59,65,66,72,75,77,79]. Advice was provided at the time of care in 85% of trials (46/54) [2,3,13-18,20-28,30-36,38-40,42-49,51-59,62-70,73-79] most often on a desktop or laptop computer (51%; 26/51) [2,3,14-17,21,22,28,30,34-39,46-49,51,53-56,62-64,67,70,72-74] or by existing non-prescribing staff (22%; 11/51) [18,23-26,30,40,42-44,71,76,79]. "
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    ABSTRACT: The use of computerized clinical decision support systems (CCDSSs) may improve chronic disease management, which requires recurrent visits to multiple health professionals, ongoing disease and treatment monitoring, and patient behavior modification. The objective of this review was to determine if CCDSSs improve the processes of chronic care (such as diagnosis, treatment, and monitoring of disease) and associated patient outcomes (such as effects on biomarkers and clinical exacerbations). We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for potentially eligible articles published up to January 2010. We included randomized controlled trials that compared the use of CCDSSs to usual practice or non-CCDSS controls. Trials were eligible if at least one component of the CCDSS was designed to support chronic disease management. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of relevant outcomes. Of 55 included trials, 87% (n = 48) measured system impact on the process of care and 52% (n = 25) of those demonstrated statistically significant improvements. Sixty-five percent (36/55) of trials measured impact on, typically, non-major (surrogate) patient outcomes, and 31% (n = 11) of those demonstrated benefits. Factors of interest to decision makers, such as cost, user satisfaction, system interface and feature sets, unique design and deployment characteristics, and effects on user workflow were rarely investigated or reported. A small majority (just over half) of CCDSSs improved care processes in chronic disease management and some improved patient health. Policy makers, healthcare administrators, and practitioners should be aware that the evidence of CCDSS effectiveness is limited, especially with respect to the small number and size of studies measuring patient outcomes.
    Implementation Science 08/2011; 6(1):92. DOI:10.1186/1748-5908-6-92 · 4.12 Impact Factor
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    • "Additional file 2 Table S2 shows that 20/41 (49%) CCDSSs were integrated with an electronic medical record [1,17,25,27,29,31,32,34-36,39,41-46,49,50,52,56,59] including at least five also integrated with a computerized order entry system [1,32,42,49,56] and 21/41 (51%) were stand-alone computer systems [15,16,18-22,24,26,28,30,33,37,38,40,47,48,51,53-55,57,58]. The data entry method varied across systems, with a non-practitioner decision-maker entering data on 29/39 (74%) studies [1,15,17,21,23-25,27,29,31,32,34-55,59] and automatic entry through electronic health records in 15/39 (38%) cases [1,17,27,29,31,34-36,41,42,46,49,50,56,59]. In all but one study [26], physicians used all PPC CCDSSs, either solely or shared with other healthcare providers including trainees [1,25,28,29,39,41,42,46-48,52], advanced practice nurses [1,17-19,30,50,59], physician assistants [18,19,33], and social workers [26]. "
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    ABSTRACT: Computerized clinical decision support systems (CCDSSs) are claimed to improve processes and outcomes of primary preventive care (PPC), but their effects, safety, and acceptance must be confirmed. We updated our previous systematic reviews of CCDSSs and integrated a knowledge translation approach in the process. The objective was to review randomized controlled trials (RCTs) assessing the effects of CCDSSs for PPC on process of care, patient outcomes, harms, and costs. We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews Database, Inspec, and other databases, as well as reference lists through January 2010. We contacted authors to confirm data or provide additional information. We included RCTs that assessed the effect of a CCDSS for PPC on process of care and patient outcomes compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive. We added 17 new RCTs to our 2005 review for a total of 41 studies. RCT quality improved over time. CCDSSs improved process of care in 25 of 40 (63%) RCTs. Cumulative scientifically strong evidence supports the effectiveness of CCDSSs for screening and management of dyslipidaemia in primary care. There is mixed evidence for effectiveness in screening for cancer and mental health conditions, multiple preventive care activities, vaccination, and other preventive care interventions. Fourteen (34%) trials assessed patient outcomes, and four (29%) reported improvements with the CCDSS. Most trials were not powered to evaluate patient-important outcomes. CCDSS costs and adverse events were reported in only six (15%) and two (5%) trials, respectively. Information on study duration was often missing, limiting our ability to assess sustainability of CCDSS effects. Evidence supports the effectiveness of CCDSSs for screening and treatment of dyslipidaemia in primary care with less consistent evidence for CCDSSs used in screening for cancer and mental health-related conditions, vaccinations, and other preventive care. CCDSS effects on patient outcomes, safety, costs of care, and provider satisfaction remain poorly supported.
    Implementation Science 08/2011; 6(1):87. DOI:10.1186/1748-5908-6-87 · 4.12 Impact Factor
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