Download PDF
Appl Clin Inform 2024; 15(01): 192-198
DOI: 10.1055/a-2250-6305
Case Report

An Electronic Health Record Alert for Inpatient Coronavirus Disease 2019 Vaccinations Increases Vaccination Ordering and Uncovers Workflow Inefficiencies

Kameron Collin Black
1   Department of Medicine, Oregon Health and Science University, Portland, Oregon
,
Nicole Ashley Snyder
2   Rocky Vista University, Parker, Colorado
,
Mengyu Zhou
1   Department of Medicine, Oregon Health and Science University, Portland, Oregon
,
Zhen Zhu
1   Department of Medicine, Oregon Health and Science University, Portland, Oregon
,
Colby Uptegraft
3   Health Informatics Directorate, Defense Health Agency, Falls Church, Virginia
,
Ani Chintalapani
1   Department of Medicine, Oregon Health and Science University, Portland, Oregon
4   Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
,
Benjamin Orwoll
4   Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
5   Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Despite mortality benefits, only 19.9% of U.S. adults are fully vaccinated against the coronavirus disease 2019 (COVID-19). The inpatient setting is an opportune environment to update vaccinations, and inpatient electronic health record (EHR) alerts have been shown to increase vaccination rates.

Objective Our objective was to evaluate whether an EHR alert could increase COVID-19 vaccinations in eligible hospitalized adults by prompting providers to order the vaccine.

Methods This was a quasiexperimental pre–post-interventional design study at an academic and community hospital in the western United States between 1 January, 2021 and 31 October, 2021. Inclusion criteria were unvaccinated hospitalized adults. A soft-stop, interruptive EHR alert prompted providers to order COVID-19 vaccines for those with an expected discharge date within 48 hours and interest in vaccination. The outcome measured was the proportion of all eligible patients for whom vaccines were ordered and administered before and after alert implementation.

Results Vaccine ordering rates increased from 4.0 to 13.0% at the academic hospital (odds ratio [OR]: 4.01, 95% confidence interval [CI]: 3.39–4.74, p < 0.001) and from 7.4 to 11.6% at the community hospital (OR: 1.62, 95% CI: 1.23–2.13, p < 0.001) after alert implementation. Administration increased postalert from 3.6 to 12.7% at the academic hospital (OR: 3.21, 95% CI: 2.70–3.82, p < 0.001) but was unchanged at the community hospital, 6.7 to 6.7% (OR: 0.99, 95% CI: 0.73–1.37, p = 0.994). Further analysis revealed infrequent vaccine availability at the community hospital.

Conclusion Vaccine ordering rates improved at both sites after alert implementation. Vaccine administration rates, however, only improved at the academic hospital, likely due in part to vaccine dispensation inefficiency at the community hospital. This study demonstrates the potential impact of complex workflow patterns on new EHR alert success and provides a rationale for subsequent qualitative workflow analysis with alert implementation.

Keywords

computerized soft-stop - clinical decision support - electronic health records - decision support systems - vaccination - COVID-19 - academic hospital

Author Contributions

K.C.B contributed in conceptualization, investigation, methodology, and writing. N.S. was involved in investigation, and writing. M.Z. contributed in conceptualization, investigation, supervision, writing. Z.Z. helped in writing. C.U. contributed in conceptualization, writing, supervision. A.C. contributed in writing, and supervision while B.O was in volved in investigation, writing, and supervision.


Protection of Human and Animal Subjects

This study was reviewed by the OHSU Institutional Review Board and deemed exempt (STUDY00026409).


Data Availability

The data involved in this study are available in the article.




Publication History

Received: 03 July 2023

Accepted: 19 January 2024

Accepted Manuscript online:
22 January 2024

Article published online:
06 March 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Haas EJ, Angulo FJ, McLaughlin JM. et al. Impact and effectiveness of mRNA BNT162b2 vaccine against SARS-CoV-2 infections and COVID-19 cases, hospitalisations, and deaths following a nationwide vaccination campaign in Israel: an observational study using national surveillance data. Lancet 2021; 397 (10287): 1819-1829
    CrossrefPubMedGoogle Scholar
  • 2 Thompson MG, Stenehjem E, Grannis S. et al. Effectiveness of Covid-19 vaccines in ambulatory and inpatient care settings. N Engl J Med 2021; 385 (15) 1355-1371
    CrossrefPubMedGoogle Scholar
  • 3 U.S. Department of Health and Human Services COVID Data Tracker. Accessed January 29, 2024 at: https://covid.cdc.gov/covid-data-tracker
    PubMed
  • 4 Williamson EJ, Walker AJ, Bhaskaran K. et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020; 584 (7821) 430-436
    CrossrefPubMedGoogle Scholar
  • 5 Pryor GE, Marble K, Velasco FT, Lehmann CU, Basit MA. COVID-19 mass vaccination resource calculator. Appl Clin Inform 2021; 12 (04) 774-777
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Bratic JS, Cunningham RM, Belleza-Bascon B, Watson SK, Guffey D, Boom JA. Longitudinal evaluation of clinical decision support to improve influenza vaccine uptake in an integrated pediatric health care delivery system, Houston, Texas. Appl Clin Inform 2019; 10 (05) 944-951
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Roberts MB, Ferguson C, McCartney E. et al. Suboptimal COVID-19 vaccine uptake among hospitalised patients: an opportunity to improve vulnerable, hard-to-reach population vaccine rates. Intern Med J 2022; 52 (10) 1691-1697
    CrossrefPubMedGoogle Scholar
  • 8 World Health Organization. Methodology for the Assessment of Missed Opportunities for Vaccination. 2017
    PubMedGoogle Scholar
  • 9 Cohen ES, Ogrinc G, Taylor T, Brown C, Geiling J. Influenza vaccination rates for hospitalised patients: a multiyear quality improvement effort. BMJ Qual Saf 2015; 24 (03) 221-227
    CrossrefPubMedGoogle Scholar
  • 10 Kim S, Hughes CA, Sadowski CA. A review of acute care interventions to improve inpatient pneumococcal vaccination. Prev Med 2014; 67: 119-127
    CrossrefPubMedGoogle Scholar
  • 11 Abba-Aji M, Stuckler D, Galea S, McKee M. Ethnic/racial minorities' and migrants' access to COVID-19 vaccines: a systematic review of barriers and facilitators. J Migr Health 2022; 5: 100086
    CrossrefPubMedGoogle Scholar
  • 12 Williams N, Tutrow H, Pina P, Belli HM, Ogedegbe G, Schoenthaler A. Assessment of racial and ethnic disparities in access to COVID-19 vaccination sites in Brooklyn, New York. JAMA Netw Open 2021; 4 (06) e2113937
    CrossrefPubMedGoogle Scholar
  • 13 Bilal U, Mullachery PH, Schnake-Mahl A. et al. Heterogeneity in spatial inequities in COVID-19 vaccination across 16 large US cities. Am J Epidemiol 2022; 191 (09) 1546-1556
    CrossrefPubMedGoogle Scholar
  • 14 Peña JM, Schwartz MR, Hernandez-Vallant A, Sanchez GR. Social and structural determinants of COVID-19 vaccine uptake among racial and ethnic groups. J Behav Med 2023; 46 (1-2): 129-139
    CrossrefPubMedGoogle Scholar
  • 15 Greenes R. Clinical Decision Support: The Road to Broad Adoption. 2nd ed.. Academic Press; 2014
    Google Scholar
  • 16 Osheroff JA. Improving Medication Use and Outcomes with Clinical Decision Support: A Step by Step Guide. Healthcare Information and Management Systems Society; 2009
    Google Scholar
  • 17 Stephens AB, Wynn CS, Hofstetter AM. et al. Effect of electronic health record reminders for routine immunizations and immunizations needed for chronic medical conditions. Appl Clin Inform 2021; 12 (05) 1101-1109
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Fiks AG, Grundmeier RW, Biggs LM, Localio AR, Alessandrini EA. Impact of clinical alerts within an electronic health record on routine childhood immunization in an urban pediatric population. Pediatrics 2007; 120 (04) 707-714
    CrossrefPubMedGoogle Scholar
  • 19 Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ. A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med 2001; 345 (13) 965-970
    CrossrefPubMedGoogle Scholar
  • 20 Oregon Health Authority. Oregon COVID-19 Vaccination Rates. Published April 10, 2023. Accessed June 17, 2023 at: https://visual-data.dhsoha.state.or.us/t/OHA/views/OregonVaccineMetricsSummaryTable/OregonCOVID-19VaccineProgressSummaryTable?%3Adisplay_count=n&%3Aembed=y&%3AisGuestRedirectFromVizportal=y&%3Aorigin=viz_share_link&%3AshowAppBanner=false&%3AshowVizHome=n
    PubMedGoogle Scholar
  • 21 MacDonald NE. SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: definition, scope and determinants. Vaccine 2015; 33 (34) 4161-4164
    CrossrefPubMedGoogle Scholar
  • 22 McDonald S, Basit MA, Toomay S. et al. Rolling up the sleeve: equitable, efficient, and safe COVID-19 mass immunization for academic medical center employees. Appl Clin Inform 2021; 12 (05) 1074-1081
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Kwan JL, Lo L, Ferguson J. et al. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ 2020; 370: m3216
    CrossrefPubMedGoogle Scholar
  • 24 Oliver SE, Gargano JW, Marin M. et al. The Advisory Committee on Immunization Practices' Interim Recommendation for Use of Moderna COVID-19 Vaccine—United States, December 2020. MMWR Morb Mortal Wkly Rep 2021; 69 (5152) 1653-1656
    CrossrefPubMedGoogle Scholar
  • 25 Oliver SE, Gargano JW, Marin M. et al. The Advisory Committee on Immunization Practices' Interim Recommendation for Use of Pfizer-BioNTech COVID-19 Vaccine—United States, December 2020. MMWR Morb Mortal Wkly Rep 2020; 69 (50) 1922
    CrossrefPubMedGoogle Scholar
  • 26 Centers for Disease Control and Prevention. FAQs for the Interim Clinical Considerations for COVID-19 Vaccination. Accessed November 12, 2023 at: https://www.cdc.gov/vaccines/covid-19/clinical-considerations/faq.html#print
    PubMedGoogle Scholar
  • 27 McGreevey III JD, Mallozzi CP, Perkins RM, Shelov E, Schreiber R. Reducing alert burden in electronic health records: state of the art recommendations from four health systems. Appl Clin Inform 2020; 11 (01) 001-012
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 McCoy AB, Russo EM, Johnson KB. et al. Clinician collaboration to improve clinical decision support: the Clickbusters initiative. J Am Med Inform Assoc 2022; 29 (06) 1050-1059
    CrossrefPubMedGoogle Scholar
  • 29 Kassakian SZ, Yackel TR, Gorman PN, Dorr DA. Clinical decisions support malfunctions in a commercial electronic health record. Appl Clin Inform 2017; 8 (03) 910-923
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Liu S, Kawamoto K, Del Fiol G. et al. The potential for leveraging machine learning to filter medication alerts. J Am Med Inform Assoc 2022; 29 (05) 891-899
    CrossrefPubMedGoogle Scholar
  • 31 McCoy AB, Thomas EJ, Krousel-Wood M, Sittig DF. Clinical decision support alert appropriateness: a review and proposal for improvement. Ochsner J 2014; 14 (02) 195-202
    PubMedGoogle Scholar
  • 32 McFadden K, Seale H. A review of hospital-based interventions to improve inpatient influenza vaccination uptake for high-risk adults. Vaccine 2021; 39 (04) 658-666
    CrossrefPubMedGoogle Scholar
  • 33 Dexter PR, Perkins SM, Maharry KS, Jones K, McDonald CJ. Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA 2004; 292 (19) 2366-2371
    CrossrefPubMedGoogle Scholar
  • 34 Oregon's COVID-19 Data Dashboards. COVID-19 Data and Case Counts. Oregon Health Authority. Published May 10, 2023. Accessed September 24, 2023. https://public.tableau.com/app/profile/oregon.health.authority.covid.19/viz/OregonsCOVID-19DataDashboards-TableofContents/TableofContentsStatewide
    PubMedGoogle Scholar