Immunization Prompts in EHRs

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Several studies have examined the effectiveness of EHR prompts to remind providers to give immunizations, with mixed success:

Immunization Prompts in EHRs

In a cluster-randomized trial,(1) an EHR alert for influenza vaccine appeared on the screen at all visits for patients with asthma aged 5-19 years. The authors found that vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, which represented a 0.6% greater improvement (not statistically significant). Another study by the same lead author(2) examined the effect of immunization alerts on rates of young children up-to-date for immunization. In that intervention study, rates of children under age 24 months who were up-to-date increased from 81.7% prior to the intervention, to 90.1% after the intervention.

A few studies have examined the effect of computerized alerts on pneumococcal vaccination for adults in inpatient settings,(3,4) and have found standing orders to be more effective than reminders in increasing immunization rates (51% vs. 31% in the Dexter study, p<0.001). Another prospective study(5) found that a computerized reminder in an emergency department increased rates of pneumococcal vaccination for patients over 65 years old by 5%.

In a commentary responding to the 2009 Fiks et al. study,(6) Sittig et al. noted that providing clinical decision support (CDS) in the form of alerts to encourage desired health care activities may not be sufficient to make a substantial impact. One must first ensure that the intervention is well accepted. In the cases of influenza vaccination at acute visits, as well as pneumococcal vaccination on inpatient wards, poor patient acceptance as well as physicians' low priority of vaccination in these settings were likely barriers to a greater effect from reminders. Both patients and providers have to be convinced that the immunization is worthwhile for a brief reminder to make substantial differences in immunization rates. In addition, the placement of the reminder in the physician’s workflow was noted to be a critical issue in all of these studies, and should be carefully planned and tested.

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Use of Clinical Decision Support to Increase Influenza Vaccination: Multi-year Evolution of the System


  1. Fiks A. G., Hunter K. F., Localio A. R., Grundmeier R. W., Bryant-Stephens T., Luberti A. A., et al. Impact of electronic health record-based alerts on influenza vaccination for children with asthma. Pediatrics. 2009;124(1):159-169.[1]
  2. Fiks A. G., Grundmeier R. W., Biggs L. M., Localio A. R., Alessandrini E. A. Impact of clinical alerts within an electronic health record on routine childhood immunization in an urban pediatric population. Pediatrics. 2007;120(4):707-714.[2]
  3. Coyle C. M., Currie B. P. Improving the rates of inpatient pneumococcal vaccination: impact of standing orders versus computerized reminders to physicians. Infect Control Hosp Epidemiol. 2004;25(11):904-907.[3]
  4. Dexter P. R., Perkins S. M., Maharry K. S., Jones K., McDonald C. J. Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA. 2004;292(19):2366-2371.[4]
  5. Dexheimer J. W., Jones I., Waitman R., Talbot T., Gregg W., Aronsky D. Prospective evaluation of a closed-loop, computerized reminder system for pneumococcal vaccination in the emergency department. AMIA Annu Symp Proc. 2006:910.[5]
  6. Sittig D. F., Teich J. M., Osheroff J. A., Singh H. Improving clinical quality indicators through electronic health records: it takes more than just a reminder. Pediatrics. 2009;124(1):375-377.[6]

Submitted by Cynthia Rand