Synchronized Immunization NotifiCations
| Status: | Not yet recruiting |
|---|---|
| Conditions: | Vaccines |
| Therapuetic Areas: | Immunology / Infectious Diseases |
| Healthy: | No |
| Age Range: | Any - 17 |
| Updated: | 3/23/2017 |
| Start Date: | April 2017 |
| End Date: | March 2018 |
| Contact: | Melissa Stockwell, MD MPH |
| Email: | mss2112@columbia.edu |
| Phone: | 212-342-5732 |
Immunization is one of the most effective public health interventions. Yet, nationally
coverage has consistently fallen short of national goals, and has remained for the most part
stagnant. The continued presence of vaccine-preventable diseases poses a threat to public
health. In addition to needed improvement of immunization coverage for the general
pediatric/adolescent population, some children with chronic medical conditions need specific
additional immunizations, yet many fail to receive them.
Immunization reminders for providers in the electronic health record (EHR) are a type of
clinical decision support (CDS) that can reduce missed immunization opportunities. One
limitation of these reminders is that they generally depend only on data local to the EHR,
which can be incomplete due to record scatter, leading to inaccurate alerts. An Immunization
Information System (IIS), also known as an immunization registry, is a population-based
system that collects immunization data primarily for children and adolescents from providers
at a regional or state level.
The investigators seek to couple bidirectional exchange of IIS immunization information and
forecasting tools with patient level medical history from the EHR to deliver accurate,
patient-specific EHR immunization reminders.
coverage has consistently fallen short of national goals, and has remained for the most part
stagnant. The continued presence of vaccine-preventable diseases poses a threat to public
health. In addition to needed improvement of immunization coverage for the general
pediatric/adolescent population, some children with chronic medical conditions need specific
additional immunizations, yet many fail to receive them.
Immunization reminders for providers in the electronic health record (EHR) are a type of
clinical decision support (CDS) that can reduce missed immunization opportunities. One
limitation of these reminders is that they generally depend only on data local to the EHR,
which can be incomplete due to record scatter, leading to inaccurate alerts. An Immunization
Information System (IIS), also known as an immunization registry, is a population-based
system that collects immunization data primarily for children and adolescents from providers
at a regional or state level.
The investigators seek to couple bidirectional exchange of IIS immunization information and
forecasting tools with patient level medical history from the EHR to deliver accurate,
patient-specific EHR immunization reminders.
National immunization coverage has consistently fallen short of Healthy People 2010 and 2020
goals and has remained relatively stagnant over the past few years for many immunizations.
One important group with a high risk of under-immunization are children with chronic medical
conditions (CMCs), who are also at increased risk of serious morbidity and even death from
vaccine preventable diseases. One of the key interventions to improve immunization coverage
in both the general population and children with CMCs is to decrease missed opportunities
for immunization. Immunization reminders in the electronic health record (EHR) are a type of
clinical decision support (CDS) that can reduce missed opportunities. In a recent project,
the investigators successfully employed such reminders to increase influenza immunization.
One limitation of EHR immunization reminders is that they generally act only on local EHR
immunization data. If that data is incomplete, a provider may be erroneously alerted to
order an immunization the child does not need. The likelihood of incomplete local data is
high. Nearly one-quarter of children in the U.S. visit more than one immunization provider
in their first three years of life, leading to fragmented and incomplete records. Low-income
and minority children are especially susceptible to immunization record fragmentation as
they are more likely to receive care from multiple clinics and providers. Children with CMCs
are also at high-risk since their care is often shared between a primary care provider and
subspecialists.Harnessing Immunization Information Systems (IIS) data can help overcome this
limitation. IIS are population-based systems that collect immunization data primarily for
children and adolescents from providers at a regional or state level, consolidating
patient's immunization data into a single location no matter where administered. There are
currently IIS in 50 states, five cities, and the District of Columbia. However, in most
cases, IIS data are available to providers only on the IIS's website. Yet, frontline care
providers are most likely to benefit when an IIS provides information at point of patient
care within their EHR workflow. This type of bidirectional exchange of immunization
information between IIS and EHR systems is a proposed Stage 3 Meaningful Use objective; this
consolidated data would be the most complete data to use for an EHR reminder, but is rarely
used.
Another challenge associated with EHR-based immunization reminders is that pediatric and
adolescent immunization schedules are complex, requiring up to 35 immunizations plus the
annual influenza vaccine. Each immunization series has its own minimum age and dosing
intervals, and new immunizations are not uncommon. However, many EHRs may not have or
aggressively maintain comprehensive immunization decision rules.
IIS can help overcome this limitation as well. Many include tools for forecasting when doses
are next due and can provide that information during data exchange with an EHR, but that has
not been assessed.
Bringing IIS immunization data and forecasting tools into a local EHR to power CDS will be
helpful for the general population. However, one limitation of immunization CDS, whether
provided by an IIS or native to the EHR, is that it does not account for subtleties required
by children with certain CMCs who may need extra immunizations specific to their condition
or cannot receive certain immunizations. A logical next-step is to couple exchange of IIS
immunization data and forecasting tools with patient-level EHR information regarding medical
conditions to power accurate, patient-specific EHR immunization reminders. This has yet to
be done.
Aim 1: Assess the impact of EHR reminders integrated with immunization data and forecasting
from a regional IIS on receipt of generally recommended immunizations in a low-income,
urban, pediatric and adolescent population.
Aim 2: Assess the impact of integrated EHR reminders that also incorporate patient's medical
conditions on receipt of immunizations specifically recommended for children and adolescents
with chronic medical conditions.
Hypothesis 1: Lower rates of under-immunization will be observed when reminders are 'on' vs.
'off'.
Hypothesis 2: Lower rates of over-immunization will be observed when reminders are 'on' vs.
'off'.
Hypothesis 3: Higher rates of captured opportunities will be observed when reminders are
'on' vs. 'off'.
Hypothesis 4: There will be no difference in reminder impact on generally recommended
immunizations for children with and without chronic medical conditions (CMCs)
In this three-year project, investigators will conduct a randomized cluster crossover
pragmatic clinical trial to assess immunization outcomes during periods when an integrated
immunization reminder is 'on' vs. 'off' for generally recommended immunizations as well as
ones specific for children with CMCs. The proposed work will generate empiric knowledge
regarding the best practices for implementing IIS-supported immunization reminders for both
children with and without CMCs. The results may help guide local and national efforts on
both immunization data exchange and EHR reminders.
goals and has remained relatively stagnant over the past few years for many immunizations.
One important group with a high risk of under-immunization are children with chronic medical
conditions (CMCs), who are also at increased risk of serious morbidity and even death from
vaccine preventable diseases. One of the key interventions to improve immunization coverage
in both the general population and children with CMCs is to decrease missed opportunities
for immunization. Immunization reminders in the electronic health record (EHR) are a type of
clinical decision support (CDS) that can reduce missed opportunities. In a recent project,
the investigators successfully employed such reminders to increase influenza immunization.
One limitation of EHR immunization reminders is that they generally act only on local EHR
immunization data. If that data is incomplete, a provider may be erroneously alerted to
order an immunization the child does not need. The likelihood of incomplete local data is
high. Nearly one-quarter of children in the U.S. visit more than one immunization provider
in their first three years of life, leading to fragmented and incomplete records. Low-income
and minority children are especially susceptible to immunization record fragmentation as
they are more likely to receive care from multiple clinics and providers. Children with CMCs
are also at high-risk since their care is often shared between a primary care provider and
subspecialists.Harnessing Immunization Information Systems (IIS) data can help overcome this
limitation. IIS are population-based systems that collect immunization data primarily for
children and adolescents from providers at a regional or state level, consolidating
patient's immunization data into a single location no matter where administered. There are
currently IIS in 50 states, five cities, and the District of Columbia. However, in most
cases, IIS data are available to providers only on the IIS's website. Yet, frontline care
providers are most likely to benefit when an IIS provides information at point of patient
care within their EHR workflow. This type of bidirectional exchange of immunization
information between IIS and EHR systems is a proposed Stage 3 Meaningful Use objective; this
consolidated data would be the most complete data to use for an EHR reminder, but is rarely
used.
Another challenge associated with EHR-based immunization reminders is that pediatric and
adolescent immunization schedules are complex, requiring up to 35 immunizations plus the
annual influenza vaccine. Each immunization series has its own minimum age and dosing
intervals, and new immunizations are not uncommon. However, many EHRs may not have or
aggressively maintain comprehensive immunization decision rules.
IIS can help overcome this limitation as well. Many include tools for forecasting when doses
are next due and can provide that information during data exchange with an EHR, but that has
not been assessed.
Bringing IIS immunization data and forecasting tools into a local EHR to power CDS will be
helpful for the general population. However, one limitation of immunization CDS, whether
provided by an IIS or native to the EHR, is that it does not account for subtleties required
by children with certain CMCs who may need extra immunizations specific to their condition
or cannot receive certain immunizations. A logical next-step is to couple exchange of IIS
immunization data and forecasting tools with patient-level EHR information regarding medical
conditions to power accurate, patient-specific EHR immunization reminders. This has yet to
be done.
Aim 1: Assess the impact of EHR reminders integrated with immunization data and forecasting
from a regional IIS on receipt of generally recommended immunizations in a low-income,
urban, pediatric and adolescent population.
Aim 2: Assess the impact of integrated EHR reminders that also incorporate patient's medical
conditions on receipt of immunizations specifically recommended for children and adolescents
with chronic medical conditions.
Hypothesis 1: Lower rates of under-immunization will be observed when reminders are 'on' vs.
'off'.
Hypothesis 2: Lower rates of over-immunization will be observed when reminders are 'on' vs.
'off'.
Hypothesis 3: Higher rates of captured opportunities will be observed when reminders are
'on' vs. 'off'.
Hypothesis 4: There will be no difference in reminder impact on generally recommended
immunizations for children with and without chronic medical conditions (CMCs)
In this three-year project, investigators will conduct a randomized cluster crossover
pragmatic clinical trial to assess immunization outcomes during periods when an integrated
immunization reminder is 'on' vs. 'off' for generally recommended immunizations as well as
ones specific for children with CMCs. The proposed work will generate empiric knowledge
regarding the best practices for implementing IIS-supported immunization reminders for both
children with and without CMCs. The results may help guide local and national efforts on
both immunization data exchange and EHR reminders.
Inclusion Criteria:
- medical visit at study site during analytic period
Exclusion Criteria:
We found this trial at
2
sites
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New York, New York 10032
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