Provider prompts remind the practitioner that individual patients are due for specific vaccines to help ensure that immunizations are not overlooked during a visit. Prompts are typically active identifiers that a patient is due for vaccination, such as an electronic health record (EHR) alert, a verbal cue from a nurse, or a ‘sticky note’ left on a patient’s chart. Some people also consider passive reminders to be prompts, e.g., a checklist that a provider can choose to refer to during each patient visit.
When designing prompts, offices should consider their setting and what works best with providers’ workflows. With EHR-generated prompts, EHR-based decision support tools can be integrated with vaccine guidelines (such as the CDC immunization schedules), providing real-time guidance during patient encounters. However, this approach relies on an accurate immunization history in the EHR and use of the most up-to-date immunization schedule. An EHR prompt can also accommodate specific intervals or situations (e.g., annual influenza vaccination), specific ages (e.g., Tdap at age 11), or specific health conditions (e.g., pneumococcal vaccination when diagnosed with chronic heart or lung disease). EHR prompts may be “opt-in” or carry a stronger behavioral nudge, such as default orders that must be deselected.
In some settings, a manual process may be preferred. For example, a member of the clinical staff can review the patient’s vaccination record and cue the provider regarding which vaccines are due. For example, the provider may be cued that the patient is due for HPV vaccine by putting an HPV Vaccine Information Statement where the provider will see it before the patient is discharged.
Some studies have suggested that a combination approach is most effective. For example, Szilagyi and colleagues showed that prompts via EHR alone without nurse involvement may be insufficient to increase immunization rates. Likewise, Rand and colleagues showed that combined EHR and nurse/medical assistant-generated prompts led to substantial improvements in missed opportunities and vaccination rates.
Key reasons to use provider prompts
- They work! The Community Preventive Services Task Force recommends provider reminders based on strong evidence of effectiveness in increasing vaccination rates.
- Prevent missed opportunities. Prompts help guarantee that a vaccine is not overlooked, especially during acute care, chronic care, and follow-up visits. They also help when the office is especially busy.
- Improve workflow efficiency in direct patient care. If the need for vaccination was assessed before the healthcare provider enters the exam room, the time spent with the patient can be used to focus on the patient’s other health needs.
- Provide education. Prompts can be designed to offer tips for providers, on everything from who needs post-vaccination serology to vaccine communication to vaccine administration.
- Gather actionable data. EHR prompts can be designed so the provider either orders the vaccine or documents the reason why the vaccine was not ordered (e.g., parental refusal). Such data can be used in quality improvement efforts.
Designing prompts that work
Provider prompts should be integrated into the routine for visits of any type at your practice. Developing a process for the prompts in your setting should follow a standard quality improvement (QI) framework, such as Plan-Do-Study-Act. This will allow you to develop a prompt that addresses current gaps in vaccination in your practice and fits into the workflow.
In any QI project, it is critical to identify the problem you need to solve. For example, if your practice has EHR prompts, but your data show they are not used 40% of the time, work to understand why they are not being used and explore what additional cue can help clinicians in a standardized workflow. Do they need a different visual cue? Would a manual prompt help? Should the EHR prompt come at the beginning of the visit instead of the end?
When designing vaccination prompts, ensure that:
- The process is standardized but may be flexed for different visit types (according to the practice’s policies).
- Roles are clear regarding who will check vaccination eligibility and who will deliver the prompt.
- The prompt is clearly recognized whether it is visual or audible.
- Data are collected on vaccination completion rates. This will show if prompts are associated with higher uptake.
- Data are captured on visits during which a vaccine prompt was used, but the vaccine was not given. This will show either that the parent refused or that the prompt was ineffective.
Provider prompts are a valuable tool for increasing immunization rates by helping clinicians to consistently identify patients due for vaccines and order vaccines during the visit. As the immunization schedule becomes more complex, prompts from up-to-date computer algorithms and knowledgeable staff can optimize the use of a provider’s time caring for patients while also increasing overall vaccination rates in the practice.
Contributed by: Sharon G. Humiston, MD, MPH, FAAP
Provider prompts remind the practitioner that individual patients are due for specific vaccines to help ensure that immunizations are not overlooked during a visit. Prompts are typically active identifiers that a patient is due for vaccination, such as an electronic health record (EHR) alert, a verbal cue from a nurse, or a ‘sticky note’ left on a patient’s chart. Some people also consider passive reminders to be prompts, e.g., a checklist that a provider can choose to refer to during each patient visit.
When designing prompts, offices should consider their setting and what works best with providers’ workflows. With EHR-generated prompts, EHR-based decision support tools can be integrated with vaccine guidelines (such as the CDC immunization schedules), providing real-time guidance during patient encounters. However, this approach relies on an accurate immunization history in the EHR and use of the most up-to-date immunization schedule. An EHR prompt can also accommodate specific intervals or situations (e.g., annual influenza vaccination), specific ages (e.g., Tdap at age 11), or specific health conditions (e.g., pneumococcal vaccination when diagnosed with chronic heart or lung disease). EHR prompts may be “opt-in” or carry a stronger behavioral nudge, such as default orders that must be deselected.
In some settings, a manual process may be preferred. For example, a member of the clinical staff can review the patient’s vaccination record and cue the provider regarding which vaccines are due. For example, the provider may be cued that the patient is due for HPV vaccine by putting an HPV Vaccine Information Statement where the provider will see it before the patient is discharged.
Some studies have suggested that a combination approach is most effective. For example, Szilagyi and colleagues showed that prompts via EHR alone without nurse involvement may be insufficient to increase immunization rates. Likewise, Rand and colleagues showed that combined EHR and nurse/medical assistant-generated prompts led to substantial improvements in missed opportunities and vaccination rates.
Key reasons to use provider prompts
- They work! The Community Preventive Services Task Force recommends provider reminders based on strong evidence of effectiveness in increasing vaccination rates.
- Prevent missed opportunities. Prompts help guarantee that a vaccine is not overlooked, especially during acute care, chronic care, and follow-up visits. They also help when the office is especially busy.
- Improve workflow efficiency in direct patient care. If the need for vaccination was assessed before the healthcare provider enters the exam room, the time spent with the patient can be used to focus on the patient’s other health needs.
- Provide education. Prompts can be designed to offer tips for providers, on everything from who needs post-vaccination serology to vaccine communication to vaccine administration.
- Gather actionable data. EHR prompts can be designed so the provider either orders the vaccine or documents the reason why the vaccine was not ordered (e.g., parental refusal). Such data can be used in quality improvement efforts.
Designing prompts that work
Provider prompts should be integrated into the routine for visits of any type at your practice. Developing a process for the prompts in your setting should follow a standard quality improvement (QI) framework, such as Plan-Do-Study-Act. This will allow you to develop a prompt that addresses current gaps in vaccination in your practice and fits into the workflow.
In any QI project, it is critical to identify the problem you need to solve. For example, if your practice has EHR prompts, but your data show they are not used 40% of the time, work to understand why they are not being used and explore what additional cue can help clinicians in a standardized workflow. Do they need a different visual cue? Would a manual prompt help? Should the EHR prompt come at the beginning of the visit instead of the end?
When designing vaccination prompts, ensure that:
- The process is standardized but may be flexed for different visit types (according to the practice’s policies).
- Roles are clear regarding who will check vaccination eligibility and who will deliver the prompt.
- The prompt is clearly recognized whether it is visual or audible.
- Data are collected on vaccination completion rates. This will show if prompts are associated with higher uptake.
- Data are captured on visits during which a vaccine prompt was used, but the vaccine was not given. This will show either that the parent refused or that the prompt was ineffective.
Provider prompts are a valuable tool for increasing immunization rates by helping clinicians to consistently identify patients due for vaccines and order vaccines during the visit. As the immunization schedule becomes more complex, prompts from up-to-date computer algorithms and knowledgeable staff can optimize the use of a provider’s time caring for patients while also increasing overall vaccination rates in the practice.
Contributed by: Sharon G. Humiston, MD, MPH, FAAP