title: Improving immunization delivery using an electronic health record: the ImmProve project.
abstract: OBJECTIVE
  Though an essential pediatric preventive service, immunizations are challenging to deliver reliably. Our objective was to measure the impact on pediatric immunization rates of providing clinicians with electronic health record-derived immunization prompting.
  
  
  METHODS
  Operating in a large, urban, hospital-based pediatric primary care clinic, we evaluated 2 interventions to improve immunization delivery to children ages 2, 6, and 13 years: point-of-care, patient-specific electronic clinical decision support (CDS) when children overdue for immunizations presented for care, and provider-specific bulletins listing children overdue for immunizations.
  
  
  RESULTS
  Overall, the proportion of children up to date for a composite of recommended immunizations at ages 2, 6, and 13 years was not different in the intervention (CDS active) and historical control (CDS not active) periods; historical immunization rates were high. The proportion of children receiving 2 doses of hepatitis A immunization before their second birthday was significantly improved during the intervention period. Human papillomavirus (HPV) immunization delivery was low during both control and intervention periods and was unchanged for 13-year-olds. For 14-year-olds, however, 4 of the 5 highest quarterly rates of complete HPV immunization occurred in the final year of the intervention. Provider-specific bulletins listing children overdue for immunizations increased the likelihood of identified children receiving catch-up hepatitis A immunizations (hazard ratio 1.32; 95% confidence interval 1.12-1.56); results for HPV and the composite of recommended immunizations were of a similar magnitude but not statistically significant.
  
  
  CONCLUSIONS
  In our patient population, with high baseline uptake of recommended immunizations, electronic health record-derived immunization prompting had a limited effect on immunization delivery. Benefit was more clearly demonstrated for newer immunizations with lower baseline uptake.
authors.affiliation: Divisions of General Pediatrics and Epidemiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC. Electronic address: dbundy@musc.edu.
authors.forename: David G
authors.initials: DG
authors.lastname: Bundy
authors.forename: Nichole M
authors.initials: NM
authors.lastname: Persing
authors.forename: Barry S
authors.initials: BS
authors.lastname: Solomon
authors.forename: Tracy M
authors.initials: TM
authors.lastname: King
authors.forename: Peter N
authors.initials: PN
authors.lastname: Murakami
authors.forename: Richard E
authors.initials: RE
authors.lastname: Thompson
authors.forename: Lilly D
authors.initials: LD
authors.lastname: Engineer
authors.forename: Christoph U
authors.initials: CU
authors.lastname: Lehmann
authors.forename: Marlene R
authors.initials: MR
authors.lastname: Miller
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D020000:Decision Support Systems, Clinical; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D017589:Immunization Programs / Q000379:methods*; D007223:Infant; D008297:Male; D010372:Pediatrics / Q000379:methods; D058996:Quality Improvement; D017010:Reminder Systems
keywords: clinical decision support systems; immunizations; quality improvement