Using Active Choice Within the Electronic Health Record to Increase Influenza Vaccination Rates.
BACKGROUND
Despite the benefits of influenza vaccination, each year more than half of adults in the United States do not receive it.


OBJECTIVE
To evaluate the association between an active choice intervention in the electronic health record (EHR) and changes in influenza vaccination rates.


METHODS
Observational study.


METHODS
Adults eligible for influenza vaccination with a clinic visit at one of three internal medicine practices at the University of Pennsylvania Health System between September 2010 and March 2013.


METHODS
The EHR confirmed patient eligibility during the clinic visit and, upon accessing the patient chart, prompted the physician and their medical assistant to actively choose to "accept" or "cancel" an order for the influenza vaccine.


METHODS
Change in influenza vaccination order rates at the intervention practice compared to two control practices for the 2012-2013 flu season, comparing trends during the prior two flu seasons adjusting for time trends and patient and clinic visit characteristics.


RESULTS
The sample (n = 45,926 patients) was 62.9% female, 35.9% white, and 54.4% black, with a mean age of 50.2 years. Trends were similar between practices during the 2 years in the pre-intervention period. Vaccination rates increased in both groups in the post-intervention year, but the intervention practice using active choice had a significantly greater increase than the control (adjusted difference-in-difference: 6.6 percentage points; 95% CI, 5.1-8.1; P < 0.001), representing a 37.3% relative increase compared to the pre-intervention period. More than 99.9% (9938/9941) of orders placed during the study period resulted in vaccination.


CONCLUSIONS
Active choice through the EHR was associated with a significant increase in influenza vaccination rates.
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. mpatel@upenn.edu.|The Wharton School, University of Pennsylvania, Philadelphia, PA, USA. mpatel@upenn.edu.|Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA. mpatel@upenn.edu.|Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. mpatel@upenn.edu.|Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA. mpatel@upenn.edu.
Mitesh S
MS
Patel
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.|The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.|Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.|Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.|Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA.
Kevin G
KG
Volpp
The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
Dylan S
DS
Small
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Craig
C
Wynne
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.|Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
Jingsan
J
Zhu
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Lin
L
Yang
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Steven
S
Honeywell
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Susan C
SC
Day
D000328:Adult; D000368:Aged; D002755:Choice Behavior; D057286:Electronic Health Records / Q000639:trends*; D005260:Female; D006801:Humans; D007252:Influenza Vaccines / Q000627:therapeutic use*; D007251:Influenza, Human / Q000453:epidemiology / Q000517:prevention & control / Q000523:psychology; D008297:Male; D008875:Middle Aged; D010358:Patient Participation / Q000523:psychology / Q000639:trends*; D011897:Random Allocation; D014611:Vaccination / Q000523:psychology / Q000639:trends*
D007252:Influenza Vaccines
active choice; behavioral economics; choice architecture; electronic health record; influenza vaccination; nudge; physician behavior