How this Ohio safety-net system tapped into EHRs, health IT to improve vaccination rates


Despite the well-documented success of vaccines in helping to improve public health, vaccination rates remain lower than Healthy People 2020 goals.

Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., has paid for and provided editorial input on this material.

Healthy People is an initiative launched by the US Department of Health and Human Services (HHS) to improve the health of Americans through evidence-based, 10-year objectives, one of which includes the reduction of preventable infectious disease through the improvement of nationwide vaccination rates. In 2015, national benchmarks for certain vaccine categories remained well below Healthy People 2020 goals.

While vaccination rates remain below Healthy People 2020 goals for certain infectious diseases, health systems and hospitals have resources and initiatives they can use to boost vaccination rates. One such resource is the electronic health record (EHR).

EHRs have the potential to help physicians promote patient care through vaccination, according to Joe Vasey, PhD, principal data analyst for health care technology company Practice Fusion: "By relying on structured, coded health data and dates, an EHR can systematically identify eligible patients on the basis of objective criteria in compliance with CDC guidelines."

Cleveland-based MetroHealth System provides a model for health care leaders looking to launch HER and other health IT-driven vaccination improvement initiatives. MetroHealth was the first safety-net health system to implement Epic's HER platform in 1999. By 2014, the health system achieved HIMSS Electronic Medical Record Adoption Model Stage 7 for all of its ambulatory clinics and hospitals. In 2015, Metro earned HIMSS' Davies Award for outstanding achievement in leveraging health IT solutions to improve patient care outcomes.

David Kaelber, MD, PhD, chief medical informatics officer and vice president of health informatics at MetroHealth System, describes the culture in each department across MetroHealth as focused on using health IT solutions to improve care. Over the last 5 years, the health care system placed a particular emphasis on improving vaccination rates through the use of an EHR and other health IT solutions. The systemwide effort aligns with MetroHealth's general emphasis on population health management and eliminating gaps in care. MetroHealth implemented 4 health IT-focused strategies to boost vaccination rates.

1. Create EHR reminders for every vaccine and update reminders regularly.

While providing vaccines at every patient contact point on the MetroHealth care continuum is a systemwide standard, care gaps can still arise. To eliminate potential care gaps, MetroHealth implemented vaccine-specific health IT interventions. These interventions included EHR alerts for all vaccine schedules recommended by the Advisory Committee on Immunization Practices (ACIP).

"Using standard Epic clinical decision support tools, I implemented reminders and alerts for all ACIP-approved vaccines," said David Bar-Shain, MD, director of informatics for clinical decision support at MetroHealth. "These reminders and alerts have resulted in a significant improvement in our vaccination rates across the MetroHealth System and are a model for Epic customers on how to do vaccination decision support." Additionally, the health system updates the EHR with any new ACIP vaccine schedule recommendations in a timely fashion.

2. Engage patients through smartphones and electronic patient portals.

As a safety-net provider, MetroHealth serves many individuals without access to home Internet services. However, a majority of their patients own smartphones. For this reason, most of the health system's patient engagement and vaccination improvement solutions are designed with smartphone technology in mind.

Among these solutions is a wellness registry that incorporates the system's entire patient population and notifies patients and their caregivers of specific wellness needs. MetroHealth uses the health IT solution to identify and notify patients in need of a particular vaccine before scheduled appointments and after missed appointments. As for the latter, MetroHealth also deploys automated messaging to encourage patients who missed appointments for vaccine administration to reschedule and return to their care facility to be vaccinated as soon as possible.

Automated messaging solutions were particularly effective for MetroHealth's adolescent patient population. The system launched an outreach program to notify adolescents' parents and guardians when their children, aged 11 to 18 years, were scheduled for a vaccine. The outreach program notified parents via phone calls, text messages, and direct mail. The initiative delivered more than 7,000 vaccine reminder messages — 3,334 automated voice messages, 2,631 text messages, and 1,129 postcards — over the span of 24 weeks. In that period, 1,324 vaccinations occurred in 959 patient visits. Among the adolescents whose parents received messages, 25.5% received at least one recommended vaccine.

The success of the adolescent messaging initiative spurred the health system to launch a similar program for adult vaccination reminders in 2013. MetroHealth estimates this program has led to substantial improvements in adult vaccination rates among its patient population.

Additionally, MetroHealth offers patients access to an online portal, which contains reminders for future services, including vaccinations, and provides patients access to summaries of care visits and their personal vaccine history. To encourage utilization of the portal, patients are educated about its benefits and uses at multiple care contact points. Additionally, vaccination reminders prompt patients to self-report vaccines received outside the health system. When patients report not receiving a certain vaccine, the reminder prompts patients to select one of 3 options in response:

  • They intend to get the vaccine.
  • They're unsure if they'll get the vaccine.
  • They decline to get the vaccine.

Based upon the patient's selected response, MetroHealth targets vaccine outreach, such as informing patients who are interested in vaccination where and when they can receive the vaccine.

3. Support clinicians through health IT training and EHR solutions.

MetroHealth also uses the EHR to offer clinical decision-making support to providers during patient visits. During patient interactions, the EHR alerts providers to clinical reminders and best practice advisories for vaccination. Clinicians also have access to patient demographic data, vaccine history, allergies, and possible history of adverse events. Additionally, when a vaccine is administered as a part of a series, the EHR prompts clinicians to schedule future orders for additional doses. The decision-making support solution improved workflow efficiency for MetroHealth by reducing the amount of time staff spends generating manual reports and conducting patient outreach.

Staff training is an important part of the effectiveness of MetroHealth's vaccine initiative. The health system invests in staff training to ensure providers are getting the most out of its health IT solutions. Types of training offered to MetroHealth providers include online modules and in-person educational services.

4. Exchange health information and enable electronic prescribing.

The exchange of patient health information is vital to improving quality, safety, patient outcomes, and coordination of care. To ensure the integration of accurate patient health information into the clinical workflow, MetroHealth exchanges health information, including information on vaccinations, with multiple health systems across the Cleveland metropolitan area thousands of times every day.

"MetroHealth recognized the inherent potential for their technology to connect clinical information from outside their four walls," Dr. Kaelber said. "By creating a strategy, this technology was integrated into clinical workflow to improve health care quality and improve the patient experience." According to Dr. Kaelber, health IT solutions have likely benefited MetroHealth providers through improved efficiency, assisting in the delivery of quality care and enabling vaccination administration at multiple points in the care cycle.

The information exchange system also maximizes the benefits of electronic prescribing. When a patient is unable to receive a vaccine in a clinic setting, a prescription for the vaccine is then delivered electronically to the patient's preferred pharmacy. The system also immediately alerts MetroHealth of vaccinations administered to patients at retail pharmacies.

A new era of improved vaccination coverage through technology

As MetroHealth's vaccine program demonstrates, health IT solutions have the potential to help health systems improve vaccination rates among certain patient populations. The near ubiquitous use of technologies such as smartphones among the US population offers a significant opportunity for vaccination outreach. In fact, numbers suggest there are more cell phones in the US than there are people, most (87%) adults in the US have a cell phone, and that rate may be higher in low-income populations.

"Technology, ever present in society, offers new and emerging methods to improve vaccination coverage.

Because of its prevalence and flexibility, technology provides promising tools to address vaccination barriers for families, health care providers, and the broader community."

Hospital and health system leaders looking to bring their respective organizations into this new era can look to health systems like MetroHealth as models for health IT adoption.

HIMSS=Healthcare Information and Management Systems Society.

In the 20th century, improvements to childhood survival rates boosted life expectancy in the United States. This was largely attributable to reduced pediatric mortality linked to infectious disease. Vaccination and improved sanitation can, in large part, be credited for this advancement, according to the CDC.


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