Over time, physicians were increasingly likely to accept pre-selected vaccination orders; by Year 3 83% of orders were accepted. A bigger challenge was improving vaccine administration after physician order, which improved dramatically after the medication administration record was integrated into the electronic medical record. Also, since most internal medicine patients met criteria for vaccination, sophisticated rule-building was unnecessary. In fact, since not all patients who meet high-priority criteria for vaccination could be identified using clinical data, building rules to selectively trigger the CDS system would have resulted in missed opportunities to vaccinate high-risk patients.
Our findings illustrate the tenet that to successfully implement CDS it is essential to address workflow integration, healthcare worker-system interaction, local culture, and transition of most processes to the electronic system. 1,3,12–15
During Year 1, we attempted CDS in a predominantly paper-based system; for example, electronic orders were printed at the nurses station, which delayed notification of nurses about the order during a time critical process. Since our CDS rule was triggered by the “Discharge Patient” order, nurses were required to vaccinate patients in the relatively short time between the discharge order and the patient's departure. Although we considered other CDS triggers, each potential solution had challenges. For example, during Year 2 we tested automated electronic reminders to nurses, triggered by patient admission. Unfortunately, nurses rarely followed the policy. We considered using temporal triggers, e.g., orders presented by hospital day, but this was not an option with our CDS system. Finally, we attempted to use the admission order as a trigger for the pre-selected order, but could not resolve technical difficulties.
During Year 1, physicians who were exposed to a reminder, rather than the pre-selected order, did not place the order. Likely because in part, there was no medication CPOE, and physicians either had to write the order in the paper chart or search for the electronic order at a time when there was no CPOE for medications. During Year 2, increased vaccine administration by nurses likely resulted from increased functionality of the electronic medical record; for example, availability of an electronic task list for nurses. In Year 2, despite improved physician acceptance of the order and increased vaccine administration, coverage levels remained low.
Since nursing and physician reminders were unsuccessful during Years 1 and 2, in Year 3 we focused on using pre-selected physician orders. To facilitate nursing administration of vaccine during the discharge process, we intended to test presenting the pre-selected order to physicians upon both patient admission and discharge. However, despite successful use of the rule in the test environment, we were unable to reliably use the order triggered by patient admission. Specifically, influenza orders triggered by patient admission usually were not accepted by the system; therefore, the pharmacist could not verify the order electronically. Since Year 3 vaccination rates were dramatically improved, we believe that the low vaccine administration rates during Years 1 and 2 were primarily due to incomplete maturation of the electronic system, rather than logistical challenges posed by triggering the pre-selected order on patient discharge.
Our experiences illustrate how CDS implementations require attention to local workflow, in particular, transition of workflow from paper-based to electronic systems. This may partly explain the relatively low penetration of CDS in healthcare settings, especially since many institutions do not have the expertise to tailor less flexible vendor-provided systems to their needs. 4,16
Despite these challenges, we achieved significant and meaningful increases in vaccination coverage using CDS. By Year 3, over 50% of patients not vaccinated before hospitalization, were vaccinated during their hospital stay.
At our hospital, a written universally-applied standing orders policy was ineffective, even after augmenting the policy with electronic reminders to nurses. In addition to nurses' concerns about acting without an individual physician's order, during educational sessions many nurses expressed concerns about the influenza vaccine. After recognizing these substantial local barriers, during Year 3 we abandoned electronic nursing reminders—despite proven success at another institution. 17
For the following reasons, we presented the pre-selected order to all patients: incomplete electronic problem lists compromise the sensitivity of electronic inferences of chronic medical conditions, some criteria are not electronically captured (e.g., living with a high-risk person), we were hesitant to increase nurses' workload by creating an electronic form to screen patients, and influenza vaccination is safe and effective for all patients.
Our findings are limited in that we evaluated patients in a single, large, urban public hospital, nurses at other hospitals may be more likely to respond to electronic reminders and standing orders policies. 17
Also, we did not determine previous vaccination history through patient interview; however, a bedside interview may have influenced patients' desire for vaccination and biased our results.
We encountered several challenges during implementation of a CDS rule to increase influenza vaccination. These challenges included local cultural issues—nurses were reluctant to carry out standing orders—and technical issues, such as incomplete integration of our electronic medical record and lack of functionality of a vendor-provided system. Despite these challenges, we observed early and nearly complete physician acceptance of the CDS-generated order. After integration of the electronic medication administration record, there was a dramatic increase in nurses' administration of vaccine. Use of CDS can dramatically improve patient care, but success may be realized only after understanding the local workflow and culture, and near-complete transition from paper to electronic processes.