Enhancing Immunization Clinical Decision Support to Support Personalized Guidance and Shared Decision Making Recommendations

Background:

Background: Immunization clinical decision support (CDS) systems provide much needed guidance for clinicians in interpreting immunization guidelines and determining when vaccinations are due. In most circumstances, patients should be vaccinated according to the standard Advisory Committee on Immunization Practices (ACIP) schedule. However, for some patients the standard recommendations encoded into the CDS fail to address individual health. For example, underspecfication in ICD-10 codes for immunocompromised status led to confusion about whether a patient should or should not be given vaccines. Additionally, the system we currently used only allowed for limited ‘on’ and ‘off’ designations, resulting in some families choosing to self-select as “no to all vaccines” even there were some vaccines they were interested in their child receiving such as school required vaccines. As some new vaccines have included a shared decision making recommendation, including the meningitis B vaccine and the COVID vaccines, we recognized the need for a more finite level of control in our immunization CDS.

Methods:

Methods: We overhauled our immunization CDS backend to provide increased flexibility in rule interpretation and recommendation presentation. First, we switched from a binary interpretation of rules (due or not due) to a three-level interpretation (due and default selected, due but not default selected, or not due). Diagnoses that previously had shut off notices that a vaccine were due were re-interpreted to note that the vaccine would be due, but that a specific diagnosis in the chart indicated it should not be defaulted as selected. We developed a provider portal accessible by the clinician in real time to update rule recommendations at the patient level allowing a clinician to control for a patient what immunizations would be recommended at the antigen level. To facilitate ease of use for the clinician, we included pre-populated selections for reasons a parent may elect to defer on default immunizations. Additionally, we provided links to content on supporting shared decision making for immunizations.

Results:

Results: The updated immunization CDS successfully allowed clinicians to modify recommended vaccinations at the patient and antigen level. Multiple scenarios were tested including personal history of varicella, which can be driven by problem list entries, and history of hepatitis A infection with natural immunity, for which diagnosis data is insufficient for altering the recommendations. In all cases clinicians were able to unselect default recommendation for immunizations.

Conclusion:

Conclusion: Immunization CDS, which previously only allowed for default selection of immunizations was successfully modified to support personal preferences, finite recommendations related to previously inaccessible information within the EHR, and to allow for future implementation of shared decision making recommendation level immunizations. The interphase developed allowed for clinician updating of immunization recommendations in real-time at the patient level and antigen level.