Use of clinical decision support to increase influenza vaccination: multi-year evolution of the system

Despite recognition that clinical decision support (CDS) can improve patient care, there has been poor penetration of this technology into healthcare settings. We used CDS to increase inpatient influenza vaccination during implementation of an electronic medical record, in which pharmacy and nursing transactions increasingly became electronic. Over three influenza seasons we evaluated standing orders, provider reminders, and pre-selected physician orders. A pre-intervention cross-sectional survey showed that most patients (95%) met criteria for vaccination. During our intervention, physicians were increasingly likely to accept pre-selected vaccination orders, Year 1 (47%), Year 2 (77%), Year 3 (83%); however vaccine administration by nurses was suboptimal. As electronic medical record functionality improved, patient receipt of vaccine increased dramatically, Year 1 [0/36; 0%], Year 2 [8/66; 12%], Year 3 [286/805; 36%]. Successful use of clinical decision support to increase inpatient influenza vaccination only occurred after initiation of CPOE for all medications and integration of an electronic medication administration record. Also, since most patients met criteria for influenza vaccination, complicated logic to identify high-risk patients was unnecessary.