Using Active Choice Within the Electronic Health Record to Increase Influenza Vaccination Rates
Despite the benefits of influenza vaccination, each year more than half of adults in the United States do not receive it.
To evaluate the association between an active choice intervention in the electronic health record (EHR) and changes in influenza vaccination rates.
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.
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.
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.
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.
Active choice through the EHR was associated with a significant increase in influenza vaccination rates.
KEY WORDSactive choice choice architecture nudge physician behavior behavioral economics electronic health record influenza vaccination
- 2.Disease Burden of Influenza. Available online at: http://www.cdc.gov/flu/about/disease/burden.htm. Accessed September 15, 2016.
- 5.FluVaxView. Centers for Disease Control and Prevention. Available online at: http://www.cdc.gov/flu/fluvaxview/. Accessed September 15, 2016.
- 6.Fewer Than Half of Americans Report Having Gotten A Flu Vaccine this Season. Centers for Disease Control and Prevention. Available online at: http://www.cdc.gov/flu/news/half-of-americans-received-flu-vaccine.htm. Accessed September 15, 2016.
- 7.Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001–2013. National Center for Health Statistics. Centers for Disease Control and Prevention. Available online at: http://www.cdc.gov/nchs/products/databriefs/db236.htm. Accessed September 15, 2016.
- 10.Souza NM, Sebaldt RJ, Mackay JA, Prorok JC, Weise-Kelly L, Navarro T, Wilczynski NL, Haynes RB, CCDSS Systematic Review Team. Computerized clinical decision support systems for primary preventive care: a decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes. Implement Sci. 2011;6:87.CrossRefPubMedPubMedCentralGoogle Scholar
- 16.Patel MS, Volpp KG, Small DS, Wynn C, Zhu J, Yang L, Honeywell S, Day SC. Using active choice within the electronic health record to increase physician ordering and patient completion of high-value cancer screening tests. Healthcare J Deliv Sci Innov. 2016;4:340–5.Google Scholar
- 17.Campbell DT, Stanley JC. Experimental and Quasi-Experimental Designs for Research. Dallas, TX: Houghton Mifflin Co; 1963.Google Scholar
- 20.Shadish WR, Cook TD, Campbell DT. Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston, MA: Houghton-Mifflin; 2002.Google Scholar
- 21.Patel MS, Patel N, Small DS, Rosin R, Rohrbach JI, Stromberg N, Hanson CW, Asch DA. Change in length of stay and readmissions among hospitalized medical patients after inpatient medicine service adoption of mobile secure text messaging. J Gen Intern Med. 2016;31(8):863–70.CrossRefPubMedGoogle Scholar
- 23.Rogers WH. Regression standard errors in clustered samples. Stata Tech Bull Rep. 1993;3:88–94.Google Scholar
- 25.Newman SC. Biostatistical Methods in Epidemiology. New York: Wiley; 2001:136.Google Scholar
- 29.Centers for Disease Control and Prevention. Past Flu Seasons. Available online at: https://www.cdc.gov/flu/pastseasons/index.htm. Accessed January 15, 2017.
- 30.Thomas RE, Lorenzetti DL. Interventions to increase influenza vaccination rates of those 60 years and older in the community. Cochrane Database Syst Rev. 2014;7:CDOO5188.Google Scholar
- 39.Gerber JS, Prasad PA, Fiks AG, Localio AR, Grundmeier RW, Bell LM, Wasserman RC, Keren R, Zaoutis TE. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA. 2013;309(22):2345–52.CrossRefPubMedGoogle Scholar