FluAlert: Influenza Vaccine Alerts for Providers in the Electronic Health Record - 2012

Principal Investigator
Funding Mechanism
PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
Grant Number
R18 HS 018158
Project Period
August 2009 – July 2013
AHRQ Funding Amount

Summary: The Advisory Committee on Immunization Practices recommends that all children age 6 months and older receive the influenza vaccine. Despite this recommendation, vaccine delivery rates are low, even when the vaccine is available. This project aimed to tailor, implement, and evaluate influenza vaccine alerts in an electronic health record (EHR) for pediatric providers serving minority low-income populations at four community health centers.

Each of the four study sites is affiliated with the New York-Presbyterian Hospital Ambulatory Care Network (ACN) and Columbia University and located in a federally designated Health Professional Shortage Area. All providers in the study are part of the same general pediatric group practice and receive uniform influenza vaccine-related provider education. In 2008, the practices had a volume of nearly 64,000 visits by approximately 22,000 children, the majority of whom were covered by Medicaid and were Latino. The Vaccine for Children Program provides most of the vaccines given at the practices.

In the first year of this project, Dr. Stockwell and her research team conducted focus groups and individual interviews with health care providers, nurses, and parents to elicit information for customizing the content, format, and features of the electronic alerts (FluAlert). In the second year, the alerts were iteratively refined and piloted among beta users based on end-user feedback. In the third year, the alerts were pilot tested within the four study sites using a cluster cross-over design. Throughout the study, the research team tracked process indicators such as user rates and obtained feedback from clinical sites. At the end of the project, user satisfaction will be assessed using survey data. Costs will be measured by comparing alert costs with published vaccine effectiveness rates and determining the costs for influenza-associated hospitalizations, outpatient visits, and impact on parent productivity.

Specific Aims:

  • Integrate tailored provider influenza vaccine alerts into the EHRs of urban pediatric community health centers. (Achieved)
  • Evaluate the impact of tailored provider influenza alerts on pediatric influenza vaccine delivery rates. (Ongoing)
  • Evaluate the impact of tailored provider influenza alerts on pediatric influenza coverage rates. (Ongoing)

2012 Activities: The FluAlert cluster cross-over trial began in October 2011 and continued until March 2012. Two clinics were randomly assigned to begin the study with the FluAlert activated and two clinics with it off. After 4 weeks, the activation status was reversed. The activation process was to be switched twice so that each clinic had two 4-week periods when FluAlert was active and two 4-week periods when it was off; each had an on and off period in the fall and winter. In this manner, the cluster cross-over design used each clinic as its own control group. Vaccine delivery performance is being compared during periods when the FluAlert was active to periods when it was off. After the trial was completed, Dr. Stockwell worked with a statistician to analyze the study data.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track and the project budget funds are slightly underspent to conserve funds to complete the trial and subsequent data analysis.

Preliminary Impact and Findings: Analysis of the transcripts from focus groups with physicians identified several barriers to influenza vaccine delivery, including clinic resource issues, problems with multiple sources of immunization information, and lack of time to complete the vaccination process. The physicians also identified ways to improve the computerized reminder, such as timing of presentation, ability to access multiple sources of immunization records, and facilitation of vaccine ordering and documentation. These results were published in the March-April 2011 volume of Preventive Medicine in a manuscript titled FluAlert: a qualitative evaluation of providers’ desired characteristics and concerns regarding computerized inf luenza vaccination alert.

Focus groups were also held with parents to learn more about their experiences with the flu vaccine and their thoughts about how to improve communication with providers. Parents indicated the importance of hearing about both benefits and potential risks of the vaccine, especially when vaccine safety is a concern. Thematic analysis indicated that parents want to learn about their child’s risk for influenza and the side effects, safety, effectiveness, and timing of the vaccine.

In the 10-week pilot period, FluAlert generated 1,949 alerts. Fifty-four percent of the time (n=1,048), the alert indicated that the child was in need of an influenza vaccine. For those 1,048 instances, the vaccine was ordered 29 percent of the time; declined 34 percent of the time; and deferred 37 percent of the time. In cases when the vaccine was declined, the reason for declining the vaccine was documented 93 percent of the time. Children had greater odds of being vaccinated for flu when FluAlert was turned on than when it was turned off.

Analysis of the cluster cross-over trial is underway. The process evaluation showed that clinicians acted 82 percent of the time when a vaccine was required, two-thirds of those times they vaccinated. When vaccination did not occur, clinicians recorded a reason 98 percent of the time. Data analysis will continue in 2013.

Target Population: Low SES/Low Income*, Medicaid, Pediatric*, Racial or Ethnic Minorities*: Latinos, Teenagers

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ’s priority populations.