General Description

This workflow describes how EHRs and other clinical software systems can use information to assist with administering and reporting immunizations given to patients in the provider setting. This includes:

1. Providing patient education to help the patient understand the immunization about to be administered,
2. Documenting reasons why a recommended immunization is not given (e.g., patient refusal, fever on the day of the visit, etc.)
3. Administration of the vaccine to the patient
4. Documenting all of the information about the process (i.e., which vaccine, lot number and expiration date, body site of the injection, etc.)
5. Submitting the report to the public health registry, and
6. Providing the patient with a summary of vaccine status.

Requirements Within This Workflow

5.1: Provide Access to Vaccine Information Statement(s)

5.2: Record Vaccine Administration Deferral

5.3: Record Past Immunizations

5.4: Notify of Vaccine Dose Ineligibility

5.5: Document Vaccine Ineligibility Override Reason

5.6: Enter Vaccination Order

5.7: Review Patient Immunization History

5.8: Link Standard Codes to Immunization Data

5.9: Record Vaccine Administration

5.10: Produce Standard Patient Immunization History Report

5.11: Transmit Standard Patient Immunization History Report

5.12: Produce Configurable Patient Immunization History Report

5.13: Transmit Configurable Patient Immunization History Report

5.14: Produce Immunization Forecast Report

Who Performs This Workflow

• Clinicians (physicians, nurses, and other personnel who assist with providing immunizations)
• Patients or caregivers with permission to access an individual’s information
• Public health immunization registry (as a receiver of the immunization report)

Examples of Work Related to this Workflow

• Two vendors interviewed for this effort have evaluated 2D bar coding to document vaccine administration into their EHR systems.
• Bar code readers for linear and 2D bar codes are readily available at relatively low cost.
• To date, testing the use of bar codes in administering vaccinations has not identified an ideal workflow for implementing bar code assisted documentation of vaccine administration.
• Some work has found scanning bar codes on individual vaccine doses after vaccine administration may be easier for the provider’s staff.  However, such a practice is contrary to the patient safety initiatives that encourage bar coding prior to vaccine administration.
• The Drug Quality Security Act (9/27/2014) requires all pharmaceuticals to have human readable or bar code on packaging for the lowest unit of sale.
  • Most vaccines contain linear bar codes on the vial containing the vaccine (the unit of use), as well as on the packaging. Linear bar codes allow 48 alphanumeric characters and include NDC numbers to identify the drug, but not lot number and expiration date.
  • The Act requires adding a 2D bar code no later than 2017, but only at the level of packaging (unit of sale). 2D bar codes allow 2335 alphanumeric characters allowing room for the NDC number plus expiration date and lot number.
• A study of 215 practices – using 24 EHR vendor products – evaluated 2D bar code.
  • The study found significant satisfaction regarding the accuracy of documentation and the ease of entering vaccine stock into the EHR to allow ordering from inventory.
  • Most practices included in the study experienced additional burden, since only some of the vaccine products in the testing were bar coded.
  • Most practices were interested in implementing bar coding to document vaccine administration if a threshold of 76 to 99% of vaccines had 2D bar codes.
  • No vendor identified has yet included incorporation of the Vaccine Information Statement (VIS) and its expiration date into the software.^[1]
• When a clinician does not administer a vaccination based on clinical guidelines, it is important that the reason for the deferral is available, so that other clinicians can use this information to guide subsequent decision making regarding vaccinations. The core data elements for reporting immunizations to public health registries include contraindications, exemptions/parent refusals, and history of vaccine preventable disease, all of which may represent deferral reasons that should be documented.^[2]
• Reporting for clinical quality measures for hospitals and ambulatory physicians also requires documentation and reporting of deferrals. Managing such documentation is one of the reasons for difficulty implementing electronic clinical quality measures (eCQMs) in EHRs.^[3],[4] A more usable mechanism to document deferrals is needed.

[1] Centers for Disease Control and Prevention. About Two-Dimensional (2D) Vaccine Barcodes. November 19, 2014. Available at: http://www.cdc.gov/vaccines/programs/iis/2d-vaccine-barcodes/about.html. Accessed 9 December 2014.

[2] Centers for Disease Control and Prevention. Immunization Information System Functional Standards, 2013-2017. August 1, 2012. Available at: http://www.cdc.gov/vaccines/programs/iis/func-stds.pdf. Accessed 9 December 2014.

[3]GarridoTerhilda et. al. “e-Measures: Insight into the Challenges and Opportunities of Automating Publicly Reported Quality Measures.” 20 March 2014. J Am Med Inform Assoc. 2014;21:181-184. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3912717/. Accessed 9 December 2014.

[4] Eisenberg F, Lasome C. Martins-Baptista R, et. al. “A Study of the Impact of Meaningful Use Clinical Quality Measures.” American Hospital Association. 2013. Web. 20 March 2014. Available at: http://www.aha.org/research/policy/ecqm.shtml. Accessed 9 December 2014.