The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed.
Mrs. Morales refuses to allow her daughter Maria to receive DPT vaccine. Dr. Smith’s entry of the refusal is stored in her EHR system as coded information. Thus, the EHR system can access it for the immunization report that is sent to the public health registry. The information also is available to Dr. Smith and her staff as part of Maria’s record.
When a clinician does not administer a vaccination it is important that the reason for the deferral is available to guide other clinicians who might order or administer the same antigen. 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.[i]
All products evaluated support documentation of immunization deferrals, including the reason for the deferral (medical or patient request) and the expected duration of the deferral. Products that provide immunization forecasts also update the timing for the next dose on the patient’s vaccine schedule.
- Vendor Perspective. Usability evaluation such as UCD may help address mechanisms to capture deferrals and to make the information available to other providers when addressing the same vaccine antigens.
- Provider and Implementer Perspective. Review with your EHR vendor how the system manages vaccine deferrals.
Click here for test script scenarios that include the capability, Record Vaccine Administration Deferral. The scripts also indicate successful performance for each of the test sections.
The data elements include the vaccine deferral reasons specific to the clinical scenario in the test script.
[i] 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.