Workflow 3: Manage Information For Clinical Decision Making

General Description

This workflow describes how EHRs use information to support clinical decision-making.  The information begins when the provider receives a vaccine forecast from the public health immunization registry.  The forecast lists the appropriate immunizations for a patient based on his or her known history and the most up-to-date immunization schedule. The forecast provides important information that helps providers make the appropriate decisions regarding which vaccines to administer and when.

In addition, the physician must assess if the patient has any conditions or laboratory test findings that would alter the decision about which vaccine to provide. The forecast addresses vaccine-vaccine interactions, but immunization registries do not have individual patient diagnoses or results that might impact which vaccine should be given and when.

Once the vaccine history in the EHR is reconciled with the history from the public health immunization registry, the forecast must be re-checked. The information may be processed directly by the EHR, a public health immunization registry (IIS), a third party web service, or other clinical decision support (CDS) resource. The provider must use the information provided along with information known about the patient to make the final decision about what immunization to give the patient (if any) and enter any orders appropriate to that decision.

Requirements Within This Workflow

3.1: View Immunization Forecast

3.2: View Reconciled Immunization Forecast

3.3: Modify Antigen Recommendations Based on Allergy History

3.4: Modify Antigen Recommendations Based on Active Diagnoses

3.5: Update Patient Immunization Schedule

3.6: Receive Dose Not Indicated Alert for Single Vaccine Order

3.7: Receive Dose Not Indicated Alert Upon Vaccine Administration

3.8: Save History of Clinical Decision Support Recommendations

Who Performs the Workflow

  • Clinicians (physicians, nurses, and other personnel who assist with providing immunizations).
  • Patients or caregivers who participate in the decision-making about which of several vaccine options to choose, and who may decline a vaccine once they are appropriately informed about the risks and benefits.
  • Public health immunization registries (IIS’) that provide the patient’s initial vaccine forecast and may also re-process the forecast with new information a provider submits from his or her EHR or other clinical software system.
  • The EHR and registry software, and/or a third party clinical decision support web service also participate in the process.

Examples of Work Related to This Workflow

  • The Advisory Committee on Immunization Practices, an Advisory Committee to the CDC Director, develops recommendations about how to use vaccines to control diseases in the United States.[1] CDC publishes the recommendations regularly as public health advice.[2]
  • CDC also provides the Clinical Decision Support for Immunization (CDSi) logic specification as an authoritative, implementation-neutral foundation for technical and non-technical immunization-related clinical decision support.[3] CDSi includes business rules logic, test cases, supportive data, workflow descriptions, and describes methods to determine if the vaccine doses a patient received are appropriate (valid) when compared to the ACIP recommended schedule. Based on the logic, a clinical decision support engine can recommend the earliest and latest acceptable dates for providing each vaccine as well as the appropriate intervals between individual vaccines. The clinical decision support engine can also indicate if individual doses already given are not valid because they were given ahead of the prescribed vaccination schedule. A clinical decision support engine that incorporates CDSi content requires a mechanism to capture patient information and send results to a clinician for review and reconciliation with all known patient information.
  • Some EHR vendors indicate they have started to evaluate use of CDSi content within CDS engines in their software. Most vendors express a preference for an external service to provide such decision support for their products.

[1] Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices. June 13, 2014. Available at: Accessed 30 November 2014.

[2] Centers for Disease Control and Prevention. Immunization Schedules. January 31, 2014. Available at: Accessed 30 November 2014.

[3] Centers for Disease Control and Prevention. Clinical Decision Support for Immunization (CDSi). 11 February 2014. Web. 4 March 2014.  Available at: Accessed 9 December 2014.