Effect of Electronic Health Record Reminders for Routine Immunizations and Immunizations Needed for Chronic Medical Conditions.

BACKGROUND: Immunization reminders in electronic health records (EHR) provide clinical decision support (CDS) that can reduce missed immunization opportunities. Little is known about using CDS rules from a regional immunization information system (IIS) to power local EHR immunization reminders. OBJECTIVE: This study aimed to assess the impact of EHR reminders using regional IIS CDS-provided rules on receipt of immunizations in a low-income, urban population for both routine immunizations and those recommended for patients with chronic medical conditions (CMCs). METHODS: We built an EHR-based immunization reminder using the open-source resource used by the New York City IIS in which we overlaid logic regarding immunizations needed for CMCs. Using a randomized cluster-cross-over pragmatic clinical trial in four academic-affiliated clinics, we compared captured immunization opportunities during patient visits when the reminder was "on" versus "off" for the primary immunization series, school-age boosters, and adolescents. We also assessed coverage of CMC-specific immunizations. Up-to-date immunization was measured by end of quarter. Rates were compared using chi square tests. RESULTS: Overall, 15,343 unique patients were seen for 26,647 visits. The alert significantly impacted captured opportunities to complete the primary series in both well-child and acute care visits (57.6% on vs. 54.3% off, p = 0.001, and 15.3% on vs. 10.1% off, p = 0.02, respectively), among most age groups, and several immunization types. Captured opportunities for CMC-specific immunizations remained low regardless of alert status. The alert did not have an effect on up-to-date immunization overall (89.1 vs. 88.3%). CONCLUSION: CDS in this population improved captured immunization opportunities. Baseline high rates may have blunted an up-to-date population effect. Converting Centers for Disease Control and Prevention (CDC) rules to generate sufficiently sensitive and specific alerts for CMC-specific immunizations proved challenging, and the alert did not have an impact on CMC-specific immunizations, potentially highlighting need for more work in this area.

Making the standard more standard: a data and query model for knowledge representation in the Arden syntax.

CONTEXT: Arden Syntax is a Health Level Seven (HL7) standard that can be used to encode computable knowledge. However, dissemination of knowledge is hampered by lack of standard database linkages in Arden knowledge bases (KB). Moreover, the HL7 Reference Information Model (RIM) is object-oriented and hence incompatible with the current Arden data model. Also, significant investment has been made in Arden KBs that would be lost if a backward-incompatible data model were adopted. OBJECTIVE: To define a data model that standardizes database linkages and provides object-oriented features while maintaining backward compatibility. ANALYSIS: We identified the objects of the RIM that could be used as a schema for standard database queries. We propose extensions to Arden to accommodate this model, including the manipulation of objects. CONCLUSION: A data model that standardizes database linkages and introduces object-oriented constructs will facilitate knowledge transfer without violation of backward compatibility in the Arden Syntax.

Challenges in implementing a knowledge editor for the Arden Syntax: knowledge base maintenance and standardization of database linkages.

CONTEXT: Incorporation of research findings into clinical practice lags behind their dissemination in the medical literature. Arden Syntax is a standard that could be used to encode evidence in a clinical decision support system (CDSS). However, dissemination of knowledge is hampered by lack of standard linkages to clinical databases. OBJECTIVE: To create a knowledge editor that facilitates transfer of knowledge from the medical literature to clinical practice via a CDSS. METHODS: Using a Web browser-based application, we implemented linkages to MEDLINE to permit queries on demand and registration of queries to be executed periodically, with results copied into Arden Medical Logic Modules (MLMs). To facilitate standardization of MLMs, database linkages are encoded using emerging HL7 standards such as a data model (virtual medical record). CONCLUSIONS: A Web-based application can facilitate transfer of knowledge into clinical practice and knowledge base maintenance through periodic queries and deployment of standards for knowledge representation.