Using Computerized Physician Order Entry to Ensure Appropriate Vaccination of Patients with Inflammatory Bowel Disease

INTRODUCTION

Inflammatory bowel disease (IBD) is a disorder in which an aberrant immune response in a genetically susceptible host, with influences from environmental factors, leads to intestinal inflammation.¹ Two patterns of disease, Crohn disease and ulcerative colitis, have been described. While these patterns are thought to represent distinct clinical entities, treatment regimens for the conditions tend to overlap. Many of these therapeutic approaches involve efforts to manipulate the body's immune response, either by modulation of effector cells or the inflammatory cytokines that they produce.² These immunomodulatory treatment regimens, in combination with underlying immune dysregulation, increase the risk of infections, many of which are preventable via vaccination.³ Accordingly, vaccines against influenza and pneumococcal pneumonia are indicated for all patients with IBD, while vaccines such as hepatitis A and B, human papillomavirus, and meningococcal meningitis are only indicated for patients with specific risk factor profiles.⁴ Some vaccines are contraindicated in patients who are receiving immunosuppressive medications; typically, these are live or live attenuated vaccines such as measles-mumps-rubella, varicella zoster, and herpes zoster.

Many gastroenterologists take the responsibility of ordering vaccinations for their patients with IBD, and resources such as the Cornerstones Checklist for IBD Patients (Cornerstones Health, Inc.)⁵ have been developed to help providers select appropriate vaccines. The intent of providers in the Department of Gastroenterology at Ochsner Medical Center is to order vaccinations for patients with IBD. However, physicians have reported inconsistent implementation of this practice, and various studies have shown substandard vaccination rates in patients with IBD.^6,-,8 Given the importance of ensuring patients with IBD are appropriately vaccinated, we designed a quality improvement project to determine the perceived barriers to ordering these vaccines and to make the process easier.

RESULTS

Intervention

Using the Cornerstones Checklist for IBD Patients,⁵ we worked with Epic representatives to construct an order panel that included vaccines against hepatitis A, hepatitis B, human papillomavirus, meningococcus, measles-mumps-rubella, pneumococcus, tetanus-diphtheria-acellular pertussis, varicella zoster, herpes zoster, and influenza (Figure). Each vaccination order was accessible simply by clicking a box in the SmartSet. Based on our survey responses, we incorporated a prompt to remind providers to order vaccinations, and we ensured that information was displayed about indications and contraindications for selected vaccinations. We also included a referral mandate to the infectious disease injection department (a system requirement for patients to receive their vaccinations).

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Figure.

Epic vaccination order panel for patients with inflammatory bowel disease.

DISCUSSION

In many cases, patients with IBD tend to be young and unencumbered by other health problems. Consequently, for patients with IBD, their gastroenterologist may be the only physician they see on a regular basis. Therefore, if gastroenterologists do not order vaccinations for patients with IBD, they are unlikely to receive the vaccinations. As noted previously, our providers recognized this fact and consistently agreed that physicians in the gastroenterology department are responsible for ensuring that their patients with IBD receive appropriate vaccinations.

During the preintervention period, we found that providers had different comfort levels with ordering the correct vaccinations in Epic. Consequently, we designed our order panel to facilitate vaccination orders. Although we may have introduced an element of leading bias by administering 2 different surveys, respondents seemed to agree that our order panel made the process easier. Additionally, respondents somewhat agreed or strongly agreed that their clinic encounters with patients with IBD were more efficient after the order panel was implemented.

Previous studies show improved adherence to various treatment guidelines with the use of order panels.^9,-⇓⇓13 We hoped that greater efficiency in ordering vaccines would lead to more vaccinations among patients with IBD. However, only 4 of 10 respondents strongly agreed that they were ordering vaccines more frequently. One possible explanation for this response is that those who responded neutrally or in the negative may have already been ordering all the necessary vaccinations for their patients with IBD. Another possible explanation is that the 2-month intervention period was not enough time to demonstrate a difference in patterns. A worthwhile follow-up to this project would be to determine if more patients with IBD are receiving these vaccinations.

While our results indicate that the vaccination order panel is generally useful, it is not without flaws. Most notably, establishing follow-up appointments for vaccinations in a series is a difficult task and a problem that predates our study. We attempted to address follow-up by specifying the time intervals in which the vaccinations were to take place; however, it is not clear if patients are receiving follow-up appointments. Patients receive their vaccinations in the infectious disease injection department, a separate department from the gastroenterology clinic. Even though the orders for subsequent vaccinations in a series can be specified, the appointments must be scheduled. The requirement for multiple visits to the infectious disease injection department to obtain a series of vaccinations can have an impact on patient adherence. Follow-up will likely require coordination with the infectious disease injection department. However, coordination may prove difficult because staff in the infectious disease injection department only administer injections and are not directly involved in ensuring patient compliance with vaccination schedules. Therefore, if a patient misses a vaccination appointment, no default rescheduling process exists, and the patient may easily be lost to follow-up. An alternative is to keep a stock of series-based vaccines in our clinic facility.

CONCLUSION

We used the order entry function in Epic to facilitate vaccination ordering for patients with IBD. Our results indicate that the order panel we built made ordering vaccinations easier and more efficient compared to the previous process. We hope this order panel promotes improved patient care and becomes a future area of study for how Epic and other electronic health records may be used.