Improved influenza and pneumococcal vaccination in rheumatology patients taking immunosuppressants using an electronic health record best practice alert

Arthritis Rheum. 2009 Nov 15;61(11):1505-10. doi: 10.1002/art.24873.


Objective: To examine whether an electronic health record (EHR) best practice alert (BPA), a clinical reminder to help guideline adherence, improved vaccination rates in rheumatology patients receiving immunosuppressants. Guidelines recommend yearly influenza and pneumococcal vaccination with revaccination for patients age >65 years who are taking immunosuppressive medications.

Methods: A vaccination BPA was developed based on immunosuppressant treatment, age, and prior vaccinations. At site 1, a hospital-based academic practice, physicians ordered vaccinations. At site 2, a community-based practice, physicians signed orders placed by nurses. Demographics, vaccination rates, and documentation (vaccination or no administration) were obtained. Chi-square and Fisher's exact test analysis compared vaccination and documentation rates for October 1 through December 31, 2006 (preBPA), and October 1 through December 31, 2007 (postBPA). Breslow-Day statistics tested the odds ratio of improvement across the years between the sites.

Results: PostBPA influenza vaccination rates significantly increased (47% to 65%; P < 0.001), with significant improvement at both sites. PostBPA pneumococcal vaccination rates likewise significantly increased (19% to 41%; P < 0.001). PostBPA documentation rates for influenza and pneumococcal vaccinations also increased significantly. Site 2 (nurse-driven) had significantly higher preBPA vaccination rates for influenza (69% versus 43%; P < 0.001) than pneumococcal (47% versus 15%; P < 0.001).

Conclusion: The use of a BPA significantly increased influenza and pneumococcal vaccination and documentation rates in rheumatology patients taking immunosuppressants. A nurse-driven process offered higher efficacy. An EHR programmed to alert providers is an effective tool for improving quality of care for patients receiving immunosuppressants.

MeSH terms

  • Aged
  • Benchmarking
  • Electronic Health Records / statistics & numerical data
  • Female
  • Guideline Adherence / statistics & numerical data*
  • Humans
  • Immunocompromised Host
  • Immunosuppressive Agents / therapeutic use*
  • Influenza Vaccines / therapeutic use*
  • Male
  • Middle Aged
  • Pneumococcal Vaccines / therapeutic use*
  • Quality of Health Care
  • Rheumatic Diseases / drug therapy*
  • Rheumatic Diseases / immunology
  • Rheumatology / standards*


  • Immunosuppressive Agents
  • Influenza Vaccines
  • Pneumococcal Vaccines