Literature Review
The Problem in the Literature
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Literature Review Methodology
A literature review was conducted to contextualize the identified practice problem and determine the interventions and strategies most appropriate to address its impact on cognitive task load. Peer-reviewed sources were searched in the Herzing University library’s medical and nursing databases, Google Scholar, and public health authority websites like CDC.gov. The review of journal articles was limited to those published within the previous five years where the full text was available. Themes of complexity in immunization management, EHRs as contributors to cognitive workload and the impacts of cognitive burden were identified and explored.
The Complexity of Immunization Management
Providers who must evaluate vaccination status and manage immunizations face a daunting task driven by complex vaccination guidelines and the use of combination vaccines for childhood immunizations. Combination vaccines, widely used as an efficient way to immunize against multiple diseases with a single injection, present a significant challenge when determining a patient’s immunity to a particular disease. A typical example is Vaxelis, a multi-antigen vaccine for diphtheria, tetanus, pertussis, poliomyelitis, Haemophilus influenzae type b (HIB), and hepatitis B (U.S. Food and Drug Administration [FDA], 2018). A similar vaccine, Pentacel, immunizes against the same diseases, except for Hepatitis B (FDA, 2008). Using Vaxelis for an entire series requires a fourth dose of another pertussis vaccine. In contrast, Pentacel does not require an additional pertussis dose but will result in a patient not immunized against hepatitis B if used alone. Providers must have a working knowledge of the coverage of each vaccine formulation or take the additional time to research the vaccine and mentally map the vaccine products to covered diseases.
Adding to the challenge are the Centers for Disease Control and Prevention’s (CDC) age-based immunization schedules, which are disease-centric rather than vaccine-centric (CDC, 2024a; CDC, 2024b). Without Clinical Decision Support, the cognitive burden of translating these immunization guidelines to vaccination requirements is onerous and prone to error, even for the most experienced provider. This is further complicated by the frequency with which vaccination recommendations change and the complexity of some guidelines. One such example is the recently added respiratory syncytial virus (RSV) monoclonal antibody recommendations for infants, which differ based on age, weight, and whether the infant is entering their first RSV season before the age of 8 months (Jones et al., 2023).
Providers face additional difficulty when a child starts a vaccine series late, is at least 30 days behind schedule, has complex medical conditions, or is at increased risk for certain communicable diseases. In the case of a late start or a missed scheduled dose, the provider must refer to the CDC’s immunization catch-up schedules, which can involve analyzing multiple data points such as current age, age at last dose, time since last dose, and the number of doses administered to determine the correct course of action (CDC, 2024c). Patients with complex medical conditions such as immunosuppression, pregnancy, or other risk factors require additional decision-making based on guidance in the CDC’s supplemental immunization schedule (CDC, 2024d), which may suggest additional immunizations or indicate that some immunizations are contraindicated for the patient.
Given the complex and ever-changing nature of vaccination guidelines, it is unsurprising that tens of thousands of errors occur in U.S. childhood immunizations alone each year (Kirtland et al., 2019), and that nearly one-third of those errors are related to incorrect timing or age-inappropriate administrations (Institute for Safe Medication Practices, 2022).
EHRs as a Contributor to Provider Cognitive Burden
EHR utilization for office-based providers has increased by over 400% since 2004, and nearly 90% of providers now use an electronic health record (EHR) system (Office of the National Coordinator for Health Information Technology [ONC], n.d.). However, EHR technology has often failed to live up to its promise of improving care delivery processes, and nowhere is this more apparent than in immunization management. Numerous studies have identified EHR design as a factor that can directly influence the cognitive workload required for various tasks. In their research at the University of North Carolina at Chapel Hill, Mazur et al. (2019) identified that a relatively small change in how the EHR presented laboratory results to resident physicians had a statistically significant impact on task performance and objective measures of workload but not perceived workload. However, Pollack and Pratt (2020) did find that enhanced visualizations in the EHR decreased subjective cognitive workload when used for prioritization tasks.
Impact of Increased Cognitive Burden
In their seminal work on reducing errors in healthcare, To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) (2000, p. 163) noted that healthcare systems must not rely on the weaker aspects of cognition like working memory, and as such safer designs avoid reliance on it. Despite the IOM's recognition of the need for designs that reduce cognitive burden and reliance on working memory, studies continue to identify EHRs as a significant contributor to cognitive workload (Mazur et al., 2019; Pollack & Pratt, 2020) and its contribution to clinician burnout (Asgari et al., 2024; Harry et al., 2021; Kroth et al., 2019; Wu et al., 2024) and decision fatigue (Maier et al., 2024; Pignatiello et al., 2020).
Interventions Identified in the Literature
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Literature Review Methodology
To ensure relevance to the stated problem, reviewed articles that did not include provider-focused interventions were eliminated from consideration. However, a dearth of studies addressing provider cognitive burden in immunization management required including studies where the outcomes measured were changes in vaccination rates. In synthesizing intervention-related literature, themes of provider audit/feedback, provider alert clinical decision support (CDS), and evaluated vaccine forecasting CDS were identified and analyzed.
Provider Alert Clinical Decision Support
Provider alert CDS (“provider alerts”) is a technology integrated into most EHRs that notifies providers of patient-specific situations deemed clinically significant, such as a prior adverse reaction to a prescribed drug or, less commonly, to address a gap in care. Provider alerts are usually patient-specific and binary: they are displayed when a patient record meets specific criteria and are not displayed otherwise.
In their quality improvement project targeting influenza vaccination rates in hospitalized children, Orenstein et al. (2021) concluded that patients were 3.25 times more likely to receive an influenza vaccine when a provider prompt was implemented. Similarly, a meta-analysis of evidence on the efficacy of interventions on human papillomavirus (HPV) vaccination rates in the ambulatory setting found a statistically significant improvement with electronic provider alerts (Chandeying & Thongseiratch, 2023), and similar results have also been seen with routine immunizations in adults (Loskutova et al., 2020; Stephens et al., 2021). However, one systematic review found that when compared to provider alerts combined with provider feedback, provider alerts alone had a limited impact on overall vaccination rates (Abdullahi et al., 2020).
While multiple studies have validated the efficacy of provider alert CDS, alone or in combination with provider feedback, in improving vaccination rates across settings and patient populations, the potential for alert fatigue has been identified as a negative consequence (Chen et al., 2020; Stephens et al., 2021) of this type of intervention. One approach to moderating this unintended consequence, using a machine learning algorithm to suppress low-quality immunization provider alerts, was successfully piloted by Chen et al. (2020) with no negative impact on vaccination rates.
Evaluated Vaccine Forecasting Clinical Decision Support
Evaluated vaccine forecasting CDS (“vaccine forecasting”) is a specialized form of clinical decision support designed to assist providers with immunization analysis and planning. This form of CDS uses inputs of patient demographics, vaccine history, and current Advisory Committee on Immunization Practices (ACIP) immunization recommendations to represent a patient’s immunization status visually, identify immunizations currently due, and project future vaccination needs. While this technology has been available to users of select state and local immunization registries for some time (American Immunization Registry Association [AIRA], 2024), evidence regarding integrated use in EHRs is limited.
In 2016, the Centers for Disease Control and Prevention (CDC) (2024e) made available a free, expert-maintained toolkit for developing immunization-specific clinical decision support called CDSi. While CDSi led to the proliferation of vaccine forecast CDS as a function of immunization registries (IRs), widespread availability of this CDS remains unavailable to most IR users, with only fourteen registries in the U.S. currently offering fully compliant vaccine forecasting CDS (AIRA, 2024). Similarly, a 2023 systematic review of immunization registries found that only 12% offered vaccine forecasting CDS (Donckels et al., 2023). One reason for the limited number of fully AIRA-compliant CDSi implementations is the lack of standard means of integrating CDSi data and logic definitions into immunization information systems and EHRs. In response to this shortcoming, an open-source solution called Immunization Calculation Engine (ICE) was developed by several stakeholders, creating an easily deployable, stand-alone service that addresses the computational layer and integration limitations of CDSi (Arzt et al., 2022).
While evidence regarding the efficacy of vaccine forecasting is limited, results are promising and its use has been recommended as a standard for adult immunization management in general practice (Hunter et al., 2020). In a quality improvement project implemented in 70 community pharmacies, Bacci et al. (2019) reported a fifteen percent increase in closed vaccination opportunities when pharmacists consulted an immunization registry’s vaccine forecasting CDS. The use of vaccine forecasting has also demonstrated a statistically significant improvement in first-dose HPV vaccination rates in adolescents (Vinci et al., 2022) and general immunization rates in adults (Stephens et al., 2021).
Provider Audit and Feedback
Provider audit and feedback is an intervention that measures provider compliance with established targets and periodically presents that information to the provider. Intending to improve performance over time, feedback is often presented as a time series in a graphical format, alone or in combination with comparative data such as peer performance, organizational targets, or industry benchmarks. While numerous studies have reported the effectiveness of provider feedback in improving vaccination rates, it is generally implemented in conjunction with other interventions as part of a multi-approach, targeted intervention (Loskutova et al., 2020; Stephens et al., 2021; Vinci et al., 2022). In a randomized clinical trial, Finney Rutten et al. (2024) found that provider audits and feedback without other interventions did not increase adolescent HPV vaccination rates. However, when combined with vaccine forecasting (Vinci et al., 2022) or provider alerts (Abdullahi et al., 2020; Loskutova et al., 2020), provider feedback contributes to improved vaccination rates, supporting the intervention’s value as an adjunct to those approaches.
Opportunities for Additional Research
While the studies identified in this review represent a variety of clinical settings, patient populations, and target vaccines, all used some form of vaccination rates as the measure of improvement. While increasing vaccination rates is a public health priority (U.S. Department of Health and Human Services, n.d.) and has direct benefits for patients, provider cognitive burden (Asgari et al., 2024) and vaccination errors (Institute for Safe Medication Practices, 2022; Kirtland et al., 2019) are areas of potential improvement related to his problem that are worthy of additional research.