The U.S. Department of Health and Human Services (HHS) (n.d.) has established a goal of increasing vaccination rates in children and adults as part of the Healthy People 2030 initiative, with thirteen general, infectious disease, and child-specific objectives.

Eight of these thirteen objectives are actively being measured, with the remaining five currently in developmental or baseline measurement phases.

Of the objectives actively being measured, reducing the rate of hepatitis A infection and increasing the proportion of people who receive an annual influenza vaccine are worsening, and no improvement has been seen in the number of children receiving diphtheria, tetanus, and acellular pertussis (DTaP) vaccine by the age of two (HHS, n.d.).

In addition to the need for improved vaccination rates, opportunities to reduce preventable vaccination errors that result in under-immunization also exist. A report by the Institute for Safe Medical Practices (ISMP) (2019) found that thirty-eight percent of reported vaccination errors were a type that could potentially be improved by making information and decision support available at the point of care.

These errors include wrong age (17.4%), extra dose (10.5%), vaccine or component omission (2.7%), and wrong time or interval (7.8%) (ISMP, 2019). A retrospective analysis of immunization information system data by Kirtland et al. (2019) found that between 0.05% and 0.01% of live attenuated vaccines in children ages 12 months to six years were administered at an incorrect interval. While these percentages seem relatively small, when extrapolated to the U.S. population they represent approximately 58,000 under-immunized children over four years with an estimated revaccination cost of $ 9,679,780 (Kirtland et al., 2019).

In their seminal work on errors in healthcare, To Err is Human: Building a Safer Health System, the Institute of Medicine (2000, p. 163) noted that healthcare systems must not depend on weaker aspects of cognition, such as working memory, and safer designs should avoid reliance on it. Despite recognition of the need for designs that reduce cognitive burden, a quarter century later, studies continue to identify EHRs as significant contributors to cognitive workload (Mazur et al., 2019; Pollack & Pratt, 2020) and associated 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).

EHR designs that follow the principles of cognitive ergonomics are optimized for cognitive workload factors of attention, working memory, and decision-making (Branaghan & Lafko, 2020; Li-Wang et al., 2023), improving cognitive load, performance, errors, and burnout.

Immunizations are an essential component of preventive healthcare, reducing the risk of a wide range of communicable diseases and their long-term sequela such as chronic liver disease after hepatitis B infection (Centers for Disease Control and Prevention [CDC], 2023b), increased risk of anal, cervical, or oropharyngeal cancer with human papillomavirus (HPV) infection (CDC, 2023a), and orchitis, pancreatitis or hearing loss after mumps infection (CDC, 2021).

Under-immunized patients face an increased risk of illness and, in the case of immunization error, may be unaware that they require re-vaccination. Missed vaccination opportunities may require an otherwise unnecessary office visit, resulting in additional costs in transportation, lost work, or time away from school.

Over the past fifteen years, the U.S. has seen an unprecedented increase in adoption of electronic health records in U.S. physician practices. While electronic records have many benefits, such as instant retrievability, portability, and the ability to incorporate data from outside organizations, the technology has failed to fully deliver on promises to improve workflow for providers.

Two areas of persistent concern are the impact of increased cognitive burden on providers and the correlation between EHR use and clinician burnout (Asgari et al., 2024).

These issues result in

• Increased cognitive workload
• Increased task time
• Reduced confidence when analyzing and planning immunizations

Given the estimated shortage of over 121,000 physicians by 2030 (Zhang et al., 2020), reducing EHR-related provider burnout must be a priority for any physician practice. In addition to the implications for patients and providers, missed vaccination opportunities equate to lost revenue and result in decreased performance on vaccination-related quality measures, which can further degrade financial performance. Also impacting financial performance is the additional time required to analyze and plan immunization-related care, which increases the time required for each patient encounter.

Improving immunization-related performance can

• Improve provider efficiency
• Reduce a contributor to provider burnout & turnover
• Improve patient trust
• Reduce costs