Optimizing Patient Visits: Implementing Immunizations Into the Ambulatory Clinic Workflow

Childhood vaccinations prevent 4 million deaths worldwide each year, and immunizations are expected to preserve the lives of more than 50 million people from 2021 to 2030.¹ According to the CDC, administration of the measles vaccine and hepatitis B vaccine can prevent an estimated 19 million and 14 million deaths, respectively, by 2030.¹ These predicted achievements are promising, but disruptions from the global COVID-19 pandemic had a marked impact on vaccine availability and uptake. In 2021, the most infants aged under 1 year globally since 2009 were not given basic vaccinations; further, complete vaccination around the world dropped from 86% in 2019 to 81% in 2021.² The US Department of Health and Human Services’ Healthy People 2030 focuses on vaccine-preventable diseases; it involves 3 goals aimed at expanding vaccination: (1) maintaining the elimination of measles, rubella, congenital rubella syndrome, and polio; (2) increasing the proportion of people having vaccination records in an information system; and (3) increasing the proportion of adults (age, ≥ 19 years) who receive recommended vaccines.³ Ambulatory care pharmacists are in an ideal position to assist with achieving these Healthy People 2030 goals.

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Implementing Vaccinations Into the Ambulatory Care Workflow

Ambulatory care pharmacists work with a diverse set of patients in a variety of settings, including accountable care organizations, community and chain pharmacies, outpatient clinics, physician offices, and hospitals. Services rendered by ambulatory pharmacists include management of chronic diseases, comprehensive medication review, and oversight of transitions of care; in addition, they order laboratory tests, interpret the results, and monitor patients’ laboratory values. Pharmacists in these settings can alsoconduct immunization screening and administration.⁴ Within some specialties (eg, diabetes self-management, HIV management, pediatrics, and geriatric specialty clinics), pharmacists can educate patients about reducing risks by receiving recommended vaccinations based on age and comorbidities.⁵ Furthermore, the participation of ambulatory care pharmacists in wellness and health promotion through avenues such as health fairs and patient education classes provides a unique opportunity for various screenings and administration of vaccines.

Pharmacists in all 50 states and the District of Columbia are allowed to administer vaccinations; however, to do so, they must complete state-specific requirements.⁶ These requirements may include completing a certification program, entering a protocol under a supervisory practitioner, maintaining liability insurance, and reporting vaccinations to state immunization information systems (eg, Florida SHOTS).⁷ Although all states allow pharmacists to administer vaccinations, each state has different eligible patient populations and vaccine requirements (eg, age restrictions, prescription requirements, vaccine type).⁶ Vaccines that pharmacists can administer may also vary based upon pharmacist-provider protocols. An immunization certification is essential for implementing vaccination into the ambulatory clinic workflow.

Ambulatory care pharmacists also can conduct immunization screenings before patient visits and after they receive access to the respective state’s immunization information system. Many clinics incorporate patient work-up templates into their workflow to assist with identifying medication adjustments and areas for patient education. Including a section focused on immunization recommendations based on patient age and disease states (eg, diabetes) can assist in identifying vaccines that may benefit the patient but that have not been administered. Pharmacists must verify this information with the patient, because some systems may not be inclusive if the vaccination was receivedin another state or country. The Figure illustrates how this concept may be incorporated into the ambulatory clinic workflow.

Image From Pharmacy Times® Immunization Guide for Pharmacists June 2023

Ambulatory care pharmacy residents also play a major role in increasing both patient awareness about recommended vaccination and vaccination rates. Residency program directors, preceptors, and residents must demonstrate ongoing professionalism and contribution to the profession and participate in prevention and wellness promotion programs. One way to meet these qualifications is to be involved in community service activities, such as health fairs and other events to promote good health.⁸ Activities in the ambulatory care setting can include pharmacist-run vaccination administration clinics offered every 1 to 2 months as well as immunization screenings held at health fairs using state immunization information systems. Another method is to incorporate vaccinations into group classes. After educating patients on the importance of vaccinations, a selected set of vaccinations can be offered at the end of each session or requested by the patient.

Patient Engagement During Visits

Patient engagement during visits is important so that patients do not have to schedule a follow-up visit to receive recommended vaccines. According to the World Health Organization, patient engagement is defined as “the process of building the capacity of patients, families, carers,as well as health care providers, to facilitate and support the active involvement of patients in their own care, in order to enhance safety, quality,and people-centeredness of health care service delivery.”⁹ Multiple avenues can be used to assist with patient engagement. In the ambulatory care setting, surveys and quizzes assessing patients’ knowledge, beliefs, and areas of concerns can be used as the foundation of understanding the patients’ current viewpoint. These avenues enable the pharmacist to identify areas for patient education and motivational interviewing. Areas for discussion may highlight risks and benefits (eg, adverse events, statistics, immunization studies,effects of developing vaccine-preventable diseases) and common misconceptions.¹⁰ A similar approach to the 5 major steps to intervention (“the 5 A’s”) of tobacco cessation can be used for administering vaccinations¹¹:

• Ask – Identify and document immunization status for recommended immunizations for every patient at every visit.
• Advise – Urge patients to receive immunizations.
• Assess – Determine whether the patient currently is willing to receive immunizations.
• Assist – For patients willing to receive immunizations, offer recommended immunizations during the current visit.
• Arrange – Schedule follow-up visits for patients who would like to receive immunizations but not at the current visit.

To administer same-day vaccinations, a vaccine inventory should be kept at the clinic site, or a partnership should be made with a local pharmacy to supply needed vaccines. To do this, pharmacists can gauge the number of patients who may want to receive immunizations and keep enough vaccines in stock to meet the current demand. By engaging patients during visits, better health outcomes and improved health literacy can be expected.¹²

Clinical Decision Support and the EHR Vaccine Pathway

According to the Agency for Healthcare Research and Quality, clinical decision support (CDS) is a process used to provide timely information to help inform decisions about a patient’s care.¹³ Various types of CDS include documentation templates, alerts, and order sets.¹⁴ The CDC asserts that CDS is most beneficial when the information provided is evidence-based and given to the right people through the right channels in the right intervention format at the right points in the workflow. By implementing CDS, improvement in patient outcomes and high-quality care can be expected.^15,16 These benefits were demonstrated in 2 studies that focused on implementing immunization-focused CDS into the electronic health record (EHR) for children.^17,18

Documentation Templates

Documentation templates used by ambulatory care pharmacists can vary based on clinic, specialty, and EHR system. Common template sections may include a review of systems, vital signs, history of presentillness, medications, clinical laboratory results, at-home monitoring values (eg, blood pressure), nonpharmacologic interventions (eg, diet, exercise), social history, assessment, and patient-centered care plan. To improve immunization rates, a section on recommended immunizations can be added to the documentation templates. Additionally, alerts can beincorporated into these templates to ease the process of identifying recommended immunizations.

Alerts

Notifications can be passive prompts or clinical alerts that appear in an EHR. Passive prompts include visual cues such as highlighted text, an exclamation mark, or a small flag. Clinical alerts indicate information that must be reviewed prior to continuing the encounter.¹⁴ These alerts can provide information on recommended vaccinations and ensure that immunizations are reviewed at every visit. By incorporating these alerts into the documentation template, ambulatory care pharmacists are required to document patients’ current immunization status and, if applicable, reasons that recommended vaccinations have been declined. These alerts also enable pharmacists to order recommended vaccines through order sets based on the pharmacist-practitioner established protocol and to add administered vaccinations to the patient’s EHR.

Order Sets

Order sets are a type of CDS within EHR systems that can yield safe, efficient, and evidence-based patient care. They consist of a collection of orders or steps located in 1 place for a specific condition, process, or clinical scenario.¹⁹ Use of order sets saves time in ordering, increases adherence to best practices, and minimizes variations in care.^19,20 Examples of order sets that can be used based on disease state and age recommendations include the

following²¹:

• for patients with diabetes, annual influenza vaccine (inactive or recombinant preferred); tetanus and diphtheria (Td) or tetanus, diphtheria, and pertussis (Tdap) booster every 10 years (following initial Tdap dose); shingles vaccine (in patients aged ≥ 50 years); pneumococcal vaccine; COVID-19 vaccine; measles, mumps, and rubella (MMR) vaccine; varicella vaccine; human papillomavirus (HPV) vaccine (through age 26 years); and hepatitis B vaccine;
• for patients with HIV, annual influenza vaccine(inactive or recombinant only); Td or Tdap booster every 10 years (following initial Tdap dose); pneumococcal vaccine; meningococcal conjugate vaccine; hepatitis A vaccine; hepatitis B vaccine; HPV vaccine; MMR vaccine; COVID-19 vaccine; shingles vaccine (in patients ≥ 19 years); and varicella vaccine (administration of some vaccinations depends upon CD4 count [eg, MMR and varicella vaccines not recommended if CD4 count < 200 cells/μL or CD4 percentage < 15%]);
• for patients with cardiovascular disease, annual influenza vaccine (inactivated or recombinant preferred); Td or Tdap booster every 10 years (following initial Tdap dose); shingles vaccine (in patients aged ≥ 50 years); COVID-19 vaccine; MMR vaccine; varicella vaccine; HPV vaccine; hepatitis B; and pneumococcal vaccine;
• for patients with lung disease, annual influenzavaccine (inactivated or recombinant preferred); Td or Tdap booster every 10 years (following initial Tdap dose); shingles vaccine (in patients aged ≥ 50 years); COVID-19 vaccine; MMR vaccine; varicella vaccine; HPV vaccine; hepatitis B; and pneumococcal vaccine;
• for patients with end-stage renal disease or who are on hemodialysis, annual influenza vaccine (inactivated or recombinant preferred); Td or Tdap booster every 10 years (following initial Tdap dose); shingles vaccine (in patients aged ≥ 50 years); pneumococcal vaccine; hepatitis B vaccine; HPV vaccine; MMR vaccine; COVID-19 vaccine; and varicella vaccine;
• for patients with cancer or other immunosuppressive conditions (excluding HIV), annual influenza vaccine (inactivated or recombinant only); Td or Tdap booster every 10 years (following initial Tdap dose); pneumococcal vaccine; shingles vaccine (in patients ≥ 19 years); COVID-19 vaccine; hepatitis B vaccine; and HPV vaccine;
• for patients aged 19 to 49 years, COVID-19 vaccine; annual influenza vaccine (inactivated, recombinant, or live attenuated based on comorbidities); Td or Tdap booster every 10 years (following initial Tdap dose); MMR vaccine; varicella vaccine; HPV vaccine; hepatitis B vaccine; and
• for patients 50 years and older, annual influenza vaccine (inactivated or recombinant only); Td or Tdap booster every 10 years (following initial Tdap dose); shingles vaccine; pneumococcal vaccine; COVID-19 vaccine; MMR vaccine; varicella vaccine; and hepatitis B vaccine (in patients aged ≥ 60 years with risk factors for hepatitis B).

Conclusion

Ambulatory care pharmacists are in an ideal position to vaccinate more eligible patients. Increased immunization rates can be accomplished by incorporating vaccinations into the workflow, engaging patients during visits, and using various types of CDS.

Additional vaccination schedules can be found on the CDC’s Vaccines & Immunizations webpage (https://www.cdc.gov/vaccines/index.html).

About The Author

Mekaliah Creese, PharmD, AAHIVP, is a PGY-2 ambulatory care pharmacy resident at Nova Southeastern University College of Pharmacy in Fort Lauderdale, Florida.

References

1. Fast facts on global immunization. CDC. Updated April 20, 2023. Accessed May 1, 2023. https://www.cdc.gov/globalhealth/immunization/data/fast-facts.html#:~:text=Immunization%20Prevents%20Death%20Worldwide

2. Immunization coverage. World Health Organization. July 14, 2022. Accessed May 4, 2023. https://www.who.int/news-room/fact-sheets/detail/immunization-coverage

3. Healthy People 2030. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed May 1, 2023. https://health.gov/healthypeople/objectives-and-data/browse-objectives/infectious-disease

4. Smith M. FAQ:basics of ambulatory care pharmacy practice. American Society of Health-System Pharmacists. 2019. Accessed May 1, 2023. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/basics-of-ambulatory-care-pharmacy-practice.pdf

5. Reducing risks. Association of Diabetes Care & Education Specialists. Accessed May 1, 2023. https://www.diabeteseducator.org/living-with-diabetes/Tools-and-Resources/reducing-risks

6. Pharmacist immunization authority. National Alliance of State Pharmacy Associations. April 25, 2023. Accessed May 1, 2023. https://naspa.us/resource/pharmacist-authority-to-immunize/#:~:text=The%20pharmacist's%20authority%20to%20prescribe,patient%20age%20for%20each%20stateImmunization administration certification.

7. Florida Board of Pharmacy. Accessed May 1, 2023. https://floridaspharmacy.gov/licensing/immunization-administration-certification/

8. ASHP Commission on Credentialing. Guidance document for the ASHP accreditation standard for postgraduate year two (PGY2) pharmacy residency programs. American Society of Health-System Pharmacists. March 2021. Accessed April 30, 2023. https://www.ashp.org/-/media/assets/professional-development/residencies/docs/pgy2-guidance-document.pdf

9. Patient engagement. Technical series on safer primary care. World Health Organization. 2016. Accessed May 1, 2023. https://apps.who.int/iris/bitstream/handle/10665/252269/9789241511629-eng.pdf

10. How to address COVID-19 vaccine misinformation. CDC. Reviewed November 3, 2021. Accessed May 1, 2023. https://www.cdc.gov/vaccines/covid-19/health-departments/addressing-vaccine-misinformation.html

11. Five major steps to intervention (the “5 A’s”). Agency for Healthcare Research and Quality. Reviewed December 2012. Accessed May 1, 2023. https://www.ahrq.gov/prevention/guidelines/tobacco/5steps.html#:~:text=Successful%20intervention%20begins%20with%20identifying

12. Health literacy research and best practices. CDC. Reviewed August 16, 2021. Accessed May 1, 2023. https://www.cdc.gov/healthliteracy/researchevaluate/patient-engage.html

13. Clinical decision support. Agency for Healthcare Research and Quality. Reviewed June 2019. Accessed May 1, 2023. https://www.ahrq.gov/cpi/about/otherwebsites/clinical-decision-support/index.html

14. What is clinical decision support? CDC. Reviewed August 22, 2022. Accessed May 1, 2023. https://www.cdc.gov/opioids/healthcare-admins/ehr/clinical-decision-support.html

15. Clinical decision support. HealthIT.gov. Reviewed April 10, 2018. Accessed May 1, 2023. https://www.healthit.gov/topic/safety/clinical-decision-support

16. Clinical decision support: more than just “alerts” tipsheet. Updated July 2014. HealthIT.gov. Accessed May 1, 2023. https://www.healthit.gov/sites/default/files/clinicaldecisionsupport_tipsheet.pdf

17. Au L, Oster A, Yeh GH, Magno J, Paek HM. Utilizing an electronic health record system to improve vaccination coverage in children. Appl Clin Inform. 2010;1(3):221-231. doi:10.4338/ACI-2009-12-CR-0028

18. Orenstein EW, ElSayed-Ali O, Kandaswamy S, et al. Evaluation of a clinical decision support strategy to increase seasonal influenza vaccination among hospitalized children before inpatient discharge. JAMA Netw Open. 2021;4(7):e2117809. doi:10.1001/jamanetworkopen.2021.17809

19. McGreevey JD 3rd. Order sets in electronic health records: principles of good practice. Chest. 2013;143(1):228-235. doi:10.1378/chest.12-0949

20. Ballard D, Ogola G, Fleming N, et al. The impact of standardized order sets on quality and financial outcomes. Accessed May 1, 2023. https://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Ballard_12.pdf

21. Vaccines & immunizations. CDC. Reviewed February 16, 2021. Accessed May 1, 2023. https://www.cdc.gov/vaccines/index.html