According to background information in the article, few medical interventions rival influenza and pneumococcal vaccines in their ability to reduce illness and save costs and lives. Yet in the past, among individuals older than 65 years, as many as 34 percent have not received their annual influenza vaccine and 38 percent have not received their annual pneumococcal vaccine. Computerized reminder systems increase influenza and pneumococcal vaccination rates, but computerized standing order systems have not been previously evaluated.
Paul R. Dexter, M.D., of Wishard Memorial Hospital and Indiana University School of Medicine, Indianapolis, and colleagues compared the effects of computerized standing orders for influenza and pneumococcal vaccines in a randomized trial using the computerized physician reminder system as a control. The trial included 3,777 general medicine patients discharged from 1 of 6 study wards during a 14-month period (November 1, 1998, through December 31, 1999) composed of 2 overlapping influenza seasons at an urban public teaching hospital.
The hospital's computerized physician order entry system identified inpatients eligible for influenza and pneumococcal vaccination. For patients with standing orders, the system automatically produced an order directing a nurse to administer the vaccine at time of discharge. For patients with reminders, the computer provided reminders to physicians that included vaccine orders during routine order entry sessions.
During the approximately 6 months of the influenza season, 50 percent of all hospitalized patients were identified as eligible for influenza vaccination. Twenty-two percent of patients hospitalized during the entire 14 months of the study were found eligible for pneumococcal vaccination. The researchers found that patients with standing orders received an influenza vaccine significantly more often (42 percent) than those patients with reminders (30 percent). Patients with standing orders received a pneumococcal vaccine significantly more often (51 percent) than those with reminders (31 percent).
"Computer-assisted nurse standing orders improve inpatient immunization rates more than physician reminders, and would be likely to have the same advantage when applied to many kinds of preventive screening (e.g., cholesterol, cancer) in many care settings. Furthermore, their adoption faces fewer barriers because they can be delivered as part of normal nursing workflow through the order management systems used widely in health care institutions today. However, physician vaccination reminders require delivery mechanisms (e.g., physician order entry systems) that do not yet exist in most institutions. Computer-assisted standing orders could reduce the high rate of omissions documented [in another study] for many preventive care interventions," the authors conclude.
(JAMA. 2004; 292: 2366-2371. Available post-embargo at JAMA.com)
Editor's Note: This work was supported in part by a grant from the Agency for Healthcare Research and Quality, as well as contracts from the National Library of Medicine, in part from the Regenstrief Foundation, and the Indiana Genomics Initiative of Indiana University, which is supported in part by Lilly Endowment Inc.
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