Campaign Toolkit

IT / Documentation: Level 1

Standardize documentation in EHR

Determine opportunities to standardize documentation in the electronic health record (EHR) to reduce staff workload, ensure accuracy of data, and improve data utilization. Ensure improvements are informed by relevant stakeholders, executed with the help of internal and external IT experts, and incorporated into staff training.

Documentation is a vital step in vaccine administration. Providers require up-to-date, easily understood information to guide patient care, and organizations need accessible, actionable data to track vaccination rates, gaps in care, and progress towards established goals. To standardize vaccine documentation in your EHR, follow the steps below.

Step 1:

Convene stakeholders to review existing EHR workflows

Be sure to solicit insights and feedback from frontline providers and staff throughout the process, as they feel the greatest impact from EHR changes and are best positioned to advise on how to reduce any disruption to existing clinical workflows. In addition, leadership buy-in is often necessary when significant changes to an organization’s EHR are proposed, so engage your Chief Medical Officer, Chief Quality Officer, and others as needed.

Step 2:

Identify areas for improvement in your EHR

Review the information currently captured in your EHR. Keep in mind what is recorded, when and how it is entered and captured, and who is expected to record immunization information. Be sure to consult any existing resources that can inform your documentation needs, including vaccination standing orders, back-office orientation materials, and immunization protocols for practice. Consider the following questions as you identify areas for improvement:

Step 3:

Update your EHR

Work with your internal IT department as well as your EHR vendor to determine how to best leverage your EHR to capture immunization data. Updates to EHR systems can take time, so plan accordingly when setting goals and timelines. Consider some of the best practices listed below.

Use existing features. Many EHR systems have built-in features that can increase efficiency, accuracy, and standardization. For example, drop-down menus and pre-populated fields can standardize nomenclature across generic and brand vaccine names. A searchable dictionary, another commercially available tool, can help users find data like vaccination names and brands.

Increase the number of structured data fields. Data in tables, rows, and columns are easier to access and analyze than open-text fields. For example, explore tracking vaccine declinations in a structured field rather than an open notes field.

Leverage other technologies. Organizations can use bar code systems, like those used in grocery stores, to automate the process of recording data about specific vaccines. This enables your team to apply special stickers and scan vials as opposed to manually entering information.

Step 4:

Train staff on EHR changes

Once changes are made, be sure to train staff accordingly. Incorporate changes to the vaccine documentation process into staff and provider education where applicable.