As a family physician for about 30 years now, and former “Immunization Czar” in my private practice, I lament the current state of Childhood Immunizations.

Why?

I lament the simple olden days, when a few immunizations existed, and new ones came along rarely.

I could memorize the list, and provide advice and prevention efficiently.

For simplicity, I will only refer to childhood immunizations here. Adult immunizations have some unique features.

Progress brought complexity.

New vaccines came along every year. The guidelines changed every year, in stages (ACIP recommended; then later all the authorities approved; then insurance payors reimbursed; and finally states mandated). I had new memorization to learn every year. Sometimes, I had blowback: a vaccine was not yet covered by insurance, or it was in short supply, or it required a new refrigerator for which we had neither space nor funding.

Now, it’s even more complex:

We have rolling shortages, which might be national or local.
We have combination vaccines, in overlapping, but not identical patterns.
A particular single component vaccine might be available from two different manufacturers, but have different admin schedules (3 doses for one, but 4 doses for the other).
Government-sponsored programs might require special ordering and tracking. The government choice of vaccines might differ from my organizations prior choices.
Consumers are demanding customizations (break up my MMR into the 3 separate components) that fragment and complicate matters even further. This item alone could have me ranting for pages. I won’t rant, for now.
The CDC schedule is offered as a range of choices, adding complexity at most well child visits. I order as individual vaccine components (MMR, or Tdap, or HiB/HepB). The nurse draws up the vaccine from a bottle marked with a brand name. He or she might have to adjust for temporary shortages, using Pediarix one week, and something else next week, depending on local supplies.

How can a human brain handle all this?
Not very well.

How can this be safe?
I think it is not.

How can this be made more efficient?
Our software could do this, but the design requirements are challenging.

Ideally, the decision support would be embedded in our EHRs.

The vaccine requirement/availability database that is used by our EHR would be maintained nationally, by the CDC, or by another entity along the lines of Multum (which maintains prescription drug databases).

The availability database could be modified locally, to reflect institutional formulary choices, or pharmacy shortages.

The decision support would examine a patient’s age, previous immunizations, and recommend a preferred dose for today (and acceptable alternatives).

The EHR database would communicate with regional or national immunization registries. That way, patients who move, or who must change providers, or who use multiple providers (the ED, the primary care physician, the developmental pediatrician, the pulmonologist) would have their immunization progress schedule available to all the providers.

Dear reader, do you know of an application or institution doing it well?

Jeff Belden MD

beldenj@health.missouri.edu