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The American Journal of Managed Care November 2017
Using the 4 Pillars to Increase Vaccination Among High-Risk Adults: Who Benefits?
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Electronic Reminder's Role in Promoting Human Papillomavirus Vaccine Use
Jaeyong Bae, PhD; Eric W. Ford, PhD, MPH; Shannon Wu, BA; and Timothy Huerta, PhD, MS
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Joseph A. Ladapo, MD, PhD; and Dave A. Chokshi, MD, MSc
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Electronic Reminder's Role in Promoting Human Papillomavirus Vaccine Use

Jaeyong Bae, PhD; Eric W. Ford, PhD, MPH; Shannon Wu, BA; and Timothy Huerta, PhD, MS
The use of the electronic health record’s clinical reminder functionality is systematically related to higher human papillomavirus vaccine administration rates.
We performed sensitivity tests to address concerns that the actual use of the reminder function, not merely the simple adoption of clinical reminders, guarantees the improvement in care. Using 2012 data that are able to differentiate “routine use” and “nonroutine use” of clinical reminders, we compared rates of HPV vaccine immunizations by the level of clinical reminder use. Compared with physicians who did not adopt clinical reminders, physicians routinely using clinical reminders were more likely to order HPV vaccines (eAppendix Table [eAppendix available at]). On the other hand, physicians nonroutinely using clinical reminders were not consistently more likely to order HPV vaccines compared with physicians not adopting clinical reminders. Thus, these results indicate that we may have underestimated the association of clinical reminder use with HPV vaccine immunizations, which supports the robustness of our primary findings. 


Among physicians reporting that they used clinical reminders, the measure was positively correlated with HPV vaccine immunizations. The associations are greater in magnitude for males aged 11 to 21 years than females aged 11 to 26 years. One explanation for this phenomenon is that physicians may consider HPV to be primarily a gynecological issue. Therefore, the reminder would have a greater impact in populations where the disease risk is less well understood.

No such associations of clinical reminder use and HPV vaccine immunizations were seen in the subpopulation of younger adolescents. The difference between age groups suggests that certain behavioral characteristics associated with recommending the HPV vaccine may be difficult to overcome in the younger population.25 Given that HPV vaccine immunization is designed to have greater impact earlier in life, this result suggests that clinical reminders may not be adequate in increasing vaccination rates in this population. It may be necessary to couple clinical reminders with other behavioral interventions for physicians. Tobacco use, in particular, merits attention, as those who smoke are at elevated risk for oral cancers that need HPV exposure to develop.26 

The significant increase in vaccination rates associated with clinical reminder use that we saw in the male population aged 11 to 21 years is a promising avenue for intervention. For HPV, the disease burden for the individual and the population decreases significantly even with small increases in vaccination rates.27 Given that males have a higher prevalence of HPV infections, they merit additional attention.28 Thus, targeting males to receive HPV vaccination immunizations through clinical reminders provides a positively disproportionate return on vaccination rates and disease burden. These results also suggest that barriers to HPV vaccination recommendations may be less for males than females. Many parents are resistant to vaccination of their daughters due to the concern that the HPV vaccine may encourage sexual debut of their daughters.29,30 

Reviewing the control variables, several key observations can be made. As expected, preventive care visits were associated with significantly higher rates of HPV vaccination, along with visits to patients’ own primary care physicians. We saw no significant associations between race and HPV vaccination. This suggests that disparities in HPV preventive care may be minimal in this sample population. However, it is important to carefully monitor the traditionally underserved population, often with higher rates of cervical cancer, to ensure that access to preventive care visits is available in order to obtain HPV vaccines.25 


There are limitations to this study. We used a cross-sectional snapshot to determine the correlation between clinical reminders and HPV vaccination rates; thus, we cannot establish a causal relationship. It could be that physicians adopting new technology, such as EHRs, and clinical decision support systems tend to follow recently released recommendations on HPV vaccination. It is also possible that physicians who adhere to clinical guidelines on vaccination are more interested in and likely to adopt clinical support systems as tools to improve their quality of care. Furthermore, the lack of longitudinal data means that patients are not being tracked over time. Given that the HPV vaccine requires 3 doses to be administered over an extended period, it is not possible to assess whether reminders promote better completion of the recommended regime.31 

Additionally, the NAMCS cannot identify whether the vaccine order is for the first, second, or third dose of HPV vaccine. Besides, the NAMCS data set is a self-report survey by physicians and staff members, who may be prone to over- or under-report preventive services and EHR functionalities. Furthermore, the NAMCS does not sufficiently report on both patient and physician practice characteristics, and these unobservable characteristics, such as patient socioeconomic characteristics or physician age and years of practice, could confound the association between clinical reminder use and our outcome of interest. Finally, the NAMCS information on the diversity and complexity of EHR systems and specific functionalities used in clinical practices was limited. Thus, we cannot fully identify whether and how different EHR systems and their clinical reminder functions help HPV vaccine orders in visits made by adolescents who are recommended to take HPV vaccines. In addition, this study could not address the impact of type of vendor, data architecture, and end-user interface.

Minority access to practices with high-functioning EHRs and the concomitant impact on preventive care is an area that merits more research. If EHRs produce a significant improvement in care quality, as most expect, then this trend represents an emerging disparity. Another area of research that needs further work is related to the herd immunity effect of HPV vaccines. If relatively small increases in vaccination rates lead to significantly large reductions in HPV infection rates, this needs to be better understood. 


Clinical reminders are positively correlated with better care processes related to HPV vaccination. Promoting the routine use of clinical reminders for vaccination will yield significant benefits for the general population. Clinician-initiated recommendation is a key ingredient in starting successful HPV vaccinations.25,32 Thus, clinical reminders serve as an important gateway for physicians to initiate a conversation on HPV vaccination with families. This is especially important in addressing coverage in traditionally underserved populations. Especially for HPV vaccinations, where strong social barriers may exist in its disease etiology and cause, it is important to decrease other barriers for clinical opportunity.33

Author Affiliations: School of Health Studies, Northern Illinois University (JB), Dekalb, IL; Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (EWF, SW), Baltimore, MD; Department of Family Medicine, College of Medicine, The Ohio State University (TH), Columbus, OH.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (JB, EWF); acquisition of data (JB); analysis and interpretation of data (JB, SW, TH); drafting of the manuscript (JB, EWF, SW, TH); critical revision of the manuscript for important intellectual content (JB, EWF, TH); statistical analysis (TH); administrative, technical, or logistic support (EWF, SW); and supervision (TH).

Address Correspondence to: Eric W. Ford, PhD, MPH, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Hampton House 533, Baltimore, MD 21205. E-mail:

1. CDC. Incidence, prevalence, and cost of sexually transmitted infections in the United States. Published February 2013. Accessed October 8, 2016.

2. Markowitz LE, Dunne EF, Saraiya M, et al; CDC. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR-05):1-30.

3. Trottier H, Franco EL. Human papillomavirus and cervical cancer: burden of illness and basis for prevention. Am J Manag Care. 2006;12(suppl 17):S462-S472.

4. Zhai L, Tumban E. Gardasil-9: a global survey of projected efficacy. Antiviral Res. 2016;130:101-109. doi: 10.1016/j.antiviral.2016.03.016.

5. Suryadevara M, Paton L, Domachowske JB. Adolescent immunization: 2015 and beyond. Pediatr Ann. 2015;44(4):e82-e88. doi: 10.3928/00904481-20150410-09.

6. Hymel PA. Decreasing risk: impact of HPV vaccination on outcomes. Am J Manag Care. 2006;12(suppl 17):S473-S483.

7. Drolet M, Deeks SL, Kliewer E, Musto G, Lambert P, Brisson M. Can high overall human papillomavirus vaccination coverage hide sociodemographic inequalities? an ecological analysis in Canada. Vaccine. 2016;34(16):1874-1880. doi: 10.1016/j.vaccine.2016.02.069.

8. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature. JAMA Pediatr. 2014;168(1):76-82. doi: 10.1001/jamapediatrics.2013.2752.

9. Dempsey AF, Davis MM. Overcoming barriers to adherence to HPV vaccination recommendations. Am J Manag Care. 2006;12(suppl 17):S484-S491.

10. Bae J, Ford EW, Huerta TR. The electronic medical record’s role in support of smoking cessation activities. Nicotine Tob Res. 2016;18(5):1019-1024. doi: 10.1093/ntr/ntv270. 

11. Bae J, Hockenberry JM, Rask KJ, Becker ER. Evidence that electronic health records can promote physician counseling for healthy behaviors. Health Care Manage Rev. 2017;42(3):258-268. doi: 10.1097/HMR.0000000000000108.

12. Bae J, Huerta TR, Ford EW. Cardiovascular disease documentation and counseling in electronic medical records. Prev Med. 2016;88:27-32. doi: 10.1016/j.ypmed.2016.03.017.

13. De Leon SF, Shih SC. Tracking the delivery of prevention-oriented care among primary care providers who have adopted electronic health records. J Am Med Inform Assoc. 2011;18(suppl 1):i91-i95. doi: 10.1136/amiajnl-2011-000219.

14. Federman DG, Kravetz JD, Lerz KA, et al. Implementation of an electronic clinical reminder to improve rates of lung cancer screening. Am J Med. 2014;127(9):813-816. doi: 10.1016/j.amjmed.2014.04.010.

15. Furukawa MF. Electronic medical records and efficiency and productivity during office visits. Am J Manag Care. 2011;17(4):296-303.

16. Loo TS, Davis RB, Lipsitz LA, et al. Electronic medical record reminders and panel management to improve primary care of elderly patients. Arch Intern Med. 2011;171(17):1552-1558. doi: 10.1001/archinternmed.2011.394.

17. Mishuris RG, Linder JA, Bates DW, Bitton A. Using electronic health record clinical decision support is associated with improved quality of care. Am J Manag Care. 2014;20(10):e445-e452.

18. Rand CM, Blumkin A, Szilagyi PG. Electronic health record use and preventive counseling for US children and adolescents. J Am Med Inform Assoc. 2014;21(e1):e152-e156. doi: 10.1136/amiajnl-2013-002260. 

19. Schwartz AR, Levin FL, O’Neil JA Jr, Braithwaite RS. Pilot of decision support to individualize colorectal cancer screening recommendations. Am J Manag Care. 2015;21(7):e439-e446.

20. Wagholikar KB, MacLaughlin KL, Henry MR, et al. Clinical decision support with automated text processing for cervical cancer screening. J Am Med Inform Assoc. 2012;19(5):833-839. doi: 10.1136/amiajnl-2012-000820.

21. Tarver WL, Menachemi N. The impact of health information technology on cancer care across the continuum: a systematic review and meta-analysis. J Am Med Inform Assoc. 2016;23(2):420-427. doi: 10.1093/jamia/ocv064.

22. Mennemeyer ST, Menachemi N, Rahurkar S, Ford EW. Impact of the HITECH Act on physicians’ adoption of electronic health records. J Am Med Inform Assoc. 2016;23(2):375-379. doi: 10.1093/jamia/ocv103.

23. Ai C, Norton EC. Interaction terms in logit and probit models. Econ Letters. 2003;80(1):123-129. doi: 10.1016/S0165-1765(03)00032-6.

24. Karaca-Mandic P, Norton EC, Dowd B. Interaction terms in nonlinear models. Health Serv Res. 2012;47(1 pt 1):255-274. doi: 10.1111/j.1475-6773.2011.01314.x.

25. Brewer NT, Fazekas KI. Predictors of HPV vaccine acceptability: a theory-informed, systematic review. Prev Med. 2007;45(2-3):107-114. doi: 10.1016/j.ypmed.2007.05.013.

26. Fakhry C, Gillison ML, D’Souza G. Tobacco use and oral HPV-16 infection. JAMA. 2014;312(14):1465-1467. doi: 10.1001/jama.2014.13183.

27. Jemal A, Simard EP, Dorell C, et al. Annual report to the nation on the status of cancer, 1975-2009, featuring the burden and trends in human papillomavirus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst. 2013;105(3):175-201. doi: 10.1093/jnci/djs491.

28. Gillison ML, Broutian T, Pickard RK, et al. Prevalence of oral HPV infection in the United States, 2009-2010. JAMA. 2012;307(7):693-703. doi: 10.1001/jama.2012.101.

29. Ferrer HB, Trotter C, Hickman M, Audrey S. Barriers and facilitators to HPV vaccination of young women in high-income countries: a qualitative systematic review and evidence synthesis. BMC Public Health. 2014;14:700. doi: 10.1186/1471-2458-14-700.

30. Quinn GP, Murphy D, Malo TL, Christie J, Vadaparampil ST. A national survey about human papillomavirus vaccination: what we didn’t ask, but physicians wanted us to know. J Pediatr Adolesc Gynecol. 2012;25(4):254-258. doi: 10.1016/j.jpag.2012.02.007.

31. Dobson SR, McNeil S, Dionne M, et al. Immunogenicity of 2 doses of HPV vaccine in younger adolescents vs 3 doses in young women: a randomized clinical trial. JAMA. 2013;309(17):1793-1802. doi: 10.1001/jama.2013.1625.

32. Fiks AG, Grundmeier RW, Mayne S, et al. Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt. Pediatrics. 2013;131(6):1114-1124. doi: 10.1542/peds.2012-3122.

33. Vadaparampil ST, Kahn JA, Salmon D, et al. Missed clinical opportunities: provider recommendations for HPV vaccination for 11-12 year old girls are limited. Vaccine. 2011;29(47):8634-8641. doi: 10.1016/j.vaccine.2011.09.006.
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