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Simple and Elaborated Clinician Reminder Prompts for Human Papillomavirus Vaccination: A Randomized Clinical Trial

      Abstract

      Objective

      To evaluate the effects of simple and elaborated health care provider (HCP) reminder prompts on human papillomavirus (HPV) vaccine initiation rates.

      Methods

      Twenty-nine pediatric HCPs serving 5 pediatric clinics were randomized to 1 of 3 arms: 1) usual practice control, 2) simple reminder prompt, and 3) elaborated reminder prompt, which included suggested language for recommending the early adolescent platform vaccines. Prompts were delivered via a computer-based clinical decision support system deployed in the 5 clinics. Eligible patients were ages 11 to 13 years, had not received HPV vaccine, and were due for meningococcal ACWY (MenACWY) vaccine and/or the tetanus, diphtheria, and pertussis booster (Tdap). Receipt of HPV vaccine was determined via automated queries sent to the Indiana immunization registry. Data were analyzed via logistic regression models, with generalized estimating equations used to account for the clustering of patients within HCPs.

      Results

      Ten HCPs in the control group saw 301 patients, 8 HCPs in the simple prompt group saw 124, and 11 HCPs in the elaborated prompt group saw 223. The elaborated prompt arm had a higher rate of HPV vaccination (62%) than the control arm (45%): adjusted odds ratio, 2.76; 95% confidence interval, 1.07 to 7.14. The simple prompt arm did not differ significantly from the control arm with respect to HPV vaccine initiation, which might have been because of the small sample size for this arm. MenACWY and Tdap rates did not vary across the 3 arms.

      Conclusions

      Results suggest that an elaborated HCP-targeted reminder prompt, with suggested recommendation language, might improve rates of HPV vaccine initiation.

      Keywords

      What's New
      In this study of pediatric health care providers, we found that an elaborated prompt, which included a suggested recommendation script, resulted in higher first dose administration of human papillomavirus vaccine to 11- to 13-year-old patients compared with a usual care condition.
      Human papillomavirus (HPV) is the primary cause of nearly all cervical cancers in women and many other anogenital and oropharyngeal cancers, as well as genital warts in men and women.
      • Parkin D.M.
      • Bray F.
      Chapter 2: The burden of HPV-related cancers.
      The 9-valent HPV vaccine has been shown to prevent infection and disease resulting from the 7 HPV types associated with many cancers and the 2 types associated with 90% of genital warts (types 6 and 11).
      • Garland S.M.
      • Kjaer S.K.
      • Munoz N.
      • et al.
      Impact and effectiveness of the quadrivalent human papillomavirus vaccine: a systematic review of 10 years of real-world experience.
      Moreover, accumulating evidence indicates that the vaccine is quite safe, with few or no severe adverse events tied to vaccination.
      • Gee J.
      • Weinbaum C.
      • Sukumaran L.
      • et al.
      Quadrivalent HPV vaccine safety review and safety monitoring plans for nine-valent HPV vaccine in the United States.
      Vaccinating young adolescents before sexual debut is important because the 9-valent HPV vaccine is a preventive vaccine and has not been shown to affect infections that have already occurred. Moreover, HPV vaccines stimulate a stronger immune response among younger, compared with older, adolescents.
      • Pedersen C.
      • Petaja T.
      • Strauss G.
      • et al.
      Immunization of early adolescent females with human papillomavirus type 16 and 18 L1 virus-like particle vaccine containing AS04 adjuvant.
      However, the full cost and health benefits of HPV vaccine can only be realized if the vaccine is widely accepted. HPV vaccination rates in the United States, although gradually increasing over time, remain well below the Healthy People 2020 goal of 80% series completion, and well below rates for the other early adolescent platform vaccines, meningococcal ACWY (MenACWY) and the tetanus, diphtheria, and pertussis booster (Tdap).
      • Walker T.Y.
      • Elam-Evans L.D.
      • Singleton J.A.
      • et al.
      National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 Years - United States, 2016.
      In the United States, one of the primary parent-identified reasons for vaccinating children against HPV was a health care provider (HCP) recommendation.
      • Garcini L.M.
      • Galvan T.
      • Barnack-Tavlaris J.L.
      The study of human papillomavirus (HPV) vaccine uptake from a parental perspective: a systematic review of observational studies in the United States.
      Similarly, among those who have not received the HPV vaccine, the lack of HCP recommendation has been identified as a major reason for nonvaccination.
      • Holman D.M.
      • Benard V.
      • Roland K.B.
      • et al.
      Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature.
      • Donahue K.L.
      • Stupiansky N.W.
      • Alexander A.B.
      • et al.
      Acceptability of the human papillomavirus vaccine and reasons for non-vaccination among parents of adolescent sons.
      Although HCPs generally embrace their important role in recommending HPV vaccine, these recommendations might nevertheless be unevenly carried out because of such issues as time constraints, perceptions of risk associated with patient age, availability of insurance or other coverage, safety and/or efficacy concerns, and the perceived need to discuss HPV as a sexually transmitted infection.
      • Vadaparampil S.T.
      • Kahn J.A.
      • Salmon D.
      • et al.
      Missed clinical opportunities: provider recommendations for HPV vaccination for 11-12 year old girls are limited.
      Vaccine risk communication, in general, is a challenge to HCPs.
      • Evans G.
      • Bostrom A.
      The evolution of vaccine risk communication in the United States: 1982-2002.
      Some providers believe that extensive discussion of risks and benefits of vaccines (including sexuality issues related to HPV transmission in particular) might alarm, rather than reassure parents, and might take up too much time. Survey research with HCPs and audio-recorded conversations between pediatric HCPs and parents of adolescents suggest that many struggle with how to effectively recommend HPV vaccine.
      • Shay L.A.
      • Street R.L.
      • Baldwin A.S.
      • et al.
      Characterizing safety-net providers’ HPV vaccine recommendations to undecided parents: a pilot study.
      • Sturm L.
      • Donahue K.
      • Kasting M.
      • et al.
      Pediatrician-parent conversations about human papillomavirus vaccination: an analysis of audio-recordings.
      • Gilkey M.B.
      • Malo T.L.
      • Shah P.D.
      • et al.
      Quality of physician communication about human papillomavirus vaccine: findings from a national survey.
      One proposed approach to improving HPV vaccination rates and reducing missed opportunities for vaccination is implementation of provider reminder prompts delivered via an electronic health record (EHR) system. However, previous research on the effects of such prompts have shown mixed results.
      • Fiks A.G.
      • Grundmeier R.W.
      • Mayne S.
      • et al.
      Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt.
      • Ruffin M.T.
      • Plegue M.A.
      • Rockwell P.G.
      • et al.
      Impact of an electronic health record (EHR) reminder on human papillomavirus (HPV) vaccine initiation and timely completion.
      • Szilagyi P.G.
      • Serwint J.R.
      • Humiston S.G.
      • et al.
      Effect of provider prompts on adolescent immunization rates: a randomized trial.
      • Bundy D.G.
      • Persing N.M.
      • Solomon B.S.
      • et al.
      The ImmProve Project: leveraging electronic health record data to promote immunization delivery.
      The objective of this study was to evaluate the effect of HCP-targeted computer-based clinical decision support (CDS) prompts on delivery of adolescent-platform vaccines (MenACWY, HPV, Tdap) among adolescents who had not yet received any doses of HPV vaccine. In Indiana, there is a large discrepancy between MenACWY and Tdap vaccination coverage in adolescents (both approximately 89% in 2016) and HPV vaccine initiation (54% for girls and 37% for boys), highlighting missed opportunities for HPV vaccine administration. We evaluated a simple prompt as well as an elaborated prompt with suggested recommendation language (hereafter referred to as the elaborated prompt condition), with both delivered via an EHR system. The inclusion of the elaborated prompt condition represents a unique approach to assess CDS prompt effects. We hypothesized a linear increase in HPV vaccination initiation rates across the 3 conditions (representing a reduction in missed opportunities): usual care control, simple prompt, and elaborated prompt.

      Methods

      Setting

      This study was implemented in 5 pediatric primary care clinics that are part of Eskenazi Health, a large safety net health system serving Marion County, Indiana, which includes the city of Indianapolis. The 5 study clinics are all located in urban Indianapolis and serve largely low-income, minority children, with 70% of families served receiving Medicaid. Patients are nearly 50% non-Hispanic black and one-third Hispanic. For the 12-month period from March 2013 to March 2014, there were 3513 children 11 to 13 years of age seen at these clinics. The 5 clinics were targeted for this study because all use the Child Health Improvement through Computer Automation (CHICA) CDS system.
      • Anand V.
      • Biondich P.G.
      • Liu G.
      • et al.
      Child health improvement through computer automation: the CHICA system.

      CHICA System

      Since 2004 the CHICA system has supported health services research related to pediatric care, including screening, counseling, anticipatory guidance, and chronic disease diagnosis and management.
      • Anand V.
      • Carroll A.E.
      • Biondich P.G.
      • et al.
      Pediatric decision support using adapted Arden Syntax.
      CHICA is a computer-based CDS system that is unique in several respects. These include a tailored user interface, a prioritization scheme that assures the HCPs receive the highest priority reminders, and the ability to collect data directly from families in the waiting room.
      • Anand V.
      • Carroll A.E.
      • Downs S.M.
      Automated primary care screening in pediatric waiting rooms.
      CHICA acts as a front end to the EHR system used by Eskenazi. The EHR and CHICA communicate using industry standard Health Level 7 communication protocols.
      • Biondich P.G.
      • Downs S.M.
      • Anand V.
      • et al.
      Automating the recognition and prioritization of needed preventive services: early results from the CHICA system.
      When a patient checks into a CHICA clinic, CHICA receives a registration message. In response CHICA requests a download of the patient's record from the EHR. CHICA applies a set of rules to the patient's data to select 20 yes/no questions that are presented to the family via electronic tablets. The nurse or medical assistant enters data such as height and weight using the same tablet. CHICA applies another set of rules to the patient's record and the data from the families to select up to 6 reminders to deliver to the HCP. Each of these reminders states the reason for the reminder and provides up to 6 check-box responses with which the HCP can document his or her response. The HCP's responses are stored as coded data elements, and CHICA writes text directly into the EHR documenting the information recorded in the check boxes. However, CHICA is not directly linked to order sets and does not lead to a default of the vaccines being ordered.
      CHICA has been studied extensively, and several randomized controlled trials have shown the system's effectiveness in improving adherence to guidelines and quality of care. For example, CHICA has been applied to parental smoking cessation,
      • Downs S.M.
      • Zhu V.
      • Anand V.
      • et al.
      The CHICA smoking cessation system.
      preventive screening,
      • Carroll A.E.
      • Biondich P.G.
      • Anand V.
      • et al.
      Targeted screening for pediatric conditions with the CHICA system.
      maternal depression screening,
      • Carroll A.E.
      • Biondich P.
      • Anand V.
      • et al.
      A randomized controlled trial of screening for maternal depression with a clinical decision support system.
      attention deficit–hyperactivity disorder diagnosis,
      • Carroll A.E.
      • Bauer N.S.
      • Dugan T.M.
      • et al.
      Use of a computerized decision aid for ADHD diagnosis: a randomized controlled trial.
      and autism screening.
      • Bauer N.S.
      • Sturm L.A.
      • Carroll A.E.
      • et al.
      Computer decision support to improve autism screening and care in community pediatric clinics.
      Recently we created a link to Indiana's immunization registry, Children and Hoosier Immunization Registry Program (CHIRP), and have developed a process for displaying and capturing immunization data through CHICA.
      CHICA was installed in its first clinic in 2004. Additional clinics were added over the next 5 years. Therefore, participating clinics had used CHICA 7 to 12 years at the time of this study. Before this study CHICA supported vaccination decision-making by producing a worksheet showing the Centers for Disease Control and Prevention vaccination grid and indicating which vaccines had been given and which were forecast to be due. However, with the exception of seasonal influenza vaccine, there were no prompts for other vaccinations before this study.

      Participants

      All pediatric HCPs (ie, pediatricians, family physicians, and nurse practitioners) serving the 5 CHICA clinics were included in this study.

      Study Design

      To evaluate the effects of 2 automated HCP reminder interventions on initiation of HPV vaccination, we conducted a 3-arm randomized controlled trial. Details of the trial design are described in ClinicalTrials.gov (NCT02551887). Briefly, the study used a cluster randomization design, in which HCPs serving 5 pediatric clinics in Indianapolis, Indiana, were randomized to 1 of 3 arms: 1) usual practice control, where vaccination recommendations were made by care providers on the basis of their existing methods for determining eligibility, 2) computer-generated messages reminding providers of MenACWY, HPV, and Tdap vaccination eligibility (simple prompt), and 3) computer-generated reminders with a suggested script for recommending the 3 adolescent platform vaccines (elaborated prompt; see Fig. 1 for enrollment and allocation diagram). We stratified according to clinic site to ensure that all clinics were represented in each of the 3 arms. The content of the simple and elaborated prompts are presented in Figure 2. Male and female children 11 to 13 years of age who had not previously received HPV vaccines were eligible for study participation. Children also had to be eligible for MenACWY and/or Tdap vaccine. The prompts indicated exactly which of these vaccines was due with the HPV vaccine.
      Figure thumbnail gr2
      Figure 2Content of simple and elaborated prompts. Prompts showed which of the vaccines (meningococcal ACWY and/or tetanus, diphtheria, and pertussis booster [Tdap]) was due with the human papillomavirus (HPV) vaccine.
      In this study, CHICA identified all children of targeted age then verified their eligibility for inclusion by checking their immunization records in CHIRP. Intervention HCPs of eligible patients received immunization reminders with or without elaboration at patients' clinical visits. During the study period, the HPV prompts (simple as well as elaborate) were given the same relatively high priority. For example, it was given a higher priority than evaluating attention deficit–hyperactivity disorder in a child with nonspecific symptoms of inattention, but a lower priority than a patient experiencing food insecurity. Its position (approximately 43rd of 185) made it very likely that it would appear among the 6 prompts for an eligible patient. On average, HCPs respond to 50% of prompts in CHICA.
      • Downs S.M.
      • Anand V.
      • Dugan T.M.
      • et al.
      You can lead a horse to water: physicians’ responses to clinical reminders.
      This was consistent in the present study in which 59 of 124 (48%) of HCPs responded to the simple prompt and 112 of 222 (50%) responded to the elaborate prompt.
      Providers were given no special instruction regarding the HPV prompts. They are accustomed to seeing a variety of alerts from CHICA, so there was no particular surprise at seeing a new one. The study team meets approximately quarterly with each clinic, and if questions arose, the clinics were simply told that CHICA had new reminders about HPV vaccines.
      Receipt of MenACWY, HPV, and Tdap vaccines in all eligible patients were recorded and confirmed by subsequent queries of CHIRP. If a patient did not receive an HPV vaccine at the initial visit, that patient was eligible to be entered in the study at subsequent visits even if seeing a HCP in a different arm of the study. The results were analyzed according to encounter, so the patient could be counted in both arms on separate occasions. The trial was implemented in 2014 to 2015. The study was approved by a local institutional review board. The requirement for written informed consent was waived.

      Data Analyses

      Participant demographic and clinical characteristics were summarized according to treatment group. MenACWY, HPV, and Tdap vaccine uptake rates for the 3 groups were comparatively examined. To accommodate the potential correlations in vaccine receipt among children seen by the same provider, we performed logistic regression analysis of vaccine uptake using generalized estimating equations. We then repeated the analysis, but controlled for the possible effects of patient sex and race. All analyses were conducted using SAS version 9.3 (SAS Institute, Inc, Cary, NC). P values less than .05 were considered statistically significant.

      Results

      Thirty-one pediatric HCPs were evaluated for inclusion in this study. Two were deemed ineligible because they were adolescent medicine specialists who saw few children 11 to 12 years of age, leaving 29 HCPs who participated in the study and saw 648 children who met the age inclusion criterion of 11 to 13 years of age and were due for their first HPV vaccine. For 21 of these children no information on vaccine administration at the appointment was available, meaning the child could not be identified in the immunization registry, leaving 627 eligible children. Among the 29 HCPs, 10 were randomized to the control arm and saw 298 patients; 8 were randomized to the simple reminder group and saw 118 patients; and 11 were randomized to the elaborated prompt group and saw 211 patients (Fig. 1). Providers were 67% female (n = 20), 2 were nurse practitioners and the remainder were physicians. Patients were 11 (78%), 12 (16%), and 13 (6%) years of age. Other patient characteristics are summarized in Table 1.
      Table 1Sample Characteristics Across Intervention Groups
      Intervention Condition
      ControlPromptElaborated Prompt
      Health care providers10811
      Patients301124223
      Percentage female434547
      Race/ethnicity, %
       Non-Hispanic black49.870.238.1
       Non-Hispanic white12.07.313.5
       Hispanic17.35.630.0
       Other/unknown20.916.918.4
      HPV, first dose, %455962
      Tdap, %828383
      Meningococcal (MenACWY), %818183
      HPV, second dose, % (of those eligible)808180
      HPV indicates human papillomavirus; Tdap, tetanus, diphtheria, and pertussis booster.
      The HPV vaccination rates for the 3 intervention groups are presented in Table 1. For comparison purposes, the table also includes Tdap and MenACWY vaccination rates. For the elaborated prompt group, the HPV vaccination rate (62%) was significantly greater than that in the control group (45%; odds ratio, 2.74; 95% confidence interval [CI], 1.06–7.05; P = .036). Although the simple prompt group appeared to have a higher rate of HPV vaccine administration than the control (59% vs 45%) this difference was not statistically significant when adjusted with generalized estimating equations. Rates of MenACWY and Tdap vaccination were not statistically different across the groups. Adjusting for patient sex and race/ethnicity, the adjusted odds ratio (AOR) for the elaborated prompt group remained statistically significant compared with the control group (AOR, 2.76; 95% CI, 1.07–7.14; Table 2). Using a Cochran-Armitage test, we also found a significant increasing linear trend in HPV vaccination rates across the 3 groups (P < .001). Patient sex also was a significant predictor of first-dose HPV administration; boys had lower odds of receiving vaccine compared with girls.
      Table 2Adjusted Multivariable Logistic Regression With GEE Predicting HPV Vaccine Initiation
      AOR95% CIP
      Intervention
       ControlReference
       Simple prompt1.110.50–2.48.800
       Elaborated prompt2.761.07–7.14.036
      Sex
       FemaleReference
       Male0.680.55–0.83.001
      Race
       Non-Hispanic blackReference
       Non-Hispanic white0.660.35–1.22.183
       Hispanic0.890.47–1.68.717
       Other0.870.47–1.62.663
      GEE indicates generalized estimating equations; HPV, human papillomavirus; AOR, adjusted odds ratio; and CI, confidence interval.
      Post hoc analyses also were performed to compare the 2 prompt groups and to evaluate the combined elaborated and simple prompt groups compared with the control. Although nearly statistically significant, the elaborated prompt group was not different from the simple prompt group (AOR, 2.49; 95% CI, 0.98–6.35; P = .06). Furthermore, a combined analysis of any prompt compared with the control indicated no significant difference between the 2 groups (AOR, 1.83; 95% CI, 0.86–3.90).

      Discussion

      In this randomized trial, we tested the introduction of a simple prompt, a traditional form of CDS facilitated by an EHR system, to remind HCPs about vaccine eligibility, and an elaborated prompt, a form of CDS that included a suggested script to use when recommending vaccines to patients. Results from the trial indicate that although the simple prompt did not have an effect, the elaborated prompt significantly improved the rate of first dose administration of the HPV vaccine compared with a control group. All 3 arms of the study had similar vaccine administration rates for Tdap and MenACWY, underscoring the effect of the elaborated prompt on the HPV vaccine. The results are further noteworthy because they occurred in a population of under-represented groups in which neither race nor ethnicity was a determinant in the vaccine administration rate.
      The results from this trial contribute to a growing body of literature on the effect of decision support delivered via information and communications technologies on vaccine uptake. Recent reviews of the evidence on CDS technologies to remind providers about vaccine eligibility trend toward the positive but remain mixed.
      • Crocker-Buque T.
      • Edelstein M.
      • Mounier-Jack S.
      Interventions to reduce inequalities in vaccine uptake in children and adolescents aged <19 years: a systematic review.
      • Francis D.B.
      • Cates J.R.
      • Wagner K.P.
      • et al.
      Communication technologies to improve HPV vaccination initiation and completion: a systematic review.
      Although a pre–post study reported no effect of reminder prompts,
      • Bundy D.G.
      • Persing N.M.
      • Solomon B.S.
      • et al.
      The ImmProve Project: leveraging electronic health record data to promote immunization delivery.
      a retrospective cohort study observed higher HPV vaccine uptake for female patients attending clinics that used electronic prompts compared with those attending clinics that did not use prompts.
      • Ruffin M.T.
      • Plegue M.A.
      • Rockwell P.G.
      • et al.
      Impact of an electronic health record (EHR) reminder on human papillomavirus (HPV) vaccine initiation and timely completion.
      Similarly, a multicomponent HCP-focused intervention that included EHR-based alerts increased rates of first dose administration
      • Fiks A.G.
      • Grundmeier R.W.
      • Mayne S.
      • et al.
      Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt.
      and reduced missed opportunities for HPV vaccination.
      • Mayne S.L.
      • duRivage N.E.
      • Feemster K.A.
      • et al.
      Effect of decision support on missed opportunities for human papillomavirus vaccination.
      However, a cluster randomized trial that evaluated a simple reminder prompt reported no difference in uptake in a diverse population of adolescents.
      • Szilagyi P.G.
      • Serwint J.R.
      • Humiston S.G.
      • et al.
      Effect of provider prompts on adolescent immunization rates: a randomized trial.
      These reviews and research studies, as well as other reviews of information and communications technology interventions to improve vaccine uptake,
      • Kim S.S.
      • Patel M.
      • Hinman A.
      Use of m-Health in polio eradication and other immunization activities in developing countries.
      • Stockwell M.S.
      • Fiks A.G.
      Utilizing health information technology to improve vaccine communication and coverage.
      suggest that reminders to providers might work best in combination with interventions that remind or educate patients, because the decision to vaccinate is one often made in the context of a patient-provider relationship. In this trial, we observed a statistically significant 17% higher rate of HPV vaccine uptake in the elaborated prompt group and a nonsignificant but encouraging 14% higher rate in the simple prompt group. Because the simple prompt group had the smallest sample size, it is possible that the lack of significance was because of inadequate power. Further, the elaborated prompt group did not have significantly higher HPV vaccination rates than the simple prompt group. Therefore, we cannot conclusively state that the elaborated prompt was better than the simple prompt intervention or that the simple prompt was ineffective. However, this trial adds evidence that provider-targeted CDS prompts can be effective at increasing vaccine uptake in diverse patient populations. Interestingly, interviews conducted with the HCPs after completion of the study indicated that most recalled seeing the prompts, but few believed that the prompts influenced their behavior, despite evidence to the contrary.
      • Dixon B.E.
      • Kasting M.L.
      • Wilson S.
      • et al.
      Health care providers’ perceptions of use and influence of clinical decision support reminders: qualitative study following a randomized trial to improve HPV vaccination rates.
      Additionally, HPV vaccination rates did not increase to the same level as Tdap and MenACWY, suggesting that a combination strategy involving patient education as well as reminders sent directly to patients, strategies identified in the systematic reviews, might have further increased vaccine uptake in our population.
      An important limitation in this study as well as all studies involving provider-targeted CDS interventions
      • Kim S.S.
      • Patel M.
      • Hinman A.
      Use of m-Health in polio eradication and other immunization activities in developing countries.
      is that CDS only has the potential to improve vaccination rates for those who come to clinics. This limitation suggests that future work should include study of more complex CDS interventions that, in parallel, provide reminders to HCPs as well as patients and families. Another limitation is the unequal distribution of HCPs across conditions, a problem that can occur when randomizing small numbers of participants. The clinics represented in this study were all located in 1 urban area and all used the CHICA CDS system, potentially limiting generalizability of the findings to clinics in other locations and clinics that do not use the CHICA system. Furthermore, we did not have baseline HCP vaccination rates and it is possible that more effective vaccinators happened to be randomized to the elaborated prompt group, particularly because of the relatively small number of providers. However, we did not find that Tdap or MenACWY vaccination rates varied across the 3 groups, suggesting that the HCPs in the elaborated prompt group were not, in general, more effective vaccinators than those in the other 2 conditions. Also, we did not stratify on the basis of number of patients 11 to 13 years of age typically seen by the HCPs. As a result, the simple prompt group resulted with fewer patients represented than the other 2 arms. Finally, data were collected several years ago, in 2013 to 2014 and it is possible that changes in practice since that time might make the study interventions less or more effective. Despite these limitations, the results of this study point in a promising direction, showing that an elaborated EHR prompt, which included suggested language for recommending adolescent vaccines, significantly enhanced administration of the first dose of HPV vaccine compared with the usual care control group. A wider evaluation of this kind of elaborated prompt using established EHR systems would be a valuable next step.

      Acknowledgments

      Financial disclosure: Publication of this article was supported by the Centers for Disease Control and Prevention.
      This study was supported by the Merck-Regenstrief Program in Personalized Health Care Research and Innovation (Project 14). Its contents are the sole responsibility of the authors and do not reflect the official view of Merck & Co, Inc.
      The opinions or views expressed in this professional education supplement are those of the authors and do not necessarily reflect the opinions or recommendations of the Centers for Disease Control and Prevention.

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