摘要：Objectives. Immunization forecasting systems evaluate patient vaccination histories and recommend the dates and vaccines that should be administered. We described the conceptualization, development, implementation, and distribution of a novel immunization forecaster, the Texas Children’s Hospital (TCH) Forecaster. Methods. In 2007, TCH convened an internal expert team that included a pediatrician, immunization nurse, software engineer, and immunization subject matter experts to develop the TCH Forecaster. Our team developed the design of the model, wrote the software, populated the Excel tables, integrated the software, and tested the Forecaster. We created a table of rules that contained each vaccine’s recommendations, minimum ages and intervals, and contraindications, which served as the basis for the TCH Forecaster. Results. We created 15 vaccine tables that incorporated 79 unique dose states and 84 vaccine types to operationalize the entire United States recommended immunization schedule. The TCH Forecaster was implemented throughout the TCH system, the Indian Health Service, and the Virginia Department of Health. The TCH Forecast Tester is currently being used nationally. Conclusions. Immunization forecasting systems might positively affect adherence to vaccine recommendations. Efforts to support health care provider utilization of immunization forecasting systems and to evaluate their impact on patient care are needed. Vaccines are widely cited as one of public health’s greatest successes, 1 and are estimated to have prevented 42 000 deaths and 20 million disease episodes in the United States in 2009, saving an associated $13.5 billion in direct costs and $68.8 billion in societal costs. 2 Timely receipt of vaccines effectively protects children against vaccine-preventable diseases and reduces disease outbreaks. 3 Because of these life-saving benefits, vaccines are routinely recommended throughout an individual’s lifetime, with most administered during infancy and early childhood. In the United States, vaccine recommendations are developed by The Advisory Committee on Immunization Practices (ACIP), a group of medical and public health experts selected by the US Department of Health and Human Services. 4 The resulting recommendations are approved and published by the Centers for Disease Control and Prevention (CDC), and are subsequently endorsed by many professional organizations, including the American Academy of Pediatrics, the American Academy of Family Practitioners, and the Pediatric Infectious Disease Society. These recommendations are updated annually. Current vaccine recommendations are complex and require that health care providers consider the child’s age, all relevant precautions and contraindications to vaccination, vaccines that have been previously administered, and the time that has elapsed since the last dose of a specific vaccine was administered. The 2014 US immunization schedule recommends up to 54 doses of vaccine (depending on combination of vaccines utilized) against 16 diseases by age 18 years, with up to 28 doses recommended for routine administration during the first 2 years of life. 5 Given this complexity, automated systems that interpret vaccine recommendations in the context of each child’s vaccine history are extremely helpful to health care providers. The advent of electronic health technology, particularly electronic health record (EHR) systems and immunization information systems, has greatly enhanced health care providers’ ability to accurately evaluate their patients’ vaccination histories, and therefore, follow ACIP vaccine recommendations. Both the American Recovery and Reinvestment Act and Healthy People 2020 include provisions that support the meaningful use of EHR systems. 6 The Health Information Technology for Economic and Clinical Health Act is included in the American Recovery and Reinvestment Act and outlines objectives to improve health care systems nationally through interoperability and exchange of data among EHR systems. 7 Implementation of EHR systems in accordance with meaningful use standards has the added benefit of incentive payments to health care providers and hospitals. These standards continue to be implemented in several phases; the third and last phase is still under development and implementation is scheduled to occur by 2017. One such provision (SGRP 401B) included in stage 3 of meaningful use is directly applicable to vaccine recommendations and specifies that health care providers should have the “capability to receive, generate or access appropriate age-, gender- and immunization history-based recommendations” through the implementation of “an immunization recommendation system that establishes baseline recommendations and allows for local/state variations.” 8 These systems are referred to as immunization forecasters. Clinical decision support systems, which are commonly referred to as immunization forecasting systems, utilize information technology to provide health care providers with patient-specific information to improve and enhance clinical care. 9 Immunization forecasters employ software algorithms to assess patient vaccination status and recommend the dates and vaccines that should be administered. Immunization forecasting systems operationalize ACIP vaccine recommendations and ensure that accurate and consistent vaccine administration practices are followed. Widespread adoption of immunization forecasting systems has the potential to increase health care provider adherence to ACIP vaccine recommendations in a standardized manner, reduce missed opportunities, and prevent outbreaks of disease associated with underimmunization. 10 Recognizing the clinical need for a forecasting system and the absence of nationally available, affordable products, a team of experts at Texas Children’s Hospital (TCH) developed an immunization forecasting system that can be used for patients treated within the TCH system and beyond. We describe the conceptualization, development, implementation, and distribution of the TCH Forecaster.
