Introduction: Electronic health records have been widely introduced into clinical practice. The aim of this study was to determine whether a small interface change could improve compliance with a key quality indicator, namely antenatal pertussis vaccination. 
Methods: Audits were performed between 1–31 July 2015 and 1–31 July 2017 of all deliveries at the Centenary Hospital for Women and Children to determine compliance with antenatal pertussis vaccination. The single difference between time points was changing the interface so the antenatal pertussis vaccination field became compulsory. 
Results: 275 and 299 women delivered in the audit periods. Vaccination rates almost doubled (52.7% vs 91.4%, p\u3c0.0001).
Conclusion: Small interface changes increase compliance. Interface change could be considered for key quality outcomes in patient care

Orefice, Roberto

Quinlivan, Julie

English

ResearchOnline@ND

The University of Notre Dame Australia ResearchOnline@ND Health Sciences Papers and Journal Articles School of Health Sciences 2019 Small interface changes have dramatic impacts: How mandatory fields in electronic medical records increased pertussis vaccination rates in Australian obstetric patients Roberto Orefice Julie Quinlivan The University of Notre Dame Australia, julie.quinlivan@nd.edu.au Follow this and additional works at: https://researchonline.nd.edu.au/health_article  Part of the Life Sciences Commons, and the Medicine and Health Sciences Commons  This article was originally published as: Orefice, R., & Quinlivan, J. (2019). Small interface changes have dramatic impacts: How mandatory fields in electronic medical records increased pertussis vaccination rates in Australian obstetric patients. BMJ Health and Care Informatics, 26. Original article available here: https://doi.org/10.1136/bmjhci-2019-000013 This article is posted on ResearchOnline@ND at https://researchonline.nd.edu.au/health_article/270. For more information, please contact researchonline@nd.edu.au. This is an Open Access article distributed in accordance with the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, provided the original work is properly cited and the use is non-commercial.  See: https://creativecommons.org/licenses/by-nc/4.0/   This article originally published in BMJ Health and Care Informatics available at:  https://informatics.bmj.com/content/26/1/e000013  No changes have been made to this article.  Orefice, R and Quinlivan, J. (2019) Small interface changes have dramatic impacts: How mandatory fields in electronic medical records increased pertussis vaccination rates in Australian obstetric patients. BMJ Health and Care Informatics, 26(1).  doi: 10.1136/bmjhci-2019-000013  1Orefice R, Quinlivan JA. BMJ Health Care Inform 2019;26. doi:10.1136/bmjhci-2019-000013Open access Small interface changes have dramatic impacts: how mandatory fields in electronic medical records increased pertussis vaccination rates in Australian obstetric patientsRoberto Orefice,1 Julie A Quinlivan2,3To cite: Orefice R, Quinlivan JA.  Small interface changes have dramatic impacts: how mandatory fields in electronic medical records increased pertussis vaccination rates in Australian obstetric patients. BMJ Health Care Inform 2019;26. doi:10.1136/bmjhci-2019-000013Received 30 April 2018Revised 07 August 2018Accepted 11 December 20181Department of Obstetrics and Gynaecology, Centenary Hospital for Women and Children, Canberra, Australian Capital Territory, Australia2School of Medicine, Australian National University, Canberra, Australian Capital Territory, Australia3Institute for Health Research, University of Notre Dame Australia, Fremantle, Western Australia, AustraliaCorrespondence toDr Roberto Orefice;   Roberto. Orefice@ act. gov. auOriginal research© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Summary ► There are no studies in the literature that address how changes in interfaces in electronic medical re-cords can improve guideline uptake. ► The conclusions indentified in this study could be utilised in other public health issues within maternity care such as smoking cessation.AbStrACtIntroduction Electronic health records have been widely introduced into clinical practice. The aim of this study was to determine whether a small interface change could improve compliance with a key quality indicator, namely antenatal pertussis vaccination.Methods Audits were performed between 1–31 July 2015 and 1–31 July 2017 of all deliveries at the Centenary Hospital for Women and Children to determine compliance with antenatal pertussis vaccination. The single difference between time points was changing the interface so the antenatal pertussis vaccination field became compulsory.results 275 and 299 women delivered in the audit periods. Vaccination rates almost doubled (52.7% vs 91.4%, p<0.0001).Conclusion Small interface changes increase compliance. Interface change could be considered for key quality outcomes in patient care.IntroduCtIonNumerous strategies have been trialled to improve vaccination rates in pregnant women. They have had mixed success. A recent review reported the most successful strategies to increase pregnancy vaccination compliance were direct recommendation by a treating healthcare provider on the benefits of vaccina-tion in pregnancy,1 2 advocacy that vaccination protected both the baby and the mother,3 and a high level of vaccine knowledge in parents.2 Despite these strategies, vaccination rates remain poor.1 2One strategy that has not been trialled is the use of a mandatory field in an electronic health record. As electronic health records become the standard of care, a small interface change to create a mandatory field might help improve evidence-based compliance with key quality indicators such as antenatal vaccination. The aim of this study was to determine whether a small interface change to create a mandatory field for the key quality in obstetric clinical indicator of antenatal pertussis vaccination would result in improved vaccination rates.MethodSA retrospective audit study was performed. Records of all women who delivered at the Centenary Hospital for Women and Chil-dren, Canberra, Australia, between 1–31 July 2015 (baseline period) and 1–31 July 2017 (follow-up period) were audited.In the baseline period, staff were educated about pertussis vaccination, a free clinic was established to vaccinate pregnant women, and patient education posters were displayed in clinical areas. The electronic health record antenatal attendance screen prompted staff to indicate whether pertussis vaccination had been offered and accepted or declined. Answers could be selected from a pull-down list. Once the prompt was answered, the response was autopopulated for future ante-natal encounters. However, clinicians could close the antenatal attendance screen leaving the question blank, as completion of the ques-tion was not compulsory.In the follow-up period, a small interface change was made to the antenatal attendance screen. The pertussis question became compul-sory. The electronic health record antenatal attendance screen could not be closed unless the clinician had entered a specific response to  on 26 June 2019 by guest. Protected by copyright.https://informatics.bmj.com/BMJ Health Care Inform: first published as 10.1136/bmjhci-2019-000013 on 26 June 2019. Downloaded from 2 Orefice R, Quinlivan JA. BMJ Health Care Inform 2019;26. doi:10.1136/bmjhci-2019-000013Open access Table 1 Demographics and characteristics of mothers and newborns between the two audit periods2015 2017 P valueAge in years, mean (SD) 33.3 (5.12) 31.5 (4.99) 0.001Gravidity, n (%) 0.06   1 91 (32.9) 86 (28.6)  2 82 (29.6) 117 (38.9)  3 or more 104 (37.5) 98 (32.6)Parity, n (%) 0.21   Primiparous 118 (42.6) 113 (37.5)  Multiparous 159 (57.4) 188 (62.5)Birth type, n (%) 0.05   Normal vaginal delivery 172 (62) 157 (52)  Assisted vaginal delivery 31 (11) 47 (16)  Caesarean section 74 (27) 97 (32)Maternal Indigenous, n (%)  Yes 8 (2.9) 11 (3.0) 0.61   No 269 (97.1) 290 (97.0)Gender, n (%) 0.81   Male 145 (52.3) 154 (51.2)  Female 132 (47.7) 146 (48.5)  Not stated 0 (0.0) 1 (0.3)Body mass index (kg/m2), mean (SD) 25.3 (6.07) 26.07 (7.12) 0.18Birth weight (g), mean (SD) 3244.87 (728.59) 3302.24 (655.76) 0.32Gestation (days), mean (SD) 271.39 (22.24) 272.88 (18.73) 0.38the query about pertussis vaccination. All earlier strategies for vaccination compliance remained in place.The audit periods were selected to ensure there would be at least 250 births in each time period, generating a total sample size of 500 women. This sample size was calculated to have a greater than 80% power to detect a change in vaccination rates from 50% to 80%, assuming an alpha error of 0.05.Data were collected using the Central Birth Outcome System electronic medical record and the Clinical Infor-mation System, identifying consecutive patients who deliv-ered in the audit time frames. All women who delivered a baby of more than 20 weeks’ gestation were included. Data collected included maternal demographic data, newborn outcome data and pertussis vaccination responses, which were independently verified with vaccine batch records.Discrete data were analysed using number and per cent for discrete data, and mean and SD for normative contin-uous data. Data were compared using χ2 test for discrete data and Student’s t-test for continuous data. In multivar-iate analysis, all variables significant at p<0.1 were included in the model.reSultSA total of 275 and 299 women delivered at the Centenary Hospital for Women and Children in the baseline and follow-up audit periods.Maternal and neonatal characteristics in the two audit periods are summarised in table 1. There were no signifi-cant differences in any demographic variable between the two audit periods with the exception of maternal age. The average maternal age in the 2015 cohort was 33.3 years compared with 31.5 in the 2017 cohort (p=0.001). In regard to birth modality, there was a significant trend towards fewer vaginal births and more caesarean section deliveries in the second audit period (p=0.05). There were no differ-ences identified in newborn characteristics between the two periods (all p>0.05).Figure 1 summarises the difference in pertussis vacci-nation rates between the baseline and follow-up periods. There was a significant increase in the percentage of women who were vaccinated for pertussis, with the rate almost doubling (baseline 146, 52.7%; postintervention 275, 91.4%; relative risk (RR) 1.73, 95% CI 1.54 to 1.94; p<0.0001). Multivariate analysis showed the only variable associated with a significant influence on pertussis vacci-nation rate was the difference in audit period following intervention (p<0.0001).dISCuSSIonThe introduction of a mandatory field in an electronic health record resulted in 91.4% of women receiving ante-natal pertussis vaccination compared with 52.7% when the field was optional. The baseline vaccination rate was  on 26 June 2019 by guest. Protected by copyright.https://informatics.bmj.com/BMJ Health Care Inform: first published as 10.1136/bmjhci-2019-000013 on 26 June 2019. Downloaded from 3Orefice R, Quinlivan JA. BMJ Health Care Inform 2019;26. doi:10.1136/bmjhci-2019-000013Open accessFigure 1 Percentage of women who received antenatal pertussis vaccination between the two audit periods.consistent with rates reported by the Australian Depart-ment of Health, suggesting baseline vaccination strategies at the hospital were as effective as those employed nation-ally.1 The significant rise following the introduction of a small interface change to create a mandatory data field demonstrates that this step can enhance compliance.The success of the intervention was multifactorial. It used a tool that was developed within an existing elec-tronic medical record infrastructure, avoiding the complications and resistance that can arise when intro-ducing changes into medical record systems. The manda-tory nature of the tool forced the healthcare provider to provide a response before moving onto other assess-ments. If the mandatory field was not completed, clini-cians received an automatic prompt message to complete the field and discuss the role and benefits of antenatal pertussis vaccination. This message encouraged clinicians to briefly interact about vaccinations. Such brief interven-tions have been proven to be effective in many areas of medicine, including vaccination.4Electronic medical records have become an important tool in improving adherence to clinical guidelines and improving outcomes. A review article by White and Kenton5 assessed the use of electronic medical record-based tools in educating healthcare providers on cervical cancer screening guidelines. The results showed that the use of electronic records significantly improved compli-ance with guidance and reduced inappropriate testing. Electronic records have started to complement, and in some areas replace, patient-held records in the obstetrics settings. A study by Hawley et al3 compared paper versus electronic medical records and the compliance rates of various outcome measures and clinical guidelines. There were significantly higher compliance rates in many of the pregnancy screening, assessment and advice variables.A limitation of the study is that this is not a randomised trial and there may be other factors that affected vaccina-tion rates despite multivariate analysis.This study is the first to evaluate the effect of a small interface change of creating a mandatory field to enhance compliance with a key maternity quality indicator. This is a promising result with scope for further research on the role of mandatory fields and prompts to enhance clini-cian behaviour in other areas such as antenatal influenza vaccination rates, venous thromboprophylaxis assessment and smoking in pregnancy interventions. These results suggest that minor interface changes can have significant impact.Competing interests None declared.Patient consent for publication Not required.Provenance and peer review Not commissioned; externally peer reviewed.open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.referenCeS 1. Beard FH. Pertussis immunisation in pregnancy: a summary of funded Australian State and territory programs. Commun Dis Intell Q Rep 2015;39. 2. Yuen CYS, Tarrant M. Determinants of uptake of influenza vaccination among pregnant women – a systematic review. Vaccine 2014;32:4602–13. 3. Hawley G, Jackson C, Hepworth J, et al. Sharing of clinical data in a maternity setting: how do paper hand-held records and electronic health records compare for completeness? BMC Health Serv Res 2014;14. 4. Wong VWY, Fong DYT, Tarrant M. Brief education to increase uptake of influenza vaccine among pregnant women: a study protocol for a randomized controlled trial. BMC Pregnancy Childbirth 2014;14:1–7. 5. White P, Kenton K. Use of electronic medical record-based tools to improve compliance with cervical cancer screening guidelines. Effect of an educational intervention on physician practice patterns. Obstet Gynecol 2013;17:175–81. on 26 June 2019 by guest. Protected by copyright.https://informatics.bmj.com/BMJ Health Care Inform: first published as 10.1136/bmjhci-2019-000013 on 26 June 2019. Downloaded from 

Small interface changes have dramatic impacts: How mandatory fields in electronic medical records increased pertussis vaccination rates in Australian obstetric patients

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Small interface changes have dramatic impacts: How mandatory fields in electronic medical records increased pertussis vaccination rates in Australian obstetric patients

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