Have you ever had one of those anxiety dreams where it's the end of the semester and finals are tomorrow and you haven't been studying or even going to class? For me, it's usually calculus or French. Now, it's vaccine logic.
I spent last week in Atlanta as part of the CDC's Adult Immunization Vaccine Logic committee. Apparently, I failed to burn enough bridges during the Child Immunization Logic committee process to avoid being invited back for this round. The adult vaccine world is much, much, much more complex than the childhood vaccine space but it is encroaching into our world quickly. Soon, we who focus just on pediatrics will be expected to track all of the risk factor considerations, track adjuvants with each vaccine, and review the clinical histories of every patient looking for indications to vaccinate. The purpose of our committee is, ultimately, to translate the ACIP recommendations into something "computable" for the rest of the world so that you don't get different answers to the question, "Does this person need a vaccine?" depending on whom you ask.
The committee is filled with some of the nation's leading immunization experts (and then me) - about half were highly ranked physicians and the other half were IIS developers, CDSi (Clinical Decision Support for immunizations) experts, and federal/CDC employees who work only on this issue. My role was clearly to be the "private EHR vendor obstacle" which I played as well as possible. To give this committee and its managers credit, they have us in during the development phase of the process - to often, I find that we get invited to the table too late, after some key (poor) choices have been made. These folks get it.
The meeting was largely a "working" meeting, so my small group dove into the literature for the MCV, DTap/Td/TdaP, and Varicella series. Our goal was to outline the precautions, contraindications, vaccine conflicts, evidence of immunity, and wide variety of indications to vaccine and then begin to place these in a context that the rest of the world can use for computing vaccine indication (or contraindication as the case may be). Here's a fractional list of what we accomplished:
- Identified 16 Public Health Priorities to focus initial efforts;
- Translated ACIP recommendations across 18 vaccine groups into a single common format with traceability back to 63 online publications;
- Identified 44 unique indications to vaccinate and their recommended schedules across the 18 vaccine groups;
- Reviewed and Improved 14 of the 18 vaccine groups;
- Identified 3 corrections to CDSi childhood resources;
- Brainstormed 28 impacts to health information systems when dealing with vaccines mixed with an adjuvant at the point of administration;
In the childhood world, the focus is largely on age and place in the series of expected vaccines. In the adult world, there is a massive focus on clinical conditions that trigger a recommendation. Although all of these conditions also apply to children, they aren't often used in my experience. I am going to have to go back to some of my friends and see what their logic tools do...
An interesting dichotomy that popped up during the meeting was a desire by some clinicians for stronger results from the technology while the technicians among us (such as myself or Judy Merritt from STC) argued against it. By "stronger results" I mean that the clinicians wanted the logic tools to be more black and white - "This patient needs X, this patient needs Y" vs. "Review the patient history to consider X, check this patient for a possible Y." Usually, the technicians are on the side of expanding the clinical role of technology and the clinicians are fighting it, but here it was the reverse. Why, in this instance? Because I think the technicians, like myself, are finally being confronted with making a clinical decision and we don't like it - for good reason. Interesting times ahead.