Table 2 Summary of eligible articles

Birmingham 2011[32]

Focus group

21 pediatricians/nurse practitioners; New York, US

Computerized clinical reminders (CCRs) for influenza/electronic health records (EHR)

· Too much pop-up information makes it easy to ignore all alerts

· Mixed confidence in reliability and accuracy of EHR alerts

· Strongly opposed to alerts that interrupted workflow or forced an action before continuing documentation in a note

· Concern that alerts will strain nursing staff

Clark 2006[26]

Mail survey

756/1235 family physicians; 15 states in the US

Patient immunization history tracking for RR interventions/state immunization registry

· Too much cost/staff time

· Insufficient technology assistance

Dombkowski 2007[28]

Mail survey

389/600 pediatricians and family physicians; Michigan, US

Patient immunization history tracking for RR interventions/state immunization registry

· Accuracy of Medicaid data used to identify children with asthma and the potential restriction of the registry’s high-risk indicator to only Medicaid patients

· Consistent access to the registry

· Overall accuracy and completeness of registry data

· Staff not accustomed to using registry to check patients’ immunization status

Deutchman 2000[27]

Mail survey

158/250 family physicians with pediatric patients; rural Colorado, US

Patient immunization history tracking for RR interventions/no specific system

· Integration of new system into current computerized functions

· Patient confidentiality

· Costs, staff time associated with using the system to track patients

Fung 2004[30]

Survey

261/1304 clinical staff or informatics experts from 142 Veterans Health Administration (VHA) facilities; US

CCRs including for immunizations/EHR

· Perceived utility of CCRs, training and personnel support for computer use, EHR functionalities and performance data feedback to providers at each facility

Humiston 2009[33]

Focus groups

24 family physicians and nurses; New York, US

Patient immunization history tracking for RR interventions/no specific system

· Difficulties in identifying which adolescents were vaccinated, especially due to frequent moves

· Neither EMR nor state registries are helpful given poor communication between school and primary care offices

Saville 2011[31]

Semi-structured interviews

24 pediatricians, nurses and practice administrators from 11 practices; Colorado, US

Patient immunization history tracking for RR interventions/state immunization information system

· Difficulties overcoming the obstacle of inaccurate contact information

· Perceptions of low compliance with recall notices for certain risk groups

· Perceived conflicts in the immunization algorithms between registry and the practice.

· Lack of dedicated time and personnel for recall activities

· Inaccuracies both with patient contact information and immunization data in system;

patient contact information was not routinely updated in system, only in EHR

· Unmet expectations for responses to recall efforts can lead to method discontinuation

· Extra time required to crosscheck recall with appointment schedules to ensure under-immunized patients have not already planned physician visit

Tierney 2003[23]

Semi-structured interviews and surveys

18 clinician-administrators representing adopters and non-adopters; 912 (76%) pediatricians and public health staff completed surveys; US

Patient immunization history tracking for RR interventions/no specific system

· Both adopters and non-adopters of reminder or recall messages identified time and money as the most important barriers to implementing these methods.

· Not having a simple way of identifying children at a specific age, review records or begin an initiative

· Lack of knowledge about how to get started and limited computer skills were named as barriers by only 10% to 18% of respondents in any subgroup

Wallace 2004[34]

Semi-structured interviews, questionnaires, group discussions

Clinicians at 23 Spinal Cord Injury (SCI) centers in the VHA; US

CCRs for influenza/EHR

· Lack of coordination between EHR and vaccination data so cannot be sure patient has not been vaccinated elsewhere unless extra work is done

· Different forms (and locations) for inpatients and outpatients is frustrating for clinicians

· Lack of training can result in inadequate information that is not useful

· Lack of access for all immunization staff

Yarnall 1998[29]

Survey

Physicians caring for a sample of 1314 study patients in a large community health centre*; North Carolina, US

CCRs including those for immunizations/computerized health maintenance system

· Lack of time

· Additional workload as staff still need to use and complete paper maintenance forms