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Reminders for key just-in-time recommendations: facilitating uptake of vaccines among Veterans

Published online by Cambridge University Press:  03 September 2026

Kelly Frank,
Brigid M. WilsonOpen the ORCID record for Brigid M. Wilson[Opens in a new window],
Taissa A. BejOpen the ORCID record for Taissa A. Bej[Opens in a new window],
Allison J. O’DonnellOpen the ORCID record for Allison J. O’Donnell[Opens in a new window] and
Robin L.P. JumpOpen the ORCID record for Robin L.P. Jump[Opens in a new window]
Kelly Frank
Affiliation:
Pharmacy Section, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
Brigid M. Wilson
Affiliation:
Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, OH, USADivision of Infectious Diseases & HIV Medicine in the Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
Taissa A. Bej
Affiliation:
Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, OH, USA
Allison J. O’Donnell
Affiliation:
GRECC at the VA Pittsburgh Healthcare System , Pittsburgh, PA, USADivision of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA, USA
Robin L.P. Jump*
Affiliation:
GRECC at the VA Pittsburgh Healthcare System , Pittsburgh, PA, USADivision of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA, USA
*
Corresponding author: Robin L.P. Jump; Email: robin.jump@va.gov

Abstract

To improve adult vaccinations rates, we implemented a Virtual Vaccine (ViVa) clinic that provided concise vaccine recommendations for patients with an upcoming primary care visit. Among Veterans ≥50, 36% of patients reviewed by the ViVa clinic received ≥1 of the recommended vaccines, compared to 23% of those in control groups.

Information

Type
Concise Communication
Information
Antimicrobial Stewardship & Healthcare Epidemiology , Volume 6 , Issue 1 , 2026, e253
Creative Commons
Creative Common License - CCCreative Common License - BYCreative Common License - NCCreative Common License - ND
This is a work of the US Government and is not subject to copyright protection within the United States. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America.
This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided that no alterations are made and the original article is properly cited. The written permission of Cambridge University Press or the rights holder(s) must be obtained prior to any commercial use and/or adaptation of the article.
Copyright
© Department of Veterans Affairs, 2026

Introduction

Less than 25% of adults have received all age-appropriate vaccines. 1 While patient-related factors, such as exposure to misinformation and concerns about vaccine safety, contribute to suboptimal vaccination rates, so do provider-related factors. Primary care physicians (PCPs) provide preventive care, manage acute and chronic conditions, and apply shared decision-making that accounts for patients’ social factors. Time constraints and vaccine hesitancy may cause PCPs to defer discussing vaccines, particularly those with recommendations for shared decision-making. Additional challenges faced by PCPs arise from changes to vaccine schedules and, more recently, accessing evidenced-based vaccines recommendations. 2–Reference Goldman and Hopkins6

To address these concerns and improve adult vaccination rates, we implemented a Virtual Vaccine (ViVa) clinic at a large Veterans Affairs (VA) medical center. We hypothesized that offloading the time and cognitive workload associated with identifying and prioritizing appropriate vaccines would facilitate discussions around routine vaccinations. Here, we describe the ViVa clinic and its influence on vaccine uptake among patients seen in primary care.

Methods

Setting and intervention

Between January 1 and October 21, 2025, we implemented the ViVa clinic in a subset of primary care clinics at a large VA medical center. We approached a convenience sample of primary care providers via email or in person for participation, none of whom opted out. The VA determined this project did not meet the regulatory definition of research in accordance with 38 CFR 16.102.

The ViVa clinic consisted of one physician and one pharmacist who reviewed patient charts up to one month in advance of a scheduled primary care appointment. The chart review assessed patient immunization histories documented in the VA electronic health record (EHR) as well as those from non-VA settings as accessible through the Joint Legacy Viewer. Reference Legler, Price and Parikh7 ViVa clinicians entered a brief, templated note that indicated dates of receipt of age-appropriate vaccines, which vaccines (if any) were due, and personalized recommendations as to vaccine prioritization (Supplemental Text 1). 2 When appropriate, the note included additional templated language to help PCPs to address vaccine hesitancy.

Outcomes

We extracted EHR data from the VA‘s Corporate Data Warehouse to compare patients’ vaccination status on the day of their primary care visit and 60 days after. The primary outcome was the proportion of adults ≥50 years who were up-to-date on the following vaccines: COVID-19, influenza, respiratory syncytial virus (RSV), pneumococcal disease; Shingrix; and tetanus, diphtheria, and pertussis (Tdap). Secondary outcomes included the proportion of patients who received at least one additional recommended vaccine during follow-up, measured by the change in the median number of vaccines for which each patient was up-to-date between the day of and 60 days after the primary care clinic visit. Outcomes were compared among patients seen by PCPs in intervention clinics who received a ViVa note (ViVa+), did not receive a ViVa note (ViVa-), or were seen in non-invention clinics (controls). ViVa- patients were not listed in the PCP‘s schedule when the ViVa team performed their reviews, indicating they were added to the schedule in the 4 to 5 weeks prior to their appointment. Patient demographics and outcomes were summarized using descriptive statistics.

Results

During the ten-month study period, 3,142 Veterans aged ≥50 years had qualifying primary care visits. Their median age was 71 years (IQR 62–77), and 86% were male, reflecting the broader VA primary care population (Table 1). Among the 654 patients in intervention clinics, 209 had a ViVa note entered before their visit (ViVa+), whereas 445 were not reviewed by ViVa clinicians (ViVa-). A higher proportion of ViVa+ patients were female (27%) compared to both ViVa- (16%) and control (12%) patients. Baseline vaccination status was similar across groups, with patients up to date on a median of 3 vaccines (IQR 2–4).

Table 1.

Demographics for patients with a primary care appointment January–October, 2025 a

A table comparing demographics for patients with a primary care appointment.
Table 1. Long description

A table comparing demographics for patients with a primary care appointment. The table has 10 rows and 4 columns. The columns are labeled Characteristics, ViVa+ (n=209), ViVa- (n=445), and Control (n=2,488). The rows are labeled Age, median, IQR; Male, n (%); Race (White, Black, Other); Ethnicity (Non-Hispanic, Hispanic, Other); Received >=1 vaccine within 60 days of appointment; Up-to-date vaccines, median, IQR (Baseline, Follow-up within 60 days). Row 1: Age, median, IQR: ViVa+, 72 (65, 78); ViVa-, 73 (63, 78); Control, 70 (62, 77). Row 2: Male, n (%): ViVa+, 152 (73 percent); ViVa-, 375 (84 percent); Control, 2,184 (88 percent). Row 3: Race, White: ViVa+, 134 (64 percent); ViVa-, 323 (73 percent); Control, 1,766 (71 percent). Row 4: Race, Black: ViVa+, 58 (28 percent); ViVa-, 106 (24 percent); Control, 639 (26 percent). Row 5: Race, Other: ViVa+, 15 (8 percent); ViVa-, 14 (4 percent); Control, 70 (3 percent). Row 6: Ethnicity, Non-Hispanic: ViVa+, 193 (92 percent); ViVa-, 433 (97 percent); Control, 2,396 (96 percent). Row 7: Ethnicity, Hispanic: ViVa+, 5 (2.4 percent); ViVa-, 1 (0.2 percent); Control, 27 (1.1 percent). Row 8: Ethnicity, Other: ViVa+, 11 (5.3 percent); ViVa-, 11 (2.5 percent); Control, 65 (2.6 percent). Row 9: Received >=1 vaccine within 60 days of appointment: ViVa+, 75 (36 percent); ViVa-, 120 (27 percent); Control, 572 (23 percent). Row 10: Up-to-date vaccines, median, IQR, Baseline: ViVa+, 3 (2, 4); ViVa-, 3 (2, 4); Control, 3 (1, 4). Row 11: Up-to-date vaccines, median, IQR, Follow-up within 60 days: ViVa+, 4 (2, 5); ViVa-, 3 (2, 5); Control, 3 (2, 5).

a ViVa+ and ViVa- indicate patients seen by a primary care provider in an intervention clinic for whom a Virtual Vaccine clinic (ViVa) note was vs. was not entered, respectively.

b IQR, interquartile range.

c Includes American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Asian, Multiracial, Unknown, Other, and Prefer Not to Answer.

d Includes Unknown, Other, and Prefer Not to Answer.

Overall, vaccination rates improved across all groups over the 60-day follow-up period, although the degree of improvement varied among each group. In the ViVa+ group, 36% of patients received one or more recommended vaccines compared to 27% in the ViVa- and 23% in the control groups. The median number vaccines for which ViVa+ patients were up-to-date increased from 3 (IQR 2–4) at baseline to 4 (IQR 2–5) at follow-up. Median values did not change from baseline versus 60-day follow-up for patients in the ViVa- (3, IQR 2–4 vs 3, IQR 2–5) or control clinics (3, IQR 1–4 vs 3, IQR 2–5), respectively.

The largest gains in vaccination rates among ViVa+ patients were observed for RSV and pneumococcal vaccines. RSV vaccination increased from 29% to 47% among eligible ViVa+ patients, compared to 30%–41% in the control clinic. Pneumococcal vaccination increased from 30% to 42% in the ViVa+ group, compared to 31%–35% in the control clinic (Figure 1).

Figure 1.

The proportion of primary care patients up-to-date at baseline and 60 days after their visits, stratified by the vaccine type and schedule. The starting value for the y-axis shifts to better visualize differences at baseline and follow-up, with each graph encompassing a 50% range. Up-to-date was defined as: any vaccine ever for RSV; either PCV20 or PCV21 for pneumococcal vaccines, Tdap or Td in the prior 10 years for Tdap; two prior vaccines or one prior vaccine within 60 days before for Shingrix; and any vaccine since the prior September for COVID-19 and influenza.

Bar chart showing baseline and follow-up vaccination rates for RSV, PCV, Shingrix, Tdap, COVID-19, and influenza across three groups: ViVa+, ViVa-, and Control.
Figure 1. Long description

Figure 1. Three grouped bar charts displaying vaccination rates at baseline and follow-up for three study groups: ViVa+ (intervention, engaged), ViVa- (intervention, not engaged), and Control. Panel A, titled “Schedule Established After 2020,” shows RSV vaccine rates rising from approximately 25-30% at baseline to 39-47% at follow-up, and PCV rates rising from 29-30% to 34-41%. Panel B, titled "Schedule Established Before 2017," shows Shingrix rates rising from roughly 57-64% to 61-68%, while Tdap rates were already high at baseline (90-91%) and remained stable or slightly increased at follow-up (91-94%). Panel C, titled "Seasonal Vaccines," shows COVID-19 rates rising from 32-39% to 35-41%, and influenza rates from 51-57% to 53-62%. Across all panels, follow-up rates are generally higher than baseline rates, with modest differences between groups.

Discussion

The ViVa clinic demonstrated that offloading the cognitive and administrative burden of vaccine record review and recommendation development from PCPs to a dedicated virtual team meaningfully improved adult vaccination rates. The greatest gains were seen for RSV and pneumococcal vaccines suggesting that the ViVa clinic was more effective for recently introduced vaccines or those with recent schedule changes compared to vaccines with more established schedules, including seasonal vaccines. Notably, a positive spillover effect was observed among ViVa- patients, suggesting that PCPs applied knowledge gained from reviewing ViVa notes to their broader practice.

From a systems perspective, the ViVa clinic was easy to implement. The ViVa clinicians worked asynchronously to complete a focused chart review and place a note with concise recommendations into the EHR that included the appropriate PCP as a signatory. The templated format of ViVa notes facilitated efficient identification of patients’ vaccine needs, allowing them to more readily engage in vaccine discussions with their patients.

The VA healthcare system has several notable features specific to vaccines. First, Veterans are highly vaccinated at baseline due to their military service. Reference Grabenstein, Pittman, Greenwood and Engler8 Second, except for yellow fever, adult vaccines are routinely available at VA clinical settings. Third, vaccines are free for Veterans seen within the VA system, reducing potential financial burdens. 9,10 Finally, standing orders and clinical reminders further ease potential barriers for administration of most routine vaccinations. Even with these features, the ViVa clinic intervention still yielded measurable increases in the proportion of Veterans who were up-to-date on their vaccines. These results suggest the potential for greater impact in settings where baseline vaccination rates are lower and PCP time constraints are more severe.

Our study has limitations. The intervention was conducted at a single VA medical center, which may limit generalizability. The study period coincided with COVID-19 vaccine supply disruptions within the VA, which may have attenuated observed effects for that vaccine. Finally, the groups assessed were somewhat imbalanced. The greater proportion of women in the ViVa+ compared to the ViVa- and control groups is likely a reflection of one of the intervention PCPs offering a clinical focus on women‘s health.

Further dissemination and implementation of the ViVa clinic model may generate several benefits. For individual patients, more complete vaccination coverage reduces the risk of serious preventable illness. At a population level, higher adult vaccination rates contribute to community immunity and reduced healthcare utilization. For clinical practice, ViVa demonstrates a scalable model for addressing vaccine gaps without extending visit length or disrupting clinic workflow. From a policy standpoint, these findings support consideration of asynchronous vaccination programs as a cost-effective strategy to improve adult immunization rates.

Supplementary material

The supplementary material for this article can be found at https://doi.org/10.1017/ash.2026.10800.

Acknowledgements

The authors offer their sincere gratitude to the primary care clinics who participated and offered constructive feedback on the ViVa Clinic. We are also grateful to the clinicians who have contributed to the Implementation Guide (available upon request to corresponding author).

Financial support

This work was supported in part by funds and facilities provided by the Technology Enhancing Cognition and Health Geriatric Research Education and Clinical Center at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania. The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of the Department of Veterans Affairs or of the United States government.

Competing interests

RJ is the Principal Investigator on research grants from AbacusLabs, Pfizer and Merck; she has also participated in advisory boards for Pfizer, Merck, and GSK. None of the other authors have relevant conflicts of interest to disclose.

Footnotes

†

Current Affiliation: Research Service, VA Northeast Ohio Healthcare System, Cleveland, Ohio.

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Figure 0

Table 1.Demographics for patients with a primary care appointment January–October, 2025aTable 1 long description.

Figure 1

Figure 1.Figure 1 long description.The proportion of primary care patients up-to-date at baseline and 60 days after their visits, stratified by the vaccine type and schedule. The starting value for the y-axis shifts to better visualize differences at baseline and follow-up, with each graph encompassing a 50% range. Up-to-date was defined as: any vaccine ever for RSV; either PCV20 or PCV21 for pneumococcal vaccines, Tdap or Td in the prior 10 years for Tdap; two prior vaccines or one prior vaccine within 60 days before for Shingrix; and any vaccine since the prior September for COVID-19 and influenza.