Documenting human papillomavirus vaccine refusal among adolescents in electronic health records: A mixed methods study

Background: Human papillomavirus (HPV) vaccination is often refused by patients or caregivers. We conducted a mixed-methods study to understand how health care providers document HPV vaccination refusal and use this information in subsequent encounters. Methods: Using electronic health records (EHR) in a public academic health system, we identified patients aged 9-17 years with documentation of refusal of a recommended vaccination in billing codes or clinic notes from October 15, 2015 and December 31, 2021. We summarized the number of encounters in which vaccination was refused; the incidence of HPV vaccination following an initial refusal; and the content of clinic notes describing HPV vaccination refusal. Next, we held focus groups with clinic personnel to understand strategies for documenting HPV vaccination refusal and holding future conversations about HPV vaccination. Results: Of 523 patients with a documented vaccination refusal, 351 (67 %) refused HPV. Of these, 88 (27 %) eventually received HPV vaccination; incidence of vaccination was not associated with the method used to document refusal in the EHR (ICD-10 code versus clinic note). From focus group discussions, we learned that providers usually make brief notes describing when HPV vaccination was offered and refused, and generally plan to recommend vaccination again at a subsequent encounter. Documenting specific reasons for refusal (e.g., patient age, a conflicting priority) was considered helpful to guide future conversations. Conclusions: Patients who refuse HPV vaccination might accept vaccination in the future if providers continue to recommend it. Documenting the refusal in EHR can provide meaningful context to guide subsequent recommendations.