Meaningful Use and the Pediatric EHR

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					             EHR Background
Why EHRs?

 Improve Communication

 Improve Efficiency

 Save $$

 Reduce Errors

 Take Better Care of Our Patients
              EHR Background
U.S. Acute Care Hospitals (NEJM 2007)

 Comprehensive EHR: <2%

 Basic EHR: 8-12%

 +/- Physician notes

 Bottom line: at least 90% of U.S. Hospitals do not qualify
  for a basic EHR
    EHR Background: Barriers
 Implementation $

 Maintenance $

 Physician resistance, apprehension

 Return on Investment?

 Inadequate IT staff
               Meaningful Use
 A key part of the up to $27 Billion in incentive payments in
  the HITECH (The Health Information Technology for
  Economic and Clinical Health) Act

 Through Medicaid, offers as much as $63, 750 per clinician

 Goal: To dramatically increase the adoption of the
  Electronic Health Record (EHR) by offsetting some of the
  necessary initial costs
Meaningful Use- What does it mean?

 The EHR is not a magic bullet

 Improper implementation has the potential to provide less
  effective and efficient care
   do more harm than good

 A lot of money involved, not everybody has our patients
  best interest at heart
Meaningful Use- What does it mean?
 In combination with the EHR certification process, an
  effort to ensure that EHR implementation is done

 Demonstrate compliance with core objectives in order to
  be eligible for incentive payments
 Meaningful Use- Core Objectives
 Initially released in Jan 2010, applies to the first 2 years of
  incentive program, open to comment

 Over 2000 comments: Significant concerns about pace
  and scope, meeting demands
    All objectives had to be implemented to qualify

 Final version released this past August is more flexible
    14-15 core objectives
    5 of remaining 10 can be deferred to beyond 2011-2012
    Meaningful Use- Core Objectives

 Move quickly, but not too quickly

 Speed must be balanced with flexibility for provider
  groups of varying size and levels of preparedness.
Core Objectives
Core Objectives
Other Objectives
Other Objectives
                Future Stages
 Some of the objectives that were in the proposed rule will
  be deferred to later stages

 Demonstrating outcomes
                    EHR Basics
 CPOE: Computerized Provider Order Entry

 CDS: Clinician Decision Support
   Basic: Allergy checking, Drug-drug interaction checking,
    Dosing calculators
   Advanced: Dosing shortcuts, maximum dose alerts,
    indication based support, incorporation of individual patient
    data (labs, etc).

 Tremendous potential to reduce medication errors
   44-98,000 deaths annually due to medical errors (1999)
                    EHR Risks
 More is not necessarily better

 Increased support can have deleterious effects
   Workflow efficiency
   clinician frustration
   Introduction of new errors
                 Pediatric EHR
 Variability
     Growth parameters
     Vital signs
     Physical Exam findings
     Lab values
     Medication metabolism

 Variability = Complexity

 Our population is at higher risk for medication errors
Pediatric EHR: Key Features
AAP COCIT (Council on Clinical Information Technology)
 Robust immunization support

 Growth tracking and percentile support

 Privacy

 Medication dosing

 Numerical and non-numerical data norms.
       Weight-Based Support
 Weight-based dosing
   Clearly display the calculation
   Date of the weight used

 Weight Correctness support and alerts compared to:
   CDC growth curves
   Individual patients growth pattern
     Weight-Based Support
Assist with the calculation
 Support multiple units and growth parameters (weight, BSA)

Alert when there’s an error
 Incorrect input by clinician
    0.1 vs .01 mg/kg
 Right value but calculation too high
    2 mg/kg prednisone for 50kg patient

 Don’t forget the under doses!
 Weight based + Indication based = complexity
             Dosing Calculator
 Most Basic, provides automated calculation and most
  recent weight

 Many steps still required

 New Errors?
   Each step has the opportunity to be a misstep
   Drop-down
   Keypad
             Dosing Shortcuts
 Improved Speed

 Fewer step-associated errors

 New errors?

 mg/kg/dose vs mg/kg/day
   tAll mAn shORt Man

 Patient approaching adult weight
   Won’t I have that risk anyway?
   Max dose alerts
                   Dose Alerts
 An important safeguard, especially when shortcuts are

 Significant time and resources required to create and

 Multiple environments and formularies
                     Order Sets
 Indication-based support

 Grouping commonly placed orders (admission, asthma,

 Require time and effort to design

 Input from institution specific clinicians is vital

 Maintenance
  Final Thoughts: Meaningful Use
 “Once in a lifetime”

 Many opportunities
        Patient Care
        Financial
        Efficiency & Quality
        Attracting new Physicians
        Research
             Variability & CDS

 CDS is best with fixed norms

 Documentation: Physical exam findings

 Laboratory results
       Critiquing vs Consulting
 Critiquing: design alerts to adapt to these changing norms
   No easy task
   Still runs the risk of inappropriate alerting

 Consulting: Present relevant information regardless of
  whether it is normal or abnormal
   Ubiquity = ignored?
 Final Thoughts: Pediatric EHR
 Proceed with enthusiasm, and caution

 The more involvement, the better

 Collaboration with other institutions

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