Transcript 2010 AAP National Conference & Exhibition

Information Technology Tools
for the Pediatric Hospitalist
October 16, 2011
Stuart T. Weinberg, MD, FAAP
Assistant Professor
Department of Biomedical Informatics
Department of Pediatrics
Vanderbilt University School of Medicine
[email protected]
Faculty Disclosure Information
 In the past 12 months, I have no relevant
financial relationships with the
manufacturer(s) of any commercial product(s)
and/or provider(s) of commercial services
discussed in this CME activity.
 I do not intend to discuss an
unapproved/investigative use of a commercial
product/device in my presentation
Objectives
 Understand the difference between information
technology and informatics
 Describe the variety of tools currently available to
assist pediatric hospitalists
 Understand the impact of health information
exchanges, including registries
 Be aware of current informatics strategies and
AAP efforts to improve HIT for pediatrics
Information Technology and Informatics
 Information technology centers on the technical tools –
hardware and software
 Informatics centers on the *science* - “The scientific field
that deals with biomedical information, data, and
knowledge—their storage, retrieval and optimal use for
problem-solving and decision making.” (Shortliffe).
 Clinical informatics highlights people, process,
technology.
 There are several peer-reviewed journals AND on Sep 22nd
Clinical Informatics became a Board-Certified Medical
Subspecialty.
Resolution #36SB Immunization Registry
 The Number 1 resolution at the 2010 AAP Annual
Leadership Forum.
 RESOLVED, that the Academy work to create a mechanism
that allows pediatricians ready access to existing vaccine
registries in all states; and be it further
 RESOLVED, that the Academy support the
establishment of, and consider the feasibility of
sponsorship of, a national vaccine registry/clearinghouse
with common electronic gateways to state registries,
allowing ready access to vaccine histories of patients.
Involve Your Local Informatician!
 Clinical informaticians will have valuable insights not only
into the medical workflow but also to the informatics
literature which may have already studied ‘best practices’
approaches
 Clinical informaticians should be involved *early* in the
process of designing tools and rethinking workflows – not at
the end to just implement a solution that has already been
developed
 Another example: the recent Centers for Medicare and
Medicaid Services (CMS) initiative to have hospitals offer
influenza vaccine to all inpatients
What is the Workflow of a Pediatric Hospitalist?
Two scenarios:
 In-house, shift coverage over a period of hours
 In-house and from home, shift coverage over a period
of longer hours or days, possibly covering more than
one hospital
Possible tasks:
 Inpatient and ER consults, new admissions and
coverage of existing inpatients, attendance at
deliveries, stabilization of patients for transport,
procedures
The Workflow and Tasks Help Dictate the Tools
 The Handoff – Signout
 Clinical Documentation (and Billing)
 Processing Data to/from Outside Sources
 Communication with Referring Providers
 Monitoring Patient Status
 Order Entry
 Clinical Decision Support
Signout
 Tools should support in-person and long-distance
 Signout info tends to be a mix of data that can be extracted
from patient record, additional informal comments not
intended for the medical record, and a checklist of things to
do (or NTD)
 One template in a signout tool does not fit all – signout
tends to be roles and specialty based
 Who else is using that signout tool? Campion TR Jr, Denny
JC, Weinberg ST, Lorenzi NM, Waitman LR. Analysis of a
computerized sign-out tool: identification of unanticipated
uses and contradictory content. AMIA Annu Symp Proc.
2007 Oct 11:99-104.
Clinical Documentation (and Billing)
 Multiple modalities for data entry: dictation, typing, point-
and-click templates, voice recognition, scribes
 A particular challenge for high-volume areas
 “I enjoy technology, but I have come to feel I am first a
data entry person for the insurers and then, secondly
valued as a physician.”
FOR HOSPITALISTS:
 How can documentation tools accommodate interruptions in
workflow? (voice recognition, scribes)
 How can documentation provide audit-proof support for
appropriate billing codes
Processing Data to/from Outside Sources

Interoperability and Reuse of Data….

Medical Communication Standards:
----

HL7 (Health Level 7)
DICOM (Digital Imaging and Communications in Medicine)
CCD (Continuing Care Documentation)
HITECH was passed by Congress in 2009 to support the adoption and use of Electronic
Health Records (EHRs) to achieve significant improvements in care through
meaningful use of EHRs by health care providers. Interoperability is a key component
of ‘meaningful use’.
FOR HOSPITALISTS:

Can external charts be incorporated not only in an electronic form but a *computable*
form. Example: Importing lab results not as a PDF but as discrete elements that can
be graphed among existing lab work?

Can preparations for transport include a mechanism to generate documents and
images that can be electronically sent to the receiving facility?
Communicating with Referring Providers
 Consider both ‘push’ and ‘pull’ technologies:
 Can providers access a portal to check on the status of their
patients?
 Is there a way to manage how referring providers prefer to
be contacted and with what frequency – i.e. daily updates
versus just a discharge summary?
 How can these contacts be efficiently completed? Can daily
summaries be generated and sent?
 A referring provider database will likely be necessary [and
note whether info should be sent to a *provider* or to a
*site*]
Monitoring Patient Status
 Individual patient lookup
 Dashboards of patients within and/or across multiple units
 Example: an electronic OB inpatient whiteboard which is
tracking mothers in labor – gestation, cm dilated, ROM
(meconium staining), GBS positive?, meds received
(antibiotics, steroids, etc), other pertinent info?
 Example: an electronic ER whiteboard which is displaying
patient info including age, presenting problem, LOS, status
of orders/labs/consults
 Dashboards of patients specifically on signout list? Quick
view of checklist of tasks to be performed
Order Entry
 A patient safety and healthcare quality issue
 Clinical decision support (next slide) should help make sure
the right patients are getting the right care at the right time
 Pediatric-specific features: CPOE should support age- and
weight-based dosing for medications with max and min
doses – especially helpful in critical care units
 Order Entry should also perform allergy checks, check for
drug-drug interactions, support order sets derived from
evidence-based medicine
 Personalized medicine is now being used to help guide drug
selection in some systems
Clinical Decision Support
 Incorporating recommendations and clinical guidelines from
evidence-based medicine into electronic medical records.
 June 13, 2006 - “The Roadmap for National Action on
Clinical Decision Support”
(https://www.amia.org/inside/initiatives/cds)
FOR HOSPITALISTS:
 CDS can assist with medication dosing and calculation,
problem-based order sets, reduction of missed opportunities
for preventive interventions
 Real-time algorithms can also help identify patient
subpopulations for research recruitment
Regional Informatics
 Immunization Registries
 Regional Health Information Organizations
(RHIOs)
 Health Information Exchanges (HIEs)
Immunization Registries
 July, 2010: The Task Force on Community Preventive Services
recommends immunization information systems on the basis of
strong evidence of effectiveness in increasing vaccination rates.
 Evidence is considered strong based on the findings from 71
published papers and 123 conference abstracts showing that IIS
are directly related to increasing vaccination rates and reducing
vaccine-preventable disease.
FOR HOSPITALISTS:
 Communication with immunization registries could provide a more
complete vaccination history
 Access may be an issue. Is it through a portal or is immunization
information integrated with your site’s existing EHR?
RHIOs and HIEs

Regional Health Information Organizations (RHIOs) and Health Information Exchanges
(HIEs) have been developed to share information across multiple health care
providers.

Example : Five major hospital systems participate in the Indiana Network for Patient
Care (INPC), begun in 1994. When a patient is seen in any of the 11 emergency rooms
operated by the consortium hospitals, and the patient consents, the information from
all of these institutions about one patient can be presented as one virtual medical
record. (http://www.regenstrief.org/medinformatics/inpc)

States are receiving grant money through the HITECH (Health Information Technology
for Economic and Clinical Health) Act to develop Health Information Exchanges (HIEs).
FOR HOSPITALISTS:

Chart reviews may include accessing, assimilating, and reconciling patient data coming
from sources outside of your own site.
How Are Vendors Persuaded to Develop Functionalities?
 Understand that vendor resources are currently overwhelmed by
Meaningful Use activities and requirements.
 Look for existing functionalities in your EHR that are similar and could be
potentially tweaked to accomplish your requests.
 Priorities for feature development tend to focus on the ‘biggest bang for
the buck’ – a feature that can benefit a broad range of customers, rather
than a small subgroup. Think about how your request could be generalized
to serve a similar function for a large group of users.
 American Academy of Pediatrics has several efforts underway to support
pediatric functionalities in EHRs – CHIC, Vendors Consortium, COCIT
Held on June 6th, 2011, a one-day Vendors Consortium
provided an opportunity for vendors to:
 Learn more about the pediatric community and their needs
relative to EHR system usage
 Learn more about AAP content and explore market
opportunities for the distribution of this content
 Provide feedback and preferences for the dissemination of
pediatric content through EHR systems
 Provide feedback on how the AAP can best serve the EHR
vendor community and their pediatrician clients
 Define ways of potential collaboration between vendors and the
AAP with the goal of disseminating pediatric content
Vendor’s Consortium: 18 People From 11 Vendors:
 Allscripts (2)
 Athenahealth (2)
 Cerner Corporation (1) – 1 MD
 e-MDs (2) – 1 MD
 Epic Systems Corporation (1) – 1 MD
 GE Healthcare (1)
 McKesson (1) – 1 MD
 NextGen (2)
 OptumInsight (3) – 1 MD
 Physician’s Computer Company (2)
 Sage Software (1)
Questions?
Contact Information:
Stuart T. Weinberg, MD FAAP
615-936-4239
[email protected]
http://dbmi.mc.vanderbilt.edu/people/weinberg.html