Baby Steps

Over the last few years, as healthcare has become more IT-driven, and processes like medication dosing and clinical documentation have become more automated, one area that has largely been left out in the cold in most hospital organizations has been pediatric care.

Dan Nigrin

In 2009, the San Francisco-based Health Technology Center and The Children's Partnership (Washington) launched an initiative to assess how IT can be utilized to improve pediatric care. The groups found that “there has been remarkably little focus on the use of information and communications technology” in this field, and that the “electronic tools developed primarily for adult populations lack the functionality necessary to support pediatric care.”

At leading children's hospitals around the country like Children's Hospital Boston, such findings come as no surprise. As IT and clinician leaders work together to implement clinical IT solutions, they are learning first-hand how complex such implementations can be. One of the key lessons the leader organizations have already learned? Commercial healthcare IT leaders remain notoriously behind the curve in terms of creating clinical IT offerings that meet the very complex and specific needs of children's hospitals.

That core challenge is reflected even at the federal healthcare IT policy level. For example, even the Health Information Technology for Economic and Clinical Health Act (HITECH) provisions of the American Recovery and Reinvestment Act (ARRA) of 2009 focus primarily on adult care. “In the first iteration we saw of ARRA, there was a real paucity of pediatric-specific material,” says Daniel Nigrin, M.D., CIO at the 396-bed Children's Hospital Boston.

It wasn't until recently that the availability - and quality - of IT solutions developed for children's healthcare has started to improve, and that's due largely to pressure from leading organizations, notes Nigrin. “A lot of those products just didn't meet the degree of specificity and sophistication that we needed,” he says. “So despite the fact that we wanted to get into the business of doing CPOE [computerized physician order entry] 10 or even 15 years ago, most institutions held off until early 2000.”

So why, in this advanced age of medicine, is pediatrics taking a backseat, particularly when there are an estimated 73 million children in the United States who require care? One possible explanation is that few people outside the field of pediatric care seem to comprehend the complexities involved in treating patients ranging from birth to age 18.

“At a high level, one of the biggest challenges is the fact that there is tremendous variability in how you care for patients based on age and size,” says Nigrin. This variation manifests itself in many facets of care, including medication dosing and dispensing, growth chart analysis, and electronic documentation. Among the areas of challenge:

Weight-based dosing: “The sensitivity around getting medication dosing done correctly is far greater and more difficult in the pediatric world,” says Nigrin. With adults, most medications are dosed as a specific amount, such as one gram. However, in the pediatric setting, a formula is utilized to calculate the proper dose for each child based on a rate of 15 milligrams per kilogram, according to Marvin Harper, M.D., CMIO at Children's Hospital Boston. But although weight-based dosing is safer for pediatric patients, the system isn't fool proof, adds Harper. “You also have to build in dose-range checking, or else at some point, you might exceed the amount an adult would get.”

Barcoding: Another area that gets tricky in pediatrics is barcode-facilitated medication administration. With adult patients, most medications are individually barcoded by the manufacturer; but in pediatrics, meds are often delivered in bulk amounts, and must be dispensed into proper amounts and barcoded by the hospital pharmacy, Nigrin notes. Additionally, because children usually don't take pills, certain medications are often ground up into food, and therefore are not always scanned right at the point of administration.

Growth chart analysis: The use of growth charts to track patient progress is a fundamental part of pediatric care. However, says Nigrin, there's more to it than just measuring height and weight and checking them against a table; clinicians need to be able to view information graphically to monitor trends. “And to do more sophisticated analyses, you need the capability to change the type of plot that you're using,” he notes, citing as an example charts that are tailored for patients with certain disorders.

Trailblazing Pediatric IT Efforts

As part of a project entitled, Technology-Enabled Innovations for Improving Children's Health, the Health Technology Center (San Francisco) and The Children's Partnership (Washington) identify several programs around the country utilizing innovative IT to support pediatric care:

Health-e-Access, a program at the University of Rochester Medical Center, provides interactive, Internet-based virtual visits to diagnose and treat routine childhood illnesses in 19 urban and suburban schools and childcare centers;

The University of California, Irvine, Neonatal Intensive Care Unit Program utilizes mobile technologies to assist families in providing at-home care for premature infants after leaving the NICUs;

KIDSNET, an electronic health information system for every child in the state of Rhode Island, integrates data from ten databases and allows authorized users to access data relevant to the care they are providing;

The Children's IQ Network integrates the data of children within the Washington, D.C. metropolitan area, enabling the secure electronic exchange of patient information by area physicians, primary care clinics, foster care programs and mobile medical units.

Electronic documentation: Finally, there's the issue of documenting the care of fetuses. Data such as abnormality found during an ultrasound or a list of medications the mother takes during pregnancy are stored on the mother's electronic record. However, once the infant is born, the information must populate into his or her record, says Nigrin. But this gets complicated, he adds, because while the infant's caregivers are the ones that need to access the data, it technically belongs to the mother's record. Furthermore, the fact that so many decision support algorithms are based on age can complicate care decisions for fetuses. “How do you document that into an EMR when the child has not been born yet and doesn't have a date of birth,” he asks.

Takeaways

As information technology has become a larger factor in the healthcare industry, one area of care that has been somewhat neglected is pediatrics.
The most significant factor differentiating pediatric care from adult care in terms of IT implementation is the variability in treatment based on a patient's age and size.
But while there are challenges - particularly in the areas of medication administration, growth chart analysis and clinical documentation - forward-thinking leaders have found success by collaborating with vendors to customize products to meet their needs.
It's important to develop relationships with other organizations and create a network of trusted leaders who can provide advice when rolling out applications like EMRs.

Hospitals face internal heavy lifting

While there are certainly many challenges involved in IT implementation in the pediatric setting, it's important for leaders to realize that there are opportunities for those willing to roll up their sleeves and do the work, says Nigrin. “We worked hard with our vendors to enhance the baseline products, but in terms of developing order sets and content that goes into these systems, a lot of it is developed locally,” he notes. For example, a many of the medications used in pediatrics aren't specifically approved by the FDA for use in pediatrics. Therefore, the onus is on children's care organizations to devise their own dosing guidelines.

This, says Nigrin, is where it is critical to develop relationships with other organizations and create a network of trusted leaders who can provide advice, particular when rolling out applications like EMRs. Harper agrees, adding, “I've always thought that the pediatric health IT community is a little bit more collaborative than in the adult world. And if that's true, I think the reason is because we have so many of these unique things that we deal with. So we tend to gravitate to each other to ask those questions.”