Use of health information technology by children's hospitals in the United States

Reconsidering hospital EHR adoption at the dawn of HITECH: implications of the reported 9% adoption of a "basic" EHR

Objective

In 2009, a prominent national report stated that 9% of US hospitals had adopted a “basic” electronic health record (EHR) system. This statistic was widely cited and became a memetic anchor point for EHR adoption at the dawn of HITECH. However, its calculation relies on specific treatment of the data; alternative approaches may have led to a different sense of US hospitals’ EHR adoption and different subsequent public policy.

Materials and Methods

We reanalyzed the 2008 American Heart Association Information Technology supplement and complementary sources to produce a range of estimates of EHR adoption. Estimates included the mean and median number of EHR functionalities adopted, figures derived from an item response theory-based approach, and alternative estimates from the published literature. We then plotted an alternative definition of national progress toward hospital EHR adoption from 2008 to 2018.

Results

By 2008, 73% of hospitals had begun the transition to an EHR, and the majority of hospitals had adopted at least 6 of the 10 functionalities of a basic system. In the aggregate, national progress toward basic EHR adoption was 58% complete, and, when accounting for measurement error, we estimate that 30% of hospitals may have adopted a basic EHR.

Discussion

The approach used to develop the 9% figure resulted in an estimate at the extreme lower bound of what could be derived from the available data and likely did not reflect hospitals’ overall progress in EHR adoption.

Conclusion

The memetic 9% figure shaped nationwide thinking and policy making about EHR adoption; alternative representations of the data may have led to different policy.

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

Use of a Checklist and Clinical Decision Support Tool Reduces Laboratory Use and Improves Cost

OBJECTIVE

We hypothesized that a daily rounding checklist and a computerized order entry (CPOE) rule that limited the scheduling of complete blood cell counts and chemistry and coagulation panels to a 24-hour interval would reduce laboratory utilization and associated costs.

METHODS

We performed a retrospective analysis of these initiatives in a pediatric cardiovascular ICU (CVICU) that included all patients with congenital or acquired heart disease admitted to the cardiovascular ICU from September 1, 2008, until April 1, 2011. Our primary outcomes were the number of laboratory orders and cost of laboratory orders. Our secondary outcomes were mortality and CVICU and hospital length of stay.

RESULTS

We found a reduction in laboratory utilization frequency in the checklist intervention period and additional reduction in the CPOE intervention period [complete blood count: 31% and 44% (P < .0001); comprehensive chemistry panel: 48% and 72% (P < .0001); coagulation panel: 26% and 55% (P < .0001); point of care blood gas: 43% and 44% (P < .0001)] compared with the preintervention period. Projected yearly cost reduction was $717,538.8. There was no change in adjusted mortality rate (odds ratio 1.1, 95% confidence interval 0.7-1.9, P = .65). CVICU and total length of stay (days) was similar in the pre- and postintervention periods.

CONCLUSIONS

Use of a daily checklist and CPOE rule reduced laboratory resource utilization and cost without adversely affecting adjusted mortality or length of stay. CPOE has the potential to hardwire resource management interventions to augment and sustain the daily checklist.

Electronic medical record adoption in hospitals that care for children

OBJECTIVE

Hospitals that care for children face unique barriers in electronic medical records (EMR) use that may affect their ability to meaningfully use EMR. The purpose of this study was to investigate hospitals that care for children, both freestanding and adult hospitals with children's services, to determine progress toward advanced stages of EMR use.

METHODS

The American Hospital Association survey described hospitals across the United States. Healthcare Information and Management Systems Society 2006 and 2010 databases identified hospitals' EMR use. EMR stage was classified according to previous studies. Multivariable analysis was used to determine independent predictors of EMR use.

RESULTS

The analysis included 2794 hospitals. During the study time frame, a significant increase occurred for hospitals moving into any stage of EMR in adult hospitals with children's services (47% to 75%; P < .001), while improvements for freestanding children's hospitals were modest at best (46% to 59%; P = .3). Conversely, freestanding children's hospitals had the largest gain in advance stage 3 adoption (6% to 39%; P < .001) compared to adult hospitals with children's services (6% to 23%; P < .001). Freestanding children's hospitals were less likely to use pharmacy information systems but more likely to use computerized provider order entry.

CONCLUSIONS

In 2010, freestanding children's hospitals had the highest percentage use of advanced stage EMR (39%), but the lowest improvements in percentage of hospitals entering into any stage of adoption over the study period. This trend created a digital divide among freestanding children's hospitals that may improve with pediatric-specific electronic medication management products.

Hospital electronic medical record use and cost of inpatient pediatric care

OBJECTIVE

Electronic medical record (EMR) systems are costly for hospitals to implement and maintain, and the effects of EMR on the cost of care for inpatient pediatrics remain unknown. Our objective was to determine whether delivering care with advanced-stage EMR was associated with a decreased cost per case in a national sample of hospitalized children.

METHODS

The Healthcare Cost and Utilization Project Kids Inpatient Dataset 2009 identified pediatric discharges. The Healthcare Information and Management Systems Society 2009 database identified hospitals' EMR use. EMR was classified into 3 stages, with advanced-stage 3 EMR including automation of ancillary services, automation of nursing workflow, computerized provider order entry, and clinical decision support. Multivariable linear regression was used to determine the independent effect of advanced-stage EMR on cost per case. Propensity score adjustment was included to control for nonrandom assignment of EMR use.

RESULTS

This analysis included 4,605,454 weighted discharges. EMR use by hospitals that care for children was common: 24% for stage 1, 23% stage 2, and 32% advanced stage 3. The multivariable model demonstrated that advanced stage EMR was associated with an average 7% greater cost per case ($146 per discharge).

CONCLUSIONS

The care of children across the United States with EMRs may create a safer health care system but is not associated with inpatient cost savings. In fact our primary analysis shows a 7% additional cost per case. This finding is contrary to predicted savings and may represent an added barrier in the adoption of EMR for inpatient pediatrics.

Effects of CPOE on provider cognitive workload: a randomized crossover trial

OBJECTIVE

To evaluate whether systematically developed clinical decision supports provide usability benefit or decreased cognitive workload with their use.

METHODS

Seven surgeons at a pediatric hospital at different levels of training (3 residents, 3 fellows, and 1 attending) were randomized to use either a historical control (ad hoc developed order set) or a systematically developed order set for postoperative management of appendicitis in children. After a washout period, they were crossed over to the other order set. Participants were videorecorded and completed postsurveys, including the System Usability Scale and the National Aeronautic and Space Administration-Task Load Index.

RESULTS

Participants unanimously preferred using systematically developed order sets. These order sets resulted in higher usability scores (75 ± 10 vs 60 ± 19; P < .05) and lower cognitive workload scores (37.7 ± 15 vs 52.2 ± 12; P < .05), with comparable amounts of time spent, mouse clicks, and free text entry. Orders generated were more likely to conform to established clinical guidelines.

CONCLUSIONS

Systematically designed order sets provide a reduction in cognitive workload and order variation in the context of improved system usability and improved guideline adherence. The systematically designed order set did not improve time spent, reduce mouse clicks, or reduce free text entry.

Telemedicine in an international context: definition, use, and future

PURPOSE

Use of telemedicine is increasingly prevalent in order to provide better access to expert care, and we examine telemedicine use internationally.

DESIGN/METHODOLOGY

Using Donabedian's structure, process outcome framework, we conduct an analysis of published studies in the United States, Europe, and Asia to examine the uses, conditions treated, barriers, and future of telemedicine.

FINDINGS

We identify several similarities and challenges to telemedicine use in each region. We find use of videoconferencing between providers or providers and patients for the treatment of acute and chronic conditions. Studies in the United States are more likely to identify applications for the use of chronic conditions, whereas studies in Europe or Asia are more likely to use them for acute access to expertise. Each region reported comparable challenges in reimbursement, liability, technology, and provider licensing.

RESEARCH LIMITATIONS

We compare available research articles from three diverse regions, and many of the articles were merely descriptive in nature. Furthermore, the number of articles per region varied.

PRACTICAL IMPLICATIONS

Barriers to telemedicine use include a lack of reimbursement, language commonality, technological availability, physician licensure or credentialing, trained support staff and patient privacy, and security assurances. Practitioners and policy makers should work to address these barriers.

ORIGINALITY/VALUE

Through this work, a summary of the research to date describes telemedicine use in the United States, Asia, and Europe. Identification of use and barriers may provide impetus for improving access to care by finding ways to increase telemedicine use through standardization.

Use of a health information exchange system in the emergency care of children

BACKGROUND

Children may benefit greatly in terms of safety and care coordination from the information sharing promised by health information exchange (HIE). While information exchange capability is a required feature of the certified electronic health record, we known little regarding how this technology is used in general and for pediatric patients specifically.

METHODS

Using data from an operational HIE effort in central Texas, we examined the factors associated with actual system usage. The clinical and demographic characteristics of pediatric ED encounters (n = 179,445) were linked to the HIE system user logs. Based on the patterns of HIE system screens accessed by users, we classified each encounter as: no system usage, basic system usage, or novel system usage. Using crossed random effects logistic regression, we modeled the factors associated with basic and novel system usage.

RESULTS

Users accessed the system for 8.7% of encounters. Increasing patient comorbidity was associated with a 5% higher odds of basic usage and 15% higher odds for novel usage. The odds of basic system usage were lower in the face of time constraints and for patients who had not been to that location in the previous 12 months.

CONCLUSIONS

HIE systems may be a source to fulfill users' information needs about complex patients. However, time constraints may be a barrier to usage. In addition, results suggest HIE is more likely to be useful to pediatric patients visiting ED repeatedly. This study helps fill an existing gap in the study of technological applications in the care of children and improves knowledge about how HIE systems are utilized.

Results: Survey of pediatric urology electronic medical records-use and perspectives

PURPOSE

The $19.2 billion Health Information Technology for Economic and Clinical Health Act will have a dramatic effect on the adoption of electronic medical records in the United States by directly reimbursing for the adoption of electronic medical records in the future. We sought to gain an understanding of electronic medical record use in pediatric urology to aid in the transition to electronic medical records.

MATERIALS AND METHODS

All Fellows and post-fellowship Fellow Candidates of the American Academy of Pediatrics Section on Urology were recruited to participate in the survey. Electronic and paper versions of this 50-question internal review board approved anonymous survey were sent to potential participants.

RESULTS

Of 286 pediatric urologists 165 completed the survey for a 65% response rate. Of the respondents 67.3% were pediatric urologists in academic or hospital based practice while the remaining 32.7% were in private practice. Overall 78.8% of respondents reported using electronic medical records at the hospital while 67.3% used them at the office/clinic. Of the physicians 12.1% reported that they would retire if electronic medical record use was federally mandated.

CONCLUSIONS

Pediatric urologists in the United States appear to have embraced the adoption of electronic medical records. A large number of academic/hospital based and private practice pediatric urologists have begun to use electronic medical records. Most respondents were interested in improving electronic medical record use in our field, believed that physicians would be most capable of developing ideal electronic medical records and would be interested in participating in a national cooperative effort to improve electronic medical record use.

Computerized physician order entry with decision support decreases blood transfusions in children

OBJECTIVE

Timely provision of evidence-based recommendations through computerized physician order entry with clinical decision support may improve use of red blood cell transfusions (RBCTs).

METHODS

We performed a cohort study with historical controls including inpatients admitted between February 1, 2008, and January 31, 2010. A clinical decision-support alert for RBCTs was constructed by using current evidence. RBCT orders resulted in assessment of the patient's medical record with prescriber notification if parameters were not within recommended ranges. Primary end points included the average pretransfusion hemoglobin level and the rate of RBCTs per patient-day.

RESULTS

In total, 3293 control discharges and 3492 study discharges were evaluated. The mean (SD) control pretransfusion hemoglobin level in the PICU was 9.83 (2.63) g/dL (95% confidence interval [CI]: 9.65-10.01) compared with the study value of 8.75 (2.05) g/dL (95% CI: 8.59-8.90) (P < .0001). The wards' control value was 7.56 (0.93) g/dL (95% CI: 7.47-7.65), the study value was 7.14 (1.01) g/dL (95% CI: 6.99-7.28) (P < .0001). The control PICU rate of RBCTs per patient-day was 0.20 (0.11) (95% CI: 0.13-0.27), the study rate was 0.14 (0.04) (95% CI: 0.11-0.17) (P = .12). The PICU's control rate was 0.033 (0.01) (95% CI: 0.02-0.04), and the study rate was 0.017 (0.007) (95% CI: 0.01-0.02) (P < .0001). There was no difference in mortality rates across all cohorts.

CONCLUSIONS

Implementation of clinical decision-support alerts was associated with a decrease in RBCTs, which suggests improved adoption of evidence-based recommendations. This strategy might be widely applied to promote timely adoption of scientific evidence.

Information seeking behaviors of parents whose children have life-threatening illnesses

OBJECTIVES

For children with life-threatening illnesses we sought to (1) understand the associations between parental characteristics and preferred health information sources, and (2) assess the e-health literacy of Internet-users.

STUDY DESIGN

Cross-sectional, telephone survey of 129 parents whose children are in a pediatric palliative care program in Florida.

RESULTS

Four out of five parents report that they use the Internet, and 64% of Internet-users use it daily. Parents who never use the Internet, versus parents who do use the Internet, are predominately Hispanic (50%) and have less than a high school education (64%) (P ≤ 0.023). Internet-users have high levels of e-health literacy; however, they are not confident or are unsure about the quality of information on the Internet. Not having graduated from high school was associated with a decrease in e-health literacy and using the Internet as the primary information source (vs. doctor as primary source) was associated with an increase in e-health literacy.

CONCLUSION

Parents of children with life-threatening illnesses have access to and use the Internet as a source of information about their children's health. More information is needed to explore how electronic-based interventions could be used to impact information seeking of parents whose children are in pediatric palliative care programs.

Pediatrics in the year 2020 and beyond: preparing for plausible futures

Although the future of pediatrics is uncertain, the organizations that lead pediatrics, and the professionals who practice within it, have embraced the notion that the pediatric community must anticipate and lead change to ultimately improve the health of children and adolescents. In an attempt to proactively prepare for a variety of conceivable futures, the board of directors of the American Academy of Pediatrics established the Vision of Pediatrics 2020 Task Force in 2008. This group was charged to think broadly about the future of pediatrics, to gather input on key trends that are influencing the future, to create likely scenarios of the future, and to recommend strategies to best prepare pediatric clinicians and pediatric organizations for a range of potential futures. The work of this task force led to the development of 8 "megatrends" that were identified as highly likely to have a profound influence on the future of pediatrics. A separate list of "wild-card" scenarios was created of trends with the potential to have a substantial influence but are less likely to occur. The process of scenario-planning was used to consider the effects of the 8 megatrends on pediatrics in the year 2020 and beyond. Consideration of these possible scenarios affords the opportunity to determine potential future pediatric needs, to identify potential solutions to address those needs, and, ultimately, to proactively prepare the profession to thrive if these or other future scenarios become realities.

Electronic health record decision support and quality of care for children with ADHD

OBJECTIVES

The objective of this study was to assess the effect of electronic health record (EHR) decision support on physician management and documentation of care for children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

This study involved 79 general pediatricians in 12 pediatric primary care practices that use the same EHR who were caring for 412 children who were aged 5 to 18 years and had a previous diagnosis of ADHD. We conducted a cluster randomized trial of EHR-based decision support that included (1) clinician reminders to assess ADHD symptoms every 3 to 6 months and (2) an ADHD note template with structured fields for symptoms, treatment effectiveness, and adverse effects. The main outcome measures were (1) proportion of children with visits during the 6-month study period in which ADHD was assessed and (2) quality of documentation of ADHD assessment. Generalized estimating equations were used to control for the clustering by providers.

RESULTS

Children at intervention sites were more likely to have had a visit during the study period in which their ADHD was assessed. The ADHD template was used at 32% of visits at which patients were scheduled specifically for ADHD assessment, and its use was associated with improved documentation of symptoms, treatment effectiveness, and treatment adverse effects.

CONCLUSIONS

EHR-based decision support improved the likelihood that children with ADHD had visits for as well as care related to managing this condition. Better understanding of how to optimize provider use of the decision support and templates could promote additional improvements in care.

Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system

BACKGROUND

Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates.

OBJECTIVE

The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital.

PATIENTS AND METHODS

We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80,063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17,432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation.

RESULTS

After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008-0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%-40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.

CONCLUSION

Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.

e-Health in pediatric palliative care

e-Health has the potential to improve pediatric palliative care. e-Health initiatives use the Internet or health information technology to improve quality of care and have the potential to decrease costs by reducing medical errors, reducing duplication of services, improving access to diagnostic and laboratory results, and improving communication between providers and patients, and so on. The majority of e-health initiatives are for adults and only a limited amount of evidence exists in the literature on e-health interventions in palliative care that are focused on pediatrics. To explore what role e-health could play in pediatric palliative care programs, this article aims to describe the Internet use in general in the United States and in palliative care, describe the use of health information technology in general in the United States and in palliative care, and suggest areas in pediatric palliative care that might benefit from e-health interventions.

The role of health information technology in quality improvement in pediatrics

Health information technology (HIT) will play an important role in most efforts to improve the quality of pediatric medicine, as evident from the range of investigations and projects discussed in this volume. Clement McDonald identified the importance of using information technology as an integral component of quality initiatives early in the development of electronic medical records (EMR). The role of HIT in quality improvement is not limited to tools integrated into EMR, but that remains an important strategy. Today, much attention is focused on interoperability of clinical systems that integrate and share data from multiple sources. There are also additional freestanding quality-improvement tools that can be used without an EMR. This article explores the many roles of HIT in quality improvement from several perspectives.