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Baby Steps

April 22, 2010
by Kate Huvane Gamble
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Lessons learned by leaders of one of the nation's leading children's hospitals on the complexities of IT rollouts in the pediatric setting

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
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;