Electronic health records (EHRs) are now commonplace in patient care organizations, but even today, several issues specific to children raise the risk that EHR usability can contribute to medical errors. Indeed, for the great majority of EHR systems in the marketplace, pediatric functionality has simply not been a priority, experts attest.
For instance, some folks note that EHRs’ ability to correctly track pediatric patients’ height, weight and other vital indicators is necessary to ensure that children are within normal ranges. But as the Pew Charitable Trusts and other healthcare organizations recently wrote in a letter to the Office of the National Coordinator for Health Information Technology (ONC), these functionalities in EHRs are very often geared toward adults.
For example, the letter stated, children’s weight affects the doses of medication received, which may differ from the dose typically administered to a fully-grown adult. EHR design may influence how clinicians order weight-based doses of medications, and could contribute to children receiving incorrect drug doses. In a well-known example, the weight-based dosing usability of an EHR contributed to a 16-year-old receiving 39 times the intended dose of a medication, they said. In the end, the letter urged National Coordinator for Health IT Don Rucker, M.D., “to consider and incorporate improvements to safety—especially for pediatric patients.”
But what is being done to correct what seems like such a critical health IT safety issue? About seven years ago, leaders from Raleigh-based Community Care of North Carolina (CCNC), a community network-based healthcare model organized and operated by practicing community physicians, received a federal grant under the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to evaluate the use of a Pediatric EHR Model Format to fill gaps existing across current EHR products and subsequently measure care quality outcomes. North Carolina was one of two states, along with Pennsylvania, that received funding to do a comprehensive evaluation of the format, which was developed by prominent healthcare systems such as Intermountain Healthcare, Duke Health and others, and which was commissioned by CMS (the Centers for Medicare & Medicaid Services) and AHRQ (the Agency for Healthcare Research and Quality).
It was around this time when Kern Eason, CCNC’s pediatric program manager joined the organization, specifically to develop and execute CCNC’s evaluation of the model format. Eason says, “At the time, I was getting a sense of the EHR landscape in North Carolina, examining if there were pediatric-specific systems being used in the area, and most importantly, thinking about the quality activities and metrics that CCNC is working on, either within the grant, or outside of it, and seeing if we can tie that to pediatric EHR functionality.”
Essentially, Eason explains, the intent of what CMS wanted CCNC to do, under the CHIPRA grant, was to look at the model format as a driver or as having a potential role in quality improvement. “As adults, we represent ourselves when we go to the doctor, but children are always brought to the visit by a guardian. The system needs the capability to address issues like children of divorced parents in which the mother and father have different names. So how might you tie that back to the child’s record and [the provider] being able to access the information? You wouldn’t see these unique [issues] in an adult system,” says Eason.
As such, CCNC project leaders, including Eason and Marian Earls, M.D., deputy chief medical officer, thought to look at these requirements through the lens of certain quality metrics—ones that were important to pediatrics such as developmental and behavioral screening. “So much of what pediatricians do is assessing that a child is developing adequately, making sure that the weight and height are [normal], and screening for autism and ADHD (Attention Deficit Hyperactivity Disorder). So we said, how can these requirements enhance the functionality of the EHR to deliver care that’s at that highest standard? That lens allowed us to approach the format in this way, it gave us leverage when talked to pediatric practices that partnered with us on this project, and it helped us do the evaluation from a user perspective,” Eason says.
In its approach, CCNC didn’t want to take just the words of the EHR vendors or the pediatric practices independently, but rather look at those in conjunction with each other and compare them. An example, Eason offers, would be when a vendor says that its system has the ability to do weight-based dosing. “So we said, how can we assess not only what the vendor has built to address the [adjustment of a prescription based on a child’s weight], but also the user’s experience and whether they are using the functionality or are even aware that the functionality exists in the EHR system?” Eason says.
At that time, when Eason was studying meaningful use requirements and around EHRs, and certification standards, he found that for pediatrics, there were only a handful of basic requirements, such as having a growth chart, which of course is ubiquitous to EHR systems used in pediatric systems today. “It was really basic. And even systems that were certified under that pediatric certification were so light in their ability to address complexities in pediatric healthcare,” he says.
What Was CCNC Able to Do?
When Dr. Earls first got started on this project, she assumed that once the requirements were reviewed, and when the grant expired, ONC would start to set mandates for EHR systems. But that’s not what happened, she attests. After CHIPRA ended, CMS gave the contract to research firm RTI International so it could take the results from both states’ evaluations—North Carolina and Pennsylvania. According to Earls, RTI distilled more than 500 requirements down to 46, which was then called the Children’s EHR Format 2015 Priority List.
From there, this past October, ONC called Earls to Washington, D.C. to share her expertise in the field. At that meeting was the American Academy of Pediatrics (AAP), an association which Earls said “was very interested and involved from the beginning,” and which worked with vendors on a national level to enhance their functionality. AAP recommended to ONC to begin with the pediatric EHR requirements in eight basic areas, which Earls says “are basic and don’t get deep into clinical content.” Earls adds that the stakeholders involved at that meeting had long discussions about next steps and about other requirements that may need to be added, but she notes that she doesn’t exactly know where things go from here.
Marian Earls, M.D.
Positively on the vendor front, many of the companies that CCNC worked with on this grant were willing to examine their systems, and potential gaps, without even being incentivized to do so, says Eason. “They wanted to do the right thing by their clients and make some adjustments along the way. Some enhancements were made by vendors that participated with us,” he says, offering Allscripts, eClinicalWorks and ReLi Med Solutions as three examples. To this end, two other vendors specific to the pediatric EHR space, Office Practicum and Physician’s Computer Company, participated out of curiosity to see how their systems stood up, says Eason. “But they also saw areas of opportunities to stay ahead of the path and enhance their functionality,” he adds.
Earls says that CCNC has also been working with AAP on developing vendor guidance, specifically around development and behavioral screening. In this area, still too often pediatricians are doing “incredible workarounds” or putting this content into the EHR manually. “It’s less than efficient but they have to address this need,” she says. “The vendor guide was intended to be put out there so people would incorporate this information in a way that was more useful for the practice, and also would be something that would provide structured data.”
Earls admits that it is frustrating when vendors say that a certain functionality is already the system, but in reality, it’s not structured data that can be pulled out for quality or population health management purposes. “That’s simply not what these [EHRs] are designed to do. To me, [the EHRs for pediatric purposes, as they exist] are not a whole lot different from paper charts—there is information you just can’t get out. You can get billing codes, but not what you need to do population health management,” Earls says.
And on the pediatric practice front, one practice that Eason recently spoke with is still working closely with its vendor on making these enhancements. That practice, Eason notes, is using the 46-requirement set that RTI came up with as a basis of recognizing what’s most important. He contends that this requirement is something that is needed nationally and across systems right now. “A vendor can get caught up in a large influential practice client wanting a certain functionality or a new template, which might be more of a preference than a core functionality that supports quality pediatric care,” he says.
As it stands today, the CHIPRA grant has ended, and Eason says that alone is a challenge, since vendors “don’t have me calling them every other day asking them if they [were working on enhanced functionality].” He notes, “We are competing with so many other things that vendors are working on, so it’s a slow process and time is the biggest challenge. Some of these enhancements might not happen for several more years. But we need to keep this front and center and even though it hasn’t happened as fast as I would have liked, the work isn’t going away.”