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?