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The Promise and Pitfalls of HIT in Pediatrics: What Boston Children’s Hospital Has Learned

August 7, 2018
by Rajiv Leventhal
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At the Boston Health IT Summit, a regional CIO discusses the many issues pediatricians have with health IT, and how lessons can be applied to the adult world

Nearly one-quarter (24 percent) of the total U.S. population is under the age of 18, though many providers who only care for adults might not realize that this number is so high, according to Daniel Nigrin, M.D., senior vice president and CIO, Boston Children's Hospital.

Nigrin, who presented at the Boston Health IT Summit on August 7, noted that given this large  percentage, even if a specific provider doesn’t work with kids directly, the chances are strong that someone he or she works with does. Indeed, health IT issues in pediatrics affect a much broader group than just those pediatricians, Nigrin said, as those children eventually become adults, leading to lots of back-and-forth between providers.

“Children also tend to be more susceptible to harm,” he noted, speaking to the need for advanced health IT in the pediatric community. “Things such as medication dosing can cause harm, and even death, much more so than in the adult world due to children’s size,” Nigrin said at the Health IT Summit.

And while plenty of challenges remain, Nigrin believes that a “dramatic transformation” has taken place in recent years regarding health IT functionality and the sophistication of tools that the vendor community has provided pediatricians, offering weight-based dosing as one example.

Nonetheless, Nigrin spoke about the major patient privacy conundrum in this space, particularly as it relates to adolescents and patient portals. He noted that when one thinks about the data that is shared in portals, in the context of a teenager, there is routine information such as medications, lab results, listings of physician visits, and in some cases, the sharing of clinic notes, via the OpenNotes initiative, which Boston Children’s participates in.

But for “non-routine” information, processes can get tricky, he admitted. For instance, for a teen patient who has visited his or her doctor privately—say to obtain contraceptives or for a mental health issue— how do those private conversations make it into the portal, if at all? “There is a reason pediatricians kick parents out of the room when kids become teens,” Nigrin said.

“And many of us now also have systems in which we remind patients about appointments through text messages or the portal. But is it the patient or the teenager who is [getting the message]? You have to be careful.” He added that there are lots of technical and process challenges related to privacy that still must be ironed out, and this “drives vendors crazy, because in many instances it requires a complete re-architecture of their systems.”

There are additionally plenty of health IT issues that affect newborn care as well, Nigrin said. In the olden days of healthcare technology, he explained, EHRs (electronic health records) were not developed to consider modern age-specific time units. “In pediatrics, we don’t think about the 0.019-year-old patient or the 4,440-day old-patient. We think about patients as seven- or 12-years-old.  Time-toggling in EHRs has become important, but that wasn’t thought about in the early days,” he said.

Other newborn health IT issues include linking a mother’s EHR record to baby’s EHR record, as one can be critically important for the other. A mother’s infections or pre-existing conditions, for instance, are vital to know when treating her baby, Nigrin attested. Recording the birth date and time in the EHR is also quite important, he noted, as some conditions, such as hyperbilirubinemia—which occurs when there is too much bilirubin in the blood—requires knowing the amount of time that has elapsed since the baby was born.

After Nigrin’s presentation, Healthcare Informatics Editor-in-Chief Mark Hagland sat down to ask the CIO about some of the pediatric health IT issues he outlined and how they can be compared to the adult population.

For instance, Nigrin again referenced the teenage patient portal privacy topic, noting that the analogy in the adult world would be the geriatric population. “When you have an aging parent and you as a child are assisting that parent with his or her care, even though the parent is handing over aspects of care to you, there are probably things in the record that are not appropriate for you to see.” As such, he continued, “The ability to pivot on the data that is shown or not shown is a general problem that needs to be solved by health IT community. It’s not limited to pediatrics.”

When asked about his biggest lesson learned as it relates to patient safety and pediatric health IT, Nigrin said that preventing alert fatigue would be the biggest one. He noted how there are incredible IT systems that alert clinicians if they are about to engage in inappropriate medication dosing. “But the issue is that we alert so often that providers see them as ‘nuisance alerts,’ and then inappropriately override them.”

As such, Nigrin’s team has been looking at ways to better present the alerts to providers, such as leveraging SMART on FHIR specifications. A key issue with the alerts as they exist now, he added, is that they contain a lot of text, and some color, making it tough for clinicians to quickly discern whether the alert is another nuisance or a real problem. “Doctors are overwhelmed; it’s mind-boggling when you look at the number of alerts that an inpatient doctor will receive in a day. So we’re looking at new graphical ways to present it to them,” Nigrin acknowledged. 

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