Children’s Hospital Boston is a 396-bed pediatric medical center that treats more than 527,500 patients annually and is the primary pediatric teaching hospital of Harvard Medical School. As one of the largest pediatric medical centers in the United States, Children's offers a complete range of health care services for children from birth through 21 years of age. It is a certified Magnet hospital for nursing excellence, and was ranked first in five specialties in the 2009 edition of America’s Best Children’s Hospitals as featured in U.S. News and World Report. Recently, HCI Associate Editor Kate Huvane Gamble spoke with Senior VP and CIO Daniel Nigrin, M.D., and CMO Eileen Sporing about the importance of involving nurses when selecting and implementing IT systems, the issues they’re looking to solve in rolling out technologies, and the fundamental differences in caring for pediatric patients.
KG: Do you have a real-time location system in place?
ES: Only in the ED.
DN: We have been scouting a few of those technologies for equipment tracking, but it has not been deploying widely. We’re still evaluating RFID, but not to track people.
KG: So it’s something you’re planning on further down the road?
DN: I think we’re going to keep looking. We’ve had some marginal success with the pilot, but the problem is that there are multiple competing technologies, and to us, it’s not entirely clear which is going to be the winner, so to speak. So with that industry in flux, we’re taking a more cautious approach.
KG: That sounds like a smart strategy. What about your EMR system? You have Cerner, right?
DN: We do. But just to be clear, we actually have a hybrid system. The majority of the pure clinical applications that our nurses and doctors are working in is a Cerner system, but we also have an important Epic footprint with respect to patient registration and ADT systems, as well as patient scheduling and hospital billing.
Some of the infrastructural systems related to clinical encounters are Epic-based, but the application that the doctors and nurse are using most often is the Cerner system.
KG: So you’re not best-of-breed, but you’re not a shop of one particular vendor.
DN: We do try to limit the amount of vendors, so we’re definitely not a best-of-breed shop. But we’re also not the other extreme where we’re only going to deploy applications from a single vendor. We try to limit most of our systems to being from either Cerner or Epic, but when necessary, we make exceptions to that rule.
KG: Do you have any plans for bar coded medication administration?
DN: We have a pilot running on three units using Cerner’s handheld technology, and hopefully over the course of the next year we’ll be ramping that up to extend beyond those initial three units.
KG: Now with that that particular technology, are you looking first and foremost to improve patient safety?
DN: Yes. In fact, even in this pilot already, we’ve seen some pretty impressive “good catches,” where the handheld device is firing off an alert that a medication was about to be given inappropriately to a patient for whatever reason. We’re tracking those as best we can, and it’s impressive already the numbers that we’re seeing, just based on these three individual units.
It underscores also the focus of CPOE being the only thing that’s going to reduce errors; that’s an important point that there are many other steps in the process in which errors can occur. And so the point of administration is one in which we know that errors occur, and frankly, that’s the last point where you’re going to be able to intervene before a medication is given inappropriately. So we think it’s very important.
KG: Another common driver I’ve heard in implementing technologies is for nurses to be able to spend more face time with patients. Is this something you’re striving for?
ES: Absolutely, but I think that in the real world, there’s a huge learning curve with getting accustomed to using this technology, so to expect that in the beginning is probably not realistic. For us, clearly, one of the benefits of having an electronic medical record is that we see a lot of repeat patients, and the time that both nurses and physicians used to spend pouring over old records, trying to find information in the paper record has almost been eliminated, because now that real-time review can occur with the family and the patient at the bedside. So that’s been a significant improvement.
KG: Earlier, you touched on some of the challenges that are unique to pediatric care. Can you elaborate a bit on that?
ES: Everything is different. First of all, everything that you do for patients in a pediatric world is based on their developmental stage, which includes their size and gender, so there’s not a standard way you would approach a patient in performing a procedure or giving a medication. It’s all age-based.
The second major difference has to do with the fact that the parents are the ones that help their children deal with everything, so you’re directly intervening with parents before you’re doing anything to a child. So that’s unlike in an adult situation, where you give your explanation directly to the patient, perform the procedure or give the medication, and you’re out of there. And families take on all different dimensions, so you have to be culturally appropriate and responsive to where the family is at any given point in time.
KG: It’s a really important issue, and it seems like one that has been overlooked.
ES: We actually spend a lot of time explaining that to people who don’t understand why it costs more to get care here and to deliver care here.
DS: With all of the talk around the stimulus funding for EMR systems, even as those new frameworks were coming out, it’s required lots of active discussion with the folks in Washington to remind them of the fact that some of the things that they were advocating just wouldn’t work in a pediatric environment. It’s forced us to be very forthright and vocal about some of these differences — how do you evaluate whether your EMR system is effective and the quality measures that are going to be used to engage how well you’re doing, all of these things are going to require a pediatric perspective.
ES: The easiest way to really highlight the differences is to look at the medication administration process. For most adults, the dosage and the format in which you deliver a medication is the same, regardless of the size or condition of the patient. But in children, that’s not the case at all. It’s all weight and body surface squared base, and most of the medications have to be dispensed for that individual patient, so they’re not already prepackaged in that dosage format.
And that’s just one example. Two patients in one room could be getting the same medication, and they would totally different doses, totally different schedules. Most young patients that have to have an X-ray here need to be sedated, because they can’t hold still while an X-ray is being taken, particularly an MRI or CT-scan. So there are just enormous differences, and you can imagine how that translates into the electronic environment that supports that care.
KG: With ARRA-HITECH deadlines approaching, that’s certainly a topic that needs to be considered. Now as far as your own organization, what do you have coming down the pike? Any big IT plans?
DN: As we mentioned, one of our focuses for the coming year is on expanding that point of care medication administration. We’re also thinking about some innovative new technologies that involve the patient and the patient’s family more. For example, we’ve now deployed a patient portal called MyChildrens.org. It’s similar to portals that other organizations have, in that it allows families to communicate with their nurse or physician here at the hospital. It also allows them to do some administrative functions like paying their bills, updating demographics and requesting appointments.
But what is really innovative is the personal health record that’s also part of the portal. It allows us to push out to the patients their own copy of the data, portions of the electronic medical record that we have at the hospital. For example, lab tests that are obtained for an ambulatory visit automatically get pushed out into the PHR.
We’re really planning on building this platform significantly over the next year. We’re starting to talk to the EMR vendor that is used in all of our affiliated pediatric primary care practices, which is eClinicalWorks. We’re working with them to allow data from the patients’ primary care pediatrician to also populate their PHR. So you can start to imagine that the patient will basically have a single place where all of their health data can be aggregated. We see enormous value both for the patients and the clinicians.
We’re very excited about it. After a pilot period over the course of the last year, we just rolled it out a few months ago. The uptick has been really dramatic; we’re seeing a lot of families sign on for the service.