EHR Background Why EHRs? Improve Communication Improve Efficiency Save $$ Reduce Errors Take Better Care of Our Patients

EHR Background U.S. Acute Care Hospitals (NEJM 2007) Comprehensive EHR: <2% Basic EHR: 8-12% +/- Physician notes Bottom line: at least 90% of U.S. Hospitals do not qualify for a basic EHR

EHR Background: Barriers Implementation $ Maintenance $ Physician resistance, apprehension Return on Investment? Inadequate IT staff

Meaningful Use A key part of the up to $27 Billion in incentive payments in the HITECH (The Health Information Technology for Economic and Clinical Health) Act Through Medicaid, offers as much as $63, 750 per clinician Goal: To dramatically increase the adoption of the Electronic Health Record (EHR) by offsetting some of the necessary initial costs

Meaningful Use- What does it mean? The EHR is not a magic bullet Improper implementation has the potential to provide less effective and efficient care do more harm than good A lot of money involved, not everybody has our patients best interest at heart

Meaningful Use- What does it mean? In combination with the EHR certification process, an effort to ensure that EHR implementation is done effectively. Demonstrate compliance with core objectives in order to be eligible for incentive payments

Meaningful Use- Core Objectives Initially released in Jan 2010, applies to the first 2 years of incentive program, open to comment Over 2000 comments: Significant concerns about pace and scope, meeting demands All objectives had to be implemented to qualify Final version released this past August is more flexible core objectives 5 of remaining 10 can be deferred to beyond

Meaningful Use- Core Objectives Move quickly, but not too quickly Speed must be balanced with flexibility for provider groups of varying size and levels of preparedness.

Core Objectives

Other Objectives

Future Stages Some of the objectives that were in the proposed rule will be deferred to later stages Demonstrating outcomes

EHR Basics CPOE: Computerized Provider Order Entry CDS: Clinician Decision Support Basic: Allergy checking, Drug-drug interaction checking, Dosing calculators Advanced: Dosing shortcuts, maximum dose alerts, indication based support, incorporation of individual patient data (labs, etc). Tremendous potential to reduce medication errors 44-98,000 deaths annually due to medical errors (1999)

EHR Risks More is not necessarily better Increased support can have deleterious effects Workflow efficiency clinician frustration Introduction of new errors

Pediatric EHR Variability Growth parameters Vital signs Physical Exam findings Lab values Medication metabolism Variability = Complexity Our population is at higher risk for medication errors

Pediatric EHR: Key Features AAP COCIT (Council on Clinical Information Technology) Robust immunization support Growth tracking and percentile support Privacy Medication dosing Numerical and non-numerical data norms.

Weight-Based Support Weight-based dosing Clearly display the calculation Date of the weight used Weight Correctness support and alerts compared to: CDC growth curves Individual patients growth pattern

Weight-Based Support Assist with the calculation Support multiple units and growth parameters (weight, BSA) Alert when there’s an error Incorrect input by clinician 0.1 vs.01 mg/kg Right value but calculation too high 2 mg/kg prednisone for 50kg patient Don’t forget the under doses! Weight based + Indication based = complexity

Dosing Calculator Most Basic, provides automated calculation and most recent weight Many steps still required New Errors? Each step has the opportunity to be a misstep Drop-down Keypad

Dosing Shortcuts Improved Speed Fewer step-associated errors New errors? mg/kg/dose vs mg/kg/day tAll mAn shORt Man Patient approaching adult weight Won’t I have that risk anyway? Max dose alerts

Dose Alerts An important safeguard, especially when shortcuts are utilized Significant time and resources required to create and maintain Multiple environments and formularies

Order Sets Indication-based support Grouping commonly placed orders (admission, asthma, etc) Require time and effort to design Input from institution specific clinicians is vital Maintenance

Final Thoughts: Meaningful Use “Once in a lifetime” Many opportunities Patient Care Financial Efficiency & Quality Attracting new Physicians Research

Variability & CDS CDS is best with fixed norms Documentation: Physical exam findings Laboratory results

Critiquing vs Consulting Critiquing: design alerts to adapt to these changing norms No easy task Still runs the risk of inappropriate alerting Consulting: Present relevant information regardless of whether it is normal or abnormal Ubiquity = ignored?

Final Thoughts: Pediatric EHR Proceed with enthusiasm, and caution The more involvement, the better Collaboration with other institutions