2. Why Are General Pediatricians Failing? National Study of 1536 children in the US* 12 metropolitan areas (including Indy) 142 quality indicators Children received 46.5% of indicated care – 40.7% of preventive care – 37.8% of screening – 34.5% of adolescent preventive care * Mangione-Smith, et al, NEJM 2007; 357:1515-23

3. Variable Guideline Adherence 4 practices, 210 children aged 1 yr Newborn Screening56-80% Hearing Risk Assessed0-5% Anemia Screening76-98% TB Screening2-63% Lead Screening23-94% Assess Tobacco Smoke Exposure6-38% Car Seat Counseling4-76% Smoke Detector Counseling0-27% Hot Water Heater Counseling8-37%

4. Too Many Guidelines!

5. Pediatricians Are Overwhelmed With Preventive Care Guidelines Multiple guidelines from authoritative sources – AAP – CDC – USPSTF – HRSA – ACMG – Medicaid – HMO Average preventive care visit: 18.3 minutes Pediatricians: No time for developmental assessments and psychosocial issues

6. AAP Periodicity Schedule 0.50 2.00 5.5012.00 21.00 minutes 1.00

7. USPSTF Evaluation of 230 charts in family practice – 25 services due at each patient visit (Medder) Physician time required for services – family practice – 7.4 hours per day (Yarnall) Extrapolating to only pediatric services – 16 hour per day!!

8. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents 338 Pages 450 Pages

9. Bright Futures: Set Guidelines for Health Supervision of Infants, Children, and Adolescents Mental Health Volumes 1 and 2 Physical Activity Bright Futures, Nutrition, and Oral Health Pocket Guides

10. Computer Decision Support Systems (CDSS) Can Help Critical review of 100 clinical trials of CDSS compared to usual care controls* Practitioner performance: 62/97 (64%) improved care Preventive care: 16/21 (76%) improved care Disease mgmt: 23/40 (62%) improved care * Garg, et al. JAMA, 2005; 293:1223-38

11. So if decision support systems improve rates of services…. What services should systems support?

12. Infant/Newborn Gonococcal Ophthalmia Neonatorum prophylaxis Newborn screening (select tests) Child Visual Impairment in Children Ages 0-5: Screening Blood pressure Fluoride prescription Adolescent Cervical cancer screening Chlamydial Infection screening Gonorrhea screening - (if risk) Human Immunodeficiency Virus (HIV) Infection screening - (if high risk) Sexually Transmitted Infections - (if sexually active) Depression in Adolescents Hyperbilirubinemia in Infants: Routine Screening Hip, Developmental Dysplasia: Screening Developmental screening Counseling to prevent skin cancer Cholesterol screening Depression in Children Motor Vehicle Occupant Restraints Dental Caries in Preschool Children risk assessment Exercise (Physical Activity): Counseling Healthy Diet (Nutrition): Counseling Family Violence Iron Deficiency Anemia (Anemia): Screening Lead Levels in Childhood (high risk) Overweight in Children and Adolescents: Screening Alcohol Misuse (Drinking, Risky/Hazardous) Illicit Drug Use Smoking (Tobacco Use) counseling Suicide Risk: Screening Lead Levels in Childhood (everyone) Testicular cancer screening Herpes Simplex, Genital screening Idiopathic Scoliosis in Adolescents (Scoliosis): Screening No DataDon’t Do US Preventive Services Task Force Services evaluated for children

13. AAP Statements Policy Statement – Organizational principles to guide and define the child health care system and/or improve the health of all children. Clinical Reports – Guidance for the clinician in rendering pediatric care. Clinical Practice Guidelines – Evidence-based decision-making tools for managing common pediatric conditions. 414 99 14 37:1

14. Downs’s Decision Rule ifdecision support systems get services provided andthere are more recommended services than can be done in a visit thenthe system must prioritize which services it recommends Prevalencex Severityx Effectivenessx Evidence = Priority

15. Thank You