Christopher A. Longhurst

Evidence-Based Medicine in the EMR Era

Pediatricians facing critical clinical decisions often lack data on which to draw. The authors recently put their institutions electronic medical record to unusual use to inform a decision about anticoagulation in a patient with systemic lupus erythematosus.

Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system.

BACKGROUND: Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates. OBJECTIVE: The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic childrens hospital. PATIENTS AND METHODS: We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic childrens hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80 063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17 432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation. RESULTS: After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008–0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%–40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame. CONCLUSION: Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic childrens hospital.

AKI in Hospitalized Children: Comparing the pRIFLE, AKIN, and KDIGO Definitions

BACKGROUND AND OBJECTIVES Although several standardized definitions for AKI have been developed, no consensus exists regarding which to use in children. This study applied the Pediatric RIFLE (pRIFLE), AKI Network (AKIN), and Kidney Disease Improving Global Outcomes (KDIGO) criteria to an anonymized cohort of hospitalizations extracted from the electronic medical record to compare AKI incidence and outcomes in intensive care unit (ICU) and non-ICU pediatric populations. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Observational, electronic medical record-enabled study of 14,795 hospitalizations at the Lucile Packard Childrens Hospital between 2006 and 2010. AKI and AKI severity stage were defined by the pRIFLE, AKIN, and KDIGO definitions according to creatinine change criteria; urine output criteria were not used. The incidences of AKI and each AKI stage were calculated for each classification system. All-cause, in-hospital mortality and total hospital length of stay (LOS) were compared at each subsequent AKI stage by Fisher exact and Kolmogorov-Smirnov tests, respectively. RESULTS AKI incidences across the cohort according to pRIFLE, AKIN, and KDIGO were 51.1%, 37.3%, and 40.3%. Mortality was higher among patients with AKI across all definitions (pRIFLE, 2.3%; AKIN, 2.7%; KDIGO, 2.5%; P<0.001 versus no AKI [0.8%-1.0%]). Within the ICU, pRIFLE, AKIN, and KDIGO demonstrated progressively higher mortality at each AKI severity stage; AKI was not associated with mortality outside the ICU by any definition. Both in and outside the ICU, AKI was associated with significantly higher LOS at each AKI severity stage across all three definitions (P<0.001). Definitions resulted in differences in diagnosis and staging of AKI; staging agreement ranged from 76.7% to 92.5%. CONCLUSIONS Application of the three definitions led to differences in AKI incidence and staging. AKI was associated with greater mortality and LOS in the ICU and greater LOS outside the ICU. All three definitions demonstrated excellent interstage discrimination. While each definition offers advantages, these results underscore the need to adopt a single, universal AKI definition.

Use of a Checklist and Clinical Decision Support Tool Reduces Laboratory Use and Improves Cost.

OBJECTIVE: We hypothesized that a daily rounding checklist and a computerized order entry (CPOE) rule that limited the scheduling of complete blood cell counts and chemistry and coagulation panels to a 24-hour interval would reduce laboratory utilization and associated costs. METHODS: We performed a retrospective analysis of these initiatives in a pediatric cardiovascular ICU (CVICU) that included all patients with congenital or acquired heart disease admitted to the cardiovascular ICU from September 1, 2008, until April 1, 2011. Our primary outcomes were the number of laboratory orders and cost of laboratory orders. Our secondary outcomes were mortality and CVICU and hospital length of stay. RESULTS: We found a reduction in laboratory utilization frequency in the checklist intervention period and additional reduction in the CPOE intervention period [complete blood count: 31% and 44% (P < .0001); comprehensive chemistry panel: 48% and 72% (P < .0001); coagulation panel: 26% and 55% (P < .0001); point of care blood gas: 43% and 44% (P < .0001)] compared with the preintervention period. Projected yearly cost reduction was

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

717, 538.8. There was no change in adjusted mortality rate (odds ratio 1.1, 95% confidence interval 0.7–1.9, P = .65). CVICU and total length of stay (days) was similar in the pre- and postintervention periods. CONCLUSIONS: Use of a daily checklist and CPOE rule reduced laboratory resource utilization and cost without adversely affecting adjusted mortality or length of stay. CPOE has the potential to hardwire resource management interventions to augment and sustain the daily checklist.

Impact of electronic medical record integration of a handoff tool on sign-out in a newborn intensive care unit

Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non–evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital’s system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.

Improved Physician Work Flow After Integrating Sign-out Notes into the Electronic Medical Record

Objective:To evaluate the impact of integrating a handoff tool into the electronic medical record (EMR) on sign-out accuracy, satisfaction and workflow in a neonatal intensive care unit (NICU).Study Design:Prospective surveys of neonatal care providers in an academic childrens hospital 1 month before and 6 months following EMR integration of a standalone Microsoft Access neonatal handoff tool.Result:Providers perceived sign-out information to be somewhat or very accurate at a rate of 78% with the standalone handoff tool and 91% with the EMR-integrated tool (P<0.01). Before integration of neonatal sign-out into the EMR, 35% of providers were satisfied with the process of updating sign-out information and 71% were satisfied with the printed sign-out document; following EMR integration, 92% of providers were satisfied with the process of updating sign-out information (P<0.01) and 98% were satisfied with the printed sign-out document (P<0.01). Neonatal care providers reported spending a median of 11 to 15 min/day updating the standalone sign-out and 16 to 20 min/day updating the EMR-integrated sign-out (P=0.026). The median percentage of total sign-out preparation time dedicated to transcribing information from the EMR was 25 to 49% before and <25% after EMR integration of the handoff tool (P<0.01).Conclusion:Integration of a NICU-specific handoff tool into an EMR resulted in improvements in perceived sign-out accuracy, provider satisfaction and at least one aspect of workflow.

Special Requirements for Electronic Medical Records in Adolescent Medicine

BACKGROUND In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed. METHODS A printable sign-out report was implemented within the EMR system at a tertiary academic childrens hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey. RESULTS The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process. DISCUSSION EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.

Refocusing medical education in the EMR era.

Adolescents are a group likely to seek and, perhaps, most likely to benefit from electronic access to health information. Despite significant advances in technical capabilities over the past decade, to date neither electronic medical record vendors nor many health care systems have adequately addressed the functionality and process design considerations needed to protect the confidentiality of adolescent patients in an electronic world. We propose a shared responsibility for creating the necessary tools and processes to maintain the adolescent confidentiality required by most states: (1) system vendors must provide key functionality in their products (adolescent privacy default settings, customizable privacy controls, proxy access, and health information exchange compatibility), and (2) health care institutions must systematically address relevant adolescent confidentiality policies and process design issues. We highlight the unique technical and process considerations relevant to this patient population, as well as the collaborative multistakeholder work required for adolescent patients to experience the potential benefits of both electronic medical records and participatory health information technology.

Use of Electronic Medical Record–Enhanced Checklist and Electronic Dashboard to Decrease CLABSIs

There is increasing recognition that medical education should be adapted to address the integration of the electronic medical record (EMR) into medical practice, but how this should occur and the specific educational goals have not been well defined. In this Viewpoint, we offer suggestions for updating the Accreditation Council for Graduate Medical Education (ACGME) competencies to promote optimal integration of the EMR into clinical practice, guidance for using data available within the EMR to support and evaluate the achievement of ACGME milestones, and specific steps that individual institutions can take to support this evolution in medical education. Introduction of the EMR is greatly changing the practice of medicine, bringing the benefits of increased access to data, automated clinical decision support, and opportunities for enhanced communication among physicians and with patients. As with many new technologies, the introduction of the EMR has also introduced a wide range of unintended negative consequences. A recent commentary by a ward attending at a major academic medical center described how his trainees held rounds in a secluded work room and were overly focused on the patients’ data in the EMR, often failing to incorporate significant information from the physical examination and interactions with the patient into their assessments.1 Others have noted examples of clinicians’ attention to the computer disrupting the patientphysician relationship in the pediatric examination room, to poignant effect.2 Trainees may use EMR functionality to copy large amounts of data into their progress notes, making them difficult to read and understand.3 Furthermore, clinicians are susceptible to automation bias, the tendency to place too much trust in decision support systems without recognizing the limitations of such systems.4 Given these examples of poor integration of the EMR into clinical practice, as well as the unrealized potential for the EMR to enhance medical education, it is important to examine the effect of the EMR on each of the core competencies and the role it may play in supporting the achievement of educational milestones. The medical education community has recognized that stakeholders expect physicians to use health information technology to optimize both individual and population health. The 2013 ACGME common program requirements list use of information technology as one of the competencies under practice-based learning and improvement.5 But information technology significantly affects all aspects of medical practice and therefore relates to all ACGME core competencies.6 Competency in use of the EMR should not be a goal but instead integrated into each aspect of medical practice as a tool for helping trainees achieve the 6 core competencies. For example, physician training should explicitly address and provide feedback on trainees’ ability to balance engagement with the patient and the EMR to both strengthen the patient-physician relationship and promote highly reliable patient care through accurate documentation and prudent use of clinical decision support. Communication subcompetencies should evolve to include skills for appropriately identifying and using online media such as e-mail, patient portals, and evolving mobile technologies to maintain and enhance the patient-physician relationship between office visits. As part of practice-based learning and improvement, trainees should be taught to access reports from the EMR that show their patterns of patient management for patients with specific diseases and enable the trainees to identify for themselves possible areas for practice improvement. The Table provides additional examples of potential EMR-related subcompetencies. Although this table is structured around graduate medical education core competencies, many of the lessons about optimal integration of the EMR into patient care can and should start with medical students. Emphasizing the key supportive role that technology can play in each of the core competencies should help trainees maintain the patient as the focus of attention and appropriately position the EMR as a tool to support the core mission of patient care. In addition to introducing new required skills and associated training requirements, the EMR provides new tools that can be harnessed to help achieve and evaluate previously identified milestones. The routine collection of electronic data enables the production of reports to track trainees’ experience with various types of patients, documentation of procedures, compliance with best practice guidelines in management of patients with specific diseases (eg, adequate blood pressure control in patients with hypertension), and quality of documentation of key patient information such as medication and problem lists. Specific clinical decision support tools can be developed to directly address knowledge gaps,7 and reports of alerts can be used to help identify such gaps. The Table summarizes medical education tools that should be available within a highly functional EMR. Individual academic institutions can take several steps to enable these suggestions. First, institutions can create simulated EMR environments for simulationbased training and testing of medical students and residents. In these environments, trainees can gather information from a mock patient record, be coached on how to best enter new information, and receive feedback on their ability to balance engagement with the patient and electronic documentation of the encounter. Second, academic medical centers can routinely allow medical students access to the EMR during their clinical rotations for documentation and order entry.8 Although students take care of relatively few patients, the opportuVIEWPOINT