Cynthia Kuelbs

Special Requirements for Electronic Medical Records in Adolescent Medicine

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.

Cranial computed tomographic findings in a large group of children with drowning: diagnostic, prognostic, and forensic implications.

Objectives: The primary aim of this study is to better define both the type and incidence of cranial computed tomography (CT) abnormalities in children following submersion injury. Design: This is a retrospective chart review; patients were selected from a drowning registry that extends from January 1989 to April 2006. Setting: Children’s Hospital, San Diego. Patients: Patients were included if they were admitted to the hospital with a diagnosis of drowning and had a cranial CT within 24 hrs of submersion. Of 961 patients in the registry, 156 were included. Interventions: None. Measurements and Main Results: Eighteen percent (28 of 156) of children had an abnormal initial head CT, 82% (128 of 156) had a normal CT. Fifteen percent (24 of 156) of patients initially had a normal head CT and later had an abnormal CT. Abnormal CT findings were remarkable for diffuse loss of gray-white differentiation (75% on presentation) and bilateral basal ganglia edema/infarct (50% on presentation). There was no evidence of intra- or extra-axial blood nor were there any unilateral findings in any of the abnormal CTs. Presenting Glasgow Coma Scale was significantly lower in those who presented with an abnormal versus a normal head CT (p < 0.001). All patients with an abnormal initial CT presented with a Glasgow Coma Scale of 3, and all eventually died. Outcome was also very poor in those with a normal first CT and an abnormal second CT; 54% died and 42% remained in a persistent vegetative state. Conclusions: These data from the largest study of CT findings in pediatric drowning clearly illustrate that following submersion injury, intra- or extra-axial bleeding is not seen on cranial CT. Furthermore, an abnormal CT scan at any time was associated with a poor outcome (death or persistent vegetative state). The CT findings and the presenting Glasgow Coma Scale of patients with drowning differ from those of patients who have suffered abusive head trauma.

Anal findings in children with and without probable anal penetration: A retrospective study of 1115 children referred for suspected sexual abuse

Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of this study is to compare the frequency of anal features between children with and without anal penetration. This is a retrospective blinded review of consecutive charts of children seen for suspected sexual abuse at a regional referral center from January 1. 2005 to December 31. 2009 Based on predetermined criteria, children were classified into two groups: low or high probability of anal penetration. The charts of 1115 children were included, 84% girls and 16% boys with an age range from 0.17 to 18.83 years (mean 9.20 year). 198 children (17.8%) were classified as belonging to the anal penetration group. Bivariate analysis showed a significant positive association between the following features and anal penetration: Anal soiling (p=0.046), fissure (p=0.000), laceration (p=0.000) and total anal dilatation (p=0.000). Logistic regression analysis and stratification analysis confirmed a positive association of soiling, anal lacerations and anal fissures with anal penetration. Total anal dilation was significantly correlated with a history of anal penetration in girls, in children examined in the prone knee chest position and in children without anal symptoms. Several variables were found to be significantly associated with anal penetration, including the controversial finding of total anal dilatation. Due to limitations in the study design, this finding should still be interpreted with caution in the absence of a clear disclosure from the child.

Apparent life-threatening event admissions and gastroesophageal reflux disease: the value of hospitalization.

Background No standard management plan for infants with an apparent life-threatening event (ALTE) currently exists. These infants are routinely hospitalized. Benefits of hospitalization of ALTE patients with gastroesophageal reflux disease (GERD) need definition. Objectives The study’s objectives were to determine the accuracy of a working diagnosis of GERD in infants admitted with ALTE and to describe the history and hospital course of infants with both working and discharge diagnoses of GERD. Methods Authors retrospectively reviewed records from a large children’s hospital of infants aged 1 year old and younger hospitalized from January 1, 2004, to March 1, 2007, with an admission diagnosis of ALTE. Demographics, clinical presentation, testing, hospital course, and 6-month postdischarge visits were abstracted. Intensive care admissions were excluded. Univariate and multivariate analyses identified factors associated with a discharge diagnosis of GERD. Results Three hundred thirteen infants met inclusion. Mean age was 2.1 months; mean length of stay was 2.5 days. A discharge diagnosis of GERD was most common (n = 154, 49%); 138 (89%) were initially well appearing, 10 (6%) had in-hospital events, and only 20 (13%) had upper gastrointestinal series performed. Concordance of initial working to discharge diagnosis of GERD was 96%. Nonconcordant diagnoses evolved within 24 hours. Rescue breaths and calling 911 were independently associated with a discharge diagnosis of GERD. Within 6 months, 14 patients (9%) with a discharge diagnosis of GERD had recurrent ALTE, and 5 (3%) had significant new diagnoses. Conclusions Concordance of initial working diagnosis with discharge diagnosis of GERD in ALTE patients is high. However, in hospital events, evolution to new diagnoses and recurrent ALTE suggest that hospitalization of these patients is beneficial. Diagnostic studies should not be routine but should target concerns from the history, examination, and hospital course.

Patient Portal Usage in Pediatric Urology: Is it Meaningful Use for Everyone?

Introduction The Affordable Care Act promotes multiple directives for meaningful use of the electronic health record, such as patient/provider portals, to increase patient engagement. Although portal use is common within adult health care, little information exists regarding pediatric portal use. We examined pediatric urology patient portal enrollment and activation patterns at a tertiary pediatric hospital in Southern California by race/ethnicity, preferred language, gender and residential region. Methods Retrospective electronic health record analysis of enrollment in patient portal from January 2010 to May 2016 among 10,464 patients with at least 1 outpatient urology clinic visit. Differences in adoption rates were examined using logistic regression for the categories of activated (or caregiver activated), code accepted not activated, declined and activated/then deactivated. Results Overall, 46.5% of patients/caregivers activated the portal. Primarily Spanish speaking patients were less likely to activate than English speaking patients (OR 0.25, p <0.001). Males (OR 0.89, p = 0.004); those self‐identifying racially as other (not white, Asian or black, OR 0.47, p <0.001) and Hispanic patients (OR 0.49, p <0.001) were less likely to activate. Suburban patients were up to 3 times more likely to activate portals than central urban patients depending on the region (OR 2.94, p <0.001). Multivariate logistic regression demonstrated Spanish speaking patients were 3 times less likely to activate while controlling for demographic and region variables. Conclusions Primary language and socioeconomic factors may be significant barriers to portal adoption. Patient education to reduce these barriers may increase portal acceptance and increase meaningfulness to the portal for patients/parents and providers.

Physician Perception of the Role of the Patient Portal in Pediatric Health

The patient portal, increasingly available to patients, allows secure electronic communication with physicians. Although physician attitude toward the portal plays a crucial role in patient adoption, little information regarding physician opinion of the portal is available, with almost no information gathered in the pediatric environment. Using a mixed-methods approach, physicians in a large pediatric medical facility and integrated delivery network were surveyed using an online quantitative questionnaire and structured interviews. Physicians reported the portals role in more communication efficiency for patients, parents, and providers. The portals acceptance also introduces new challenges such as frequent questions from some parents and medical visit avoidance.

MP76-14 PATIENT PORTAL USAGE IN PEDIATRIC UROLOGY: IS IT MEANINGFUL USE TO EVERYONE?

INTRODUCTION AND OBJECTIVES: Projections demonstrate a worsening shortage of urologists in the United States in the next decade. Advanced practice providers (APPs) are increasingly used in urology and other fields to improve physician productivity. While APPs have become common in urology clinics, little data exists regarding the use of APPs in the surgical setting. Though in the past, urologists were often assisted by a second surgeon for complicated operations, we hypothesized that APPs are increasingly filling that role. This study aims to quantify the change in surgical assist patterns over time for commonly performed urologic operations. METHODS: We used data derived from the Medicare Physician/Supplier Procedure Summary Master File to examine the rates of APP-assisted and surgeon-assisted procedures performed by urologists from 2003-2014, as identified by CPT codes and modifiers. The annual frequency is reported by assist type for six common urologic operations: robotic prostatectomy, open prostatectomy, radical cystectomy, open nephrectomy, open partial nephrectomy, and laparoscopic nephrectomy. The average annual rates of change were determined using least squares regression and tested using ttests (a1⁄40.05). RESULTS: Of the 677,111 urologic operations analyzed, 5.0% of cases were assisted by APPs compared to 27.0% assisted by a second surgeon. The proportion of cases assisted by an APP rose significantly for all procedures (Figure 1); conversely, the proportion of cases assisted by a second surgeon declined significantly for all procedures, except for open partial nephrectomy. The largest changes were seen in robotic prostatectomies; similar proportions of robotic prostatectomies are now performed by APPs as by second surgeons. CONCLUSIONS: Urologists are increasingly using APPs as assistants in surgery, particularly in laparoscopic and robotic cases. This trend will likely continue as the shortage of urologists worsens in coming years. At the same time, surgical assistance is less frequently being performed by a second surgeon, which may decrease opportunities for refining operative skills. APPs can be a valuable part of the surgical team, but further consideration of the impacts of this shift in practice is needed.