Michael G. Leu

Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents.

These pediatric hypertension guidelines are an update to the 2004 “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.” Significant changes in these guidelines include (1) the replacement of the term “prehypertension” with the term “elevated blood pressure,” (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.

Pediatricians’ Use of Health Information Technology: A National Survey

BACKGROUND AND OBJECTIVE: There are limited national data on pediatric health information technology adoption rates. Our objective was to determine pediatricians’ adoption rates of electronic health record systems (EHRs), barriers to adoption, and features of the systems adopted. METHODS: A survey of 1620 randomly selected US members of the American Academy of Pediatrics from February to July 2009 addressed use of EHRs and barriers to adoption. Bivariate analysis and logistic regression were used to determine associations between EHR use and various physician and practice characteristics. RESULTS: Six hundred forty-six postresidency pediatric clinicians practicing in office- or clinic-based settings responded (57.2%). Self-reported electronic medical record/EHR use was 54%/41%, but far fewer used systems that met the definition of a basic (25%) or fully functional (6%) EHR. Only 3% used a system that was fully functional and pediatric-supportive. Pediatricians practicing in multispecialty practices and those in hospital-based practices were more likely to use basic or fully functional EHRs than those in solo/2-physician practices. More than half of respondents reported financial barriers to implementing EHRs, and more than one-third were concerned about whether systems could meet their needs and whether an EHR would affect productivity. CONCLUSIONS: Pediatric adoption of fully functional EHRs lags general adoption. Barriers to adoption include financial and productivity concerns, but pediatricians are also concerned about finding systems that meet their needs. Few pediatricians use a system that is pediatric-supportive. To help identify pediatric-supportive systems, EHR certification efforts should include these requirements.

Policy statement - Using personal health records to improve the quality of health care for children

A personal health record (PHR) is a repository of information from multiple contributors (eg, patient, family, guardians, physicians, and other health care professionals) regarding the health of an individual. The development of electronic PHRs presents new opportunities and challenges to the practice of pediatrics. This policy statement provides recommendations for actions that pediatricians can take to support the development and use of PHRs for children. Pediatric health care professionals must become actively involved in developing and adopting PHRs and PHR systems. The American Academy of Pediatrics supports development of: educational programs for families and clinicians on effective and efficient use of PHRs; incentives to facilitate PHR use and maintenance; and child- and adolescent-friendly standards for PHR content, portability, security, and privacy. Properly designed PHR systems for pediatric care can empower patients. PHRs can improve access to health information, improve coordination of preventive health and health maintenance activities, and support emergency and disaster management activities. PHRs provide support for the medical home for all children, including those with special health care needs and those in foster care. PHRs can also provide information to serve as the basis for pediatric quality improvement efforts. For PHRs to be adopted sufficiently to realize these benefits, we must determine how best to support their development and adoption. Privacy and security issues, especially with regard to children and adolescents, must be addressed.

Centers Speak Up: The Clinical Context for Health Information Technology in the Ambulatory Care Setting

BackgroundClinicians in ambulatory care settings are increasingly called upon to use health information technology (health IT) to improve practice efficiency and performance. Successful adoption of health IT requires an understanding of how clinical tasks and workflows will be affected; yet this has not been well described.ObjectiveTo describe how health IT functions within a clinical context.DesignQualitative study, using in-depth, semi-structured interviews.ParticipantsExecutives and staff at 4 community health centers, 3 health center networks, and 1 large primary care organization.ApproachTranscribed audio-recorded interviews, analyzed using the constant comparative method.ResultsSystematic characterization of clinical context identified 6 primary clinical domains. These included results management, intra-clinic communication, patient education and outreach, inter-clinic coordination, medication management, and provider education and feedback. We generated clinical process diagrams to characterize these domains. Participants suggested that underlying workflows for these domains must be fully operational to ensure successful deployment of health IT.ConclusionsUnderstanding the clinical context is a necessary precursor to successful deployment of health IT. Process diagrams can serve as the basis for EHR certification, to identify challenges, to measure health IT adoption, or to develop curricular content regarding the role of health IT in clinical practice.

Standards for health information technology to ensure adolescent privacy

Privacy and security of health information is a basic expectation of patients. Despite the existence of federal and state laws safeguarding the privacy of health information, health information systems currently lack the capability to allow for protection of this information for minors. This policy statement reviews the challenges to privacy for adolescents posed by commercial health information technology systems and recommends basic principles for ideal electronic health record systems. This policy statement has been endorsed by the Society for Adolescent Health and Medicine.

Policy statement - Health information technology and the medical home

The American Academy of Pediatrics (AAP) supports development and universal implementation of a comprehensive electronic infrastructure to support pediatric information functions of the medical home. These functions include (1) timely and continuous management and tracking of health data and services over a patients lifetime for all providers, patients, families, and guardians, (2) comprehensive organization and secure transfer of health data during patient-care transitions between providers, institutions, and practices, (3) establishment and maintenance of central coordination of a patients health information among multiple repositories (including personal health records and information exchanges), (4) translation of evidence into actionable clinical decision support, and (5) reuse of archived clinical data for continuous quality improvement. The AAP supports universal, secure, and vendor-neutral portability of health information for all patients contained within the medical home across all care settings (ambulatory practices, inpatient settings, emergency departments, pharmacies, consultants, support service providers, and therapists) for multiple purposes including direct care, personal health records, public health, and registries. The AAP also supports financial incentives that promote the development of information tools that meet the needs of pediatric workflows and that appropriately recognize the added value of medical homes to pediatric care.

Improving Care for Pediatric Diabetic Ketoacidosis

OBJECTIVE: We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures. METHODS: Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets. RESULTS: Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations. CONCLUSIONS: Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities.

Effects of CPOE on Provider Cognitive Workload: A Randomized Crossover Trial

OBJECTIVE: To evaluate whether systematically developed clinical decision supports provide usability benefit or decreased cognitive workload with their use. METHODS: Seven surgeons at a pediatric hospital at different levels of training (3 residents, 3 fellows, and 1 attending) were randomized to use either a historical control (ad hoc developed order set) or a systematically developed order set for postoperative management of appendicitis in children. After a washout period, they were crossed over to the other order set. Participants were videorecorded and completed postsurveys, including the System Usability Scale and the National Aeronautic and Space Administration–Task Load Index. RESULTS: Participants unanimously preferred using systematically developed order sets. These order sets resulted in higher usability scores (75 ± 10 vs 60 ± 19; P < .05) and lower cognitive workload scores (37.7 ± 15 vs 52.2 ± 12; P < .05), with comparable amounts of time spent, mouse clicks, and free text entry. Orders generated were more likely to conform to established clinical guidelines. CONCLUSIONS: Systematically designed order sets provide a reduction in cognitive workload and order variation in the context of improved system usability and improved guideline adherence. The systematically designed order set did not improve time spent, reduce mouse clicks, or reduce free text entry.

Systematic Update of Computerized Physician Order Entry Order Sets to Improve Quality of Care: A Case Study

BACKGROUND AND OBJECTIVES: Seattle Children’s Hospital was one of the early adopters of computerized physician order entry. As part of our 2003 go-live, order sets were created opportunistically by using an ad hoc development process. A pilot study revealed that this ad hoc development process resulted in order sets that were neither internally nor externally consistent. We sought to update order sets by using software development techniques, to try and improve consistency and also to review clinical content so that they could be updated to current evidence and consensus-based best practice. We also sought to identify and categorize errors found in the original order sets. METHODS: This is a case study of a new order set development process that: (1) assigned order set ownership; (2) created and applied standards for how orders should appear and be organized within order sets; (3) supported multidisciplinary review and update; and (4) enforced submitting completed specifications before order set build. We extracted order sets into Microsoft Word specifications, updated content by using the Track Changes function, and then updated our Clinical Information System. Changes were reviewed and organized according to themes. RESULTS: We created standard order formats for 98 orders; 191 order sets were standardized. Multidisciplinary review identified medication issues in 37% of order sets (used in 47.6% of inpatient admissions). CONCLUSIONS: This case study demonstrates that it is not sufficient to simply implement computerized physician order entry. Clinical decision supports should be subject to rigorous development processes to ensure both clinical appropriateness and correctness.

Electronic prescribing systems in pediatrics

The use of electronic prescribing applications in pediatric practice, as recommended by the federal government and other national health care improvement organizations, should be encouraged. Legislation and policies that foster adoption of electronic prescribing systems by pediatricians should recognize both specific pediatric requirements and general economic incentives required to speed the adoption of these systems. Continued research into improving the effectiveness of these systems, recognizing the unique challenges of providing care to the pediatric population, should be promoted.