Shannon M. Dean

Antibody-based immunotherapy in high-risk neuroblastoma.

Although great advances have been made in the treatment of low- and intermediate-risk neuroblastoma in recent years, the prognosis for advanced disease remains poor. Therapies based on monoclonal antibodies that specifically target tumour cells have shown promise for treatment of high-risk neuroblastoma. This article reviews the use of monoclonal antibodies either as monotherapy or as part of a multifaceted treatment approach for advanced neuroblastoma, and explains how toxins, cytokines, radioactive isotopes or chemotherapeutic drugs can be conjugated to antibodies to enhance their effects. Tumour resistance, the development of blocking antibodies, and other problems hindering the effectiveness of monoclonal antibodies are also discussed. Future therapies under investigation in the area of immunotherapy for neuroblastoma are considered.

Using an inpatient portal to engage families in pediatric hospital care

Objective: Assess parent use and perceptions of an inpatient portal application on a tablet computer that provides information about a child’s hospital stay. Methods: This cross-sectional study was conducted with parents of children hospitalized on a medical/surgical unit at a tertiary children’s hospital. From December 2014 to June 2015, parents were provisioned a tablet portal application to use throughout the hospitalization. The portal includes real-time hospital vitals, medications, schedules, lab results, education, health care team pictures/roles, and request and messaging functionalities. Portal use information was gathered from tablet metadata. Parents completed discharge surveys on portal satisfaction, use, and impact on their information needs, engagement, communication, error detection, and care safety and quality. Data were analyzed using descriptive statistics and qualitative content analysis. Results: Over 6 months, 296 parents used the portal, sending 176 requests and 36 messages. No tablets were lost or damaged. The most used and liked features included vitals, medication list, health care team information, and schedules. Overall, parent survey respondents (90) were satisfied with the portal (90%), reporting that it was easy to use (98%), improved care (94%), and gave them access to information that helped them monitor, understand, make decisions, and care for their child. Many parents reported that portal use improved health care team communication (60%). Most perceived that portal use reduced errors in care (89%), with 8% finding errors in their child’s medication list. Conclusions: Overall, parents were satisfied with the inpatient portal. Portals may engage parents in hospital care, facilitate parent recognition of medication errors, and improve perceptions of safety and quality.

The Role of Copy-and-Paste in the Hospital Electronic Health Record

Before electronic health records: If you did not document it, you did not do it. After electronic health records: You documented it, but did you do it? After a slow start, hospitals in the United States have rapidly adopted electronic health records, as encouraged by the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH).1 By May 2013, more than 3800 hospitals, or about 80% of the hospitals that were eligible, had received incentive payments from the Centers for Medicare & Medicaid Services (CMS) related to the adoption, implementation, upgrading, or “meaningful use” of these records.2 Yet the application of electronic health records can be a double-edged sword. Their use can increase efficiency, facilitate information sharing, standardize hospital processes, and improve patient care1,3,4 But their use can also have unintended consequences and be subject to abuse, such as when data are duplicated or templates and checkboxes are used to generate standardized text without a good medical reason. The duplication of data in the electronic health record from one location to another is known as “cloning”5 or “copy-and-paste”3,6 and may more generally refer to multiple features, including autopopulate and templates and checkboxes that generate standardized text. Copy-and-paste is related to, yet differs from, “overdocumentation,”3,6 the practice “of inserting false or irrelevant documentation to create the appearance of support for billing higher level services,”3,6 as well as “upcoding,”5 the assignment of an inaccurate billing code to a medical procedure, treatment, or visit to inflate reimbursement. In September 2012, federal officials warned about “the misuse of electronic health records to bill for services never provided,”5 and that law enforcement agencies “will take action where warranted.”5 Two recent reports from the Office of Inspector General of the Department of Health and Human Services (OIG) analyzed how electronic health record technology can make it easier to commit fraud and found deficiencies in the implementation of recommended safeguards.3,6 The office recommended that the CMS develop a “comprehensive plan to address fraud vulnerabilities”3 and provide guidance to hospitals on the use of copy-and-paste.3 The OIG also recommended that CMS instruct its auditors to detect fraud and that audit logs that detect duplicated text be operationalized and used by CMS contractors to assist in fraud detection.3,6 Although the federal government has focused on hospitals, the misuse of copy-and-paste in office-based physician practices would raise similar issues. Does the Use of Copy-and-Paste Equal Fraud? Clearly, technology makes it easier to commit fraud when physicians use tools such as copy-and-paste or templates inappropriately. The use of these features may also contribute to poor quality in clinical notes. For instance, a social history copied and pasted into an admission note may indicate that a patient who is a candidate for a liver transplant is still consuming alcohol, when in fact the patient has been sober for months. A physician using templates and prefilled checkboxes may carelessly document a complete physical examination by default when he or she only conducted a more limited evaluation. With the erroneous use of copy-and-paste, the physician’s assessment and plan may document a decision to start treatment with antibiotics “today” for several days in a row, before the mistake is recognized and corrected. Yet these same features of electronic health records can be efficient and clinically useful when used properly. Although traditional handwritten notes may often have been more concise and exclusively served a clinical need, the purposes of a physicians’ notes have been broadened by their use for billing, to fulfill regulatory requirements, such as compliance with federal standards for the meaningful use of certified electronic health records technology,4 and to collect data for use in standardized measures of quality. For example, a core measure of meaningful use is a problem list of current and active diagnoses that all physicians update and use. Unless the problem list changes, it should be identical in each note that refers to it. Time spent in “counseling and coordination of care” may appear in a template to remind physicians to document the time spent with the patient, not to upcode but to support payment for actual care provided. A template or checklist for the care of a patient with myocardial infarction may help the physician to remember to prescribe a β-blocker or to offer smoking cessation counseling. And if a successful cholecystectomy happens in exactly the same way for 3 consecutive patients, the accompanying identical documentation of the surgical procedures should be welcomed. The federal government uses a range of federal laws, including the False Claims Act, in detecting and prosecuting health care fraud.7 When copy-and-paste is used, fraud is a concern when the documentation is known to have been duplicated or created prior to the episode of care for which reimbursement is claimed. Yet it is too easy, and often mistaken, to equate a physician’s routine use of copy-and-paste with fraud. Data replication is a feature of electronic health records; facts beyond the mere use of duplicated text are required to establish that a note may be fraudulent. Any process by which care is documented could be fraudulent. However, no process VIEWPOINT

The Effectiveness of a Bundled Intervention to Improve Resident Progress Notes in an Electronic Health Record

Providers nationally have observed a decline in the quality of documentation after implementing electronic health records (EHRs). In this pilot study, we examined the effectiveness of an intervention bundle designed to improve resident progress notes written in an EHR and to establish the reliability of an audit tool used to evaluate notes. The bundle consisted of establishing note-writing guidelines, developing an aligned note template, and educating interns about the guidelines and using the template. Twenty-five progress notes written by pediatric interns before and after this intervention were examined using an audit tool. Reliability of the tool was evaluated using the intraclass correlation coefficient (ICC). The total score of the audit tool was summarized in terms of means and standard deviation. Individual item responses were summarized using percentages and compared between the pre- and postintervention assessment using the Fisher exact test. The ICC for the audit tool was 0.96 (95% confidence interval: 0.91-0.98). A significant improvement in the total note score and in questions related to note clutter was seen. No significant improvement was seen for questions related to copy-paste. The study suggests that an intervention bundle can lead to some improvements in note writing.

Complexity of the pediatric trauma care process: implications for multi-level awareness

Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering methods, we combine interview, archival document, and trauma registry data to describe how intra-hospital care transitions affect process and team complexity. Specifically, we identify the 53 roles directly involved in patient care in each hospital unit and describe the 3324 total transitions between hospital units and the 69 unique pathways, from arrival to discharge, experienced by pediatric trauma patients. We continue the argument to shift from eliminating complexity to coping with it and propose supporting three levels of awareness to enhance the resilience and adaptation necessary for patient safety in health care, i.e., safety in complex systems. We discuss three levels of awareness (individual, team, and organizational), and describe challenges and potential sociotechnical solutions for each. For example, one challenge to individual awareness is high time pressure. A potential solution is clinical decision support of information perception, integration, and decision-making. A challenge to team awareness is inadequate “non-technical” skills, e.g., leadership, communication, role clarity; simulation or another form of training could improve these. The complex, distributed nature of this process is a challenge to organizational awareness; a potential solution is to develop awareness of the process and the roles and interdependencies within it, using process modeling or simulation.

Things Falling Through the Cracks: Information Loss During Pediatric Trauma Care Transitions

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Several clinical teams converge to support trauma care in the Emergency Department (ED); the most severe trauma cases often need surgery in the operating room (OR) and/or are admitted to the pediatric intensive care unit (PICU). These care transitions can result in loss of information or transfer of incorrect information, We interviewed 18 clinicians about communication and coordination during care transitions between the ED, OR and PICU. Clinicians completed a short questionnaire about patient safety during transitions. Results show that, although many services and units involved in pediatric trauma work well together, important patient care information may be lost in the transitions. To safely manage transitions of this fragile, unstable, complex population, we need to better manage the information flow during these transitions.

Challenges of Disposition Decision Making for Pediatric Trauma Patients in the Emergency Department

About 9.2 million children visit the emergency department (ED) in the US annually because of trauma and 20% experience a missed injury. Upon arriving to the hospital, physicians evaluate the child and make the ED disposition decision of whether to admit, operate or discharge. The objective of this study is to report the challenges mentioned by healthcare professionals about ED disposition decision making. We conducted 11 interviews with 12 healthcare professionals and identified 2 challenges of ED disposition decision making. The first challenge was timing of the decision; e.g., an ED nurse explained that a quick decision by physicians is important for providing timely patient care to critically ill children. The second challenge was leadership and team organization; e.g., the OR nurse and surgery resident both mentioned the need to know who to listen to so that they can understand what to do. Analyzing these challenges to ED disposition decision making can help to identify sociotechnical solutions for enhancing team situation awareness.

Healthcare Team Perceptions of a Portal for Parents of Hospitalized Children Before and After Implementation

BACKGROUND Patient electronic health record (EHR) portals can enhance patient and family engagement by providing information and a way to communicate with their healthcare team (HCT). However, portal implementation has been limited to ambulatory settings and met with resistance from HCTs. OBJECTIVE We evaluated HCT perceptions before and 6-months after implementation of an inpatient EHR portal application on a tablet computer given to parents of hospitalized children. METHODS This repeated cross-sectional study was conducted with HCT members (nurses, physicians, ancillary staff) on a medical/surgical unit at a quaternary childrens hospital. From December 2014-June 2015, parents of children <12 years old were given a portal application on a tablet computer. It provided real-time vitals, medications, lab results, schedules, education, HCT information and a way to send the HCT messages/requests. HCT members completed surveys pre- and post-implementation regarding their portal perceptions. Pre-post differences in HCT perceptions were compared using chi-squared, Mann-Whitney and Kruskall Wallis tests. RESULTS Pre-implementation, HCT respondents (N=94) were generally optimistic about the benefits of a portal for parents; however, all anticipated challenges to portal use. Over the next 6-months, 296 parents used the portal, sending 176 requests and 36 messages. Post-implementation, HCT respondent (N=70) perceptions of these challenges were significantly reduced (all p<0.001), including: parents (will) have too many questions (69 vs. 3%, pre-post), parents (will) know results before the HCT (65 vs. 1%), staff (would be/are) skeptical (43 vs. 21%) and there (will be/is) not enough technical support (28 vs. 1%). CONCLUSIONS All HCT respondents anticipated challenges in providing a portal to parents of hospitalized children; however, these concerns were minimized after implementation.