The pediatric Internet.

The Internet is a set of rules for computer communications that has created easy access to electronic mail, electronic mailing lists, and the World Wide Web. The "pediatric Internet" consists of a growing collection of Internet resources that deal specifically with the health care of the young. Locating this information, judging its quality, and determining its appropriate use presents difficulties, but the ubiquity of the Internet makes it imperative for child health professionals to learn the skills necessary to access and provide information via this medium. The Internet will be used increasingly for scientific publishing, the original purpose of the World Wide Web. This article presents basic definitions for the Internet, some characteristics of the pediatric Internet, guidance on how to locate information, and what the future of the pediatric Internet holds.

Implementation of the Community Outpatient Practice Experience in a large pediatric residency program.

OBJECTIVES: To determine the feasibility of implementing the Community Outpatient Practice Experience (COPE), a community-based continuity program, in a large, tertiary-care-oriented pediatric residency; to assess the impact of the continuity program on pediatric residents' experience; and to compare the experience in a variety of community practice settings. SETTINGS: Continuity clinic settings included a hospital-based residents' group practice (RGP) clinic (1989 through 1991) and a community-based program in which each resident was paired with a practicing pediatrician in the community (1991 through 1993). Community practice types included publicly funded clinics (n = 9), private practices (n = 38), and managed-care practices (n = 14). In all settings, residents spent half a day per week in continuity activity. METHODS: Measures of resident's experience (patient encounters, patient age distribution, and diagnostic mix) were compared in both settings and among community practice types. RGP data were derived from a patient scheduling database, and COPE data were obtained from patient encounter records submitted by each resident. RESULTS: Residents in RGP (108.5 resident years) had 5294-encounters with 1568 patients. In COPE (102.5 resident years), 21,978 encounters with 19,235 patients occurred. COPE residents saw significantly more patients per session (6.2 vs 1.7) than residents in RGP. The mean patient age in COPE was significantly higher than RGP (5.3 vs 2.6 years). A greater proportion of encounters in RGP were for health supervision (61% vs 30%), but a greater number of health supervision encounters per resident occurred in COPE. There was a higher proportion of patients with chronic disease in RGP (38% vs 7%), but a greater number of patients with chronic disease was seen per resident in COPE. Analysis of COPE data by practice type showed fewer patient encounters per session and a younger patient age in publicly funded sites than in private- or managed-care practices. The proportion of health supervision encounters was greatest in publicly funded sites, but the greatest number of health supervision encounters per resident occurred in managed-care practices. CONCLUSIONS: We successfully integrated a large-scale community-based continuity experience into a large, tertiary-care-oriented pediatric residency program. We present COPE as an alternative to the hospital-based continuity clinic and suggest it as a model for improving residents' primary-care experience.

American Academy of Pediatrics. Pediatric Practice Action Group and Task Force on Medical Informatics. Privacy protection and health information: patient rights and pediatrician responsibilities.

Pediatricians and pediatric medical and surgical subspecialists should know their legal responsibilities to protect the privacy of identifiable patient health information. Although paper and electronic medical records have the same privacy standards, health data that are stored or transmitted electronically are vulnerable to unique security breaches. This statement describes the privacy and confidentiality needs and rights of pediatric patients and suggests appropriate security strategies to deter unauthorized access and inappropriate use of patient data. Limitations to physician liability are discussed for transferred data. Any new standards for patient privacy and confidentiality must balance the health needs of the community and the rights of the patient without compromising the ability of pediatricians to provide quality care.

On-line resources for pediatricians.

BACKGROUND: Medical information is increasingly available on computer networks. OBJECTIVES: To familiarize the pediatrician with some of the terms associated with these on-line resources, and to describe what is available via the Internet and dial-up computer bulletin boards. DATA SOURCES: Information for this article was taken from publicly available on-line services and Internet servers. DATA EXTRACTION: Only resources relevant to pediatric practice were included. DATA SYNTHESIS: Medical information on the Internet is in a state of evolution. Useful resources for pediatricians are sparse but expanding rapidly. CONCLUSIONS: Pediatricians may use on-line computer networks to communicate. Familiarity with computer networks will become more important to pediatricians as electronic medical records, on-line medical literature, and telemedicine (the practice of medicine over long distances) become more common. Medical libraries and commercial on-line services are good places to begin to investigate the availability of medical information over computer networks.

Pediatric Internet resources. Creation and growth of the PEDINFO index.

OBJECTIVE: To illustrate the growth of pediatric-related material on the Internet as demonstrated by the growth and use of an index of pediatric Internet resources. DESIGN: Descriptive analysis. METHODS: The log files of the computer systems on which the PEDINFO index was implemented were examined. File size of the index was measured, and a record of Internet hosts that connected to the server each day was produced. A proportion of Internet sites (n = 300) were examined for author reliability and practice enhancement value. RESULTS: In a period of 14 months, the file size grew from 7 kilobytes (KB) to more than 80 KB. By November 1995, usage exceeded 250 individuals per day and has since then leveled off to about 180 users per day. Analysis of the domains of the users showed a shift from equal proportion of "com" (commercially obtained Internet addresses) and "edu" (educational institution) addresses to an increase in com addresses with a stable proportion of edu addresses. One hundred twenty-seven sites contained patient or parent information, and 62 sites contained reference material. There was a wide range of author reliability ratings. CONCLUSIONS: From the growth of PEDINFO, we conclude that an increase in pediatric-related information available on the Internet is steady, much of which is patient or parent educational material. We anticipate further growth and use of the Internet in the exchange of information and cell for further education regarding its use so that pediatricians can more easily direct their patients to the most medically relevant sources.

Information technology for children's health and health care: report on the Information Technology in Children's Health Care Expert Meeting, September 21-22, 2000.

In September 2000, the Agency for Healthcare Quality and Research and the American Academy of Pediatrics Center for Child Health Research sponsored a meeting of experts and knowledgeable stakeholders to identify 1) the special information needs of pediatric care and 2) health service research questions related to the use of information technology in children's health care. Technologies that support the care of children must address issues related to growth and development, children's changing physiology, and the unique diseases of children and interventions of pediatric care. Connectivity and data integration are particular concerns for child health care workers. Consumer health information needs for this population extend beyond the needs of one individual to the needs of the family. Recommendations of the attendees include rapid implementation of features in electronic health information systems that support pediatric care and involvement of child health experts in policy making, standards setting, education, and advocacy. A proposed research agenda should address both effectiveness and costs of information technology, with special consideration for the needs of children, the development and evaluation of clinical decision support in pediatric settings, understanding of the epidemiology of iatrogenic injury in childhood, supplementation of vocabulary standards with pediatrics-specific terminology, and improvement in health care access for children, using telemedicine.

Analysis of electronic medication orders with large overdoses: opportunities for mitigating dosing errors.

BACKGROUND: Users of electronic health record (EHR) systems frequently prescribe doses outside recommended dose ranges, and tend to ignore the alerts that result. Since some of these dosing errors are the result of system design flaws, analysis of large overdoses can lead to the discovery of needed system changes. OBJECTIVES: To develop database techniques for detecting and extracting large overdose orders from our EHR. To identify and characterize users' responses to these large overdoses. To identify possible causes of large-overdose errors and to mitigate them. METHODS: We constructed a data mart of medication-order and dosing-alert data from a quaternary pediatric hospital from June 2011 to May 2013. The data mart was used along with a test version of the EHR to explain how orders were processed and alerts were generated for large (>500%) and extreme (>10,000%) overdoses. User response was characterized by the dosing alert salience rate, which expresses the proportion of time users take corrective action. RESULTS: We constructed an advanced analytic framework based on workflow analysis and order simulation, and evaluated all 5,402,504 medication orders placed within the 2 year timeframe as well as 2,232,492 dose alerts associated with some of the orders. 8% of orders generated a visible alert, with » of these related to overdosing. Alerts presented to trainees had higher salience rates than those presented to senior colleagues. Salience rates were low, varying between 4-10%, and were lower with larger overdoses. Extreme overdoses fell into eight causal categories, each with a system design mitigation. CONCLUSIONS: Novel analytic systems are required to accurately understand prescriber behavior and interactions with medication-dosing CDS. We described a novel analytic system that can detect apparent large overdoses (≥500%) and explain the sociotechnical factors that drove the error. Some of these large overdoses can be mitigated by system changes. EHR design should prospectively mitigate these errors.

Incorporating temporal and clinical reasoning in a new measure of continuity of care.

Previously described quantitative methods for measuring continuity of care have assumed that perfect continuity exists when a patient sees only one provider, regardless of the temporal pattern and clinical context of the visits. This paper describes an implementation of a new operational model of continuity--the Temporal Continuity Index--that takes into account time intervals between well visits in a pediatric residency continuity clinic. Ideal continuity in this model is achieved when intervals between visits are appropriate based on the age of the patient and clinical context of the encounters. The fundamental concept in this model is the expectation interval, which contains the length of the maximum ideal follow-up interval for a visit and the maximum follow-up interval. This paper describes an initial implementation of the TCI model and compares TCI calculations to previous quantitative methods and proposes its use as part of the assessment of resident education in outpatient settings.

Medical informatics education in paediatric residency training.

OBJECTIVES: The objective of this study was to determine whether Medical Informatics education among house staff is included in the current residency curriculum, and to present ways in which this type of education may be improved. DESIGN: During autumn 1996 a mailed survey was distributed to chief residents of American paediatric residency programmes. Questions included the resident's use of computers, the influence of Informatics-trained faculty members on programme education and plans for curriculum expansion. SETTING: Division of General Paediatrics, University of Alabama, United States. SUBJECTS: Paediatric chief residents. RESULTS: Eighty programmes (63%) returned a survey. An average of 97% of residents use the computer for looking up patient laboratory results, while 70% use it for Medline searches. Less than half of all residents use the Internet or computer-based learning programmes. Thirty-seven per cent of programmes provided formal lectures on computer topics, and 22% of programmes provided hands-on Internet training. There was no association between the presence if Informatics faculty and current programmes; however, programmes with Informatics faculty were more likely to have future curriculum plans (P=0.04). Some of the programmes' future plans are described. CONCLUSIONS: We felt that an overall description of what is currently being done with computers would be helpful as a baseline for other programmes considering new curricula changes. Residents use the computer often to check patient laboratory results but not as much for self-education. Many programmes are expanding their Informatics curriculum. Faculty without formal Informatics training can take part in basic computer education for residents. A self-study approach by the residents has been received positively.

Interactive electronic whiteboards in the medical classroom.

Most research on computer-assisted instruction has concentrated on developing systems to be used outside the teaching environment to supplement or complement in-class teaching. We believe that interactive large-screen computers can be used effectively in the classroom as electronic whiteboards to more effectively teach select medical school courses. We describe our experience with one such device, the Xerox LiveBoard, to teach a course on computer-assisted clinical decision analysis to a group of first-year medical students.