Improving Sexual History Documentation in Teenagers.

BACKGROUND AND OBJECTIVES: Teen access to sexual health care is essential. The 21st Century Cures Act mandates that most electronic health information be shared with patients; no standard exists for how to meet this mandate for teens and their proxy caregivers. Our confidential shared teen sexual history (SexHx) section, which is not note-based, allows clinicians to easily find information, promotes clinical decision support, and protects privacy. Nevertheless, significant variability existed in SexHx section usage, SexHx documentation, and teen note-sharing practices. For teens (aged 12-17) admitted to the Pediatric Hospital Medicine service, we aim to increase the use of the SexHx section by 10% and increase History and Physical notes (H&Ps) shared with teens by 5% over 12 months. METHODS: Quality improvement methodology and tools were used to conduct a barrier analysis and implement a series of interventions, which included education, training, and electronic health record clinical decision support. Statistical process control charts were used to examine the impact of the interventions. RESULTS: At baseline, from April to July 2021, sexual activity was documented or reviewed in the SexHx section for 56% of teen patients. Over the intervention period, the center line shifted to 72%. At baseline, 76% of teen H&Ps were shared with patients. The percentage of H&Ps shared revealed a center-line shift to 81% throughout the intervention period. CONCLUSIONS: The shared teen SexHx section is an innovative tool for capturing sensitive patient history discretely. We demonstrated increased and sustained SexHx section use and H&P note-sharing in this quality improvement initiative.

Training pediatric physicians and staff to obtain data from the electronic health record.

Electronic health records (EHRs) have provided physicians with user-friendly self-service reporting tools to extract patient data from the EHR. Despite such benefits, physician training on how to use these tools has been limited. At our institution, physicians were faced with prolonged wait time for EHR data extraction requests and were unaware of self-service reporting tool availability in the EHR. Our goal was to develop an EHR data reporting curriculum for physicians and staff and examine the effectiveness of such training. In 2019, physician informaticists developed two interactive sessions to train physicians and staff on self-service reporting tools (Epic® SlicerDicer and Reporting Workbench (RWB)) available in our tertiary children's hospital EHR. We assessed participants' knowledge, confidence, and tool utilization before, after, and 3-months post training via survey. Training sessions occurred between April and August 2021. Thirty-six participants completed the study, with 25 surveys collected immediately post and 22 surveys collected at 3-months post training. Data literacy knowledge pre-test average score improved from 62% to 93% (p < 0.05) immediately post-session and 74% at 3-months post assessment (p = 0.05). Regular tool utilization increased from 29% (RWB) and 34% (SlicerDicer) pre-session to 56% and 44% at 3-months post, respectively. Participants reported increased confidence in performing SlicerDicer model selection, criteria selection, and data visualization as well as RWB report navigation, report creation, report visualization, and describing report's benefits/limitations. Ultimately, physician and staff self-service reporting tools training were effective in increasing data literacy knowledge, tool utilization, and confidence.

A Longitudinal Study of Health Care Utilization Among Infants Investigated for Maltreatment.

OBJECTIVE: To evaluate whether maltreatment investigated during infancy affects high-acuity health care utilization patterns during early childhood. METHODS: Retrospective case-control study based on linked data between child protection and hospital encounter records conducted to review health records of infants investigated for abuse and/or neglect. Cases and controls were followed longitudinally through the Rady Children's Hospital electronic health records for 4 years starting at the age of 1 year. RESULTS: A total of 3692 children were investigated for maltreatment within the first year of life. When comparisons were made between children reported for maltreatment and matched controls, children with infancy maltreatment reports had significantly more high-acuity health care encounters than matched controls (average treatment effect = 1.53, 95% Confidence Interval 1.08-1.99, P < .001). CONCLUSIONS: Infants investigated for maltreatment have greater high-acuity health care utilization in early childhood. These findings highlight this population's need for well-defined medical homes to ensure appropriate health care. Further understanding of the underlying reasons for this increased health care burden will help inform these efforts.

Counts and child protection reports of diagnosed child maltreatment before and after the COVID-19 pandemic onset.

BACKGROUND: Mechanisms for reporting child maltreatment (CM) were affected by changes in service provision immediately following the onset of the COVID-19 pandemic. OBJECTIVE: To examine changes in counts and CPS reporting of CM medical encounters before and after the onset of COVID-19. PARTICIPANTS AND SETTING: All emergency department and inpatient medical encounters with at least one CM diagnosis during the study period at Rady Children's Hospital San Diego, the largest pediatric hospital in California between 2016 and November 2021. METHODS: Using linked medical record and CPS administrative data, interrupted time series models tested for changes in monthly counts and percentages of CM medical encounters reported to CPS with the onset of COVID-19. Logistic regression tested for the likelihood of a CPS report being associated with a CM encounter. RESULTS: CM medical encounters totaled 2528, including 793 after the onset of COVID-19. Interrupted time series models indicated with the onset of the pandemic, the counts of CM encounters increased 18 % (RR: 1.18, 95 % CI 1.03-1.34) and the percentages reported to CPS increased 10 % (RR: 1.10, 95 % CI: 1.05-1.17). CM encounters that occurred after the onset of the COVID-19 pandemic had increased odds of a CPS report (fully adjusted model: OR: 1.08; 95 % CI: 1.05-1.12). CONCLUSIONS: This study found increases in monthly counts and a higher percentage of CM medical encounters with CPS reports after the pandemic onset.

The Impact of COVID-19 on Infant Maltreatment Emergency Department and Inpatient Medical Encounters.

OBJECTIVE: To assess the counts of infant maltreatment-related medical encounters at a large medical system during a 21-month span of the COVID-19 pandemic. METHODS: Retrospective data for this study came from all inpatient and emergency department medical encounters for infants from January 1, 2016, through November 30, 2021, at a single children's hospital system in California. Distributions of medical encounters were tabulated and plotted over time. Interrupted time series models were used to evaluate changes in child maltreatment medical encounters. RESULTS: Medical encounters for infants with child maltreatment diagnoses increased following the onset of COVID-19. Monthly counts of encounters with indicated maltreatment trended upward following the start of the pandemic. Interrupted time series models showed that the count of maltreatment encounters increased 64% with the onset of COVID-19. CONCLUSIONS: We found an increase in infant maltreatment medical encounters during a 21-month period following the onset of COVID-19. These findings suggest that the pandemic may have adversely affected the safety of infants and ongoing work is needed to understand better the pandemic impacts on child maltreatment.

Academic Health Centers and Humanitarian Crises: One Health System's Response to Unaccompanied Children at the Border.

University of California Health (UCH) provided a system-wide, rapid response to the humanitarian crisis of unaccompanied children crossing the southern U.S. border in the midst of the COVID-19 pandemic in 2021. In collaboration with multiple federal, state, and local agencies, UCH mobilized a multidisciplinary team to deliver acute general and specialty pediatric care to unaccompanied children at 2 Californian emergency intake sites (EISs). The response, which did not disrupt normal UCH operations, mobilized the capacities of the system and resulted in a safe and developmentally appropriate environment that supported the physical and mental health of migrant children during this traumatic period. The capacities of UCH's 6 academic health centers ensured access to trauma-informed medical care and culturally sensitive psychological and social support. Child life professionals provided access to exercise, play, and entertainment. Overall, 260 physicians, 42 residents and fellows, 4 nurse practitioners participated as treating clinicians and were supported by hundreds of staff across the 2 EISs. Over 5 months and across both EISs, a total of 4,911 children aged 3 to 17 years were cared for. A total of 782 children had COVID-19, most infected before arrival. Most children (3,931) were reunified with family or sponsors. Continuity of care after reunification or placement in a long-term shelter was enhanced by use of an electronic health record. The effort provided an educational experience for residents and fellows with instruction in immigrant health and trauma-informed care. The effort benefitted from UCH's recent experience of providing a system-wide response to the COVID-19 pandemic. Lessons learned are reported to encourage the alignment and integration of academic health centers' capacities with federal, state, and local plans to better prepare for and respond to the accelerating need to care for those in the wake of disasters and humanitarian crises.

Disappearing Help Text: Implementing a Note-Based Tool for In-Line Clinical Decision Support and Note Bloat Reduction.

OBJECTIVE: The authors describe a novel solution to the challenges of lengthy notes and poor note readability by creating an unobtrusive clinical decision support tool named "disappearing help text." METHODS: We designed this tool in Pediatric Hospital Medicine (PHM) note templates to provide in-line decision support on best documentation practices, note bloat reduction, billing compliance, and provider workflow enhancement. RESULTS: After template changes that utilized disappearing help text, we reduced the percent of notes utilizing any laboratory SmartLink from 90.2 to 15.3% for admission notes (p <0.001), 92.6 to 17.8% for progress notes (p <0.001), and 14 to 7.2% for discharge summaries (p <0.001). In admission and progress notes, this correlated with a significant reduction in the median note length as a proxy of note bloat reduction, with a 18.7% character count reduction in progress notes (p <0.001) and a 6.4% reduction in admission notes (p <0.001). PHM coding queries decreased from an average of 42 per month to 36 per month, and there was no change in PHM attending billing compliance audit performance. DISCUSSION: Note template changes that utilized disappearing help text significantly reduced the length of both progress and admission notes, a proxy for note bloat reduction, without negatively impacting coding query frequency or internal billing audit performance. One factor that likely contributed to this reduction in note length is the reduced usage of laboratory SmartLinks prompted by disappearing help text. CONCLUSION: We present the use of in-line disappearing help text embedded into note templates as a clinical decision support tool to improve note readability, educate trainees on note documentation, and protect confidential teen information. Help text implementation correlated with a reduction in the automatic insertion of laboratories into notes and a decrease in note character count.

Pre-Implementation Organizational Environment Associated with Pediatric Integrated Care Readiness in Primary Care.

Objective: To characterize pre-implementation organizational factors associated with Access To Tailored Autism Integrated Care (ATTAIN), an integrated care model for children with autism and identified or suspected co-occurring mental health needs. Methods: Pediatric primary care providers (n=36) completed surveys as part of a pilot study testing ATTAIN feasibility. Measures assessed: background characteristics; implementation climate; organizational readiness; evidence-based practice (EBP) attitudes; knowledge, confidence and comfort caring for children with autism. Results: Compared to providers from a network of primary care practices and an integrated healthcare system, providers from a Federally Qualified Health Center (FQHC) reported less positive perceptions of climate supportive of EBP implementation and, specifically, selection for openness and rewards for EBPs. Implementation climate was associated with autism knowledge, comfort with mental health referral and follow up, and organizational change efficacy. Conclusions: Findings advance understanding of pre-implementation organizational context factors important to assess for EBP implementation in diverse pediatric care settings.

Mental health screening in pediatric primary care for children with autism.

LAY ABSTRACT: Children with autism experience high rates of co-occurring mental health conditions like challenging behaviors and anxiety. However, these co-occurring mental health needs are often not identified when they first become problematic. Pediatricians and their care staff are in a good position to identify mental health needs early and support families to connect to needed services. This study describes a project focused on mental health screening for children with autism in pediatric primary care clinics. Over half of eligible patients were screened using the Pediatric Symptom Checklist-17. Many children with autism had clinically elevated scores, suggesting the need for mental health assessment or services. In particular, children with positive screens had clinical elevations on the challenging behavior and attention subscales of the Pediatric Symptom Checklist-17. This finding is consistent with typical trends in co-occurring challenging behavior presentations in children with autism. Mental health screening in primary care is feasible and offers a promising opportunity to identify co-occurring mental health needs for children with autism early. Screening rates varied between clinics, suggesting tailored to improve routine screening in pediatric primary care for children with autism.

Implementation outcomes from a pilot of "Access to Tailored Autism Integrated Care" for children with autism and mental health needs.

LAY ABSTRACT: Children with autism frequently experience co-occurring mental health needs. The "Access to Tailored Autism Integrated Care (ATTAIN)" model was co-created with caregivers, pediatric providers, and health care leaders to identify mental health needs and link to mental health care for autistic children. This article describes outcomes from a pilot study of Access to Tailored Autism Integrated Care with 36 pediatric primary care providers from seven clinics within three healthcare systems. Providers participated in an initial Access to Tailored Autism Integrated Care training and received ongoing online support over 4 months with autistic patients ages 4-16 years old. Survey and interview assessments measured provider perceptions of feasibility, acceptability, and intentions to continue using Access to Tailored Autism Integrated Care after the pilot. Providers reported that Access to Tailored Autism Integrated Care was feasible, acceptable, that the initial training was helpful in their implementation but that more specific and tailored implementation support was needed. Results show that Access to Tailored Autism Integrated Care is a promising model to support mental health screening and linkage for children with autism in primary care. Findings provide information on specific areas of the Access to Tailored Autism Integrated Care model that could be benefit from additional refinement to support more widespread use in primary care settings.

Opportunities for Early Identification: Implementing Universal Depression Screening with a Pathway to Suicide Risk Screening in a Pediatric Health Care System.

OBJECTIVES: To describe the implementation process and assess results of a large-scale universal depression screening program with pathways to suicide risk screening in a pediatric integrated delivery network. STUDY DESIGN: This retrospective study analyzes depression and suicide risk screening data for 95 613 patients ages 12-17 years. RESULTS: Of the 95 613 adolescent patients who were screened for depression, 2.4% (2266) screened positive for risk for moderate-severe depression (>10 Patient Health Questionnaire; 9-item version) and 4.1% (3942) endorsed elevated suicide risk (≥1 Columbia Suicide Severity Rating Scale). Overall, 51% of screened patients who present with a primary psychiatric concern screened positive for elevated risk of suicide (2132). Two percent of screened patients who presented with a primary medical concern screened positive for elevated risk of suicide. Nearly one-half (45.9%) of all elevated suicide risk screenings were from patients with a primary medical concern. CONCLUSIONS: A large-scale universal depression screening program with a pathway to identify elevated suicide risk was implemented in a pediatric health care system using the Patient Health Questionnaire and the Columbia Suicide Severity Rating Scale. This screening program identified youth with moderate-severe depression and elevated risk for suicide with and without presenting psychiatric concerns across service settings.

Assessment of Prevalence of Adolescent Patient Portal Account Access by Guardians.

Importance: Patient portals can be configured to allow confidential communication for adolescents' sensitive health care information. Guardian access of adolescent patient portal accounts could compromise adolescents' confidentiality. Objective: To estimate the prevalence of guardian access to adolescent patient portals at 3 academic children's hospitals. Design, Setting, and Participants: A cross-sectional study to estimate the prevalence of guardian access to adolescent patient portal accounts was conducted at 3 academic children's hospitals. Adolescent patients (aged 13-18 years) with access to their patient portal account with at least 1 outbound message from their portal during the study period were included. A rule-based natural language processing algorithm was used to analyze all portal messages from June 1, 2014, to February 28, 2020, and identify any message sent by guardians. The sensitivity and specificity of the algorithm at each institution was estimated through manual review of a stratified subsample of patient accounts. The overall proportion of accounts with guardian access was estimated after correcting for the sensitivity and specificity of the natural language processing algorithm. Exposures: Use of patient portal. Main Outcome and Measures: Percentage of adolescent portal accounts indicating guardian access. Results: A total of 3429 eligible adolescent accounts containing 25 642 messages across 3 institutions were analyzed. A total of 1797 adolescents (52%) were female and mean (SD) age was 15.6 (1.6) years. The percentage of adolescent portal accounts with apparent guardian access ranged from 52% to 57% across the 3 institutions. After correcting for the sensitivity and specificity of the algorithm based on manual review of 200 accounts per institution, an estimated 64% (95% CI, 59%-69%) to 76% (95% CI, 73%-88%) of accounts with outbound messages were accessed by guardians across the 3 institutions. Conclusions and Relevance: In this study, more than half of adolescent accounts with outbound messages were estimated to have been accessed by guardians at least once. These findings have implications for health systems intending to rely on separate adolescent accounts to protect adolescent confidentiality.

A Quality Improvement Initiative to Improve Discharge Timeliness and Documentation.

INTRODUCTION: Discharge communication is critical for the continuity of patient care. However, discharge summaries are often not available in time for follow-up visits, and the content is inconsistent. We aimed to decrease the average time to discharge summary completion by 25%, reduce deficiencies (information errors) by 50%, and increase discharge summary template use to >80% in 6 months. METHODS: A pediatric interprofessional team used quality improvement methods to identify barriers and implement interventions, including discharge summary completion time expectation, electronic health record discharge summary template changes addressing gaps, and training. Notable changes to the template included embedded writing tips to guide writers and specific template choices for common diagnoses to standardize content. The primary outcome measure was the mean discharge summary completion time. Secondary measures were the percentage of discharge summaries with deficiencies and the rate of template use. RESULTS: After interventions, the mean discharge summary completion time decreased by 70% (from 71.5 to 21.8 hours). Discharge summary deficiencies decreased 44% (from 4.5% to 2.5%), and template use increased from 62% to 97%. CONCLUSION: Quality improvement methods and a newly designed electronic health record-discharge summary template were used to dramatically improve discharge summary timeliness and standardize content to streamline continuity of care.

Are You In or Are You Out? Provider Note Sharing in Pediatrics.

BACKGROUND: The OpenNotes initiative launched an international movement aimed at making health care more transparent by improving communication with, and access to, information for patients through provider note sharing. Little has been written either on provider note sharing in pediatric and adolescent populations or on the impact of system default settings versus voluntary provider note sharing. OBJECTIVE: We describe our journey as a pediatric integrated delivery network to default share notes in ambulatory specialty practices not only with parent proxies but also with teens and discuss the methods that led to a successful implementation. METHODS: Retrospective analysis of every ambulatory shareable medical provider note written in pediatric subspecialty clinics within an integrated pediatric delivery network from April 2017 through March 2019. RESULTS: From April 2017 to February 2018, a total of 221,655 notes were shareable based on organizational policies, yet only 224 (0.1%) were actually shared with patients and families. After implementing a system of default release of notes from March 2018 to January 2019, a total of 224,960 notes were shareable, of which 191,379 (85%) were shared. CONCLUSION: Requiring providers to take an action to share notes (opt-in) results in few notes being shared while requiring providers to take an action to not share notes (opt-out) results in high levels of note sharing. We demonstrate that default release of notes in pediatric organizations to both proxies and teens is not only achievable but also likely to lead to increased provider note sharing with patients without obvious negative impact on providers or the organization.

Medication Reconciliation Improvement Utilizing Process Redesign and Clinical Decision Support.

BACKGROUND: Despite years of attention, hospitals continue to struggle to implement successful medication reconciliation. This study aimed to increase the percentage of hospital admission medication reconciliation (AdmMedRec) completion to ≥ 95% in 12 months at a large academic children's hospital. METHODS: A quality improvement (QI) project was initiated in April 2017 by an interdisciplinary team of physicians, nurses, pharmacists, and analysts, co-led by a pediatric hospitalist and chief medical information officer. Interventions were implemented through sequential Plan-Do-Study-Act cycles. Process maps, fishbone diagrams, and failure mode and effects analysis were used to identify AdmMedRec failures. Baseline data from 12,481 admission encounters July 2016-April 2017 were analyzed. Interventions included electronic health record (EHR) workflow redesign, clarification of clinicians' responsibilities, targeted training, Best Practice Advisory alert, and weekly reporting of specialty- and physician-specific performance data. Data from 13,082 postintervention period admission encounters were examined. Reconciliation by therapeutic drug classes was calculated as a proxy for quality. RESULTS: AdmMedRec completion rate increased from a baseline of 73% to 95% within 7 months from the start of this project and was sustained at 94% during the postintervention period. Psychiatry and hospital medicine demonstrated the largest improvements, with rates increasing from 17% to 88% and 76% to 98%, respectively. Percentages of reconciled medications in all 13 therapeutic classes, including high-risk drugs, improved significantly (p < 0.05). CONCLUSIONS: Using an interdisciplinary team and interventions focused on process and culture changes, this QI initiative was successful at increasing AdmMedRec rates and reducing omission errors across all therapeutic drug classes.

A mixed methods study to adapt and implement integrated mental healthcare for children with autism spectrum disorder.

BACKGROUND: There is a critical need for effective implementation of integrated healthcare systems for children with autism spectrum disorder (ASD). Children with ASD have many service needs, including the need to access effective mental healthcare, given high rates of co-occurring psychiatric conditions. Pediatric primary care is an ongoing point of healthcare that is well positioned to identify mental health concerns and facilitate linkage to mental health services for children with ASD. However, identifying mental health problems in children with ASD by primary care providers is complex, subject to being overlooked and may significantly vary based on primary care organizational characteristics. Efforts targeting integrated primary-mental healthcare implementation require a tailored approach for children with ASD. METHODS: This mixed methods, community-partnered study will apply the Exploration, Preparation, Implementation, Sustainment (EPIS) framework (Aarons et al., 2011; Moullin et al., in press) to adapt and implement an integrated care model, "Access to Tailored Autism INtegrated Care" (ATTAIN), in pediatric practices within three diverse healthcare settings for children ages 4-18 years. Key inner context factors from the Exploration, Preparation, and Implementation phases of the EPIS framework will guide three objectives of this study: (1) to identify targets to improve mental health screening and linkage to mental health services in primary care for children with ASD, (2) to adapt integrated care procedures to facilitate identification of mental health problems and linkage to evidence-based care for children with ASD, and (3) to examine feasibility, acceptability, and uptake of the adapted integrated mental healthcare model through a pilot study in pediatric primary care. DISCUSSION: Improving integrated mental healthcare for children with ASD could have a significant public health impact on mental healthcare access, child clinical outcomes, and reduction in healthcare costs. Results from this mixed methods study will inform selection of implementation strategies to conduct larger-scale implementation of tailored integrated mental healthcare for children with ASD that will ultimately help to address the high unmet mental health needs for these children.

Clinician opioid prescribing practices and patient utilization of prescribed opioids in pediatrics.

OBJECTIVE: Little is known regarding clinician prescribing of opioid medications and of patient use of prescribed opioid medications in pediatrics. The authors sought to learn more about pediatric clinician opioid prescribing practices and patient utilization and disposal of prescribed opioids. DESIGN: Cross-sectional, observational study. SETTING: Tertiary care pediatric healthcare center. PARTICIPANTS: Pediatric clinicians who prescribe opioid medications and parents of children prescribed an opioid medication. MAIN OUTCOME MEASURES: Clinicians were surveyed about opioid prescribing practices for acute pain management in children, and parents were asked about utilization and disposal of prescribed opioids. RESULTS: Most clinician respondents (64 percent) reported prescribing opioid medications to manage acute pain. The typical length of opioid prescriptions was limited to 7 days (93 percent). Parents reported a high prevalence of leftover opioid medications (86 percent). Most (59 percent) did not dispose of the remaining medication. CONCLUSIONS: Targets for intervention to reduce unnecessary opioid exposure in youth are identified.

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 healthcare, 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 one outpatient urology clinic visit. Differences in adoption rates were examined using logistic regression for the following categories: activated (or caregiver activated); code accepted not activated; declined; or activated/then deactivated. RESULTS: Overall, 46.5% of patients/caregivers activated the portal. Primarily Spanish-speaking patients were less likely to activate (OR 0.25, p <.001) than English-speaking patients. Males (OR 0.89, p =.004); those self-identifying racially as Other (not White, Asian, or African American) (OR 0.47, p <.001); and Hispanic patients (OR 0.49, p <.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 <.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.