Electronic Documentation in Pediatrics: The Rationale and Functionality Requirements.

Clinical documentation has dramatically changed since the implementation and use of electronic health records and electronic provider documentation. The purpose of this report is to review these changes and promote the development of standards and best practices for electronic documentation for pediatric patients. In this report, we evaluate the unique aspects of clinical documentation for pediatric care, including specialized information needs and stakeholders specific to the care of children. Additionally, we explore new models of documentation, such as shared documentation, in which patients may be both authors and consumers, and among care teams while still maintaining the ability to clearly define care and services provided to patients in a given day or encounter. Finally, we describe alternative documentation techniques and newer technologies that could improve provider efficiency and the reuse of clinical data.

Electronic Documentation in Pediatrics: The Rationale and Functionality Requirements.

Clinical documentation is a fundamental component of the practice of medicine. It has significantly evolved over the past decade, largely because of the growth of health information technology and electronic health records. Although government agencies and other professional organizations have published position statements on the structure and use of electronic documentation, few have specifically addressed the documentation needs for the care of children. A policy statement on electronic documentation of clinical care by general pediatric and subspecialist providers by the American Academy of Pediatrics is needed. This statement provides insight on the unmet needs of key stakeholders to direct future research and development of the electronic media necessary to enhance the wellness of children and improve health care delivery. It also addresses the challenges and opportunities for efficient and effective clinical documentation in pediatrics.

Increasing Recognition and Diagnosis of Adolescent Depression: Project RedDE: A Cluster Randomized Trial.

Adolescent depression causes appreciable morbidity and is underdiagnosed in primary care. This study investigated whether a quality improvement collaborative (QIC) increases the frequency of adolescent depression diagnoses, thus reducing missed diagnoses. METHODS: During a cluster-randomized clinical trial, a national cohort of primary care pediatric practices worked in different orders based on randomization to improve performance on each of three different diagnoses; one was increasing adolescent depression diagnoses. While improving their first diagnosis during an 8-month action period, practices collected control data for a different diagnosis. In two subsequent 8-month periods, practices worked to improve two additional diagnoses and continued to provide data on the ability to sustain and maintain improvements. The QIC intervention included day-long video conferences, transparent data sharing, analysis of failures, QI coaching, and tools to help improve diagnostic performance, including the Patient Health Questionnaire-9 Modified. The primary outcome was the measured frequency of depression diagnoses in adolescent health supervision visits compared via generalized mixed-effects regression models. RESULTS: Forty-three practices were randomized with 31 in the final analysis. We included 3,394 patient visits in the control and 4,114 in the intervention phases. The adjusted percentage of patients with depression diagnoses increased from 6.6% in the control to 10.5% in intervention phase (Risk Difference (RD) 3.9%; 95% CI 2.4%, 5.3%). Practices sustained these increases while working on different diagnoses during the second (RD -0.4%; 95% CI -2.3, 1.4%), and third action periods (RD -0.1%; 95% CI -2.7%, 2.4%). CONCLUSIONS: A QIC intervention can sustainably increase adolescent depression diagnoses.

The design and conduct of Project RedDE: A cluster-randomized trial to reduce diagnostic errors in pediatric primary care.

BACKGROUND: Diagnostic errors contribute to the large burden of healthcare-associated harm experienced by children. Primary care settings involve high diagnostic uncertainty and limited time and information, creating ideal conditions for diagnostic errors. We report on the design and conduct of Project RedDE, a stepped-wedge, cluster-randomized controlled trial of a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care. METHODS: Project RedDE cluster-randomized pediatric primary care practices into one of three groups. Each group participated in a quality improvement collaborative targeting the same three diagnostic errors (missed diagnoses of elevated blood pressure and adolescent depression and delayed diagnoses of abnormal laboratory studies), but in a different sequence. During the quality improvement collaborative, practices worked both independently and collaboratively, leveraging general quality improvement strategies (e.g. process mapping) in addition to error-specific content (e.g. pocket guides for blood pressure norms) delivered during the intervention phase for each error. The quality improvement collaborative intervention included interactive learning sessions and webinars, quality improvement coaching at the team level, and repeated evaluation of failures via root cause analyses. Pragmatic data were collected monthly, submitted to a centralized data aggregator, and returned to the practices in the form of run charts comparing each practice's progress over time to that of the group. The primary analysis used patients as the unit of analysis and compared diagnostic error proportions between the intervention and baseline periods, while secondary analyses evaluated the sustainability of observed reductions in diagnostic errors after the intervention period ended. RESULTS: A total of 43 practices were recruited and randomized into Project RedDE. Eleven practices withdrew before submitting any data, and one practice merged with another participating practice, leaving 31 practices that began work on Project RedDE. All but one of the diverse, national pediatric primary care practices that participated ultimately submitted complete data. Quality improvement collaborative participation was robust, with an average of 63% of practices present on quality improvement collaborative webinars and 85% of practices present for quality improvement collaborative learning sessions. Complete data included 30 months of outcome data for the first diagnostic error worked on, 24 months of outcome data for the second, and 16 months of data for the third. LESSONS LEARNED AND LIMITATIONS: Contamination across study groups was a recurring concern; concerted efforts were made to mitigate this risk. Electronic health records played a large role in teams' success. CONCLUSION: Project RedDE, a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care, successfully recruited and retained a diverse, national group of pediatric primary care practices. The stepped-wedge, cluster-randomized controlled trial design allowed for enhanced scientific efficiency.

Diagnostic Errors in Primary Care Pediatrics: Project RedDE.

OBJECTIVE: Diagnostic errors (DEs), which encompass failures of accuracy, timeliness, or patient communication, cause appreciable morbidity but are understudied in pediatrics. Pediatricians have expressed interest in reducing high-frequency/subacute DEs, but their epidemiology remains unknown. The objective of this study was to investigate the frequency of two high-frequency/subacute DEs and one missed opportunity for diagnosis (MOD) in primary care pediatrics. METHODS: As part of a national quality improvement collaborative, 25 primary care pediatric practices were randomized to collect 5 months of retrospective data on one DE or MOD: elevated blood pressure (BP) and abnormal laboratory values (DEs), or adolescent depression evaluation (MOD). Relationships between DE or MOD proportions and patient age, gender, and insurance status were explored with mixed-effects logistic regression models. RESULTS: DE or MOD rates in pediatric primary care were found to be 54% for patients with elevated BP (n = 389), 11% for patients with abnormal laboratory values (n = 381), and 62% for adolescents with an opportunity to evaluate for depression (n = 400). When examining the number of times a pediatrician may have recognized an abnormal condition but either knowingly or unknowingly did not act according to recommended guidelines, providers did not document recognition of an elevated BP in 51% of patients with elevated BP, and they did not document recognition of an abnormal laboratory value without a delay in 9% of patients with abnormal laboratory values. CONCLUSIONS: DEs and MODs occur at an appreciable frequency in pediatric primary care. These errors may contribute to care delays and patient harm.

Impact of newborn follow-up visit timing on subsequent ED visits and hospital readmissions: an instrumental variable analysis.

OBJECTIVE: To determine whether newborn first outpatient visit (FOV) within 3 days of discharge is associated with reduced rates of emergency department (ED) visits and hospital readmissions. METHODS: Retrospective cohort analysis was performed of all newborns who were born and had outpatient follow-up within a large academic medical center to determine whether they had ED visits or hospital readmission within 2 weeks after hospital discharge. Multivariable regression using an instrumental variable for timing of FOV was conducted to estimate the relationship between FOV within 3 days of discharge and ED visits and hospital readmissions within 2 weeks of discharge, adjusting for potential confounders. Stratified analyses assessed this relationship in subpopulations with medical or social risk factors. RESULTS: Of 3282 newborns, 178 (5%) had 1 or more ED visits or hospital readmissions within 2 weeks of hospital discharge. FOV within 3 days was not significantly associated with ED visits and readmissions in the instrumental variable analysis (IVA) (-0.035, P = .11) or the ordinary least squares analysis (OLS) (0.006, P = .52). The difference in coefficients between these analyses, however, suggests that IVA successfully adjusted for some unmeasured bias. In stratified analyses, only newborns born to African American mothers or discharged by family medicine providers demonstrated a significant relationship between FOV within 3 days and reduced odds of ED visits and readmissions. CONCLUSIONS: No significant relationship between outpatient visit timing and ED visits and hospital readmissions was found. Further study is needed to assess the impact of early outpatient visits on other newborn outcomes.

Factors associated with timing of first outpatient visit after newborn hospital discharge.

OBJECTIVE: To determine factors associated with newborns having their first outpatient visit (FOV) beyond 3 days after postpartum hospital discharge. METHODS: Retrospective cohort analysis of all newborns born at a large urban university hospital during a 1-year period, discharged home within 96 hours of birth, and with an outpatient visit with an affiliated provider within 60 days after discharge. RESULTS: Of 3282 newborns, 1440 (44%) had their FOV beyond 3 days after discharge. Newborns born to first-time mothers, breast-feeding, at high risk for hyperbilirubinemia, or with a pathological diagnosis were significantly (P < .05) less likely to have FOV beyond 3 days in adjusted multivariable analysis, while newborns born via Caesarian section, of older gestational age, with Medicaid insurance, or discharged on a Thursday or Friday were more likely to have FOV beyond 3 days. Discharging provider characteristics independently associated with FOV beyond 3 days included family medicine providers, providers out of residency longer, and providers practicing at the institution longer. In addition, practice of outpatient follow-up had an independent impact on timing of FOV. Having an appointment date and time recorded on the nursery record or first appointment with a home nurse decreased the odds that time to FOV was beyond 3 days of discharge. CONCLUSIONS: Physician decisions regarding timing of outpatient visit after newborn discharge may take into account newborn medical and social characteristics, but certain patient, provider, and practice features associated with this timing may represent unrecognized barriers to care.

Health care consumers' preferences around health information exchange.

PURPOSE Consumer buy-in is important for the success of widespread federal initiatives to promote the use of health information exchange (HIE). Little is known, however, of consumers' preferences around the storing and sharing of electronic health information. We conducted a study to better understand consumer preferences regarding the privacy and security of HIE. METHODS In 2008 we conducted a cross-sectional, random digit dial telephone survey of residents in the Hudson Valley of New York State, a state where patients must affirmatively consent to having their data accessed through HIE. RESULTS There was an 85% response rate (N = 170) for the survey. Most consumers would prefer that permission be obtained before various parties, including their clinician, could view their health information through HIE. Most consumers wanted any method of sharing their health information to have safeguards in place to protect against unauthorized viewing (86%). They also wanted to be able to see who has viewed their information (86%), to stop electronic storage of their data (84%), to stop all viewing (83%), and to select which parts of their health information are shared (78%). Among the approximately one-third (n = 54) of consumers who were uncomfortable with automatic inclusion of their health information in an electronic database for HIE, 78% wished to approve all information explicitly, and most preferred restricting information by clinician (83%), visit (81%), or information type (88%). CONCLUSION Consumers in a state with an opt-in consent policy are interested in having greater control over the privacy and security of their electronic health information. These preferences should be considered when developing and implementing systems, standards and policies.

Healthcare consumers' attitudes towards physician and personal use of health information exchange.

BACKGROUND: Health information exchange (HIE), the electronic transmission of patient medical information across healthcare institutions, is on the forefront of the national agenda for healthcare reform. As healthcare consumers are critical participants in HIE, understanding their attitudes toward HIE is essential. OBJECTIVE: To determine healthcare consumers' attitudes toward physician and personal use of HIE, and factors associated with their attitudes. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: English-speaking residents of the Hudson Valley of New York. MAIN MEASURE: Consumer reported attitudes towards HIE. KEY RESULTS: Of 199 eligible residents contacted, 170 (85%) completed the survey: 67% supported physician HIE use and 58% reported interest in using HIE themselves. Multivariate analysis suggested supporters of physician HIE were more likely to be caregivers for chronically ill individuals (OR 4.6, 95% CI 1.06, 19.6), earn more than $100,000 yearly (OR 3.5, 95% CI 1.2, 10.0), and believe physician HIE would improve the privacy and security of their medical records (OR 2.9, 95% CI 1.05, 7.9). Respondents interested in using personal HIE were less likely to be female (OR 0.4, 95% CI 0.1, 0.98), and more likely to be frequent Internet-users (OR 3.3, 95% CI 1.03, 10.6), feel communication among their physicians was inadequate (OR 6.7, 95% CI 1.7, 25.3), and believe personal HIE use would improve communication with their physicians (OR 4.7, 95% CI 1.7, 12.8). CONCLUSIONS: Consumer outreach to gain further support for ongoing personal and physician HIE efforts is needed and should address consumer security concerns and potential disparities in HIE acceptance and use.

Physicians' attitudes towards copy and pasting in electronic note writing.

BACKGROUND: The ability to copy and paste text within computerized physician documentation facilitates electronic note writing, but may affect the quality of physician notes and patient care. Little is known about physicians' collective experience with the copy and paste function (CPF). OBJECTIVES: To determine physicians' CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use. DESIGN: Cross-sectional survey. PARTICIPANTS: Resident and faculty physicians within two affiliated academic medical centers currently using a computerized documentation system. MEASUREMENTS: Responses on a self-administered survey. RESULTS: A total of 315 (70%) of 451 eligible physicians responded to the survey. Of the 253 (80%) physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes. While noting that inconsistencies (71%) and outdated information (71%) were more common in notes containing copy and pasted text, few physicians felt that CPF had a negative impact on patient documentation (19%) or led to mistakes in patient care (24%). The majority of physicians (80%) wanted to continue to use CPF. CONCLUSIONS: Although recognizing deficits in notes written using CPF, the majority of physicians used CPF to write notes and did not perceive an overall negative impact on physician documentation or patient care. Further studies of the effects of electronic note writing on the quality and safety of patient care are required.

Physicians' attitudes towards copy and pasting in electronic note writing.

The ability to copy and paste text within computerized physician documentation facilitates electronic note writing but may affect the quality of physician notes and patient care. Little is known about physicians' collective experience with the copy and paste function (CPF). We surveyed resident and faculty physicians within two affiliated academic medical centers in order to describe physicians' CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use.