1. Information Technology Tools for the Pediatric Hospitalist Stuart T. Weinberg, MD, FAAP Assistant Professor Department of Biomedical Informatics Department of Pediatrics Vanderbilt University School of Medicine stuart.weinberg@vanderbilt.edu October 16, 2011

2. Faculty Disclosure Information In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation

3. Objectives Understand the difference between information technology and informatics Describe the variety of tools currently available to assist pediatric hospitalists Understand the impact of health information exchanges, including registries Be aware of current informatics strategies and AAP efforts to improve HIT for pediatrics

5. Information Technology and Informatics Information technology centers on the technical tools – hardware and software Informatics centers on the *science* - “ The scientific field that deals with biomedical information, data, and knowledge — their storage, retrieval and optimal use for problem-solving and decision making. ” (Shortliffe). Clinical informatics highlights people, process, technology. There are several peer-reviewed journals AND on Sep 22 nd Clinical Informatics became a Board-Certified Medical Subspecialty.

6. Resolution #36SB Immunization Registry The Number 1 resolution at the 2010 AAP Annual Leadership Forum. RESOLVED, that the Academy work to create a mechanism that allows pediatricians ready access to existing vaccine registries in all states; and be it further RESOLVED, that the Academy support the establishment of, and consider the feasibility of sponsorship of, a national vaccine registry/clearinghouse with common electronic gateways to state registries, allowing ready access to vaccine histories of patients.

7. Involve Your Local Informatician! Clinical informaticians will have valuable insights not only into the medical workflow but also to the informatics literature which may have already studied ‘best practices’ approaches Clinical informaticians should be involved *early* in the process of designing tools and rethinking workflows – not at the end to just implement a solution that has already been developed Another example: the recent Centers for Medicare and Medicaid Services (CMS) initiative to have hospitals offer influenza vaccine to all inpatients

8. What is the Workflow of a Pediatric Hospitalist? Two scenarios: In-house, shift coverage over a period of hours In-house and from home, shift coverage over a period of longer hours or days, possibly covering more than one hospital Possible tasks: Inpatient and ER consults, new admissions and coverage of existing inpatients, attendance at deliveries, stabilization of patients for transport, procedures

10. The Workflow and Tasks Help Dictate the Tools The Handoff – Signout Clinical Documentation (and Billing) Processing Data to/from Outside Sources Communication with Referring Providers Monitoring Patient Status Order Entry Clinical Decision Support

11. Signout Tools should support in-person and long-distance Signout info tends to be a mix of data that can be extracted from patient record, additional informal comments not intended for the medical record, and a checklist of things to do (or NTD) One template in a signout tool does not fit all – signout tends to be roles and specialty based Who else is using that signout tool? Campion TR Jr, Denny JC, Weinberg ST, Lorenzi NM, Waitman LR. Analysis of a computerized sign-out tool: identification of unanticipated uses and contradictory content. AMIA Annu Symp Proc. 2007 Oct 11:99-104.

12. Clinical Documentation (and Billing) Multiple modalities for data entry: dictation, typing, point- and-click templates, voice recognition, scribes A particular challenge for high-volume areas “I enjoy technology, but I have come to feel I am first a data entry person for the insurers and then, secondly valued as a physician.” FOR HOSPITALISTS: How can documentation tools accommodate interruptions in workflow? (voice recognition, scribes) How can documentation provide audit-proof support for appropriate billing codes

13. Processing Data to/from Outside Sources Interoperability and Reuse of Data…. Medical Communication Standards: --HL7 (Health Level 7) --DICOM (Digital Imaging and Communications in Medicine) --CCD (Continuing Care Documentation) HITECH was passed by Congress in 2009 to support the adoption and use of Electronic Health Records (EHRs) to achieve significant improvements in care through meaningful use of EHRs by health care providers. Interoperability is a key component of ‘meaningful use’. FOR HOSPITALISTS: Can external charts be incorporated not only in an electronic form but a *computable* form. Example: Importing lab results not as a PDF but as discrete elements that can be graphed among existing lab work? Can preparations for transport include a mechanism to generate documents and images that can be electronically sent to the receiving facility?

14. Communicating with Referring Providers Consider both ‘push’ and ‘pull’ technologies: Can providers access a portal to check on the status of their patients? Is there a way to manage how referring providers prefer to be contacted and with what frequency – i.e. daily updates versus just a discharge summary? How can these contacts be efficiently completed? Can daily summaries be generated and sent? A referring provider database will likely be necessary [and note whether info should be sent to a *provider* or to a *site*]

15. Monitoring Patient Status Individual patient lookup Dashboards of patients within and/or across multiple units Example: an electronic OB inpatient whiteboard which is tracking mothers in labor – gestation, cm dilated, ROM (meconium staining), GBS positive?, meds received (antibiotics, steroids, etc), other pertinent info? Example: an electronic ER whiteboard which is displaying patient info including age, presenting problem, LOS, status of orders/labs/consults Dashboards of patients specifically on signout list? Quick view of checklist of tasks to be performed

16. Order Entry A patient safety and healthcare quality issue Clinical decision support (next slide) should help make sure the right patients are getting the right care at the right time Pediatric-specific features: CPOE should support age- and weight-based dosing for medications with max and min doses – especially helpful in critical care units Order Entry should also perform allergy checks, check for drug-drug interactions, support order sets derived from evidence-based medicine Personalized medicine is now being used to help guide drug selection in some systems

17. Clinical Decision Support Incorporating recommendations and clinical guidelines from evidence-based medicine into electronic medical records. June 13, 2006 - “The Roadmap for National Action on Clinical Decision Support” (https://www.amia.org/inside/initiatives/cds) FOR HOSPITALISTS: CDS can assist with medication dosing and calculation, problem-based order sets, reduction of missed opportunities for preventive interventions Real-time algorithms can also help identify patient subpopulations for research recruitment

18. Regional Informatics Immunization Registries Regional Health Information Organizations (RHIOs) Health Information Exchanges (HIEs)

19. Immunization Registries July, 2010: The Task Force on Community Preventive Services recommends immunization information systems on the basis of strong evidence of effectiveness in increasing vaccination rates. Evidence is considered strong based on the findings from 71 published papers and 123 conference abstracts showing that IIS are directly related to increasing vaccination rates and reducing vaccine-preventable disease. FOR HOSPITALISTS: Communication with immunization registries could provide a more complete vaccination history Access may be an issue. Is it through a portal or is immunization information integrated with your site’s existing EHR?

23. RHIOs and HIEs Regional Health Information Organizations (RHIOs) and Health Information Exchanges (HIEs) have been developed to share information across multiple health care providers. Example : Five major hospital systems participate in the Indiana Network for Patient Care (INPC), begun in 1994. When a patient is seen in any of the 11 emergency rooms operated by the consortium hospitals, and the patient consents, the information from all of these institutions about one patient can be presented as one virtual medical record. (http://www.regenstrief.org/medinformatics/inpc) States are receiving grant money through the HITECH (Health Information Technology for Economic and Clinical Health) Act to develop Health Information Exchanges (HIEs). FOR HOSPITALISTS: Chart reviews may include accessing, assimilating, and reconciling patient data coming from sources outside of your own site.

24. How Are Vendors Persuaded to Develop Functionalities? Understand that vendor resources are currently overwhelmed by Meaningful Use activities and requirements. Look for existing functionalities in your EHR that are similar and could be potentially tweaked to accomplish your requests. Priorities for feature development tend to focus on the ‘biggest bang for the buck’ – a feature that can benefit a broad range of customers, rather than a small subgroup. Think about how your request could be generalized to serve a similar function for a large group of users. American Academy of Pediatrics has several efforts underway to support pediatric functionalities in EHRs – CHIC, Vendors Consortium, COCIT

26. Held on June 6 th, 2011, a one-day Vendors Consortium provided an opportunity for vendors to: Learn more about the pediatric community and their needs relative to EHR system usage Learn more about AAP content and explore market opportunities for the distribution of this content Provide feedback and preferences for the dissemination of pediatric content through EHR systems Provide feedback on how the AAP can best serve the EHR vendor community and their pediatrician clients Define ways of potential collaboration between vendors and the AAP with the goal of disseminating pediatric content

27. Vendor’s Consortium: 18 People From 11 Vendors: Allscripts (2) Athenahealth (2) Cerner Corporation (1) – 1 MD e-MDs (2) – 1 MD Epic Systems Corporation (1) – 1 MD GE Healthcare (1) McKesson (1) – 1 MD NextGen (2) OptumInsight (3) – 1 MD Physician’s Computer Company (2) Sage Software (1)

30. Questions? Contact Information: Stuart T. Weinberg, MD FAAP 615-936-4239 stuart.weinberg@vanderbilt.edu http://dbmi.mc.vanderbilt.edu/people/weinberg.html