Over the last 50 years, the electronic health record (EHR) has emerged as a critical tool in the delivery of safe, efficient, quality healthcare. EHR systems have evolved from basic single-office databases into sophisticated applications capable of managing clinical documentation, laboratory results, images, and other patient data across care settings as well as providing decision support to promote safe patient care, reduce errors, and support adherence to practice guidelines. Data captured within the EHR are used to support nearly every aspect of patient care, including related billing and auditing activities. Increasingly, these data are also being used for quality improvement and research.

Hospitalists and the patients whom we treat stand to benefit greatly from well-implemented EHRs that provide tools to review growth data and immunization histories, to identify when vital signs and laboratory values exceed normal parameters for age, and to deliver age-, weight-, and condition-appropriate decision support for medication dosing and management. However, most commercially available EHR systems were designed with adult patients in mind. Configuring these systems to care for children often requires additional customization, which can translate to the need for hospitalists to invest time working with EHR implementation teams to ensure that safe, efficient, quality pediatric care can be delivered. This is especially important for hospitalists who work in pediatric units within larger adult-centered hospitals. In this chapter, we provide a brief background of EHR systems, discuss the role of clinical decision support (CDS) tools in delivering safe, efficient, quality pediatric hospital care, and review important patient safety considerations for hospitalists who may be asked to participate in the design, implementation, or optimization of an EHR.

HISTORY OF HOSPITAL MEDICAL RECORDS

The practice of keeping medical records is one of the cornerstones of medicine. Hippocrates, the ancient Greek physician and father of Western medicine, famously kept and advocated for the use of medical records as early as the fifth century BC.¹ These earliest medical records were chronological accounts of individual patient cases and served as important tools in the initial understanding of the natural history of diseases, patient outcomes, and sharing of knowledge among practitioners. Such physician-based records dominated medical documentation for centuries and relied on the diligence of the conscientious physician to accurately document, maintain and preserve this information.

In the mid-nineteenth century, the emergence of record keeping in hospitals represented an early attempt to organize patient information primarily for tracking cases and billing.² Some saw the additional value of the aggregate information from the hospital population for improving patient care. In 1863, social reformer, nurse, and statistician Florence Nightingale described the challenges presented by the limitations of medical record keeping at that time:

The call for structuring and standardizing the medical record to improve its usefulness for healthcare and research grew stronger in the twentieth century, at the same time the computer was emerging as a tool for business and research. In the 1960s, physician Lawrence Weed proposed transitioning to a problem-oriented medical record to improve the ability of clinicians to identify, manage, and treat a patient’s problems in the context of a shared record, as well as to measure and advance the quality of care delivered. He advocated for the use of the computer as a tool to provide better access to the medical record and help guide care delivery.^4,5 Weed’s concepts helped guide the design of early EHRs, and some of these concepts are now standard components of medical documentation.

STRUCTURE AND COMPONENTS OF MODERN EHRs

Modern EHRs continue to evolve from their origins as basic databases into sophisticated applications capable of managing clinical documentation, laboratory results, imaging, and other patient data across care settings. Although many use the terms EHR and electronic medical record (EMR) interchangeably, there is a distinction: EMR classically refers to the electronic version of the paper chart contained in a single office, while EHR refers to the patient-based record of care across multiple care settings and providers.⁶ In 2003, the Institute of Medicine (IOM) developed the following definition of the EHR:

To further illustrate this definition, the IOM broadly outlined EHR core functions, shown in Table 6-1.

A hospital’s EHR provides these functions by integrating numerous components.⁸ The Admission, Discharge and Transfer (ADT) component manages patient location and identifying information. The Computerized Physician Order Entry (CPOE) component enables the entry of orders that can then be communicated to different staff members or to specific hospital departments like the pharmacy, radiology, and laboratory. The Laboratory Information System (LIS) component handles laboratory result data transmission, and a Picture Archive and Communication System (PACS) component manages radiographic images and reports. Additional components manage non-clinical functions, including billing and accounting services.

PEDIATRIC-SPECIFIC EHR FUNCTIONS

The care of children presents many unique challenges for EHR systems. The American Academy of Pediatrics’ (AAP) Council on Clinical Information Technology identified many key EHR features for pediatricians practicing in ambulatory and inpatient settings.⁹ These features include immunization support, growth tracking, medication dosing, and age-based data norms (Table 6-2). Among the most often cited concerns surrounding pediatric EHR adoption is the lack of robust functionality within commercial systems for providing pediatric care.^10-13 Most pediatric-specific features are not automatically built-in when a hospital purchases an EHR, and those that are included often require detailed configuration by teams of clinicians, pharmacists, and the EHR vendor. During this process, special attention must be paid to the complexities of caring for patients whose care needs, normal reference ranges for vital sign and laboratory data, and recommended best screening and treatment practices can vary greatly and change rapidly with age, body weight, physiology, and developmental level.

To further address the need for standards in the development of EHRs that could help meet the needs of children, the Agency for Healthcare Research and Quality (AHRQ) recently developed the Children’s EHR Format.¹⁴ The goal of the format was to provide the many key stakeholders, including EHR developers, EHR purchasers, and the end user care providers, with an understanding of the minimum requirements for data standards and EHR features to optimize pediatric healthcare. These lists of features by the AAP and the AHRQ can serve as a useful starting point for hospitalists evaluating potential new EHR systems or optimizing the features of an existing system.

CURRENT STATE OF EHR ADOPTION IN CHILDREN’S HOSPITALS

Although the first EHR systems were implemented in the 1970s, a recent survey of children’s hospitals revealed that only 17.9% had a basic EHR system, and only 2.8% met criteria for having a comprehensive EHR.¹² While over 95% of hospitals had radiology images and lab results available electronically, fewer had drug-allergy alerts (62%), age-based dosing support (44%), CPOE (34%), problem lists (24%), and physician notes (13%). Financial costs were identified as the largest barrier to EHR adoption or comprehensive feature implementation. Recent efforts by the United States government to provide financial incentives for EHR use may stimulate advancement in these low adoption rates.

FEDERAL INCENTIVES FOR EHR ADOPTION

In an effort to spur adoption of health information technology, the federal government allocated 155 billion dollars in the American Recovery and Reinvestment Act of 2009 (ARRA) to fund Title XIII, the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act allocates nearly 26 billion dollars to incentivize the adoption and “Meaningful Use” of certified EHR systems, as strictly defined by the Office of the National Coordinator for Healthcare Information Technology (ONCHIT). These incentives are in the form of Medicare and Medicaid payments to eligible professionals and hospitals.^15,16

The three stages of Meaningful Use are designed to help organizations guide their incremental implementations of EHR systems.^17,18 The goal of Stage 1 is to implement an EHR capable of data capture and sharing, followed by Stage 2’s requirement to demonstrate more advanced clinical processes and finally Stage 3’s requirement to show improved patient outcomes¹⁹ (Table 6-3). Hospitals must attest that their EHR meets certain quality measures for certification in order to advance to the next stage. To aid providers in undertaking EHR implementations, the HITECH act also describes funding for the creation of Regional Extension Centers (RECs) to provide information technology support, as well as other workforce training and research programs in information technology.¹⁷