This chapter will address the following American College of Graduate Medical Education competencies: patient care, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice.

Patient Care: This chapter will help the pediatric health care provider use patient-centered technology to provide care that is individualized, evidence based, compassionate, and family centered.

Practice-Based Learning and Improvement: This chapter will help the pediatric health care provider understand and apply quality improvement (QI) to patient care, using QI cycles to address practice-based improvement, and using information technology to facilitate care, including the EMR and online educational resources that are essential elements to enhance practice-based learning and improvement.

Interpersonal and Communication Skills: This chapter will help the pediatric health care provider use technology to enhance effective exchange of information, in collaboration with patients and families, as well as with other health professionals.

Systems-Based Practice: This chapter will help the pediatric health care provider understand the use of information systems in patient care and demonstrate an awareness of the larger system of health care delivery and ability to interact with the system to optimize patient outcomes.

Technology to enhance health care delivery is currently advancing at a rapid pace. HIT can facilitate and integrate the multiple facets of health care delivery. It can also be used to enhance patient-centered communication. In addition, HIT can be leveraged to generate practice—and population level longitudinal data to inform systems—level changes for the prevention and management of disease. As articulated by Dr. David Blumenthal, former US National Coordinator for Health Information Technology, “Information is the lifeblood of modern medicine. HIT is destined to be its circulatory system. Without that system, neither individual physicians nor health care institutions can perform at their best or deliver the highest quality care, any more than an Olympian could excel with a failing heart.”¹ In this light, effective utilization of HIT can be seen as vital to childhood obesity management and prevention efforts in our country.^2,3

The Chronic Care Model provides a framework for a multidimensional approach to the care of patients with chronic conditions.⁴ This model, with its emphasis on the importance of effective partnerships among patients, clinicians, the health care system, and the community can aptly be applied to the management of children with obesity.⁴ As part of the Chronic Care Model, components of the health care system important to these effective partnerships include self-management support, decision support, delivery system design, and clinical information systems.⁴ These components create an organizational framework for health care delivery that informs the patient, prepares the health care clinician, and initiates productive interactions between the patient and health care clinicians.⁴ The ultimate goal is to provide coordinated, family-centered, and evidence-based care to patients and their families in all areas of their life (Figure 16-1).⁵

HIT is integral in delivering health care to children, especially those with chronic diseases like obesity that are dependent on strong partnerships with the child’s health care team and that are heavily influenced by community and environmental factors.^5,6 HIT can be used to provide CDS to pediatric health care providers in order to assist them in identifying, assessing, and managing children with obesity in a standardized and evidence-based manner.^5,6 HIT can also be in the form of patient and family self-management tools to inform and educate patients and families, while supporting and motivating them to adhere to medical recommendations and health goals.⁵ Finally, clinical information systems can be used to analyze health care delivery and patient outcomes at the individual practice level, at a health care systems level, and on a larger population health level in order to determine best strategies for delivering quality care that will improve clinical outcomes.⁵

The Institute of Medicine has released multiple reports that discuss the importance of HIT to improving the efficacy, safety, and quality of the US health care system.^7,8 The US Department of Health and Human Services (DHHS) has echoed this sentiment, saying: “Broad use of HIT has the potential to improve healthcare quality, prevent medical errors, increase the efficiency of care provision and reduce unnecessary healthcare costs, increase administrative efficiencies, decrease paperwork, expand access to affordable care and improve population health.”⁹

The Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act (ARRA) of 2009, provides financial incentives to eligible hospitals and health care clinicians to adopt and meaningfully use EHR technology to improve patient care.^1,10 The Act also supports the establishment of programs to guide hospitals and health care clinicians in the implementation of EHR technology. Ultimately, it aims to improve the quality, safety, and efficiency of care while reducing disparities; engage patients and families in their care; promote public and population health; improve care coordination; and promote the privacy and security of EHRs.^1,10

HIT can be used to close the gap between best practices and actual care. Despite pediatric obesity recommendations emphasizing the role of the pediatric primary care clinician in the prevention and management of obesity in children,^{11, 12, 13, 14} studies demonstrate low rates of identification of obesity, assessment of obesity-related comorbidities, counseling around obesity, and follow-up for obesity in pediatric primary care settings.^{15, 16, 17, 18, 19} Even when obesity is identified, clinicians commonly fail to communicate that a child has obesity,²⁰ which contributes to a parent’s misperception about their child’s weight status.²¹ Pediatricians also have an important role in providing anticipatory guidance,^22,23 and yet families consistently report a need for improvement in pediatrician delivery of anticipatory guidance related to obesity.^24,25 In addition, children with obesity are not often referred to dietitians, behavioral counseling, or tertiary weight management centers for further management.^{19,26, 27, 28}

Commonly, health care providers caring for children report limited knowledge of current clinical practice guidelines as well as feeling uncomfortable and ineffective in managing obesity.^{18,19,29, 30, 31} Pediatric health care providers consistently report barriers to the management of obesity, including lack of time and resources, as well as perceived treatment failures.^{18,19,29, 30, 31} Having identified these barriers, pediatric health care providers report that they would support electronic methods to easily identify patients with obesity, remind them of current guidelines, facilitate ordering, and provide resources to families.²⁹ CDS tools are evidence-based tools designed to provide the clinician with knowledge that is specific to that patient at an appropriate time and point of care in order to facilitate a high quality care decision.

CDS can be used for the identification of children with obesity. As discussed in Chapter 12, the body mass index (BMI) status of a child should be assessed at every well-child visit by the calculation of BMI and BMI percentile. During a clinical encounter, EHR can automatically and accurately perform these repetitive tasks for health care providers. Many EHRs can also automatically and accurately plot a child’s weight and BMI on individualized growth charts that allow providers to longitudinally monitor a child’s weight status (Figure 16-2). Use of the EHR allows for ease of access to tailored growth charts; for example, obesity-specific growth charts with a larger range of weight and BMI values, or growth charts specific to patients with Down syndrome, whose weight and height velocity differ from other children. Further, a provider can be prompted to select the diagnosis code of obesity or morbid obesity, when triggered by an elevated BMI percentile.

CDS tools can be effective in helping pediatric health care providers identify children who have overweight and obesity, with improved BMI screening rates reported in 5 of 8 studies implementing CDS tools in pediatric primary care practices.^{32, 33, 34, 35, 36, 37, 38, 39, 40, 41} A meta-analysis of 3 studies found that pediatric primary care clinicians who used EHRs were 2.5 times more likely to complete BMI screening than clinicians who did not use EHRs.^16,37,39,40

Once a child’s weight status is determined, CDS tools can be used to assist pediatric health care providers in further assessment of obesity-related risk. Evaluation of a child with obesity should include a comprehensive assessment for comorbidities of obesity, which if present, indicate a need for more extensive monitoring and intensive management. CDS tools can facilitate and standardize this process through use of a structured encounter note with embedded reminders to complete a family history focused on obesity and related comorbidities and a review of systems specific to obesity. The EHR can also trigger automatic electronic alerts that help the provider recognize high blood pressure readings and prompt the provider to order indicated laboratory tests (Figure 16-3).

After programming pediatric obesity CDS tool in their EHR, a large network of pediatric primary care practices demonstrated improved diagnosis of obesity and healthy lifestyle counseling. Pediatric obesity CDS tools included an EHR-embedded family history assessment and alerts for laboratory assessment of obesity-related comorbidities.⁴¹ Use of similar CDS tools in another large network of pediatric primary care practices⁶ demonstrated improved clinician behaviors surrounding assessment of obesity-related comorbidities and healthy lifestyle counseling. However, using an EHR alone is insufficient to impact on the care of children with obesity,⁴⁰ and further research is needed to determine the optimal set of CDS tools needed to ensure adoption of best practices.

CDS can be used for interdisciplinary management of children with obesity. As described in Chapter 15, a key component of obesity management is determination of a patient’s and family’s readiness to change and recommendation of appropriate lifestyle and behavioral goals.^11,12 A survey of risk behaviors can be completed at home prior to the office visit via a patient portal linked to the EHR or facilitated at the time of the visit. CDS tools can facilitate and standardize this process through delivering selected risk behaviors at the point of care with suggested guidance. Alternatively, a structured encounter note can prompt the health care provider to complete an assessment of lifestyle behaviors, discuss with a family their readiness to change, and provide evidence-based counseling around lifestyle behaviors.

CDS tools can record evidence-based goal setting, which can be tracked longitudinally and shared among multiple clinicians when using the EHR. Tracking goals and associated behavior changes can help providers identify how achieved goals and changed behaviors impact weight and weight-related outcomes, offering an opportunity for feedback to patients (Figure 16-4). CDS tools significantly increase nutrition and activity counseling rates by clinicians.^6,36,37,41 However, further research is needed to determine if use of CDS tools actually improves short-term outcomes, such as diet and activity behaviors, or long-term outcomes like weight status.

As discussed previously, one of the advantages of the EHR is its ability to seamlessly and accurately track not only patient goals, but also patient weight status and metabolic risk. Chapter 12 discussed the importance of multidisciplinary management of children with obesity, incorporating the expertise of multiple clinicians, including dietitians, exercise physiologists, social workers, psychologists, and other subspecialty care clinicians. The EHR thus offers an additional advantage of integrating information from multiple clinicians in a way that allows for comprehensive and efficient care coordination. Finally, at the completion of a visit, the EHR can provide standardized patient instruction materials, which may include evidence-based healthy lifestyle messages as well as relevant community resources which may be helpful to the family (see Figure 16-4).

HIT can be used for the management of children with obesity outside the clinical setting. Systematic reviews report that over 90% of adolescents in the United States have Internet access, over 75% own a mobile phone, and approximately 50% send text messages daily.⁴² Among adults in the United States, 85% report accessing the Internet daily, over 90% have a mobile phone, and over 75% use their phones for text messaging.^43,44 Access to and use of technology continues to increase over time, especially among younger age groups.^42,44

Potential benefits of using technology to provide adjunctive obesity management to children and their families include accessibility to technology in multiple settings, interactivity and opportunity for immediate and tailored feedback, capability to incorporate interactive and creative media and employ social networking strategies, and ability to provide interventions frequently and in a cost-effective manner. Because of these benefits, technology can be a useful adjunctive tool to improve health behaviors around obesity management.⁴³

Successful obesity treatment depends on a patient’s and their family’s ability to enact and then maintain behavior and lifestyle changes. This requires reinforcement of concepts, as well as continual engagement and motivation. HIT can help achieve these goals by improving communication between clinicians and families, as well as providing tools for self-monitoring and self-management of a child’s obesity outside the clinical setting.