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January 21, 2008

Pediatric EMRs: Big Considerations for Small Patients
By Selena Chavis
For The Record
Vol. 20 No. 2 P. 14

By issuing a set of specialty-specific guidelines, the American Academy of Pediatrics hopes to lend a hand to puzzled pediatricians mulling over EMR technology.

In the evolving marketplace of electronic medical records (EMRs), physicians and healthcare organizations press forward toward adoption in the hopes that most of the major pitfalls to success have already been identified. As with any significant initiative, however, most professionals recognize and expect that some issues will surface and be identified by way of the ever reliable “trial-and-error” method.

In the case of specialized areas of medicine, many physicians and healthcare organizations are finding out that the one-size-fits-all approach to EMR deployment just does not work.

In fact, the American Academy of Pediatrics (AAP) recently took steps to identify guidelines for EMR adoption specific to pediatric needs. “It’s a policy statement detailing what functions we believe are important for an EMR when the care of children is involved,” says S. Andrew Spooner, MD, MS, FAAP, a pediatrician who serves on the AAP Council on Clinical Information Technology. “We want systems that will work in pediatrician practices and children’s hospitals.”

A study recently commissioned by the Centers for Disease Control and Prevention (CDC) suggests that 29% of U.S. office-based physicians in 2006 reported using either a partial or full EMR system, up from 22% in 2005. Spooner believes adoption rates among pediatricians fall below that average, noting that “it’s still in the early adoption phase of the curve.”

A recent survey by the Child Health Evaluation and Research Unit of the division of general pediatrics at the University of Michigan Health System supports his belief. Of 1,000 pediatricians surveyed—58% of whom responded—21.3% reported having an EMR in their practice. The proportion with EMRs increased with practice size, from 3.5% in solo practices to 14.2% in small practices and 31.9% in large practices. Those in a practice network were more likely to report having an EMR than those in independent practices, according to the study.

Andrew J. Schuman, MD, a New Hampshire-based pediatrician who developed his own pediatric EMR product, says he “liked the concept of the EMR but found that [what was available on the market] was not suitable for a pediatric office.”

Finding products to effectively address pediatric needs will be the challenge for most pediatricians, especially those in smaller, independent practices, according to Mark M. Simonian, MD, FAAP, a California-based pediatrician who serves on the AAP Council on Clinical Information Technology. “It’s a challenge because there is so much out there,” he says, noting that there are only a smattering of EMRs specific to pediatric practices because there has been limited market demand until now. “It’s got to be custom for their practice.”

Guidelines for Success
Spooner says child healthcare providers continually find that the many clinical information systems developed prior to AAP guidelines have limited usefulness in pediatrics because they are generally designed for adult care. The primary areas identified by the AAP that need to be addressed include immunization management, growth tracking, medication dosing, data norms, and privacy in special pediatric populations. “If they [EMRs] don’t do those things, they are probably not pediatric-competent at all,” Simonian says.

Immunization Management
The ability to efficiently record multiple immunizations is critical for pediatric health maintenance activities, and state and federal regulations add a complexity to the process of recording immunization administration that is absent from adult guidelines.

“All of these activities require support from the information system used to track immunization data,” Spooner explains, adding that the National Childhood Vaccine Injury Act has numerous requirements for immunization data recording. “Among these is the requirement to deliver to the parent a vaccine information statement [VIS] and to record when it was given and which version of the VIS was given.”

In addition to recording requirements, Spooner says it’s important that pediatric EMRs be interoperable with electronic immunization information systems or registries and feature immunization decision support.

The guidelines explain that “systems for encoding rules about which immunizations are due and when they are projected to be due have been in existence for years,” he says. “For an EMR system to fully support a pediatric practice, it must be able to take previous immunization data and derive, at the point of care, logical conclusions about the currency of immunization and recommend the appropriate immunizations.”

Simonian confirms the significance of proper immunization support in a pediatric office, noting that “immunization and growth tracking are just very intimate to what the pediatrician does.”

Growth Tracking and Norms
From the standpoint of growth tracking, Spooner says child health providers must make judgments about a patient’s health by reviewing a plot of body measurements—including weight, height, head circumference, and body mass index—over time. An EMR should provide base percentile curves from an accepted source of what is average and what is not. “Some general purpose EMRs miss this,” Spooner says.

And there are other areas where data must be tailored to fit children. “Norms is another very tricky area for the EMR market,” Spooner adds, pointing out that with all the numerical data, you need a computer that understands norms for pediatric populations.

Medication Dosing
Since the predominant method for calculating pediatric drug dosages is based on body weight, the guidelines suggest that the EMR system should be able to incorporate weight into the prescribing process and make recommendations based on accepted references.

To ensure accuracy, the guidelines also point to the need for follow-up by the EMR system when body weight is not available. The report also suggests the need for an EMR to require dosing adjustments as weight increases and determine whether the documented weight is recent enough to be used for decision support.

Additionally, the EMR should support the ability to compute safe and convenient doses for liquid medications, the incorporation of age-based dosing decision support, and the capability to generate instructions for pharmacies for dividing prescriptions by home and school use.

“It seems so simple, but even the EMR we are implementing at [a local children’s hospital] doesn’t do it the way I want it to,” Spooner remarks. “There are still a lot of gaps in these systems.”

Patient Identification
Spooner notes that many changes can occur in the days and weeks following a child’s birth, and the ability to accurately capture patient identifiers is crucial to an EMR product’s success.

The guidelines point out that many EMR systems require the use of a government-issued identification number, but newborn infants do not receive these numbers for a significant period of time after birth. Therefore, an EMR should allow registration to occur with temporary identifiers.

Also, because infants sometimes undergo name changes in the days and weeks following birth, EMR systems should support the retrieval of previously used data or temporary names.

While privacy is an issue for all electronic interchange in healthcare, Spooner says it becomes trickier with pediatric populations. With adolescent populations, Spooner says the parameters of privacy can be individual to specific patients and families. “It’s considered best practice in pediatric care to have some kind of agreement this way,” he notes. “You at least want your computer to comply with what you have agreed to with the family.”

The guidelines also point to specific needs for children in foster care, adoptions, guardianships, and emergency treatment.

According to John Deutsch, vice president at EMR Experts, the greatest challenges facing the market for specialty EMRs arise from a limited marketplace.

“Many of the specific EMRs from vendors that only focus on a few specialties tend to have one thing in common—lack of money devoted to research and development,” he says, citing his belief that for the majority of EMR vendors, business is not profitable. “With this being said, how can a vendor focused on only a few specialties compete against vendors that are developing products for all specialties and doing a great job in all these specialties?”

Spooner agrees, noting that there have been only a handful of products developed specifically as pediatric EMRs, none of which are mainstream. “There’s not enough of a market,” he says.

Most vendors that address larger enterprise markets have the resources and capabilities to address pediatric needs, but, according to Schuman, the products—which can cost upward of $20,000—pose a financial challenge for many small practices.

“I was at a great advantage that I could develop my own,” he says. “The small traditional practice has to buy the EMR, invest in software and hardware and the training. That’s a big endeavor.”

Deutsch has seen many specialty EMRs that are plagued by bugs and lack features and support.

Concerning Shuman’s EMR product, he says that it “was built on the notion that it had to work into the workflow of my office.” It integrates the necessary functions outlined by the AAP, as well as all the paper used in his office. The product also provides extras such as customized instruction sheets for parents and other “fun” components that would appeal to families.

While he has had some success in selling a handful of the products, Schuman acknowledges that most pediatricians are interested in a total package integrating an EMR with a practice management function.

Simonian suggests that many physicians look at the cost of an EMR from the wrong vantage point, focusing on initial costs rather than future benefits. “Some people have different concepts of what they should be paying for [an EMR product],” he says. “One of the systems can equate to a half-time person in their office.”

Along with challenges in the marketplace are fears that general practice EMRs will create difficulties for pediatric patients up the road. “We’re a little more concerned about children treated outside the pediatric setting,” Spooner says, pointing out that industry statistics suggest 50% of children and adolescents are seen by a doctor other than a pediatrician. “A child with a cold or broken ankle or cut … it’s very likely they will be seen outside the pediatric setting.”

An Evolving Concept
According to Spooner, specialty EMRs are just part of the evolving landscape of EMR adoption and development. He believes the guidelines and functions suggested by the AAP can be useful for patients of all ages. “None of these areas are specific to pediatrics,” he says. “There is no such thing as a purely pediatric function.”

Simonian agrees, noting that “it’s much more efficient for EMR vendors to address the larger markets” with these functions.

Deutsch believes that pediatrics will be one of the better specialty areas for EMR adoption and specialized functions. “It’s very easy to implement since the specialty adheres to a fairly common and predictable workflow and requires a lot of ongoing health maintenance care,” he says.

The AAP is taking a proactive stance in pushing its guidelines with the belief that the best way to get the functions mainstream will be through accreditation groups such as the Certification Commission for Healthcare Information Technology (CCHIT). “The vendors just want to sell a product that satisfies and sells,” Spooner notes. “We’re trying to elevate the importance of these things any way we can.”

Emphasizing that certification is a path to accelerating the adoption of these standards, Spooner also recognizes that there are many challenges to the process. “CCHIT has the problem in that everyone is coming at them with things they want EMRs to do,” he says. “[The guidelines] are doable, but you have to deal with the reality of the marketplace.”

The biggest drivers, according to Spooner, will be customers. While a children’s hospital would not purchase an EMR without the base functionalities outlined by the AAP, Spooner’s concern is about the general hospital down the road.

“We would like the CCHIT process to promote some kind of base functionality,” he says.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.