Specialized Needs of a Pediatric EHR
Additional information regarding pediatric informatics may be found here:Special considerations for Pediatric Practices
- 1 Highlights of the Specialized Needs of a Pediatric Electronic Health Record
- 2 Immunizations
- 3 Medication Dosing
- 4 Graphical Representation of Growth Charts
- 5 Norms for Pediatric Data
- 6 Privacy and Guardianship
- 7 Summary
- 8 References:
Highlights of the Specialized Needs of a Pediatric Electronic Health Record
Much of the research regarding the functions of an Electronic Health Record have not addressed the specialized needs of a large majority of our population: children, adolescents and young adults. The tools pediatricians use in their daily practice are quite unique. Pediatricians specialized needs include a substantial immunization database, the use of growth charts produced by the World Health Orgnazation and the Centers for Disease Control, and health care plans and medication administration instructions that can follow children as they progress through school and can be easily interpreted and enforced by people they associate with: parents, teachers, child care workers, coaches and even bus drivers.
Documenting of immunizations:
Administration and recording of vaccinations is a major event at any pediatrician’s office and is extremely time-consuming. Great attention to detail must be documented including the type of vaccine, manufacturer, lot number, expiration date, site the immunization was given, and the route of administration, including any allergies the patient may have. Many pediatricians utilize a state vaccination documentation database. A unified interface with these databases would be a useful tool in keeping track of vaccinations as children grow and may move or travel frequently.
Clinical Decision Support (CDS) for immunizations and recommendations:
In our highly mobile society, it is crucial for recording of vaccinations to be accurate and easily accessible so that recommendations for vaccines are correctly identified, and go with the patient as they relocate. Our current state immunization database is useful in this area in that vaccinations given in the state (or simply recorded as historicals in the state) are all merged into one database. This database then allows a query of which vaccinations the child is suggested to have at their next age level, as recommended by the Centers for Disease Control and The American Academy of Pediatrics. Statewide, this system is sufficient, but nationally, and even more so globally, there can be major disparities among vaccinations received among children from different countries, and a universal database can bring awareness to vaccination recommendations and boosters that are different or lag behind. 
Dosing by Body Weight
The standard of care in medication calculations in the pediatric environment are computed based on the patient’s body weight. The smaller size of pediatric patients makes any errors highly poisonous or even lethal. An EHR system should be able to easily calculate the appropriate medication dosing based on the entered body weight and provide a suggested dose based on the medication library. When applicable, the prescriber should also be alerted to any dosing levels outside of the recommended range by using accepted pediatric references, or when weights entered do not match up with the growth curve charts of the same visit. The provider should also be alerted when no pediatric references exist. An EHR that supports reliable pediatric and neonate dosing systems and can interface with many vendor pharmacies and a CPOE product should be part of an e-prescribing system.
Rounding Doses for Caregivers and Medications Given at School
Many medications for infants and young children are supplied in liquid form. Because parents and other caregivers must measure a volume of liquid for each dose of medication, child health care providers must compute a volume for each dose, round it to a convenient volume, and spend time educating caregivers on the proper volume to administer. EHR systems that facilitate prescribing should support prescriptions expressed in the volume of drug to be administered and avoid expressing the prescription solely in terms of the mass of the drug. Pediatricians must often write prescriptions in which the medication is divided in 2 labeled packages—one for home administration and one for administration during the day at school, child care, or another care setting. EHR systems should provide the capability to generate instructions to the pharmacy to dispense a medication in this way. 
Graphical Representation of Growth Charts
One of the best health indicators for pediatricians is the use of a child’s body measurements, including height or length, weight, head circumference and body mass index over time. These measurements are plotted beginning at birth and at subsequent well baby and child exams throughout the patient’s life. Plots show the progression of measured values over time against curves of projected growth, commonly called percentile curves, and variations off of the curve can indicate a health problem early on. An EHR system should allow the representation of percentile curves for ease of use by pediatricians. The system should be able to distinguish height from length, and be able to accommodate corrections for premature birth in a graphical display. Percentile values should also be entwined with decision-support functions of the EHR system. An EHR system that can integrate growth charts and can calculate values and certain patient characteristics, to help pediatricians at the point of care would be invaluable.
Norms for Pediatric Data
Normal ranges for pediatric numeric data such as vital signs, growth measurements and laboratory results change over time as the child grows. A Clinical Decision Support (CDS) tool that can capture the normal ranges for the child’s age over their lifespan is essential. An alert system that can monitor and inform of abnormal and/or critical values throughout the child’s development is necessary. A system that can digest patient numbers obtained and can capture and flag abnormal values is crucial.
Privacy and Guardianship
Complex privacy and guardianship issues are of paramount importance to pediatricians, because much of the laws are state regulated and can vary immensely. Pediatricians must carefully balance health care information use and disclosure including the patient’s right to privacy of medical information and society’s need for reasonable access to medical information for the patient’s treatment, insurance payment, research, and other purposes. Special privacy considerations when treating adolescents (e.g. AIDS testing, STD treatment, pregnancy testing) require the flagging by the EHR and the adolescent may have to give explicit permission for the parent or guardian to review his or her record. Court certified documents of guardianship and custody should be easily integrated into a pediatrician’s EHR so that timely treatment of children and privacy issues are respected.
The lack of research and development of EHR’s that address the needs of pediatricians is a problem that needs to be addressed. If not, a major disservice to our children is at stake. Pediatricians needs access to immunization databases, global growth charts and specialized CDS that makes medication dosing and recognition of critical laboratory values easy at the point of care. Privacy and guardianship concerns should also be easily incorporated into a pediatric EHR.
Submitted by: Carolyn J. Allen, Pediatric RN
- 1. Spooner, S. Andrew, MD, MS, and the Council on Clinical Information Technology Special Requirements of Electronic Health Record Systems in Pediatrics,. Pediatrics Vol. 119 No. 3 March 1, 2007, pp. 631 -637.
- 2. Rosenbloom ST, Qi X, Riddle WR, et al. Implementing pediatric growth charts into an electronic health record system. J Am Med Inform Assoc.2006;13 :302– 308
- 3. Prot, Sonia, Fonta, Jean Eudes, Alberti, Corinne, et.al., Drug administration errors and their determinants in pediatric in-patients. Int J Qual Health Care (October 2005) 17 (5): 381-389.