Special considerations for Pediatric Practices

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Additional information regarding pediatric informatics may be found here: Specialized Needs of a Pediatric EHR

Electronic medical record systems were originally designed for adult care. However in pediatrics, these systems must execute certain actions unique to the care of infants, children and adolescents. These unique requirements need special consideration from designers to facilitate care, support the physician’s work and make pediatric care for children safe.

Required features

The American Academy of Pediatrics had published a list of desirable features since 2001. [1] This list includes:

  • Immunization management
  • Medication dosing
  • Growth tracking
  • Patient identification
  • Privacy
  • Data precision
  • Pediatric terminology

Immunization

Immunization has always been a critical activity in the care of children. EMR system must provide a pediatrician with the ability to record and display data that helps them to comply with the federal law. This data consists of the manufacturer’s name, lot numbers, expiration dates, and site of vaccine administration, route, and date. It also contains consent for administration or documentation of vaccine refusal. The ability to document the vaccine information statements (VIS) that are delivered to the parent, i.e. when this information was given and the version given, allows physicians to comply with the requirements of the Vaccines for Children program (VFC) and National Childhood Vaccine Injury Act. The EHR systems should also have the ability to update the immunization records in registries at the state or local levels and provide decision support that recommends the appropriate immunization from data entered at the time of care.(2,3)

Appropriate doses of medication

Another activity that requires special consideration is the prescription of medication based on age and weight or body surface area. Tools that allow physician to check current weight against the age, verify doses against accepted pediatric references, express the prescriptions in volume to be administer by caregivers and pharmacy specifications other than instructions for the parents are important functions to assist in selecting medication and prevent errors.

Growth charts

Furthermore, the ability of the EMR system to provide growth charts is a unique requirement for pediatricians. Clinicians make important decision regarding how their patients have been growing by plotting length or height, weight and head circumference against age. These graphic representations allow the pediatrician to analyze the growth velocity at specific age, by gender and against establish norm, enabling the physician to identify problems at the early stages. (4)

System designers should also take special consideration when establishing normal ranges for numeric (vital signs, body measurements, scores on standardized assessments, and laboratory results) data in view that these values change with child‘s age. Also the EMR should have the ability to present not only the chronological age but also corrected age (gestational + chronological) which is also important in the care of premature infant. (5)

It is also important for the clinician, while taking care of the pediatric population, that the EMR system has the flexibility for patient identification even though this functionality is supported with practice management software. Very often the clinician faces temporary registration of their patients in the newborn period (Baby Boy of…), and it will be ideal to be able to connect this identification with the official ones (i.e. social security numbers). This type of flexibility on patient identification, will allow easy retrieval of pre-, peri- and post-natal information at the time of patient care. Also it should allow the re-assignment of gender at later stages in cases of ambiguous genitalia when sex can not be assigned after birth.

Privacy issues

Privacy issues are very unique in the pediatric population. The EMR should have different privacy needs regarding the variability of adolescent medicine from state to state, restriction and protection of sexual and mental health information, and behavior issues. In addition the system should be able to record the different guardianships in cases of foster care, adoption, and emergency treatment. (6)

The description of pediatric terms is extremely difficult in EMR systems. The system designers needs to expand standard terminology to include concepts that adequately represent these terms by describing historical findings, psychosocial risk factors, family structural details, social history, physical examination findings, developmental problems, behavioral issue, congenital syndromes and diagnoses particular to pediatrics.

The ability to present data at the appropriate numeric precision and graphical resolution is another functionality that requires special consideration in pediatrics. The designers need to facilitate graphical representation of frequent measurements such as daily weights of weekly head circumference and to provide the ability to record the age down to the hour and minutes at the newborn stage. It is also important to recognize that small changes can have a major impact in the care of pediatric patients.

Other features that are important are the ability to archive and manage patient data for a statutorily defined period of time, provide educational materials that are appropriate for both parents and children and at varying reading levels, create pedigree diagrams, display age at all times thought out the user interface, select age based documentation template and order sets on the basis of a patient’s age and indicate the source of patient data, particularly when the source is not the patient or the parent.


Additional Features

Developmental Screenings.

Anticipatory Guidance Content.

Specific Pediatric Guideline Content.


The American Academy of Pediatrics official informatics initiative: CHIC (Child Health Informatics Center)

CHIC

References

  1. Special requirements for electronic medical record systems in pediatrics. Pediatrics 2001; 108; 5133-515.
  2. Lyznicki JM, Rinaldi RC. Childhood immunization and the vaccines for Children Program. Arch Fam Med. 1994; 3:728-730.
  3. National Childhood Vaccine Injury Act: requirements for permanenet vaccination records and for reporting selected event after vaccination. JAMA.1988: 259: 2527-2528.
  4. Rosenbloom ST, Qi X, Riddle WR, et al. Implementing pediatric growth charts into an electronic medical record system. J AM Med Inform Assoc. 2006: 13: 302-308.
  5. American Academy of Pediatrics, Committee on Fetus and Newborn. Age terminology during the perinatal period. Pediatrics. 2004; 114: 1362-1364.
  6. American Academy of Pediatrics, Committee of Emergency Medicine. Consent for medical services for children and adolescents. Pediatrics. 2003: 111: 703-706.


Spooner SA. Special requirements of electronic health record systems in pediatrics. Pediatrics. 2007 Mar;119(3):631-7.