EHR-S DSTU Functional Outline: DRAFT SPECIAL POPULATIONS – PEDIATRICS – DIRECT CARE (DC1) V2
ID / Name / Statement / Description / See Also / Rationale / Special PopulationsPediatrics / Gaps / Citations
DC.1 / Care Management
DC.1.1 / Health information capture, management, and review / For those functions related to data capture, data may be captured using standardized code sets or nomenclature, depending on the nature of the data, or captured as unstructured data. Care-setting dependent data is entered by a variety of caregivers. Details of who entered data and when it was captured should be tracked. Data may also be captured from devices or other Tele-Health Applications. / S.3.1.4 / The pediatric EHR should be configured so that once the patient gender and age is entered,(including gestation age if child is born <38 weeks gestation) age/gender appropriate forms are presented to the caregiver entering the data. For example, the appropriate templates for growth data fields would be presented to the caregiver utilizing CDC standards based on the demographic data (ie length, weight, head circumference for <36 months,: Height , weight, BMI for over 36 months. In addition standardized health maintenance forms, school forms, athletic forms, immunization forms would be presented according to standardized demographic data.
Demographic data for children would also include data fields for guardianship, or standardized forms for children in foster care so the data could be easily transferred from one caregiver to another electronically..
Data should be able to be shared with registries—for example—state immunization registries, metabolic disease registries, lead poisoning registry, potentially CDC registries.
PRIVACY ISSUES specific to pediatric patients---Certain adolescent data such as psychological counseling, sexual history, treatment for drug abuse [NA1]can be requested by the adolescent to be sequestered from the medical record available to parents. Therefore the EHR must have a capability of managing this data in a separate category.
Hearing Screening at Birth is undertaken in 38 states by automated screening devices. It is possible to send the screening outcomes from about 16 manufacturers to the information systems used at the birthing facility, the Medical Home office or the state department of health – thus minimizing data entry errors. Similarly, data from newborn metabolic screening is sent electronically to information systems. TF
Comment re device capture: should we note that device capture should be the preferred method of data entry to minimize entry errors from human intervention. / Standardized HL-7 acceptable forms for age appropriate health maintenance, sports physicals, immunizations etc.. Also specialized forms for children in guardianship or foster care situations. / ISO/TS 18308 - Health Informatics - Requirements for an Electronic Health Record Architecture; ASTM E 1769 Standard Guide for Properties of Electronic Health Records and Record Systems
AmericanAcademy of Pediatrics standardized health forms
DC.1.1.1 / Identify and maintain a patient record / Identify and maintain a single patient record for each patient. / Key identifying information is stored and linked to the patient record. Static data elements as well as data elements that will change over time are maintained. A lookup function uses this information to uniquely identify the patient. / Supports delivery of effective healthcare, Improves efficiency, Improves patient safety / Patient identifier. A universal patient identifier is a desirable but as yet unachieved goal. Any system that is ultimately implemented to assign such identifiers will need to provide for assignment immediately at the time of birth (or even before birth for prenatal procedures performed on the fetus). EMR systems may need to accommodate temporary (ie, changing) data in this key field, including certain identifying data associated with a patient change in the perinatal period. For example, infants are often named with their mother’s surname or full name (eg, “Infant Boy Smith” or “Boy June Jones”) at the time of birth, and this is changed in the first few days of life. Flexibility of search criteria to allow for changing identification data are desirable in pediatric systems. Systems should be able to maintain a record of multiple names used by a patient.
Create ability to communicate with registries---state, CDC etc / In the England NHS, the newborn hearing screening system is primed by electronic birth notification (NN4B) for all babies. If available in the US, this approach of priming IT systems with such a number would reduce errors. TF / Newborn Screening Programme, NHS 2004, Como Professor Adrian Davis , Medical Research Council. TF
DC.1.1.2 / Manage patient demographics / Capture and maintain demographic information. Where appropriate, the data should be clinically relevant, reportable and trackable over time. / Contact information including addresses and phone numbers, as well as key demographic information such as date of birth, sex, and other information is stored and maintained for reporting purposes and for the provision of care. / S.1.4.0; S.1.4.1; S.1.4.2; I.1.4.4; I.1.4.5 / Supports delivery of effective healthcare, Improves efficiency, Improves patient safety / Time of birth. The time of a child’s birth is important in calculating exact age in the first days of life and should not be omitted from EMR systems. Gestational age should be recorded and carried forward if a child is born <38 weeks gestation. Since there are children who cannot be assigned asex at birth, a data field for “undetermined” sex designation is required.
Critical in newborn metabolic screening to be able to calculate age of baby at blood spot collection for validity purposes. TF
DC.1.1.3 / Manage summary lists / Create and maintain patient-specific summary lists that are structured and coded where appropriate. / Patient summary lists can be created from patient specific data and displayed and maintained in a summary format. The functions below are important, but do not exhaust the possibilities. / S.1.4.0; S.1.4.1; S.1.4.2; I.1.4.4; I.1.4.5 / Supports delivery of effective healthcare, Improves efficiency, Facilitates management of chronic conditions, Improves patient safety / In pediatrics summary lists should include developmentatl assessment, educational status, and record what anticipatory guidance has occurred. Immunization status should be summarized with links to actual record. / Summary lists should be available for providers to view the results of various Public Health Screening Programs such as Hearing, Metabolic and Genetics, lead screeningas well as follow-up testing.These might be derived data from a series of contacts. TF
DC.1.1.3.1 / Manage problem list / Create and maintain patient-specific problem lists. / A problem list may include, but is not limited to: Chronic conditions, diagnoses, or symptoms, Functional Limitations, visit or stay-specific conditions, diagnoses, or symptoms. Problem lists are managed over time, whether over the course of a visit or stay or the life of a patient allowing documentation of historical information and tracking the changing character of problem(s) and their priority. All pertinent dates, include date noted or diagnosed, dates of any changes in problem specification or prioritization, and date of resolution are stored. This might include time stamps, where useful and appropriate. The entire problem history for any problem in the list is viewable. / Supports delivery of effective healthcare, Improves efficiency, Facilitates management of chronic conditions / Problem summary lists should include demographic data, acute and chronic illness, all procedures through age 18 , including prenatal procedures if applicable. There should be the ability to include developmental, educational, and social data as necessary. [NA2]
DC.1.1.3.2 / Manage medication list / Create and maintain patient-specific medication lists. / Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start, modification, and end dates are stored. The entire medication history for any medication, including alternative supplements and herbal medications, is viewable. Medication lists are not limited to medication orders recorded by providers, but may include, for example, pharmacy dispense/supply records and patient-reported medications. / Supports delivery of effective healthcare, Improves patient safety / Medications must be listed as appropriate pediatric doses—ie mgm/kgm/day or dose/BSA etc.
DC.1.1.3.3 / Manage allergy and adverse reaction list / Create and maintain patient-specific allergy and adverse reaction lists. / Allergens and substances are identified and coded (whenever possible) and the list is managed over time. All pertinent dates, including patient-reported events, are stored and the description of the patient allergy and ADVERSE reaction is modifiable over time. The entire allergy history, including reaction, for any allergen is viewable. The list(s) include drug reactions that are not classifiable as a true allergy and intolerances to dietary or environmental triggers. Notations indicating whether item is patient reported and/or provider verified are supported. / Supports delivery of effective healthcare, Improves efficiency, Facilitates management of chronic conditions, Facilitates self-health management, Improves patient safety / Allergies should be listed as separate entities: Food and Medications. Secondly they should be divided into allergic reactions, side effects, intolerances.[NA3]
DC.1.1.4 / Manage Patient History / Capture, review, and manage medical procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history. / The history of the current illness and patient historical data related to previous medical diagnoses, surgeries and other procedures performed on the patient, and relevant health conditions of family members is captured through such methods as patient reporting (for example interview, medical alert band) or electronic or non-electronic historical data. This data may take the form of a positive or a negative such as: "The patient/family member has had..." or "The patient/family member has not had..." When first seen by a health care provider, patients typically bring with them clinical information from past encounters. This and similar information is captured and presented alongside locally captured documentation and notes wherever appropriate. / Supports delivery of effective healthcare, Facilitates management of chronic conditions / Family member links. EMR systems should be able to maintain links to records of other family members (who may have different surnames) in the EMR system. Because an interaction with one family member often triggers an encounter with another family member (typically a sibling), EMR systems should support easy movement between records of children within in the same family.
Standardized electronic genetic diagrams should be able to be created and available for known genetic diseases —ie in Autosomal Polycystic Kidney Disease, an electronic template would allow identifying affected vs non affected individuals in multiple generations.
DC.1.1.5 / Summarize health record / Present a chronological, filterable, and comprehensive review of a patient's EHR, which may be summarized, subject to privacy and confidentiality requirements. / A key feature of an electronic health record is its ability to present, summarize, filter, and facilitate searching through the large amounts of data collected during the provision of patient care. Much of this data is date or date-range specific and should be presented chronologically. Local confidentiality rules that prohibit certain users from accessing certain patient information must be supported. / Supports delivery of effective healthcare, Improves efficiency, Facilitates management of chronic conditions, Improves patient safety / See DC.1.1.5
DC.1.1.6 / Manage clinical documents and notes / Create, addend, correct, authenticate AND CLOSE, AS NEEDED, transcribed or directly-entered clinical documentation and notes. / Clinical documents and notes may be created in a narrative form, which may be based on a template. The documents may also be structured documents that result in the capture of coded data. Each of these forms of clinical documentation are important and appropriate for different users and situations. / Supports delivery of effective healthcare, Improves efficiency, Facilitates management of chronic conditions, Improves patient safety / Standardized documents that pull previously entered demographic data should be created—ie age appropriate health forms, camp forms, athletic forms, immunization forms should be created from the configured system and prepopulated with appropriate data—ie utilizing data already entered allowing for unique update and narrative as necessary, and then allowing for printing out for use on a just in time basis. / AAP standardized forms
DC.1.1.7 / Capture external clinical documents / Incorporate clinical documentation from external sources. / Mechanisms for incorporating external clinical documentation (including identification of source) such as image documents, and other clinically relevant data are available. Data incorporated through these mechanisms is presented alongside locally captured documentation and notes wherever appropriate. / Supports delivery of effective healthcare, Improves efficiency, Facilitates management of chronic conditions, Facilitates self-health management, Improves patient safety / Growth data. Attention to the special significance of children’s growth in pediatric practice is essential for any pediatric EMR system. Recording, graphic display, and special calculations of growth patterns is a critical function. The ability to calculate, display, and compare a child’s growth percentiles and body mass index with normal ranges is vital. Because normal growth ranges vary among ethnic and geographic groups, the ability to use different ranges for different patients may be important in some practice settings. Head circumference, an important measurement used almost exclusively for care of pediatric patients, should be a part of these growth monitoring functions. Because small changes in growth parameters may be important to small patients (eg, a few grams’ weight gain in a premature neonate), systems should be able to store data on a small enough scale to [NA4]represent these changes.
Pediatiic EHR should allow school forms to be part of the medical chart / Stqandardized school forms/educationl testing/psychologic assessment forms that would integrate into the medical record
DC.1.1.8 / Capture patient-originated data / Capture and explicitly label patient-provided and patient entered clinical data, and support provider authentication for inclusion in patient history / It is critically important to be able to distinguish patient-provided and patient-entered data from clinically authenticated data. Patients may provide data for entry into the health record or be given a mechanism for entering this data directly. Patient-entered data intended for use by care providers will be available for their use. / Supports delivery of effective healthcare, Improves efficiency, Facilitates management of chronic conditions, Facilitates self-health management / The Pediatric HER should provide a mechanism and standardized forms for parents to fill out electronically to aid in care. For example: a child’s developmental status, educational level, and disease specific questionnaires that can be formally part of the EHR. / Standardized parental forms for developmental/educational status, and chronic diseases such as ADHD, asthma, etc.
Data reported by parent to provider should be distinct from “clinically authenticated” data and should be searchable as separate from other data sources. TF / AAP forms
DC.1.1.9 / Capture Patient and Family Preferences / Capture patient and family preferences at the point of care. / Patient and family preferences regarding issues such as language, religion, culture, eTechnical Committee. that may be important to the delivery of care. It is important to capture these at the point of care so that they will be available to the provider.
DC.1.2 / Care plans, guidelines, and protocols / DS.2.2 / Guidelines should be age specific. Critical to include immunization recommendations and reminders.
Should trigger anticipatory guidance recommendations. / ISO/TS 18308 Final Draft - Health Informatics - Requirements for an Electronic Health Record Architecture. (care plans); HIMSS Electronic Health Record Definitional Model June 2003 (protocols); ASTM E 1769 Standard Guide for Properties of Electronic Health Records and Record Systems
DC.1.2.1 / Present care plans, guidelines, and protocols / Present organizational guidelines for patient care as appropriate to support order entry and clinical documentation. / Care plans, guidelines, and protocols may be site specific, community or industry-wide standards. They may need to be managed across one or more providers. Tracking of implementation or approval dates, modifications and relevancy to specific domains or context is provided. / 2.2.1.3 / Supports delivery of effective healthcare, Improves efficiency, Facilitates management of chronic conditions, Improves patient safety
DC.1.2.2 / Manage guidelines, protocols and patient-specific care plans. / Provide administrative tools for organizations to build care plans, guidelines and protocols for use during patient care planning and care / Guidelines or protocols may contain goals or targets for the patient, specific guidance to the providers, suggested orders, and nursing interventions, among other items. / DC.1.2.1 / Supports delivery of effective healthcare, Improves efficiency, Facilitates management of chronic conditions, Improves patient safety / Each care plan/guideline must list source/date of update/accountable group. In pediatrics, they must include pediatric specific recommendations or note whether they exclude children.[NA5]
DC.1.2.3 / Generate and record patient-specific instructions / Generate and record patient-specific instructions related to pre- and post-procedural and post-discharge requirements. / When a patient is scheduled for a test, procedure, or discharge, specific instructions about diet, clothing, transportation assistance, convalescence, follow-up with physician, etc. may be generated and recorded, including the timing relative to the scheduled event. / Include immunization reminders, anticipatory guidance.
DC.1.3 / Medication ordering and management / Prescribing of medications. Prescribing of medications for pediatric patients is based on the age and weight or body surface area of the child. Prescription tools that supply standard recommended adult doses and do not include pediatric dose calculation functions are unlikely to be useful to pediatricians and may be misleading or potentially dangerous in the pediatric context. Functions that facilitate calculation of drug doses based on available data are essential for pediatric care. Decision support tools supplied to assist in selecting medications and preventing errors should include pediatric-specific data / The description here in the Special Populations column is also applicable to DC 2.3.1.2 TF / HIMSS Electronic Health Record Definitional Model June 2003