- Pediatric Hospital Medicine
Fellowship Director, Clinical Informatics, Stanford University Medical Center (2014 - Present)
VP of Analytics, Stanford Children's Health (2012 - Present)
Chief Medical Information Officer, Stanford Children's Health (2010 - Present)
Medical Director, Clinical Informatics, Stanford Children's Health (2007 - 2010)
Physician Lead, Clinical Informatics, Stanford Children's Health (2004 - 2007)
Honors & Awards
Letter of Teaching Distinction, Stanford University School of Medicine, Office of the Dean (2011, 2012, 2013)
Top 25 Clinical Informaticist, Modern Healthcare (2010, 2011, 2012)
Faculty Fellows Leadership Program, Stanford University School of Medicine (2010)
Board Certification: Clinical Informatics, American Board of Preventive Medicine (2014)
Board Certification: Pediatrics, American Board of Pediatrics (2004)
Residency:Stanford University School of Medicine (2004) CA
Internship:Stanford University School of Medicine (2002) CA
Medical Education:UC Davis School of Medicine (2001) CA
M.S., UC Davis, Medical Informatics (2000)
B.S., UC San Diego, Molecular Biology (1996)
Community and International Work
Vermont Oxford Network
Opportunities for Student Involvement
Roatan Volunteer Pediatric Clinic, Honduras
Latino, Carribean Garifuna
Opportunities for Student Involvement
Current Research and Scholarly Interests
Clinical Informatics is the scientific field concerned with the application of information technology to the delivery of healthcare services. In my administrative role as Chief Medical Information Officer (CMIO) at Stanford Children's Health, I oversee the Clinical Informatics and Analytics departments. I am responsible for the implementation and optimization of a comprehensive electronic medical record (EMR) system including computerized physician order entry (CPOE) with clinical decision support (CDS), patient-engaging technologies like personal health records (PHR), and our enterprise data warehouse (EDW).
Together with colleagues in the department, our applied informatics research focuses on rigorously evaluating the best ways to implement and optimize health information technology to benefit the patients we serve at Stanford Children's Health. Specific areas of focus include 1) the impact of health IT on pediatric and obstetric quality/safety 2) advancing clinical decision support through closed-loop analytics, and 3) the intersection of health IT and medical education. Results of this work have been published in peer-reviewed journals like the New England Journal of Medicine, BMJ, Pediatrics, and Applied Clinical Informatics.
Clinical Informatics Fellowship, Stanford University Medical Center
- Todd Ferris, Associate CIO, SoM - Information Resources & Technology
- Natalie Pageler, Clinical Assistant Professor, Pediatrics - Critical Care; Associate Program Director
- Jonathan Palma, Clinical Assistant Professor, Pediatrics - Neonatal and Developmental Medicine
- Christopher Sharp, Clinical Associate Professor, Medicine - General Medical Disciplines
- Pravene Nath, Clinical Assistant Professor (Affiliated) , Surgery - Emergency Medicine
For More Information:
- Clinical Informatics Literature Review Seminar
BIOMEDIN 208 (Win)
Independent Studies (8)
- Biomedical Informatics Teaching Methods
BIOMEDIN 290 (Aut, Win, Spr, Sum)
- Directed Reading and Research
BIOMEDIN 299 (Aut, Win, Spr, Sum)
- Directed Reading in Pediatrics
PEDS 299 (Aut, Win, Sum)
- Early Clinical Experience
PEDS 280 (Aut, Win, Spr, Sum)
- Graduate Research
PEDS 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
BIOMEDIN 370 (Aut, Win, Spr, Sum)
- Medical Scholars Research
PEDS 370 (Aut, Win, Spr, Sum)
- Undergraduate Directed Reading/Research
PEDS 199 (Aut, Win, Sum)
- Biomedical Informatics Teaching Methods
AKI in Hospitalized Children: Comparing the pRIFLE, AKIN, and KDIGO Definitions.
Clinical journal of the American Society of Nephrology
2015; 10 (4): 554-561
Although several standardized definitions for AKI have been developed, no consensus exists regarding which to use in children. This study applied the Pediatric RIFLE (pRIFLE), AKI Network (AKIN), and Kidney Disease Improving Global Outcomes (KDIGO) criteria to an anonymized cohort of hospitalizations extracted from the electronic medical record to compare AKI incidence and outcomes in intensive care unit (ICU) and non-ICU pediatric populations.Observational, electronic medical record-enabled study of 14,795 hospitalizations at the Lucile Packard Children's Hospital between 2006 and 2010. AKI and AKI severity stage were defined by the pRIFLE, AKIN, and KDIGO definitions according to creatinine change criteria; urine output criteria were not used. The incidences of AKI and each AKI stage were calculated for each classification system. All-cause, in-hospital mortality and total hospital length of stay (LOS) were compared at each subsequent AKI stage by Fisher exact and Kolmogorov-Smirnov tests, respectively.AKI incidences across the cohort according to pRIFLE, AKIN, and KDIGO were 51.1%, 37.3%, and 40.3%. Mortality was higher among patients with AKI across all definitions (pRIFLE, 2.3%; AKIN, 2.7%; KDIGO, 2.5%; P<0.001 versus no AKI [0.8%-1.0%]). Within the ICU, pRIFLE, AKIN, and KDIGO demonstrated progressively higher mortality at each AKI severity stage; AKI was not associated with mortality outside the ICU by any definition. Both in and outside the ICU, AKI was associated with significantly higher LOS at each AKI severity stage across all three definitions (P<0.001). Definitions resulted in differences in diagnosis and staging of AKI; staging agreement ranged from 76.7% to 92.5%.Application of the three definitions led to differences in AKI incidence and staging. AKI was associated with greater mortality and LOS in the ICU and greater LOS outside the ICU. All three definitions demonstrated excellent interstage discrimination. While each definition offers advantages, these results underscore the need to adopt a single, universal AKI definition.
View details for DOI 10.2215/CJN.01900214
View details for PubMedID 25649155
- Bordetella petrii Sinusitis in an Immunocompromised Adolescent. Pediatric infectious disease journal 2015; 34 (4): 458-?
Patient and Family Access to Electronic Health Records: A Key Ingredient for a Pediatric Learning Health System.
Journal of participatory medicine
View details for PubMedID 25664199
Clinical Informatics Fellowship Programs: In Search of a Viable Financial Model: An open letter to the Centers for Medicare and Medicaid Services.
Applied clinical informatics
2015; 6 (2): 267-70
In the US, the new subspecialty of Clinical Informatics focuses on systems-level improvements in care delivery through the use of health information technology (HIT), data analytics, clinical decision support, data visualization and related tools. Clinical informatics is one of the first subspecialties in medicine open to physicians trained in any primary specialty. Clinical Informatics benefits patients and payers such as Medicare and Medicaid through its potential to reduce errors, increase safety, reduce costs, and improve care coordination and efficiency. Even though Clinical Informatics benefits patients and payers, because GME funding from the Centers for Medicare and Medicaid Services (CMS) has not grown at the same rate as training programs, the majority of the cost of training new Clinical Informaticians is currently paid by academic health science centers, which is unsustainable. To maintain the value of HIT investments by the government and health care organizations, we must train sufficient leaders in Clinical Informatics. In the best interest of patients, payers, and the US society, it is therefore critical to find viable financial models for Clinical Informatics fellowship programs. To support the development of adequate training programs in Clinical Informatics, we request that the Centers for Medicare and Medicaid Services (CMS) issue clarifying guidance that would allow accredited ACGME institutions to bill for clinical services delivered by fellows at the fellowship program site within their primary specialty.
View details for DOI 10.4338/ACI-2015-03-IE-0030
View details for PubMedID 26171074
The Value of Clinical Teachers for EMR Implementations and Conversions.
Applied clinical informatics
2015; 6 (1): 75-79
Effective physician training is an essential aspect of EMR implementation. However, it can be challenging to find instructors who can present the material in a clinically relevant manner. The authors describe a unique physician-training program, utilizing medical students as course instructors. This approach resulted in high learner satisfaction rates and provided significant cost-savings compared to alternative options.
View details for DOI 10.4338/ACI-2014-09-IE-0075
View details for PubMedID 25848414
Successful Physician Training Program for Large Scale EMR Implementation.
Applied clinical informatics
2015; 6 (1): 80-95
End-user training is an essential element of electronic medical record (EMR) implementation and frequently suffers from minimal institutional investment. In addition, discussion of successful EMR training programs for physicians is limited in the literature. The authors describe a successful physician-training program at Stanford Children's Health as part of a large scale EMR implementation. Evaluations of classroom training, obtained at the conclusion of each class, revealed high physician satisfaction with the program. Free-text comments from learners focused on duration and timing of training, the learning environment, quality of the instructors, and specificity of training to their role or department. Based upon participant feedback and institutional experience, best practice recommendations, including physician engagement, curricular design, and assessment of proficiency and recognition, are suggested for future provider EMR training programs. The authors strongly recommend the creation of coursework to group providers by common workflow.
View details for DOI 10.4338/ACI-2014-09-CR-0076
View details for PubMedID 25848415
Special requirements for electronic medical records in neurology.
Neurology. Clinical practice
2015; 5 (1): 67-73
Electronic medical records (EMRs) are being rapidly adapted in the United States with goals of improving patient care, increasing efficiency, and reducing costs. Neurologists must become knowledgeable about the utility and effectiveness of the important parts of these systems specifically needed for care of neurology patients. The field of neurology encompasses complex disorders whose diagnosis and management heavily relies on detailed medical documentation of history and physical examination, and often on specialty-specific ancillary tests and extensive neuroimaging. Small discrepancies in documentation or absence of an in-hand ancillary test result can drastically change the current workup or treatment decision of a complex patient with neurologic disease. We describe current models and opportunities for improvements to EMRs that provide utility and efficiency in the care of neurology patients.
View details for DOI 10.1212/CPJ.0000000000000093
View details for PubMedID 25717421
Bringing cohort studies to the bedside: framework for a 'green button' to support clinical decision-making.
Journal of comparative effectiveness research
When providing care, clinicians are expected to take note of clinical practice guidelines, which offer recommendations based on the available evidence. However, guidelines may not apply to individual patients with comorbidities, as they are typically excluded from clinical trials. Guidelines also tend not to provide relevant evidence on risks, secondary effects and long-term outcomes. Querying the electronic health records of similar patients may for many provide an alternate source of evidence to inform decision-making. It is important to develop methods to support these personalized observational studies at the point-of-care, to understand when these methods may provide valid results, and to validate and integrate these findings with those from clinical trials.
View details for DOI 10.2217/cer.15.12
View details for PubMedID 25959863
A 'green button' for using aggregate patient data at the point of care.
2014; 33 (7): 1229-1235
Randomized controlled trials have traditionally been the gold standard against which all other sources of clinical evidence are measured. However, the cost of conducting these trials can be prohibitive. In addition, evidence from the trials frequently rests on narrow patient-inclusion criteria and thus may not generalize well to real clinical situations. Given the increasing availability of comprehensive clinical data in electronic health records (EHRs), some health system leaders are now advocating for a shift away from traditional trials and toward large-scale retrospective studies, which can use practice-based evidence that is generated as a by-product of clinical processes. Other thought leaders in clinical research suggest that EHRs should be used to lower the cost of trials by integrating point-of-care randomization and data capture into clinical processes. We believe that a successful learning health care system will require both approaches, and we suggest a model that resolves this escalating tension: a "green button" function within EHRs to help clinicians leverage aggregate patient data for decision making at the point of care. Giving clinicians such a tool would support patient care decisions in the absence of gold-standard evidence and would help prioritize clinical questions for which EHR-enabled randomization should be carried out. The privacy rule in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 may require revision to support this novel use of patient data.
View details for DOI 10.1377/hlthaff.2014.0099
View details for PubMedID 25006150
Optimizing Care of Adults With Congenital Heart Disease in a Pediatric Cardiovascular ICU Using Electronic Clinical Decision Support
PEDIATRIC CRITICAL CARE MEDICINE
2014; 15 (5): 428-434
The optimal location for postoperative cardiac care of adults with congenital heart disease is controversial. Some congenital heart surgeons operate on these adults in children's hospitals with postoperative care provided by pediatric critical care teams who may be unfamiliar with adult national performance measures. This study tested the hypothesis that Clinical Decision Support tools integrated into the clinical workflow would facilitate improved compliance with The Joint Commission Surgical Care Improvement Project performance measures in adults recovering from cardiac surgery in a children's hospital.Retrospective chart review comparing compliance pre- and post-Clinical Decision Support intervention for Surgical Care Improvement Project measures addressed in the critical care unit: appropriate cessation of prophylactic antibiotics; controlled blood glucose; urinary catheter removal; and reinitiation of preoperative β-blocker when indicated.Cardiovascular ICU in a quaternary care freestanding children's hospital.The cohort included 114 adults 18-70 years old recovering from cardiac surgery in our pediatric cardiovascular ICU.Clinical Decision Support tools including data-triggered alerts, smart documentation forms, and order sets with conditional logic were integrated into the workflow.Compliance with antibiotic discontinuation was 100% pre- and postintervention. Compliance rates improved for glucose control (p = 0.007) and urinary catheter removal (p = 0.05). Documentation of β-blocker therapy (nonexistent preintervention) was 100% postintervention. Composite compliance for all measures increased from 53% to 84% (p = 0.002). There were no complications related to institution of the Surgical Care Improvement Project measures. There was no in-hospital mortality.Compliance with the national adult postoperative performance measures can be excellent in a children's hospital with the help of Clinical Decision Support tools. This represents an important step toward providing high-quality care to a growing population of adults with congenital heart disease who may receive care in a pediatric center.
View details for DOI 10.1097/PCC.0000000000000124
View details for Web of Science ID 000337368600010
Use of electronic medical record-enhanced checklist and electronic dashboard to decrease CLABSIs.
2014; 133 (3): e738-46
We hypothesized that a checklist enhanced by the electronic medical record and a unit-wide dashboard would improve compliance with an evidence-based, pediatric-specific catheter care bundle and decrease central line-associated bloodstream infections (CLABSI).We performed a cohort study with historical controls that included all patients with a central venous catheter in a 24-bed PICU in an academic children's hospital. Postintervention CLABSI rates, compliance with bundle elements, and staff perceptions of communication were evaluated and compared with preintervention data.CLABSI rates decreased from 2.6 CLABSIs per 1000 line-days before intervention to 0.7 CLABSIs per 1000 line-days after intervention. Analysis of specific bundle elements demonstrated increased daily documentation of line necessity from 30% to 73% (P < .001), increased compliance with dressing changes from 87% to 90% (P = .003), increased compliance with cap changes from 87% to 93% (P < .001), increased compliance with port needle changes from 69% to 95% (P < .001), but decreased compliance with insertion bundle documentation from 67% to 62% (P = .001). Changes in the care plan were made during review of the electronic medical record checklist on 39% of patient rounds episodes.Use of an electronic medical record-enhanced CLABSI prevention checklist coupled with a unit-wide real-time display of adherence was associated with increased compliance with evidence-based catheter care and sustained decrease in CLABSI rates. These data underscore the potential for computerized interventions to promote compliance with proven best practices and prevent patient harm.
View details for DOI 10.1542/peds.2013-2249
View details for PubMedID 24567021
Core Drug-Drug Interaction Alerts for Inclusion in Pediatric Electronic Health Records With Computerized Prescriber Order Entry
JOURNAL OF PATIENT SAFETY
2014; 10 (1): 59-63
The study aims to develop a core set of pediatric drug-drug interaction (DDI) pairs for which electronic alerts should be presented to prescribers during the ordering process.A clinical decision support working group composed of Children's Hospital Association (CHA) members was developed. CHA Pharmacists and Chief Medical Information Officers participated.Consensus was reached on a core set of 19 DDI pairs that should be presented to pediatric prescribers during the order process.We have provided a core list of 19 high value drug pairs for electronic drug-drug interaction alerts to be recommended for inclusion as high value alerts in prescriber order entry software used with a pediatric patient population. We believe this list represents the most important pediatric drug interactions for practical implementation within computerized prescriber order entry systems.
View details for DOI 10.1097/PTS.0000000000000050
View details for Web of Science ID 000335830300008
View details for PubMedID 24522227
- Refocusing medical education in the EMR era. JAMA-the journal of the American Medical Association 2013; 310 (21): 2249-2250
Association between Maintenance Fluid Tonicity and Hospital-Acquired Hyponatremia
JOURNAL OF PEDIATRICS
2013; 163 (6): 1646-1651
To evaluate whether the administration of hypotonic fluids compared with isotonic fluids is associated with a greater risk for hyponatremia in hospitalized children.Informatics-enabled cohort study of all hospitalizations at Lucile Packard Children's Hospital between April 2009 and March 2011. Extraction and analysis of electronic medical record data identified normonatremic hospitalized children who received either hypotonic or isotonic intravenous maintenance fluids upon admission. The primary exposure was the administration of hypotonic maintenance fluids, and the primary outcome was the development of hyponatremia (serum sodium <135 mEq/L).A total of 1048 normonatremic children received either hypotonic (n = 674) or isotonic (n = 374) maintenance fluids upon admission. Hyponatremia developed in 260 (38.6%) children who received hypotonic fluids and 104 (27.8%) of those who received isotonic fluids (unadjusted OR 1.63; 95% CI 1.24-2.15, P < .001). After we controlled for intergroup differences and potential confounders, patients receiving hypotonic fluids remained more likely to develop hyponatremia (aOR 1.37, 95% CI 1.03-1.84). Multivariable analysis identified additional factors associated with the development of hyponatremia, including surgical admission (aOR 1.44, 95% CI 1.09-1.91), cardiac admitting diagnosis (aOR 2.08, 95% CI 1.34-3.20), and hematology/oncology admitting diagnosis (aOR 2.37, 95% CI 1.74-3.25).Hyponatremia was common regardless of maintenance fluid tonicity; however, the administration of hypotonic maintenance fluids compared with isotonic fluids was associated with a greater risk of developing hospital-acquired hyponatremia. Additional clinical characteristics modified the hyponatremic effect of hypotonic fluid, and it is possible that optimal maintenance fluid therapy now requires a more individualized approach.
View details for DOI 10.1016/j.jpeds.2013.07.020
View details for Web of Science ID 000327543200025
- Medical Education in the Electronic Medical Record (EMR) Era: Benefits, Challenges, and Future Directions ACADEMIC MEDICINE 2013; 88 (6): 753-757
- A Clinical Case of Electronic Health Record Drug Alert Fatigue: Consequences for Patient Outcome PEDIATRICS 2013; 131 (6): E1970-E1973
Embedding Time-Limited Laboratory Orders Within Computerized Provider Order Entry Reduces Laboratory Utilization
PEDIATRIC CRITICAL CARE MEDICINE
2013; 14 (4): 413-419
: To test the hypothesis that limits on repeating laboratory studies within computerized provider order entry decrease laboratory utilization.: Cohort study with historical controls.: A 20-bed PICU in a freestanding, quaternary care, academic children's hospital.: This study included all patients admitted to the pediatric ICU between January 1, 2008, and December 31, 2009. A total of 818 discharges were evaluated prior to the intervention (January 1, 2008, through December 31, 2008) and 1,021 patient discharges were evaluated postintervention (January 1, 2009, through December 31, 2009).: A computerized provider order entry rule limited the ability to schedule repeating complete blood cell counts, chemistry, and coagulation studies to a 24-hour interval in the future. The time limit was designed to ensure daily evaluation of the utility of each test.: Initial analysis with t tests showed significant decreases in tests per patient day in the postintervention period (complete blood cell counts: 1.5 ± 0.1 to 1.0 ± 0.1; chemistry: 10.6 ± 0.9 to 6.9 ± 0.6; coagulation: 3.3 ± 0.4 to 1.7 ± 0.2; p < 0.01, all variables vs. preintervention period). Even after incorporating a trend toward decreasing laboratory utilization in the preintervention period into our regression analysis, the intervention decreased complete blood cell counts (p = 0.007), chemistry (p = 0.049), and coagulation (p = 0.001) tests per patient day.: Limits on laboratory orders within the context of computerized provider order entry decreased laboratory utilization without adverse affects on mortality or length of stay. Broader application of this strategy might decrease costs, the incidence of iatrogenic anemia, and catheter-associated bloodstream infections.
View details for DOI 10.1097/PCC.0b013e318272010c
View details for Web of Science ID 000318680000016
View details for PubMedID 23439456
Immunization registries in the EMR Era.
Online journal of public health informatics
2013; 5 (2): 211-?
The CDC established a national objective to create population-based tracking of immunizations through regional and statewide registries nearly 2 decades ago, and these registries have increased coverage rates and reduced duplicate immunizations. With increased adoption of commercial electronic medical records (EMR), some institutions have used unidirectional links to send immunization data to designated registries. However, access to these registries within a vendor EMR has not been previously reported.To develop a visually integrated interface between an EMR and a statewide immunization registry at a previously non-reporting hospital, and to assess subsequent changes in provider use and satisfaction.A group of healthcare providers were surveyed before and after implementation of the new interface. The surveys addressed access of the California Immunization Registry (CAIR), and satisfaction with the availability of immunization information. Information Technology (IT) teams developed a "smart-link" within the electronic patient chart that provides a single-click interface for visual integration of data within the CAIR database.Use of the tool has increased in the months since its initiation, and over 20,000 new immunizations have been exported successfully to CAIR since the hospital began sharing data with the registry. Survey data suggest that providers find this tool improves workflow and overall satisfaction with availability of immunization data. (p=0.009).Visual integration of external registries into a vendor EMR system is feasible and improves provider satisfaction and registry reporting.
View details for DOI 10.5210/ojphi.v5i2.4696
View details for PubMedID 23923096
Using an Evidence-Based Approach to EMR Implementation to Optimize Outcomes and Avoid Unintended Consequences.
Journal of healthcare information management : JHIM
2013; 27 (3): 79-83
Implementation of an electronic medical record (EMR) with computerized physician order entry (CPOE) can provide an important foundation for preventing harm and improving outcomes. Incentivized by the recent economic stimulus initiative, healthcare systems are implementing vendor-based EMR systems at an unprecedented rate. Accumulating evidence suggests that local implementation decisions, rather than the specific EMR product or technology selected, are the primary drivers of the quality improvement performance of these systems. However, limited attention has been paid to effective approaches to EMR implementation. In this case report, we outline the evidence-based approach we used to make EMR implementation decisions in a pragmatic structure intended for replication at other sites.
View details for PubMedID 24771994
Rights and responsibilities of electronic health records (EHR) users caring for children.
Archivos argentinos de pediatria
2013; 111 (6)
View details for PubMedID 24196758
Reducing Mortality Related to Adverse Events in Children
PEDIATRIC CLINICS OF NORTH AMERICA
2012; 59 (6): 1293-?
Since the launch of the 100,000 Lives Campaign by the Institute for Healthcare Improvement (IHI), preventing medical adverse events to reduce avoidable mortality has emerged as a central focus for health care providers, institutions, regulators, insurance companies, and patients. Evidence-based interventions targeting the 6 interventions in the campaign have been associated with a reduction in preventable hospital deaths in the United States. The generalizability of the IHI's campaign to the pediatric population is only partly applicable. Pediatric experiences with rapid response teams and preventing central-line infections parallel the published experience of adults, with promise to significantly reduce preventable pediatric mortality.
View details for DOI 10.1016/j.pcl.2012.09.002
View details for Web of Science ID 000312618600007
View details for PubMedID 23116526
Special Requirements for Electronic Medical Records in Adolescent Medicine
JOURNAL OF ADOLESCENT HEALTH
2012; 51 (5): 409-414
Adolescents are a group likely to seek and, perhaps, most likely to benefit from electronic access to health information. Despite significant advances in technical capabilities over the past decade, to date neither electronic medical record vendors nor many health care systems have adequately addressed the functionality and process design considerations needed to protect the confidentiality of adolescent patients in an electronic world. We propose a shared responsibility for creating the necessary tools and processes to maintain the adolescent confidentiality required by most states: (1) system vendors must provide key functionality in their products (adolescent privacy default settings, customizable privacy controls, proxy access, and health information exchange compatibility), and (2) health care institutions must systematically address relevant adolescent confidentiality policies and process design issues. We highlight the unique technical and process considerations relevant to this patient population, as well as the collaborative multistakeholder work required for adolescent patients to experience the potential benefits of both electronic medical records and participatory health information technology.
View details for DOI 10.1016/j.jadohealth.2012.08.003
View details for Web of Science ID 000310353300002
View details for PubMedID 23084160
Internet Access and Attitudes Toward Online Personal Health Information Among Detained Youth
2012; 130 (5): 914-917
To assess Internet access and usage patterns among high-risk youth involved in the juvenile justice system, and to determine if health information technology tools might play a useful role in more actively engaging this population in their health care.A sample of 79 youth between the ages of 13 and 18 years old underwent a structured interview while detained in a large, Northern California juvenile detention facility. After an institutional review board-approved assent/consent process, youth discussed their typical Internet use when not detained, as well as their attitudes toward online access to their personal health information (PHI).Detained youth from predominantly underserved, minority communities, reported high levels of access to the Internet while outside of the detention setting, with 97% reporting using the Internet at least once per month and 87% at least weekly. Furthermore, 90% of these youth expressed interest in accessing their PHI online and sharing it with either parents or physicians.Detained adolescents describe unexpectedly high usage of the Internet and online resources when they are outside of the juvenile hall setting. These youth show an interest in, and may benefit from, accessing their PHI online. Further studies are needed to understand the potential health benefits that may be realized by engaging this population through online tools.
View details for DOI 10.1542/peds.2012-1653
View details for Web of Science ID 000310505900061
View details for PubMedID 23090346
Integrating the home management plan of care for children with asthma into an electronic medical record.
Joint Commission journal on quality and patient safety / Joint Commission Resources
2012; 38 (8): 359-365
Asthma exacerbation is one of the most common causes for pediatric hospitalization. One of the three Joint Commission quality measures--which has proven the most challenging--addresses the provision of a home management plan of care (HMPC) for discharge of pediatric inpatients with a primary diagnosis of asthma. A user-friendly electronic medical record (EMR)-generated HMPC was developed and implemented at Lucile Packard Children's Hospital (LPCH) Palo Alto, California, an HPMC needed to be completed before entry of an inpatient discharge order.A cohort study using historical controls was conducted in 2010-2011. Patients were eligible to receive an HMPC if they were between the ages of 2 and 17 years old at discharge, had a length of stay < 120 days, were not enrolled in clinical trials, and had the primary discharge diagnosis of asthma. These patients were identified by the EMR if this diagnosis was listed in the diagnosis list or problem list or if the asthma admit/discharge order set was initiated.Compliance with the HMPC increased from 65.3% for the 39 months (April 1, 2007-June 30, 2010) before integration of the HMPC into EMR to 93.7% for the 18 months after integration (July 1, 2010, through December 31, 2011); p < .0001. Users of the EMR-integrated HMPC found it to be significantly easier to complete, less time-consuming, and less prone to potential errors or omission.Lessons learned at LPCH included the need for a continuous surveillance and improvement model, which resulted in several iterations of the HMPC; the importance of soliciting user input, which resulted in improvements in work flow; and consistent support from the quality management and information technology departments, which are crucial to eliminating barriers and facilitating improvement.
View details for PubMedID 22946253
- Health information technology and patient safety BRITISH MEDICAL JOURNAL 2012; 344
Neonatal Informatics: Optimizing Clinical Data Entry and Display.
2012; 13 (2): 81-85
Displaying the vast amount of clinical data that exist in electronic medical records without causing information overload or interfering with provider thought processes is a challenge. To support the transformation of data into information and knowledge, effective electronic displays must be flexible and guide physicians' thought processes. Applying research from cognitive science and human factors engineering offers promise in improving the electronic display of clinical information. OBJECTIVES: After completing this article, readers should be able to: Appreciate the importance of supporting provider thought processes during both data entry and data review.Recognize that information does not need to be displayed and reviewed in the same way the data are entered.
View details for PubMedID 22557935
Neonatal Informatics: Transforming Neonatal Care Through Translational Bioinformatics.
2012; 13 (5): e281-e284
The future of neonatal informatics will be driven by the availability of increasingly vast amounts of clinical and genetic data. The field of translational bioinformatics is concerned with linking and learning from these data and applying new findings to clinical care to transform the data into proactive, predictive, preventive, and participatory health. As a result of advances in translational informatics, the care of neonates will become more data driven, evidence based, and personalized.
View details for PubMedID 22924023
Impact of an EMR-Based Daily Patient Update Letter on Communication and Parent Engagement in a Neonatal Intensive Care Unit.
Journal of participatory medicine
To evaluate the impact of using electronic medical record (EMR) data in the form of a daily patient update letter on communication and parent engagement in a level II neonatal intensive care unit (NICU).Parents of babies in a level II NICU were surveyed before and after the introduction of an EMR-generated daily patient update letter, Your Baby's Daily Update (YBDU).Following the introduction of the EMR-generated daily patient update letter, 89% of families reported using YBDU as an information source; 83% of these families found it "very useful", and 96% of them responded that they "always" liked receiving it. Rates of receiving information from the attending physician were not statistically significantly different pre- and post-implementation, 81% and 78%, respectively (p = 1). Though there was no statistically significant improvement in parents' knowledge of individual items regarding the care of their babies, a trend towards statistical significance existed for several items (p <.1), and parents reported feeling more competent to manage information related to the health status of their babies (p =.039).Implementation of an EMR-generated daily patient update letter is feasible, resulted in a trend towards improved communication, and improved at least one aspect of parent engagement-perceived competence to manage information in the NICU.
View details for PubMedID 23730532
Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital
APPLIED CLINICAL INFORMATICS
2012; 3 (2): 175-185
Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children's Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution.
View details for DOI 10.4338/ACI-2012-02-CR-0003
View details for Web of Science ID 000317183500003
View details for PubMedID 23620718
An evidence-based approach to activating your EMR.
Healthcare informatics : the business magazine for information and communication systems
2011; 28 (12): 47-?
View details for PubMedID 22233021
- Evidence-Based Medicine in the EMR Era NEW ENGLAND JOURNAL OF MEDICINE 2011; 365 (19): 1758-1759
- A 15-Year-Old Girl with Dysphagia, Failure to Thrive PEDIATRIC ANNALS 2011; 40 (8): 397-400
Impact of electronic medical record integration of a handoff tool on sign-out in a newborn intensive care unit
JOURNAL OF PERINATOLOGY
2011; 31 (5): 311-317
Objective:To evaluate the impact of integrating a handoff tool into the electronic medical record (EMR) on sign-out accuracy, satisfaction and workflow in a neonatal intensive care unit (NICU).Study Design:Prospective surveys of neonatal care providers in an academic children's hospital 1 month before and 6 months following EMR integration of a standalone Microsoft Access neonatal handoff tool.Result:Providers perceived sign-out information to be somewhat or very accurate at a rate of 78% with the standalone handoff tool and 91% with the EMR-integrated tool (P < 0.01). Before integration of neonatal sign-out into the EMR, 35% of providers were satisfied with the process of updating sign-out information and 71% were satisfied with the printed sign-out document; following EMR integration, 92% of providers were satisfied with the process of updating sign-out information (P < 0.01) and 98% were satisfied with the printed sign-out document (P<0.01). Neonatal care providers reported spending a median of 11 to 15 min/day updating the standalone sign-out and 16 to 20 min/day updating the EMR-integrated sign-out (P = 0.026). The median percentage of total sign-out preparation time dedicated to transcribing information from the EMR was 25 to 49% before and <25% after EMR integration of the handoff tool (P < 0.01).Conclusion:Integration of a NICU-specific handoff tool into an EMR resulted in improvements in perceived sign-out accuracy, provider satisfaction and at least one aspect of workflow.
View details for DOI 10.1038/jp.2010.202
View details for Web of Science ID 000289982300003
View details for PubMedID 21273990
Computerized Physician Order Entry With Decision Support Decreases Blood Transfusions in Children
2011; 127 (5): E1112-E1119
Timely provision of evidence-based recommendations through computerized physician order entry with clinical decision support may improve use of red blood cell transfusions (RBCTs).We performed a cohort study with historical controls including inpatients admitted between February 1, 2008, and January 31, 2010. A clinical decision-support alert for RBCTs was constructed by using current evidence. RBCT orders resulted in assessment of the patient's medical record with prescriber notification if parameters were not within recommended ranges. Primary end points included the average pretransfusion hemoglobin level and the rate of RBCTs per patient-day.In total, 3293 control discharges and 3492 study discharges were evaluated. The mean (SD) control pretransfusion hemoglobin level in the PICU was 9.83 (2.63) g/dL (95% confidence interval [CI]: 9.65-10.01) compared with the study value of 8.75 (2.05) g/dL (95% CI: 8.59-8.90) (P < .0001). The wards' control value was 7.56 (0.93) g/dL (95% CI: 7.47-7.65), the study value was 7.14 (1.01) g/dL (95% CI: 6.99-7.28) (P < .0001). The control PICU rate of RBCTs per patient-day was 0.20 (0.11) (95% CI: 0.13-0.27), the study rate was 0.14 (0.04) (95% CI: 0.11-0.17) (P = .12). The PICU's control rate was 0.033 (0.01) (95% CI: 0.02-0.04), and the study rate was 0.017 (0.007) (95% CI: 0.01-0.02) (P < .0001). There was no difference in mortality rates across all cohorts.Implementation of clinical decision-support alerts was associated with a decrease in RBCTs, which suggests improved adoption of evidence-based recommendations. This strategy might be widely applied to promote timely adoption of scientific evidence.
View details for DOI 10.1542/peds.2010-3252
View details for Web of Science ID 000290097800002
View details for PubMedID 21502229
Neonatal Informatics: Computerized Physician Order Entry.
2011; 12: 393-396
Computerized physician order entry (CPOE) is the feature of electronic medical record (EMR) implementation that arguably offers the greatest quality and patient safety benefits. The gains are potentially greater for critically ill neonates, but the effect of CPOE on quality and safety is dependent upon local implementation decisions. OBJECTIVES: After completing this article, readers should be able to: Define the basic aspects of CPOE and clinical decision support (CDS) systems.Describe the potential benefits of implementing CPOE associated with CDS in a neonatal intensive care unit (NICU).
View details for PubMedID 21804768
Implementing an Interoperable Personal Health Record in Pediatrics: Lessons Learned at an Academic Children's Hospital.
Journal of participatory medicine
This paper describes the development of an innovative health information technology creating a bidirectional link between the electronic medical record (EMR) of an academic children's hospital and a commercially available, interoperable personal health record (PHR). The goal of the PHR project has been to empower pediatric patients and their families to play a more active role in understanding, accessing, maintaining, and sharing their personal health information to ultimately improve health outcomes. The most notable challenges proved more operational and cultural than technological. Our experience demonstrates that an interoperable PHR is technically and culturally achievable at a pediatric academic medical center. Recognizing the complex social, cultural, and organizational contexts of these systems is important for overcoming barriers to a successful implementation.
View details for PubMedID 21853160
Neonatal Informatics: Information Technology to Support Handoffs in Neonatal Care.
2011; 2011 (12)
Communication failures during physician handoffs represent a significant source of preventable adverse events. Computerized sign-out tools linked to hospital electronic medical record systems and customized for neonatal care can facilitate standardization of the handoff process and access to clinical information, thereby improving communication and reducing adverse events. It is important to note, however, that adoption of technological tools alone is not sufficient to remedy flawed communication processes. OBJECTIVES: After completing this article, readers should be able to: Identify key elements of a computerized sign-out tool.Describe how an electronic tool might be customized for neonatal care.Appreciate that technological tools are only one component of the handoff process they are designed to facilitate.
View details for PubMedID 22199463
Sociotechnical Challenges of Developing an Interoperable Personal Health Record Lessons Learned
APPLIED CLINICAL INFORMATICS
2011; 2 (4): 406-419
OBJECTIVES: To analyze sociotechnical issues involved in the process of developing an interoperable commercial Personal Health Record (PHR) in a hospital setting, and to create guidelines for future PHR implementations. METHODS: This qualitative study utilized observational research and semi-structured interviews with 8 members of the hospital team, as gathered over a 28 week period of developing and adapting a vendor-based PHR at Lucile Packard Children's Hospital at Stanford University. A grounded theory approach was utilized to code and analyze over 100 pages of typewritten field notes and interview transcripts. This grounded analysis allowed themes to surface during the data collection process which were subsequently explored in greater detail in the observations and interviews. RESULTS: Four major themes emerged: (1) Multidisciplinary teamwork helped team members identify crucial features of the PHR; (2) Divergent goals for the PHR existed even within the hospital team; (3) Differing organizational conceptions of the end-user between the hospital and software company differentially shaped expectations for the final product; (4) Difficulties with coordination and accountability between the hospital and software company caused major delays and expenses and strained the relationship between hospital and software vendor. CONCLUSIONS: Though commercial interoperable PHRs have great potential to improve healthcare, the process of designing and developing such systems is an inherently sociotechnical process with many complex issues and barriers. This paper offers recommendations based on the lessons learned to guide future development of such PHRs.
View details for DOI 10.4338/ACI-2011-06-RA-0035
View details for Web of Science ID 000208686800002
View details for PubMedID 22003373
Vitamin D-Deficient Rickets in a Child With Cow's Milk Allergy
NUTRITION IN CLINICAL PRACTICE
2010; 25 (4): 394-398
This article describes the case of a 16-month-old Hispanic male toddler with cow's milk allergy living in northern California who was admitted to a children's hospital for weight loss and markedly elevated levels of serum alkaline phosphatase and parathyroid hormone. At a routine outpatient well-child visit, his mother expressed concern about a decrease in his appetite and activity level. A detailed diet history revealed that breast milk was his primary source of nutrition during his first year of life and he had not been given supplemental vitamins. With attempts to introduce cow's milk formula, he had developed a rash and swelling around the mouth. Shortly after his first birthday, his mother weaned him from breast milk and introduced unfortified rice milk as a palatable milk substitute. Upon admission he was pale and lethargic; his laboratory studies were remarkable for elevated serum alkaline phosphatase and parathyroid hormone and low levels of phosphorus, 25-hydroxy-vitamin D, and ferritin. Lower extremity radiographic studies were consistent with rickets. After 5 weeks of therapy with vitamin D(3) and iron, his serum 25-hydroxy-vitamin D level normalized. Within 12 weeks following therapy, the child demonstrated significant clinical improvement, with resolution of growth failure and bone reossification. His activity level had returned to normal. This case emphasizes the importance of adequate vitamin D intake for children with special attention to those who might have nutrition deficiencies attributable to milk allergy.
View details for DOI 10.1177/0884533610374199
View details for Web of Science ID 000283800100011
View details for PubMedID 20702845
Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System
2010; 126 (1): 14-21
Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates.The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital.We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80,063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17,432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation.After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008-0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%-40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.
View details for DOI 10.1542/peds.2009-3271
View details for Web of Science ID 000279431000003
View details for PubMedID 20439590
Improved physician work flow after integrating sign-out notes into the electronic medical record.
Joint Commission journal on quality and patient safety / Joint Commission Resources
2010; 36 (2): 72-78
In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed.A printable sign-out report was implemented within the EMR system at a tertiary academic children's hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey.The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process.EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.
View details for PubMedID 20180439
Development of a Web-based decision support tool to increase use of neonatal hyperbilirubinemia guidelines.
Joint Commission journal on quality and patient safety / Joint Commission Resources
2009; 35 (5): 256-262
The 2004 American Academy of Pediatrics (AAP) guidelines for management of hyperbilirubinemia in the newborn infant at > or =35 weeks of gestation recommend that clinicians systematically asses the risk of severe hyperbilirubinemia before hospital discharge. Using the guidelines requires access to the printed nomograms, calculation of the infant's age in hours, and manual plotting of total bilirubin results. The combination of a common clinical problem with the existence of guidelines for best practice is an ideal target for clinical informatics tools to help improve compliance. A Web-based clinical decision support tool was developed on the basis of a combination of published data and linear extrapolation to automate the hour-specific risk stratification nomogram and phototherapy nomogram.After BiliTool, the clinical decision support tool that contained the AAP clinical guidelines, was made publicly available, Web-site usage was monitored. An online survey composed of 10 multiple-choice, Likert-scale, and yes-no questions was made available.The number of site visits has increased over time. Of the 469 respondents to the survey, 297 respondents considered themselves tool "users".Rapid uptake and high ratings for clinical utility confirm that Web-based clinical decision support tools are in high demand and may increase use of clinical guidelines. Given the risk of human error with manual age calculation and nomogram plotting, this tool may also decrease the likelihood of medical errors, particularly with integration into the electronic medical record. Concomitant release of Web-based decision support tools with clinical guidelines would optimize the guidelines' adoption and implementation. Also, the integration of BiliTool into the electronic medical record may serve as a model for integrating other Web-based clinical decision support tools.
View details for PubMedID 19480378
Alphanumeric paging in an academic hospital setting
AMERICAN JOURNAL OF SURGERY
2006; 191 (4): 561-565
To determine whether implementation of an alphanumeric-paging system would improve physician work environment.Surveys were distributed to all general surgery residents, faculty, and nurses before and after implementation of an alphanumeric-paging system. Housestaff also kept a detailed log of paging activity before and after the intervention.User satisfaction with the paging system was measured using a Likert format survey. Interruptions to patient care and pages requiring a call back were tracked using paging logs.Physician perceptions of the capability of text paging before the intervention were high and did not differ significantly postintervention. For nursing staff, postintervention perceptions of the text-paging system were significantly more positive than preintervention, especially with regard to perceived improvements in patient care (54.1% versus 81.6%, P < .05). Residents' paging logs reflected significantly decreased interruptions to patient care after the intervention (28.2% versus 46.9%, P < .05), with less pages requiring a call back (100% versus 73.6%, P < .05).Study participants rated the alphanumeric-paging system highly. Text-paging technology has the potential to reduce interruptions in patient care and improve physician work efficiency and satisfaction.
View details for DOI 10.1016/j.amjsurg.2005.06.037
View details for Web of Science ID 000236508800024
View details for PubMedID 16531156
- Perceived increase in mortality after process and policy changes implemented with computerized physician order entry PEDIATRICS 2006; 117 (4): 1450-1451
- Index of suspicion PEDIATRICS IN REVIEW 2004; 25 (10): 364-369
A practical guideline for calculating parenteral nutrition cycles.
Nutrition in clinical practice
2003; 18 (6): 517-520
Both physiologic and psychological reasons for cycling total parenteral nutrition (TPN) have been well established. Despite widespread acceptance of this practice, the only previously published method for calculating TPN cycle rates is inherently flawed.A mathematical formula was derived to facilitate reliable calculation of cyclic TPN flow rates as a function of total volume and cycle time. A publicly accessible website was subsequently developed to expedite rapid determination of TPN cycles.A fail-safe method of calculating TPN cycle flow rates can be expressed as F = V/(4T-10), where F is equal to the basal flow rate (mL/h), T is equal to the desired cycle time (hours), and V is equal to the total volume of TPN (mL) to be delivered in 24 hours. The basal flow rate and twice the basal flow rate are used for the first and last 2 hours of the TPN cycle, and the remainder of the cycle runs at 4 times the basal flow rate. TPN cycles may be easily calculated online using this formula at http://peds.stanford.edu/tpn.html.We have developed a fail-safe method of calculating TPN cycle flow rates that will consistently deliver the desired volume and have made an online implementation of this formula publicly available.
View details for PubMedID 16215087
- Isolation of Leclercia adecarboxylata from an infant with acute lymphoblastic leukemia CLINICAL INFECTIOUS DISEASES 2001; 32 (11): 1659-1659