- Clinical Informatics
- Neonatal-Perinatal Medicine
Program Director, Clinical Informatics Fellowship, Stanford University School of Medicine (2015 - Present)
Medical Director, Clinical Informatics Innovation, Lucile Packard Children's Hospital Stanford (2016 - Present)
Medical Director, Clinical Informatics Analytics, Lucile Packard Children's Hospital Stanford (2012 - 2015)
Associate Program Director, Clinical Informatics Fellowship, Stanford University School of Medicine (2014 - 2015)
Associate Medical Director, Clinical Informatics, Lucile Packard Children's Hospital (2009 - 2009)
Physician Lead, Neonatal Informatics, Lucile Packard Children's Hospital (2008 - 2008)
Honors & Awards
Alpha Omega Alpha Medical Honor Society, University of Florida College of Medicine (2004)
Gold Humanism Honor Society, University of Florida College of Medicine, Chapman Chapter (2004)
Pediatric Clerkship Honor Roll for Teaching Excellence, Stanford University School of Medicine (2006, 2008)
First Place, Innovate 4 Healthcare Challenge, Johnson & Johnson; University of Maryland School of Business (2012)
Award of Excellence for Information Optimization, Hewlett Packard/Autonomy (2014)
Boards, Advisory Committees, Professional Organizations
Member, American Medical Informatics Association (AMIA) (2009 - Present)
Stanford Designated Representative, AMIA Academic Forum (2015 - Present)
Member, AMIA Community of Clinical Informatics Program Directors (CCIPD) (2015 - Present)
Fellow, American Academy of Pediatrics (AAP); Perinatal Section Member (2005 - Present)
Member, AAP Council on Clinical Information Technology (COCIT) (2015 - Present)
Member, Association of Medical Directors of Information Systems (AMDIS) (2009 - Present)
Member, Epic Neonatology Steering Board (2012 - Present)
Board Certification: Neonatal-Perinatal Medicine, American Board of Pediatrics (2014)
Board Certification: Clinical Informatics, American Board of Preventive Medicine (2014)
Board Certification: Pediatrics, American Board of Pediatrics (2008)
MS, Biomedical Informatics, Stanford University School of Medicine (2012)
Fellowship:Lucile Packard Children's Hospital (2012) CA
Residency:Lucile Packard Children's Hospital (2008) CA
Medical Education:University of Florida (2005) FL
BS, Biology, Chemistry, Davidson College (2000)
Current Research and Scholarly Interests
I'm a Clinical Associate Professor of Pediatrics in the Division of Neonatal and Developmental Medicine at Stanford University. In addition to my clinical role is in newborn intensive care, I have an administrative appointment as Medical Director of Clinical Informatics at Stanford Children's Health. I completed a Master's in Biomedical Informatics at Stanford, became board certified in Clinical Informatics with the inaugural class in 2013, and serve as Program Director for the Stanford Clinical Informatics Fellowship program.
My clinical informatics efforts focus on optimizing electronic workflows for neonatology providers, and my academic interests include interventional informatics to achieve examples of a learning healthcare system. I also enjoy applying technologies such as text and predictive analytics to hospital data to enhance the quality and safety of healthcare.
I attended Davidson College and graduated cum laude from the University of Florida College of Medicine, then completed clinical training in pediatrics and neonatal-perinatal medicine at Lucile Packard Children's Hospital Stanford. During residency and fellowship my scholarly work was optimizing EMRs for neonatal care, and my Master's research was mining clinical data to predict the development of disease.
Clinical Informatics Fellowship, Stanford University Medical Center
Palo Alto, CA
- Christopher Longhurst, Clinical Associate Professor, School of Medicine
- Natalie Pageler, Clinical Associate Professor, School of Medicine
- Christopher Sharp, Clinical Associate Professor, School of Medicine
- Todd Ferris, Chief Technology Officer, SoM - Information Resources & Technology, SoM - Information Resources & Technology
For More Information:
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
View details for PubMedCentralID PMC3424284
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
Prenatal treatment of ornithine transcarbamylase deficiency.
Molecular genetics and metabolism
Patients with neonatal urea cycle defects (UCDs) typically experience severe hyperammonemia during the first days of life, which results in serious neurological injury or death. Long-term prognosis despite optimal pharmacological and dietary therapy is still poor. The combination of intravenous sodium phenylacetate and sodium benzoate (Ammonul®) can eliminate nitrogen waste independent of the urea cycle. We report attempts to improve outcomes for males with severe ornithine transcarbamylase deficiency (OTCD), a severe X-linked condition, via prenatal intravenous administration of Ammonul and arginine to heterozygous carrier females of OTCD during labor.Two heterozygote OTCD mothers carrying male fetuses with a prenatal diagnosis of OTCD received intravenous Ammonul, arginine and dextrose-containing fluids shortly before birth. Maintenance Ammonul and arginine infusions and high-caloric enteral nutrition were started immediately after birth. Ammonul metabolites were measured in umbilical cord blood and the blood of the newborn immediately after delivery. Serial ammonia and biochemical analyses were performed following delivery.Therapeutic concentrations of Ammonul metabolites were detected in umbilical cord and neonatal blood samples. Plasma ammonia and glutamine levels in the postnatal period were within the normal range. Peak ammonia levels in the first 24-48h were 53mcmol/l and 62mcmol/l respectively. The boys did not experience neurological sequelae secondary to hyperammonemia and received liver transplantation at ages 3months and 5months. The patients show normal development at ages 7 and 3years.Prenatal treatment of mothers who harbor severe OTCD mutations and carry affected male fetuses with intravenous Ammonul and arginine, followed by immediate institution of maintenance infusions after delivery, results in therapeutic levels of benzoate and phenylacetate in the newborn at delivery and, in conjunction with high-caloric enteral nutrition, prevents acute hyperammonemia and neurological decompensation. Following initial medical management, early liver transplantation may improve developmental outcome.
View details for DOI 10.1016/j.ymgme.2018.01.004
View details for PubMedID 29396029
Changing Management of the Patent Ductus Arteriosus: Effect on Neonatal Outcomes and Resource Utilization.
American journal of perinatology
Objective This historical cohort study investigated how a shift toward a more conservative approach of awaiting spontaneous closure of the patent ductus arteriosus (PDA) in preterm infants has affected neonatal outcomes and resource utilization. Methods We retrospectively studied very low birth weight infants diagnosed with a PDA by echocardiogram (ECHO) in 2006-2008 (era 1), when medical or surgical PDA management was emphasized, to those born in 2010-2012 (era 2) when conservative PDA management was encouraged. Multiple regression analyses adjusted for gestational age were performed to assess differences in clinical outcomes and resource utilization between eras. Results More infants in era 2 (35/89, 39%) compared with era 1 (22/120, 18%) had conservative PDA management (p < 0.01). Despite no difference in surgical ligation rate, infants in era 2 had ligation later (median 24 vs. 8 days, p < 0.0001). There was no difference in clinical outcomes between eras, while number of ECHOs per patient was the only resource measure that increased in era 2 (median 3 vs. 2 ECHOs, p = 0.003). Conclusion In an era of more conservative PDA management, no increase in adverse clinical outcomes or significant change in resource utilization was found. Conservative PDA management may be a safe alternative for preterm infants.
View details for DOI 10.1055/s-0037-1601442
View details for PubMedID 28376547
Health information exchange policies of 11 diverse health systems and the associated impact on volume of exchange.
Journal of the American Medical Informatics Association
2017; 24 (1): 113-122
Provider organizations increasingly have the ability to exchange patient health information electronically. Organizational health information exchange (HIE) policy decisions can impact the extent to which external information is readily available to providers, but this relationship has not been well studied.Our objective was to examine the relationship between electronic exchange of patient health information across organizations and organizational HIE policy decisions. We focused on 2 key decisions: whether to automatically search for information from other organizations and whether to require HIE-specific patient consent.We conducted a retrospective time series analysis of the effect of automatic querying and the patient consent requirement on the monthly volume of clinical summaries exchanged. We could not assess degree of use or usefulness of summaries, organizational decision-making processes, or generalizability to other vendors.Between 2013 and 2015, clinical summary exchange volume increased by 1349% across 11 organizations. Nine of the 11 systems were set up to enable auto-querying, and auto-querying was associated with a significant increase in the monthly rate of exchange (P = .006 for change in trend). Seven of the 11 organizations did not require patient consent specifically for HIE, and these organizations experienced a greater increase in volume of exchange over time compared to organizations that required consent.Automatic querying and limited consent requirements are organizational HIE policy decisions that impact the volume of exchange, and ultimately the information available to providers to support optimal care. Future efforts to ensure effective HIE may need to explicitly address these factors.
View details for DOI 10.1093/jamia/ocw063
View details for PubMedID 27301748
Safety Analysis of Proposed Data-Driven Physiologic Alarm Parameters for Hospitalized Children
JOURNAL OF HOSPITAL MEDICINE
2016; 11 (12): 817-823
Modification of alarm limits is one approach to mitigating alarm fatigue. We aimed to create and validate heart rate (HR) and respiratory rate (RR) percentiles for hospitalized children, and analyze the safety of replacing current vital sign reference ranges with proposed data-driven, age-stratified 5th and 95th percentile values.In this retrospective cross-sectional study, nurse-charted HR and RR data from a training set of 7202 hospitalized children were used to develop percentile tables. We compared 5th and 95th percentile values with currently accepted reference ranges in a validation set of 2287 patients. We analyzed 148 rapid response team (RRT) and cardiorespiratory arrest (CRA) events over a 12-month period, using HR and RR values in the 12 hours prior to the event, to determine the proportion of patients with out-of-range vitals based upon reference versus data-driven limits.There were 24,045 (55.6%) fewer out-of-range measurements using data-driven vital sign limits. Overall, 144/148 RRT and CRA patients had out-of-range HR or RR values preceding the event using current limits, and 138/148 were abnormal using data-driven limits. Chart review of RRT and CRA patients with abnormal HR and RR per current limits considered normal by data-driven limits revealed that clinical status change was identified by other vital sign abnormalities or clinical context.A large proportion of vital signs in hospitalized children are outside presently used norms. Safety evaluation of data-driven limits suggests they are as safe as those currently used. Implementation of these parameters in physiologic monitors may mitigate alarm fatigue. Journal of Hospital Medicine 2015;11:817-823. © 2015 Society of Hospital Medicine.
View details for DOI 10.1002/jhm.2635
View details for Web of Science ID 000389420100001
View details for PubMedID 27411896
Early experiences of accredited clinical informatics fellowships.
Journal of the American Medical Informatics Association
2016; 23 (4): 829-834
Since the launch of the clinical informatics subspecialty for physicians in 2013, over 1100 physicians have used the practice and education pathways to become board-certified in clinical informatics. Starting in 2018, only physicians who have completed a 2-year clinical informatics fellowship program accredited by the Accreditation Council on Graduate Medical Education will be eligible to take the board exam. The purpose of this viewpoint piece is to describe the collective experience of the first four programs accredited by the Accreditation Council on Graduate Medical Education and to share lessons learned in developing new fellowship programs in this novel medical subspecialty.
View details for DOI 10.1093/jamia/ocv209
View details for PubMedID 27206458
Development of a Web - Based Decision Support Tool to Operationalize and Optimize Management of Hyperbilirubinemia in Preterm Infants
CLINICS IN PERINATOLOGY
2016; 43 (2): 375-?
Premie BiliRecs is a novel electronic clinical decision support tool for the management of hyperbilirubinemia in moderately preterm infants less than 35 weeks gestational age. It serves to operationalize and automate current expert consensus-based guidelines, and to aid in the generation of new practice-based evidence to inform future guidelines.
View details for DOI 10.1016/j.clp.2016.01.009
View details for Web of Science ID 000378367300014
View details for PubMedID 27235214
Failed endotracheal intubation and adverse outcomes among extremely low birth weight infants.
Journal of perinatology
2016; 36 (2): 112-115
To quantify the importance of successful endotracheal intubation on the first attempt among extremely low birth weight (ELBW) infants who require resuscitation after delivery.A retrospective chart review was conducted for all ELBW infants ⩽1000 g born between January 2007 and May 2014 at a level IV neonatal intensive care unit. Infants were included if intubation was attempted during the first 5 min of life or if intubation was attempted during the first 10 min of life with heart rate <100. The primary outcome was death or neurodevelopmental impairment. The association between successful intubation on the first attempt and the primary outcome was assessed using multivariable logistic regression with adjustment for birth weight, gestational age, gender and antenatal steroids.The study sample included 88 ELBW infants. Forty percent were intubated on the first attempt and 60% required multiple intubation attempts. Death or neurodevelopmental impairment occurred in 29% of infants intubated on the first attempt, compared with 53% of infants that required multiple attempts, adjusted odds ratio 0.4 (95% confidence interval 0.1 to 1.0), P<0.05.Successful intubation on the first attempt is associated with improved neurodevelopmental outcomes among ELBW infants. This study confirms the importance of rapid establishment of a stable airway in ELBW infants requiring resuscitation after birth and has implications for personnel selection and role assignment in the delivery room.Journal of Perinatology advance online publication, 5 November 2015; doi:10.1038/jp.2015.158.
View details for DOI 10.1038/jp.2015.158
View details for PubMedID 26540244
- Case 1: Lactic Acidosis and Respiratory Distress in a 10-Day-Old Infant. NeoReviews 2015; 16 (7): e431-e433
An Exponential Increase in Regional Health Information Exchange With Collaborative Policies and Technologies.
Studies in health technology and informatics
2015; 216: 931-?
In the United States, the ability to securely exchange health information between organization has been limited by technical interoperability, patient identity matching, and variable institutional policies. Here, we examine the regional experience in a national health information exchange network by examining clinical data sharing between eleven Northern California organizations using the same health information exchange (HIE) platform between 2013-2014. We identify key policies and technologies that have led to a dramatic increase in health information exchange.
View details for PubMedID 26262233
Implementation of Data Drive Heart Rate and Respiratory Rate parameters on a Pediatric Acute Care Unit.
Studies in health technology and informatics
2015; 216: 918-?
The majority of hospital physiologic monitor alarms are not clinically actionable and contribute to alarm fatigue. In 2014, The Joint Commission declared alarm safety as a National Patient Safety Goal and urged prompt action by hospitals to mitigate the issue . It has been demonstrated that vital signs in hospitalized children are quite different from currently accepted reference ranges . Implementation of data-driven, age stratified vital sign parameters (Table 1) for alarms in this patient population could reduce alarm frequency.
View details for PubMedID 26262220
View details for PubMedCentralID PMC4824687
Red Blood Cell Transfusion Is Not Associated with Necrotizing Enterocolitis: A Review of Consecutive Transfusions in a Tertiary Neonatal Intensive Care Unit
JOURNAL OF PEDIATRICS
2014; 165 (4): 678-682
To explore the association between red blood cell transfusion and necrotizing enterocolitis (NEC) in a neonatal intensive care unit with liberal transfusion practices.A retrospective cohort study was conducted for all infants weighing <1500 g who received at least 1 packed red blood cell transfusion between January 2008 and June 2013 in a tertiary neonatal intensive care unit. The primary outcome was NEC, defined as Bell stage II or greater. The temporal association of NEC and transfusion was assessed using multivariate Poisson regression.The study sample included 414 very low birth weight infants who received 2889 consecutive red blood cell transfusions. Twenty-four infants (5.8%) developed NEC. Four cases of NEC occurred within 48 hours of a previous transfusion event. Using multivariate Poisson regression, we did not find evidence of a temporal association between NEC and transfusion (P = .32).There was no association between NEC and red blood cell transfusion. Our results differ from previous studies and suggest that the association between NEC and transfusion may be contextual.
View details for DOI 10.1016/j.jpeds.2014.06.012
View details for Web of Science ID 000342694200009
Pulmonary hypertensive crisis following ethanol sclerotherapy for a complex vascular malformation.
Journal of perinatology
2014; 34 (9): 713-715
Anhydrous ethanol is a commonly used sclerotic agent for treating vascular malformations. We describe the case of a full-term 15-day-old female with a complex venolymphatic malformation involving the face and orbit. During treatment of the lesion with ethanol sclerotherapy, she suffered acute pulmonary hypertensive crisis. We discuss the pathophysiology of pulmonary hypertension related to ethanol sclerotherapy, and propose that hemolysis plays a significant role. Recommendations for evaluation, monitoring and management of this complication are also discussed.
View details for DOI 10.1038/jp.2014.88
View details for PubMedID 25179381
Anti-Ge3 causes late-onset hemolytic disease of the newborn: the fourth case in three Hispanic families.
2013; 53 (10): 2152-2157
BACKGROUND: The Gerbich (Ge) blood group system consists of 11 antigens carried on red blood cell (RBC) membrane glycophorins C and D; of these, Ge:3 antigen is of high prevalence, and the anti-Ge3 is found to be clinically significant. CASE REPORT: A 34-week neonate born to a Hispanic mother with anti-Ge3 developed late-onset hemolysis with hyperbilirubinemia and was successfully treated with transfusions from her mother. Relevant clinical findings and laboratory results for this case are summarized and compared to three other previously reported cases; all babies were born from a mother of Hispanic ethnicity. CONCLUSION: Hemolytic disease of the fetus and new born associated with anti-Ge3 is rare but should be considered when working up a broadly reactive RBC antibody screen in women of Hispanic ethnicity. Early identification of pregnant women with anti-Ge3 is recommended for prenatal transfusion planning and close monitoring of the newborn infant for evidence of late-onset anemia.
View details for DOI 10.1111/trf.12027
View details for PubMedID 23241141
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
View details for PubMedCentralID PMC3733755
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
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
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: 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
View details for PubMedCentralID PMC3146345
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