- Pediatric Critical Care Medicine
Associate Program Director, Clinical Informatics Fellowship, Stanford University Medical Center (2014 - Present)
Medical Director of Clinical Informatics, Lucile Packard Children's Hospital (2012 - Present)
Physician Lead, Epic EMR Inpatient Implementation, Lucile Packard Children's Hospital (2012 - Present)
Associate Medical Director of Clinical Decision Support, Lucile Packard Children's Hospital (2010 - 2012)
Fellowship:Lucile Packard Children's Hospital (2010) CA
Residency:Lucile Packard Children's Hospital (2007) CA
Medical Education:Stanford University School of Medicine (2004) CA
Board Certification: Clinical Informatics, American Board of Preventive Medicine (2014)
Board Certification: Pediatrics, American Board of Pediatrics (2007)
MEd, University of Cincinnati, Medical Education (2013)
Board Certification, American Board of Preventive Medicine, Clinical Informatics (2013)
Board Certification: Pediatric Critical Care Medicine, American Board of Pediatrics (2010)
Current Research and Scholarly Interests
In my administrative role, I oversee the development and maintenance of clinical decision support tools within the electronic medical record. These clinical decision support tools are designed to enhance patient safety, efficiency, and quality of care. My research focuses on rigorously evaluating--1) how these tools affect clinician knowledge, attitudes, and behaviors; and 2) how these tools affect clinical outcomes and efficiency of health care delivery.
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 PEDIATRICS 2014; 133 (3): E738-E746
- Refocusing medical education in the EMR era. JAMA-the journal of the American Medical Association 2013; 310 (21): 2249-2250
Medical education in the electronic medical record (EMR) era: benefits, challenges, and future directions.
2013; 88 (6): 748-752
In the last decade, electronic medical record (EMR) use in academic medical centers has increased. Although many have lauded the clinical and operational benefits of EMRs, few have considered the effect these systems have on medical education. The authors review what has been documented about the effect of EMR use on medical learners through the lens of the Accreditation Council for Graduate Medical Education's six core competencies for medical education. They examine acknowledged benefits and educational risks to use of EMRs, consider factors that promote their successful use when implemented in academic environments, and identify areas of future research and optimization of EMRs' role in medical education.
View details for DOI 10.1097/ACM.0b013e3182905ceb
View details for PubMedID 23619078
- 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
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
Severe lactic acidosis and multiorgan failure due to thiamine deficiency during total parenteral nutrition.
BMJ case reports
A 16-year-old perioperative paediatric patient presented with refractory lactic acidosis and multiorgan failure due to thiamine-deficient total parenteral nutrition during a recent national multivitamin shortage. Urgent empiric administration of intravenous thiamine resulted in prompt recovery from this life-threatening condition. Despite readily available treatment, a high index of suspicion is required to prevent cardiovascular collapse and mortality.
View details for DOI 10.1136/bcr-2014-205264
View details for PubMedID 24895398
- In reply. Academic medicine 2013; 88 (12): 1790-1791
Significant Toxicity in a Young Female After Low-Dose Tricyclic Antidepressant Ingestion
PEDIATRIC EMERGENCY CARE
2012; 28 (10): 1066-1069
Tricyclic antidepressant (TCA) ingestions are a relatively common pediatric ingestion, with significant potential for both cardiac and neurological toxicity. Previous studies on pediatric TCA ingestions have found the threshold of toxicity to be 5 mg/kg.We report a case of an 8-year-old girl who presented to the emergency department with depressed mental status and seizure-like movements. An extensive workup was pursued to evaluate the cause of her mental status, which only revealed a positive urine toxicology screen for TCA. Quantified serum levels of amitriptyline were 121 ng/mL (therapeutic range, 50-300 ng/mL) and nortriptyline were 79 ng/mL (therapeutic range 70-170 ng/mL), 18 hours after onset of symptoms. Subsequent history obtained after her mental status returned to normal revealed that she had ingested amitriptyline at a dose of 0.8 mg/kg.Tricyclic antidepressant ingestion has a high potential for toxicity in pediatric patients. This case suggests, contrary to previous literature, that toxicity may occur even with small doses.
View details for DOI 10.1097/PEC.0b013e31826cebfb
View details for Web of Science ID 000309656900025
View details for PubMedID 23034495
- Making pediatrics residency programs family friendly: Views along the professional educational continuum JOURNAL OF PEDIATRICS 2006; 149 (1): 1-2
Heart rate correlates of attachment status in young mothers and their infants
JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
2005; 44 (5): 470-476
To explore heart rate (HR) correlates of attachment behavior in young mothers and their infants to generate specific hypotheses and to provide pilot data on which studies to test those hypotheses might be based.Using the strange situation procedure, patterns of attachment were assessed in 41 low-income adolescent mothers and their infants. During the procedure, the HRs of the infants and mothers were recorded. The HR changes were analyzed and infant attachment group differences were examined.Infants in all attachment groups demonstrated a similar HR response. There were, however, notably different behavioral reactions in the insecure groups: relatively increased behavioral distress in the insecure/resistant infants and relatively decreased behavioral distress in insecure-avoidant infants. Mothers of insecure-resistant infants demonstrated elevated HRs during reunions and the insecure/resistant dyads demonstrated lower consistency between HR changes in infant and mother than the secure dyads.The results suggest the discrepancy between attachment-related behavioral reactions and HR response in insecurely attached infants. Maternal and dyadic HR changes vary between the attachment groups.
View details for DOI 10.1097/01.chi.0000157325.10232.b1
View details for Web of Science ID 000228610000012
View details for PubMedID 15843769
Effect of head orientation on gaze processing in fusiform gyrus and superior temporal sulcus
2003; 20 (1): 318-329
We used functional MRI with an event-related design to dissociate the brain activation in the fusiform gyrus (FG) and posterior superior temporal sulcus (STS) for multiple face and gaze orientations. The event-related design allowed for concurrent behavioral analysis, which revealed a significant effect of both head and gaze orientation on the speed of gaze processing, with the face and gaze forward condition showing the fastest reaction times. In conjunction with this behavioral finding, the FG responded with the greatest activation to face and gaze forward, perhaps reflecting the unambiguous social salience of congruent face and gaze directed toward the viewer. Random effects analysis showed greater activation in both the FG and posterior STS when the subjects viewed a direct face compared to an angled face, regardless of gaze direction. Additionally, the FG showed greater activation for forward gaze compared to angled gaze, but only when the face was forward. Together, these findings suggest that head orientation has a significant effect on gaze processing and these effects are manifest not only in the STS, but also the FG.
View details for DOI 10.1016/S1053-8119(03)00229-5
View details for Web of Science ID 000185746400028
View details for PubMedID 14527592