- Pediatric Critical Care Medicine
Chief Medical Information Officer, Stanford Children's Health (2016 - Present)
Associate Program Director, Clinical Informatics Fellowship, Stanford University Medical Center (2014 - Present)
Associate Chief Medical Information Officer, Stanford Children's Health (2015 - 2016)
Director of Clinical Informatics, Stanford Children's Hospital (2014 - 2016)
Physician Lead, Epic EMR Inpatient Implementation, Lucile Packard Children's Hospital (2012 - 2014)
Medical Director of Clinical Informatics, Lucile Packard Children's Hospital (2012 - 2014)
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.
- Clinical Informatics Literature Review Seminar
BIOMEDIN 208 (Win)
- Independent Studies (5)
- Prior Year Courses
Graduate and Fellowship Programs
Biomedical Informatics (Phd Program)
Pediatric Critical Care Medicine (Fellowship Program)
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
Use of a Checklist and Clinical Decision Support Tool Reduces Laboratory Use and Improves Cost.
2016; 137 (1): 1-8
We hypothesized that a daily rounding checklist and a computerized order entry (CPOE) rule that limited the scheduling of complete blood cell counts and chemistry and coagulation panels to a 24-hour interval would reduce laboratory utilization and associated costs.We performed a retrospective analysis of these initiatives in a pediatric cardiovascular ICU (CVICU) that included all patients with congenital or acquired heart disease admitted to the cardiovascular ICU from September 1, 2008, until April 1, 2011. Our primary outcomes were the number of laboratory orders and cost of laboratory orders. Our secondary outcomes were mortality and CVICU and hospital length of stay.We found a reduction in laboratory utilization frequency in the checklist intervention period and additional reduction in the CPOE intervention period [complete blood count: 31% and 44% (P < .0001); comprehensive chemistry panel: 48% and 72% (P < .0001); coagulation panel: 26% and 55% (P < .0001); point of care blood gas: 43% and 44% (P < .0001)] compared with the preintervention period. Projected yearly cost reduction was $717, 538.8. There was no change in adjusted mortality rate (odds ratio 1.1, 95% confidence interval 0.7-1.9, P = .65). CVICU and total length of stay (days) was similar in the pre- and postintervention periods.Use of a daily checklist and CPOE rule reduced laboratory resource utilization and cost without adversely affecting adjusted mortality or length of stay. CPOE has the potential to hardwire resource management interventions to augment and sustain the daily checklist.
View details for DOI 10.1542/peds.2014-3019
View details for PubMedID 26681782
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
View details for PubMedID 24732291
- 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
A rational approach to legacy data validation when transitioning between electronic health record systems.
Journal of the American Medical Informatics Association
2016; 23 (5): 991-994
The objective of this project was to use statistical techniques to determine the completeness and accuracy of data migrated during electronic health record conversion.Data validation during migration consists of mapped record testing and validation of a sample of the data for completeness and accuracy. We statistically determined a randomized sample size for each data type based on the desired confidence level and error limits.The only error identified in the post go-live period was a failure to migrate some clinical notes, which was unrelated to the validation process. No errors in the migrated data were found during the 12- month post-implementation period.Compared to the typical industry approach, we have demonstrated that a statistical approach to sampling size for data validation can ensure consistent confidence levels while maximizing efficiency of the validation process during a major electronic health record conversion.
View details for DOI 10.1093/jamia/ocv173
View details for PubMedID 26977100
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
Propylene glycol toxicity in children.
The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG
2014; 19 (4): 277-282
Propylene glycol (PG) is a commonly used solvent for oral, intravenous, and topical pharmaceutical agents. Although PG is generally considered safe, when used in high doses or for prolonged periods, PG toxicity can occur. Reported adverse effects from PG include central nervous system (CNS) toxicity, hyperosmolarity, hemolysis, cardiac arrhythmia, seizures, agitation, and lactic acidosis. Patients at risk for toxicity include infants, those with renal or hepatic insuficiency, epilepsy, and burn patients receiving extensive dermal applications of PG containing products. Laboratory monitoring of PG levels, osmolarity, lactate, pyruvate, bicarbonate, creatinine, and anion gap can assist practitioners in making the diagnosis of PG toxicity. Numerous studies and case reports have been published on PG toxicity in adults. However, very few have been reported in pediatric patient populations. A review of the literature is presented.
View details for DOI 10.5863/1551-6776-19.4.277
View details for PubMedID 25762872
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