by Mary Butler
In this web series, HIM professionals working in emerging roles give advice on tackling difficult HIM problems. This month features the first in a two-part series discussing the unique challenges HIM professionals face in deploying EHRs customized to serve pediatric providers.
The HIM Problem
Questions such as “What’s your favorite stuffed animal?” or “What’s your favorite kind of blanket?” are irrelevant items to include in the electronic health record (EHR) of an adult patient. But answers to questions like these and others such as “What’s the best way to get the patient to stop crying?” are vital for delivering optimal care for a child admitted to the hospital.
Most EHRs are developed for adult and Medicare populations, so pediatric healthcare providers often find themselves on their own when it comes to tailoring their EHRs. Customizing an EHR to reflect a child’s needs and status requires special attention for both practicality and safety. Even the way information is inputted into a pediatric EHR, through the use of clinical scribes, can make a huge difference in care delivery and patient satisfaction.
The HIM Problem-Solver
Anne Tegen, MHA, RHIA, director of HIM, Children’s Hospitals and Clinics of Minnesota
Customize, Customize, Customize
Tegen’s organization began its transition to EHRs in the late 1990s and the early 2000s and she found early on that EHRs were designed only with adults in mind. Drop-down menu options for body weight, medication dosing, and lab values didn’t include ranges for neonates and older children. So when Tegen did pick a vendor, her team worked diligently to customize it.
“The dosing has to be carefully done. And we had to do all of that ourselves. In addition to that, we had to develop all of our own rules and alerts about what could be medication errors. Because everything is based on a larger weight, and none of that applied to us,” Tegen says.
Because the needs of children vary so much—patients can range in age from infants born prematurely to adolescents—Tegen’s organization developed an admission tool for each stage of development.
Although Tegen started working with EHRs in the early days of their use, customization still continues to an extent.
“You take the basic package from any of the big vendors and you have to adapt it. One thing they have developed though, we helped develop the pharmacy dosing and weights, then they discount the price for us,” Tegen says, adding that this works well for the vendor too, which can turn around and sell a customized pediatric EHR to other providers.
“It’s nice to have something already developed so you don’t have to reinvent the wheel, and you can tweak it if you have a special population you’re seeing. Not all pediatric hospitals have every service. For example, we don’t do transplants, but another pediatric hospital might. In that case they’ll have a special developmental need for that transplantation.”
Unexpected Success with Medical Scribes
Another less technical and more practical tweak to EHRs was putting them in the hands of medical scribes in hospital emergency departments as well as medical and surgical floors. Tegen’s organization prefers that scribes be college graduates or students nearing graduation, and that they be pre-med majors.
The scribes use a laptop they roll on a cart from room to room as they round on patients with the physicians. Templates have been created for the different clinics and specialties, such as neurosurgery and the neonatal ICU. Scribes pre-populate the EHRs of each patient prior to rounding, including finding new lab and radiology reports so that everything is ready for the physician. This gives physicians more time to focus on the patient and their family.
“The challenge for physicians is that normally they would come into a room and they examine a patient, listen to heart and lungs. If you just had surgery, they’ll look at the wound, and ask questions. But it’s really silent, the exam is silent,” Tegen says. “But one of the things we didn’t expect on our med/surg floor, was that if a parent is in the room with the child, and the parent hears all of this, they know exactly what’s going into the note. And they have this great update what’s happening with their child.”
In her hospital, residents are in charge of scheduling and organizing rounds, and parents are told ahead of time in the day what time the doctor will be in. This is important, says Tegen, because parents of sick kids spend a lot of time waiting around for the doctor to show up.
“The other thing we do with those rounds is that we add the nurse, the nurse is there with them, and social worker if needed, or the interpreter, the family member, whoever it is, knows exactly what’s going on. So our patient satisfaction went way up, and we just didn’t expect that. All because of scribes and the rounding team,” Tegen says.
"Overcoming the Challenges of Pediatric EHRs"
(Journal of AHIMA),