Natalie Pageler - Academia.edu (original) (raw)
Papers by Natalie Pageler
Clinical Diabetes, 2021
The coronavirus disease 2019 (COVID-19) pandemic necessitated using telehealth to bridge the clin... more The coronavirus disease 2019 (COVID-19) pandemic necessitated using telehealth to bridge the clinical gap, but could increase health disparities. This article reports on a chart review of diabetes telehealth visits occurring before COVID-19, during shelter-in-place orders, and during the reopening period. Visits for children with public insurance and for those who were non-English speaking were identified. Telehealth visits for children with public insurance increased from 26.2% before COVID-19 to 37.3% during shelter-in-place orders and 34.3% during reopening. Telehealth visits for children who were non-English speaking increased from 3.5% before COVID-19 to 17.5% during shelter-in-place orders and remained at 15.0% during reopening. Pandemic-related telehealth expansion included optimization of workflows to include patients with public insurance and those who did not speak English. Increased participation by those groups persisted during the reopening phase, indicating that priori...
Studies in health technology and informatics, 2015
The majority of hospital physiologic monitor alarms are not clinically actionable and contribute ... more 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 [1]. It has been demonstrated that vital signs in hospitalized children are quite different from currently accepted reference ranges [2]. Implementation of data-driven, age stratified vital sign parameters (Table 1) for alarms in this patient population could reduce alarm frequency.
Patient Experience Journal, 2021
To determine the effect of encounter methods on patient experience, we evaluated patient experien... more To determine the effect of encounter methods on patient experience, we evaluated patient experience survey data comparing scores between telehealth and in-person visits and pre-COVID-19 and COVID-19 time periods. Pediatric subspecialty visits were either in-person or via telehealth and received the same 16-question patient experience survey. Top box (5/5) scores were compared between in-person and telehealth visits for pre-COVID-19 and COVID-19 periods as well as between periods for in-person and telehealth visits. In addition, for both time periods and encounter methods, correlation analysis was performed to evaluate best correlation between likelihood to recommend practice and the 15 other survey questions. Comparing the COVID-19 period data, there was a statistically significant difference in the top box likelihood to recommend practice score comparing in-person to telehealth numbers (81.01% vs 87.13%, p = 0.0003). Comparing pre-COVID-19 with COVID-19, this was not true for in-person scores (79.97% vs 81.01%, p = 0.4060) or telehealth scores (82.50% vs 87.13%, p = 0.2084). The question with the highest correlation coefficient to likelihood to recommend practice was how well staff worked together in both time periods and visit methods. We conclude that Likelihood to recommend experience scores were statistically significantly higher for telehealth as compared to in-person pediatric subspecialty ambulatory visits during the COVID-19 pandemic. There were no such differences in likelihood to recommend comparing pre-vs COVID-19 time periods for either in-person or telehealth visits so the change in scoring seems to be related to the mode of care delivery.
Journal of Adolescent Health, 2021
Managing confidential adolescent health information in patient portals presents unique challenges... more Managing confidential adolescent health information in patient portals presents unique challenges. Adolescent patients and guardians electronically access medical records and communicate with providers via portals. In confidential matters like sexual health, ensuring confidentiality is crucial. A key aspect of confidential portals is ensuring that the account is registered to and utilized by the intended user. Inappropriately registered or guardian-accessed adolescent portal accounts may lead to confidentiality breaches. Methods: We used a quality improvement framework to develop screening methodologies to flag guardian-accessible accounts. Accounts of patients aged 12e17 were flagged via manual review of account emails and natural language processing of portal messages. We implemented a reconciliation program to correct affected accounts' registered email. Clinics were notified about sign-up errors and educated on sign-up workflow. An electronic alert was created to check the adolescent's email prior to account activation. Results: After initial screening, 2,307 of 3,701 (62%) adolescent accounts were flagged as registered with a guardian's email. Those accounts were notified to resolve their logins. After five notifications over 8 weeks, 266 of 2,307 accounts (12%) were corrected; the remaining 2,041 (88%) were deactivated. Conclusions: The finding that 62% of adolescent portal accounts were used/accessed by guardians has significant confidentiality implications. In the context of the Cures Act Final Rule and increased information sharing, our institution's experience with ensuring appropriate access to adolescent portal accounts is necessary, timely, and relevant. This study highlights ways to improve patient portal confidentiality and prompts institutions caring for adolescents to review their systems and processes.
Health, 2021
Introduction: To evaluate the correlation between the presence of an independent EHR (compared to... more Introduction: To evaluate the correlation between the presence of an independent EHR (compared to a shared EHR system within an adult hospital system) and an externally-derived third party ranking of children's hospitals. Methods: Children's hospitals that ranked in the top fifty of the 2019-2020 US News and World Report (USNWR) were included in the analysis. The mean and median ranking of children's hospitals with independent versus a shared EHR was evaluated. The 2019-2020 USNWR rankings of the top twenty adult hospitals in the United States were then evaluated. For each children's hospital with an associated adult hospital that was both ranked, it was noted as to whether the EHR for the children's hospital was independent or shared and statistical differences in rankings compared. Results: Among the top 50 children's hospitals included, the median USNWR ranking for hospitals was statistically different with an independent EHR than with a shared EHR (13 vs. 30.0) (p = 0.002). The 21 top ranked adult hospitals were associated with 17 children's hospitals ranked in the top 50. The median ranking for those with an independent EHR was statistically different for those with independent EHR versus shared EHR (7 vs. 28) (p = 0.002). Conclusion: Children's hospitals with an independent EHR are associated with higher scores on an independent external ranking of hospital quality compared to those which share an EHR with a partner adult hospital.
Applied Clinical Informatics, 2021
Background OpenNotes, the sharing of medical notes via a patient portal, has been extensively stu... more Background OpenNotes, the sharing of medical notes via a patient portal, has been extensively studied in adults but not in pediatric populations. This has been a contributing factor in the slower adoption of OpenNotes by children's hospitals. The 21st Century Cures Act Final Rule has mandated the sharing of clinical notes electronically to all patients and as health systems prepare to comply, some concerns remain particularly with OpenNotes for pediatric populations. Objectives After a gradual implementation of OpenNotes at an academic pediatric center, we sought to better understand how pediatric patients and families perceived OpenNotes. This article presents the detailed steps of this informatics-led rollout and patient survey results with a focus on pediatric-specific concerns. Methods We adapted a previous OpenNotes survey used for adult populations to a pediatric outpatient setting (with parents of children <12 years old). The survey was sent to patients and families vi...
Critical Care Medicine, 2020
Journal of the American Medical Informatics Association, 2020
Response to COVID-19 Across Three Health Systems". Despite how common it has been to use the term... more Response to COVID-19 Across Three Health Systems". Despite how common it has been to use the terms "master" and "slave" to describe the configuration of hardware, we should have used more culturally appropriate descriptors. We wish to foster a more inclusive scientific community, and thus these terms in Table 1 and the section titled "Implementation of inpatient telemedicine at Stanford Health Care" have been updated to read "hub" and "spoke" instead.
Journal of the American Medical Informatics Association, 2020
Objective To reduce pathogen exposure, conserve personal protective equipment, and facilitate hea... more Objective To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting. Methods Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval. Results All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in e...
Applied Clinical Informatics, 2017
Electronic Health Records (EHRs) have been quickly implemented for meaningful use incentives; how... more Electronic Health Records (EHRs) have been quickly implemented for meaningful use incentives; however these implementations have been associated with provider dissatisfaction and burnout. There are no previously reported instances of a comprehensive EHR educational program designed to engage providers and assist in improving efficiency and understanding of the EHR. Utilizing adult learning theory as a framework, Stanford Children's Health designed a tailored provider efficiency program with various inputs from: (1) provider specific EHR data; (2) provider survey data; and (3) structured observation sessions. This case report outlines the design of this individualized training program including team structure, resource requirements, and early provider response.
Journal of hospital medicine, Jan 14, 2016
Modification of alarm limits is one approach to mitigating alarm fatigue. We aimed to create and ... more 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. Ove...
Critical care medicine, 2015
Pediatric Critical Care Medicine, 2013
Pediatrics, 2013
Despite advances in electronic medication order entry systems, it has been well established that ... more Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non–evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital’s system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.
Pediatrics, 2011
OBJECTIVE: Timely provision of evidence-based recommendations through computerized physician orde... more OBJECTIVE: Timely provision of evidence-based recommendations through computerized physician order entry with clinical decision support may improve use of red blood cell transfusions (RBCTs). METHODS: 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. RESULTS: 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' c...
Pediatric Critical Care Medicine, 2014
JAMA, 2013
There is increasing recognition that medical education should be adapted to address the integrati... more There is increasing recognition that medical education should be adapted to address the integration of the electronic medical record (EMR) into medical practice, but how this should occur and the specific educational goals have not been well defined. In this Viewpoint, we offer suggestions for updating the Accreditation Council for Graduate Medical Education (ACGME) competencies to promote optimal integration of the EMR into clinical practice, guidance for using data available within the EMR to support and evaluate the achievement of ACGME milestones, and specific steps that individual institutions can take to support this evolution in medical education. Introduction of the EMR is greatly changing the practice of medicine, bringing the benefits of increased access to data, automated clinical decision support, and opportunities for enhanced communication among physicians and with patients. As with many new technologies, the introduction of the EMR has also introduced a wide range of unintended negative consequences. A recent commentary by a ward attending at a major academic medical center described how his trainees held rounds in a secluded work room and were overly focused on the patients’ data in the EMR, often failing to incorporate significant information from the physical examination and interactions with the patient into their assessments.1 Others have noted examples of clinicians’ attention to the computer disrupting the patientphysician relationship in the pediatric examination room, to poignant effect.2 Trainees may use EMR functionality to copy large amounts of data into their progress notes, making them difficult to read and understand.3 Furthermore, clinicians are susceptible to automation bias, the tendency to place too much trust in decision support systems without recognizing the limitations of such systems.4 Given these examples of poor integration of the EMR into clinical practice, as well as the unrealized potential for the EMR to enhance medical education, it is important to examine the effect of the EMR on each of the core competencies and the role it may play in supporting the achievement of educational milestones. The medical education community has recognized that stakeholders expect physicians to use health information technology to optimize both individual and population health. The 2013 ACGME common program requirements list use of information technology as one of the competencies under practice-based learning and improvement.5 But information technology significantly affects all aspects of medical practice and therefore relates to all ACGME core competencies.6 Competency in use of the EMR should not be a goal but instead integrated into each aspect of medical practice as a tool for helping trainees achieve the 6 core competencies. For example, physician training should explicitly address and provide feedback on trainees’ ability to balance engagement with the patient and the EMR to both strengthen the patient-physician relationship and promote highly reliable patient care through accurate documentation and prudent use of clinical decision support. Communication subcompetencies should evolve to include skills for appropriately identifying and using online media such as e-mail, patient portals, and evolving mobile technologies to maintain and enhance the patient-physician relationship between office visits. As part of practice-based learning and improvement, trainees should be taught to access reports from the EMR that show their patterns of patient management for patients with specific diseases and enable the trainees to identify for themselves possible areas for practice improvement. The Table provides additional examples of potential EMR-related subcompetencies. Although this table is structured around graduate medical education core competencies, many of the lessons about optimal integration of the EMR into patient care can and should start with medical students. Emphasizing the key supportive role that technology can play in each of the core competencies should help trainees maintain the patient as the focus of attention and appropriately position the EMR as a tool to support the core mission of patient care. In addition to introducing new required skills and associated training requirements, the EMR provides new tools that can be harnessed to help achieve and evaluate previously identified milestones. The routine collection of electronic data enables the production of reports to track trainees’ experience with various types of patients, documentation of procedures, compliance with best practice guidelines in management of patients with specific diseases (eg, adequate blood pressure control in patients with hypertension), and quality of documentation of key patient information such as medication and problem lists. Specific clinical decision support tools can be developed to directly address knowledge gaps,7 and reports of alerts can be used to help identify such gaps. The…
Clinical Diabetes, 2021
The coronavirus disease 2019 (COVID-19) pandemic necessitated using telehealth to bridge the clin... more The coronavirus disease 2019 (COVID-19) pandemic necessitated using telehealth to bridge the clinical gap, but could increase health disparities. This article reports on a chart review of diabetes telehealth visits occurring before COVID-19, during shelter-in-place orders, and during the reopening period. Visits for children with public insurance and for those who were non-English speaking were identified. Telehealth visits for children with public insurance increased from 26.2% before COVID-19 to 37.3% during shelter-in-place orders and 34.3% during reopening. Telehealth visits for children who were non-English speaking increased from 3.5% before COVID-19 to 17.5% during shelter-in-place orders and remained at 15.0% during reopening. Pandemic-related telehealth expansion included optimization of workflows to include patients with public insurance and those who did not speak English. Increased participation by those groups persisted during the reopening phase, indicating that priori...
Studies in health technology and informatics, 2015
The majority of hospital physiologic monitor alarms are not clinically actionable and contribute ... more 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 [1]. It has been demonstrated that vital signs in hospitalized children are quite different from currently accepted reference ranges [2]. Implementation of data-driven, age stratified vital sign parameters (Table 1) for alarms in this patient population could reduce alarm frequency.
Patient Experience Journal, 2021
To determine the effect of encounter methods on patient experience, we evaluated patient experien... more To determine the effect of encounter methods on patient experience, we evaluated patient experience survey data comparing scores between telehealth and in-person visits and pre-COVID-19 and COVID-19 time periods. Pediatric subspecialty visits were either in-person or via telehealth and received the same 16-question patient experience survey. Top box (5/5) scores were compared between in-person and telehealth visits for pre-COVID-19 and COVID-19 periods as well as between periods for in-person and telehealth visits. In addition, for both time periods and encounter methods, correlation analysis was performed to evaluate best correlation between likelihood to recommend practice and the 15 other survey questions. Comparing the COVID-19 period data, there was a statistically significant difference in the top box likelihood to recommend practice score comparing in-person to telehealth numbers (81.01% vs 87.13%, p = 0.0003). Comparing pre-COVID-19 with COVID-19, this was not true for in-person scores (79.97% vs 81.01%, p = 0.4060) or telehealth scores (82.50% vs 87.13%, p = 0.2084). The question with the highest correlation coefficient to likelihood to recommend practice was how well staff worked together in both time periods and visit methods. We conclude that Likelihood to recommend experience scores were statistically significantly higher for telehealth as compared to in-person pediatric subspecialty ambulatory visits during the COVID-19 pandemic. There were no such differences in likelihood to recommend comparing pre-vs COVID-19 time periods for either in-person or telehealth visits so the change in scoring seems to be related to the mode of care delivery.
Journal of Adolescent Health, 2021
Managing confidential adolescent health information in patient portals presents unique challenges... more Managing confidential adolescent health information in patient portals presents unique challenges. Adolescent patients and guardians electronically access medical records and communicate with providers via portals. In confidential matters like sexual health, ensuring confidentiality is crucial. A key aspect of confidential portals is ensuring that the account is registered to and utilized by the intended user. Inappropriately registered or guardian-accessed adolescent portal accounts may lead to confidentiality breaches. Methods: We used a quality improvement framework to develop screening methodologies to flag guardian-accessible accounts. Accounts of patients aged 12e17 were flagged via manual review of account emails and natural language processing of portal messages. We implemented a reconciliation program to correct affected accounts' registered email. Clinics were notified about sign-up errors and educated on sign-up workflow. An electronic alert was created to check the adolescent's email prior to account activation. Results: After initial screening, 2,307 of 3,701 (62%) adolescent accounts were flagged as registered with a guardian's email. Those accounts were notified to resolve their logins. After five notifications over 8 weeks, 266 of 2,307 accounts (12%) were corrected; the remaining 2,041 (88%) were deactivated. Conclusions: The finding that 62% of adolescent portal accounts were used/accessed by guardians has significant confidentiality implications. In the context of the Cures Act Final Rule and increased information sharing, our institution's experience with ensuring appropriate access to adolescent portal accounts is necessary, timely, and relevant. This study highlights ways to improve patient portal confidentiality and prompts institutions caring for adolescents to review their systems and processes.
Health, 2021
Introduction: To evaluate the correlation between the presence of an independent EHR (compared to... more Introduction: To evaluate the correlation between the presence of an independent EHR (compared to a shared EHR system within an adult hospital system) and an externally-derived third party ranking of children's hospitals. Methods: Children's hospitals that ranked in the top fifty of the 2019-2020 US News and World Report (USNWR) were included in the analysis. The mean and median ranking of children's hospitals with independent versus a shared EHR was evaluated. The 2019-2020 USNWR rankings of the top twenty adult hospitals in the United States were then evaluated. For each children's hospital with an associated adult hospital that was both ranked, it was noted as to whether the EHR for the children's hospital was independent or shared and statistical differences in rankings compared. Results: Among the top 50 children's hospitals included, the median USNWR ranking for hospitals was statistically different with an independent EHR than with a shared EHR (13 vs. 30.0) (p = 0.002). The 21 top ranked adult hospitals were associated with 17 children's hospitals ranked in the top 50. The median ranking for those with an independent EHR was statistically different for those with independent EHR versus shared EHR (7 vs. 28) (p = 0.002). Conclusion: Children's hospitals with an independent EHR are associated with higher scores on an independent external ranking of hospital quality compared to those which share an EHR with a partner adult hospital.
Applied Clinical Informatics, 2021
Background OpenNotes, the sharing of medical notes via a patient portal, has been extensively stu... more Background OpenNotes, the sharing of medical notes via a patient portal, has been extensively studied in adults but not in pediatric populations. This has been a contributing factor in the slower adoption of OpenNotes by children's hospitals. The 21st Century Cures Act Final Rule has mandated the sharing of clinical notes electronically to all patients and as health systems prepare to comply, some concerns remain particularly with OpenNotes for pediatric populations. Objectives After a gradual implementation of OpenNotes at an academic pediatric center, we sought to better understand how pediatric patients and families perceived OpenNotes. This article presents the detailed steps of this informatics-led rollout and patient survey results with a focus on pediatric-specific concerns. Methods We adapted a previous OpenNotes survey used for adult populations to a pediatric outpatient setting (with parents of children <12 years old). The survey was sent to patients and families vi...
Critical Care Medicine, 2020
Journal of the American Medical Informatics Association, 2020
Response to COVID-19 Across Three Health Systems". Despite how common it has been to use the term... more Response to COVID-19 Across Three Health Systems". Despite how common it has been to use the terms "master" and "slave" to describe the configuration of hardware, we should have used more culturally appropriate descriptors. We wish to foster a more inclusive scientific community, and thus these terms in Table 1 and the section titled "Implementation of inpatient telemedicine at Stanford Health Care" have been updated to read "hub" and "spoke" instead.
Journal of the American Medical Informatics Association, 2020
Objective To reduce pathogen exposure, conserve personal protective equipment, and facilitate hea... more Objective To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting. Methods Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval. Results All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in e...
Applied Clinical Informatics, 2017
Electronic Health Records (EHRs) have been quickly implemented for meaningful use incentives; how... more Electronic Health Records (EHRs) have been quickly implemented for meaningful use incentives; however these implementations have been associated with provider dissatisfaction and burnout. There are no previously reported instances of a comprehensive EHR educational program designed to engage providers and assist in improving efficiency and understanding of the EHR. Utilizing adult learning theory as a framework, Stanford Children's Health designed a tailored provider efficiency program with various inputs from: (1) provider specific EHR data; (2) provider survey data; and (3) structured observation sessions. This case report outlines the design of this individualized training program including team structure, resource requirements, and early provider response.
Journal of hospital medicine, Jan 14, 2016
Modification of alarm limits is one approach to mitigating alarm fatigue. We aimed to create and ... more 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. Ove...
Critical care medicine, 2015
Pediatric Critical Care Medicine, 2013
Pediatrics, 2013
Despite advances in electronic medication order entry systems, it has been well established that ... more Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non–evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital’s system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.
Pediatrics, 2011
OBJECTIVE: Timely provision of evidence-based recommendations through computerized physician orde... more OBJECTIVE: Timely provision of evidence-based recommendations through computerized physician order entry with clinical decision support may improve use of red blood cell transfusions (RBCTs). METHODS: 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. RESULTS: 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' c...
Pediatric Critical Care Medicine, 2014
JAMA, 2013
There is increasing recognition that medical education should be adapted to address the integrati... more There is increasing recognition that medical education should be adapted to address the integration of the electronic medical record (EMR) into medical practice, but how this should occur and the specific educational goals have not been well defined. In this Viewpoint, we offer suggestions for updating the Accreditation Council for Graduate Medical Education (ACGME) competencies to promote optimal integration of the EMR into clinical practice, guidance for using data available within the EMR to support and evaluate the achievement of ACGME milestones, and specific steps that individual institutions can take to support this evolution in medical education. Introduction of the EMR is greatly changing the practice of medicine, bringing the benefits of increased access to data, automated clinical decision support, and opportunities for enhanced communication among physicians and with patients. As with many new technologies, the introduction of the EMR has also introduced a wide range of unintended negative consequences. A recent commentary by a ward attending at a major academic medical center described how his trainees held rounds in a secluded work room and were overly focused on the patients’ data in the EMR, often failing to incorporate significant information from the physical examination and interactions with the patient into their assessments.1 Others have noted examples of clinicians’ attention to the computer disrupting the patientphysician relationship in the pediatric examination room, to poignant effect.2 Trainees may use EMR functionality to copy large amounts of data into their progress notes, making them difficult to read and understand.3 Furthermore, clinicians are susceptible to automation bias, the tendency to place too much trust in decision support systems without recognizing the limitations of such systems.4 Given these examples of poor integration of the EMR into clinical practice, as well as the unrealized potential for the EMR to enhance medical education, it is important to examine the effect of the EMR on each of the core competencies and the role it may play in supporting the achievement of educational milestones. The medical education community has recognized that stakeholders expect physicians to use health information technology to optimize both individual and population health. The 2013 ACGME common program requirements list use of information technology as one of the competencies under practice-based learning and improvement.5 But information technology significantly affects all aspects of medical practice and therefore relates to all ACGME core competencies.6 Competency in use of the EMR should not be a goal but instead integrated into each aspect of medical practice as a tool for helping trainees achieve the 6 core competencies. For example, physician training should explicitly address and provide feedback on trainees’ ability to balance engagement with the patient and the EMR to both strengthen the patient-physician relationship and promote highly reliable patient care through accurate documentation and prudent use of clinical decision support. Communication subcompetencies should evolve to include skills for appropriately identifying and using online media such as e-mail, patient portals, and evolving mobile technologies to maintain and enhance the patient-physician relationship between office visits. As part of practice-based learning and improvement, trainees should be taught to access reports from the EMR that show their patterns of patient management for patients with specific diseases and enable the trainees to identify for themselves possible areas for practice improvement. The Table provides additional examples of potential EMR-related subcompetencies. Although this table is structured around graduate medical education core competencies, many of the lessons about optimal integration of the EMR into patient care can and should start with medical students. Emphasizing the key supportive role that technology can play in each of the core competencies should help trainees maintain the patient as the focus of attention and appropriately position the EMR as a tool to support the core mission of patient care. In addition to introducing new required skills and associated training requirements, the EMR provides new tools that can be harnessed to help achieve and evaluate previously identified milestones. The routine collection of electronic data enables the production of reports to track trainees’ experience with various types of patients, documentation of procedures, compliance with best practice guidelines in management of patients with specific diseases (eg, adequate blood pressure control in patients with hypertension), and quality of documentation of key patient information such as medication and problem lists. Specific clinical decision support tools can be developed to directly address knowledge gaps,7 and reports of alerts can be used to help identify such gaps. The…