Special considerations for Pediatric Practices
Additional information regarding pediatric informatics may be found here: Specialized Needs of a Pediatric EHR
Electronic medical record systems were originally designed for adult care. However in pediatrics, these systems must execute certain actions unique to the care of infants, children and adolescents. These unique requirements need special consideration from designers to facilitate care, support the physician’s work and make pediatric care for children safe.
- 1 Required features
- 2 Immunization
- 3 Appropriate doses of medication
- 4 Growth charts
- 5 Privacy issues
- 6 Additional Features and Content (Not specifically discussed by Spooner et al (1,12)
- 7 The American Academy of Pediatrics Child Health Informatics Center (CHIC)
- 8 AAP’s Council on Clinical Information Technology ([www.aapcocit.org COCIT])
- 9 References
The American Academy of Pediatrics had published a list of desirable features since 2001.  Andrew Spooner in his 2007 article prioritizes some of these topics (12):
- Immunization management
- Medication dosing
- Growth tracking
- Patient identification
- Norms for pediatric data
- Data precision
- Pediatric terminology
In the 2010's there arose a US government initiative to further develop ideal pediatric EHR specifications, reviewed on the sister page titled Children's Electronic Health Record Format.
Immunization has always been a critical activity in the care of children. EMR system must provide a pediatrician with the ability to record and display data that helps them to comply with the federal law. This data consists of the manufacturer’s name, lot numbers, expiration dates, and site of vaccine administration, route, and date. It also contains consent for administration or documentation of vaccine refusal. The ability to document the vaccine information statements (VIS) that are delivered to the parent, i.e. when this information was given and the version given, allows physicians to comply with the requirements of the Vaccines for Children program (VFC) and National Childhood Vaccine Injury Act. The EHR systems should also have the ability to update the immunization records in registries at the state or local levels and provide decision support that recommends the appropriate immunization from data entered at the time of care.(2,3)
Appropriate doses of medication
Another activity that requires special consideration is the prescription of medication based on age and weight or body surface area. Tools that allow physician to check current weight against the age, verify doses against accepted pediatric references, express the prescriptions in volume to be administer by caregivers and pharmacy specifications other than instructions for the parents are important functions to assist in selecting medication and prevent errors.
Furthermore, the ability of the EMR system to provide growth charts is a unique requirement for pediatricians. Clinicians make important decision regarding how their patients have been growing by plotting length or height, weight and head circumference against age. These graphic representations allow the pediatrician to analyze the growth velocity at specific age, by gender and against establish norm, enabling the physician to identify problems at the early stages. (4)
System designers should also take special consideration when establishing normal ranges for numeric (vital signs, body measurements, scores on standardized assessments, and laboratory results) data in view that these values change with child‘s age. Also the EMR should have the ability to present not only the chronological age but also corrected age (gestational + chronological) which is also important in the care of premature infant. (5)
It is also important for the clinician, while taking care of the pediatric population, that the EMR system has the flexibility for patient identification even though this functionality is supported with practice management software. Very often the clinician faces temporary registration of their patients in the newborn period (Baby Boy of…), and it will be ideal to be able to connect this identification with the official ones (i.e. social security numbers). This type of flexibility on patient identification, will allow easy retrieval of pre-, peri- and post-natal information at the time of patient care. Also it should allow the re-assignment of gender at later stages in cases of ambiguous genitalia when sex can not be assigned after birth.
Privacy issues are very unique in the pediatric population. The EMR should have different privacy needs regarding the variability of adolescent medicine from state to state, restriction and protection of sexual and mental health information, and behavior issues. In addition the system should be able to record the different guardianships in cases of foster care, adoption, and emergency treatment. (6)
The description of pediatric terms is extremely difficult in EMR systems. The system designers needs to expand standard terminology to include concepts that adequately represent these terms by describing historical findings, psychosocial risk factors, family structural details, social history, physical examination findings, developmental problems, behavioral issue, congenital syndromes and diagnoses particular to pediatrics.
The ability to present data at the appropriate numeric precision and graphical resolution is another functionality that requires special consideration in pediatrics. The designers need to facilitate graphical representation of frequent measurements such as daily weights of weekly head circumference and to provide the ability to record the age down to the hour and minutes at the newborn stage. It is also important to recognize that small changes can have a major impact in the care of pediatric patients.
Other features that are important are the ability to archive and manage patient data for a statutorily defined period of time, provide educational materials that are appropriate for both parents and children and at varying reading levels, create pedigree diagrams, display age at all times thought out the user interface, select age based documentation template and order sets on the basis of a patient’s age and indicate the source of patient data, particularly when the source is not the patient or the parent.
Additional Features and Content (Not specifically discussed by Spooner et al (1,12)
In the United States, about 13% of children 3 to 17 years of age have a developmental or behavioral disability CDC: Child Development.
Pediatricians, and providers who care for children, upholding best practices will frequently use a variety of validated, specific screening tools in their day-to-day practice. A few examples of which include normal development screening (PEDS, Denver Developmental Screen), autism screening (MCHATS), ADD/behavioral health screening (Conner's Rating Scale, Vanderbilt behavioral health assessment), and local screening tools for lead exposure. There are many validated developmental screens available for use in evidence-based medical practice.(15) Due to lack of resources, or licensing issues, many EHR vendors do not/cannot provide this content integrated. Considering validated screening tools with checkbox answers are fairly ideal for use in the EHR setting, many providers are very determined to have this content, and more, integrated into their bedside workflow.
Examples of Current Problems
Significant barriers exist currently to widespread usage of EHR based developmental screens. Despite recommendations(13)appropriate developmental screening remains below 50%. Pediatrician usage of appropriate screening tools for developmental assessment increased from 23.0%-47.7%(2002: N=1617, response rate: 55%; 2009: N=1620, response rate: 57%) (Radecki, Sand-Loud et al. 2011). Although promising, this work only makes vague mention of the small percentage of screening done within electronic health records.(10) Jensen et al. (2009) examined six integrated provider EHR systems with the goal of assessing the future potential to measure child developmental screening and follow-up rates in the primary care setting. The study found all six systems capable of implementing measures but found significant flaw with data capture and reliability, as well as tracking of care coordination.(11)Despite many years of fully functional installed EHRs, most EHR-live practices are either part of the 52.3% using unsanctioned developmental screening processes (some homemade, some EHR prepackaged, or none at all) or using validated screening tools on paper and scanning them in. Scanned paper is clearly inadequate for comprehensive reporting and surveillance as required, for example, by the medical home project.(14, 15)
Anticipatory Guidance Content
Considered mundane and by some, crucial by others, anticipatory guidance represents preventative medicine at its most basic level. It involves advising parents, children and adolescents about their most important health risks and concerns in the interim between well checkups. Topics include: safety, hygiene, physical and emotional development, relationships, sexual development, major risks, and more. There are many sources for anticipatory guidance reference, the most comprehensive of which, arguably, is the Bright Futures content published by the American Academy of Pediatrics(16) There has been discussion of EHR-ready versions of Bright Futures, however , development resources and licensing have been mentioned as barriers.(see CHIC, below)
Specific Pediatric Guideline Content
There has been significant attention paid to the multitude of guidelines available for adult chronic disease, such as coronary artery disease and diabetes. Additionally, urgent care protocols for stroke and heart attack have received widespread attention. Pediatric patients suffer far less from chronic and degenerative conditions.
However, there remains a significant amount of pediatric guideline content that can be implemented and integrated into EHR. The NHLBI Guidelines for the Care of Asthma are of significant importance in the pediatrics setting.(17) Asthma accounts for significant morbidity and mortality in children.(18) Additional EHR guideline content that would be of immediate and significant usefulness would be(but certainly not limited to)ADHD evaluation and treatment guidelines, preventative care for children with Down's/Turner's/Klinefelter's/etc. syndromes, hemoglobin/lead screening, etc.
The American Academy of Pediatrics Child Health Informatics Center (CHIC)
CHIC Medical Director: Christoph U Lehmann MD FAAP (as of April 2018)
In 2009 the American Academy of Pediatrics launched the Child Health and Informatics Center (CHIC) at the AAP National Conference and Exhibition (NCE). CHIC's founding medical director, Dr. Christoph U. Lehman, MD FAAP works with the center's 8-person Project Advisory Committee to provide as much pediatric content as possible for the active HIT initiative in the United States, and globally. The site provides many resources for providers, including assistance with EMR selection, meaningful use achievement, reference to state specific resources, policy, and more.
In October, 2011 Dr. Lehmann addressed the topic of EHR pediatric informatics content, AMIA Informatics Vendor Consortium/Feature Presentation, at the annual AMIA symposium in Washington, DC. He described the June 2011 Vendor Consortium held by the AAP.(8) The Consortium was designed to be an information gathering session for both the AAP and the vendors. It was attended by representatives (Some vendors sending 2 representatives) from many of today's major EHR vendors. Dr. Lehmann outlined his broad plan to hopefully provide vendors with EHR ready content that most vendors claim their clients are desperate for. He discussed the potential for even providing pre coded information for EHR's that could include Bright Futures anticipatory guidance and care guidelines.(9) Dr. Lehmann also discussed other initiatives, one of which is an attempt to convert current and future AAP policy and guidelines into EHR friendly algorithms for easy uptake by the EHR industry. There was also mention of difficulties with licensing of information and possibly fees for usage.
AAP’s Council on Clinical Information Technology ([www.aapcocit.org COCIT])
Closely associated with the Child Health Informatics Center is the AAP’s Council on Clinical Information Technology (COCIT). In 2002 the AAP merged its Section on Computers and Other Technologies and its Task Force on Medical Informatics to form COCIT. The COCIT mission is to “provide strategic direction and leadership to promote affordable, child-friendly health information technology (HIT) and health information exchange (HIE) solutions that support quality care; and to drive the creation of successful deployment of systems which have these characteristics.” AAP members are eligible to join, and an affiliate membership category exists. It has an internally elected 11-member Executive Committee and five subcommittees of Communications, Education, Membership Outreach and Engagement, Nominations, and Policy. As of April 2018, its Chairperson is Emily Webber, MD, FAAP. COCIT and its members have been core components of the AAP’s HIT activities throughout the 2000s and 2010s. COCIT produces educational activities at the AAP’s National Conference and Exhibition. Its members played central roles in the AHRQ/CMS Children's Electronic Health Record Format Enhancement, part of congress' Child Health Insurance Program Reauthorization Act of 2009 (CHIPRA). It has produced a number of policy papers on Pediatric Informatics, found here (pediatrics.aappublications.org/collection/council-clinical-information-technology). One of these is Andrew Spooner’s article referenced on this page (12).
- Special requirements for electronic medical record systems in pediatrics. Pediatrics 2001; 108; 5133-515.
- Lyznicki JM, Rinaldi RC. Childhood immunization and the vaccines for Children Program. Arch Fam Med. 1994; 3:728-730.
- National Childhood Vaccine Injury Act: requirements for permanenet vaccination records and for reporting selected event after vaccination. JAMA.1988: 259: 2527-2528.
- Rosenbloom ST, Qi X, Riddle WR, et al. Implementing pediatric growth charts into an electronic medical record system. J AM Med Inform Assoc. 2006: 13: 302-308.
- American Academy of Pediatrics, Committee on Fetus and Newborn. Age terminology during the perinatal period. Pediatrics. 2004; 114: 1362-1364.
- American Academy of Pediatrics, Committee of Emergency Medicine. Consent for medical services for children and adolescents. Pediatrics. 2003: 111: 703-706.
- American Academy of Pediatrics, Child Health Informatics Center. .
- American Academy of Pediatrics, Vendor Consortium Project. 
- American Academy of Pediatrics, Bright Futures; Prevention and health promotion for infants, children, adolescents, and their families. 
- Radecki, L., N. Sand-Loud, et al. (2011). "Trends in the use of standardized tools for developmental screening in early childhood: 2002-2009." Pediatrics 128(1): 14-19.
- Jensen, R. E., K. S. Chan, et al. (2009). "Implementing electronic health record-based quality measures for developmental screening." Pediatrics 124(4): e648-654.
- Spooner SA. Special requirements of electronic health record systems in pediatrics. Pediatrics. 2007 Mar;119(3):631-7.
- Recommendations for preventive pediatric health care. Pediatrics. 2007;120(6):1376.
- Medical Home Portal. 
- NCQA Medical Home scoring summary ( 37 KB) PPC-PCMH Content and Scoring
- Bright Futures Anticipatory Guidance
- NHLBI Asthma Guidelines
- American Academy of Allergy, Asthma, and Immunology: Asthma Statistics
Submitted by Ed King
Revisions and addition of section on COCIT by Ben Sanders in April 2018