US adoption of health information technology as a path to improved quality of patient care (effectiveness, safety, timeliness, patient-centeredness, efficiency, and equity) has been promoted by the medical community. Children and infants (especially those with special health care needs) are at higher risk than are adults for medical errors and their consequences (particularly in environments in which children are not the primary patient population). However, development and adoption of health information technology tools and practices that promote pediatric quality and patient safety are lagging. Two inpatient clinical processes—medication delivery and patient care transitions—are discussed in terms of health information technology applications that support them and functions that are important to pediatric quality and safety. Pediatricians and their partners (pediatric nurses, pharmacists, etc) must develop awareness of technical and adaptive issues in adopting these tools and collaborate with organizational leaders and developers as advocates for the best interests and safety of pediatric patients. Pediatric health information technology adoption cannot be considered in terms of applications (such as electronic health records or computerized physician order entry) alone but must be considered globally in terms of technical (health information technology applications), organizational (structures and workflows of care), and cultural (stakeholders) aspects of what is best.

US adoption of health information technology (HIT) has been advocated by federal agencies, health care industry groups, and patient-advocacy organizations as a major approach to improve patient safety through reduction and prevention of medical errors.15  Adoption of HIT tools such as electronic health records (EHRs), computerized provider order entry (CPOE), and clinical decision support (CDS) is increasing, and although current implementation of all these HIT tools is not yet widespread in US hospitals,6,7  most hospitals that provide care for children and infants use some form of an electronic information system to manage personal health information and other data that affect children's health.8 

Children and infants have vulnerabilities and needs that are distinct from adults with regard to the management of their clinical care and its associated information. The extended normal ranges of body weights, sizes, and physiologic responses require modifications of clinical, technical, and information workflows to provide pediatric-specific care that is safe. A systematic evidence base for design and implementation of effective HIT that improves care quality and safety is needed but lacking,9  and recent observations and experience indicate that changes (such as the adoption of information technology) can introduce new and unanticipated errors.1012 

The primary reason for adopting HIT is to improve the quality and safety of care. Information technology can reduce variations that lead to task failures13  and uncertainties that increase cognitive burdens that lead to incorrect decisions. An important component in safety is the consideration (and estimation) of risk:

\[risk\ {=}\ likelihood\ of\ error\ {\times}\ severity\ of\ error\ (harm).\]

Children seem to be at higher risk than adults for medical errors, with estimates based on inpatient data suggesting that hospitalized children may be at higher (up to triple) risk of preventable adverse drug events. Contributors to these may include wider ranges of children's and infants' weights (neonates seem to be at the highest risk of adverse drug events), greater complexity of medication dosing (universal weight-based dosing is prone to calculation errors and must include consideration for adult maximum-dose limits), and higher risk in special domains (continuous intravenous infusions and chemotherapy may have higher immediate and/or cumulative toxicities than other drug types).

Another contributor to children's risk of medical errors is the variety of institutional settings in which they receive medical, surgical, and psychiatric care. Environments range from academic centers that specialize in tertiary pediatric care to general community hospitals that care primarily for adults. Each type of inpatient setting (and each individual setting) has specific attributes that may contribute to error likelihood.

The major technical barrier to adoption of pediatric HIT tools is a lack of pediatric-specific information technology standards. Among these needs for standards are pediatric data that are machine-readable, terminologies and dictionaries that fully describe pediatric clinical entities (such as pediatric drug-dose data), and electronic standards (Health Level 7 Child Health Functional Profile14  is currently in development) that adequately describe pediatric clinical events.

To establish these technical standards, there must be recognized leadership and authority as well as legislative and financial support at national, regional, and institutional levels. Standards for HIT products and practices designed for pediatric care must be based on pediatric data, not extrapolated from adult data.9  Recent efforts by the American Academy of Pediatrics (AAP) Council on Clinical Information Technology have promoted collaboration to define standard pediatric functionalities for EHRs, and the requirements for pediatrics are being addressed by the Certification Commission for Health Information Technology.15 

The child and family caregivers are central to pediatric care. Health care structures and processes, including errors and their disclosure, must be transparent to patients and families. Inpatient HIT applications must support family-centered, developmentally appropriate care of children16  and must preserve transparency and patient/family empowerment.

The primary care provider and the medical home are central in the longitudinal care of children, particularly those with special health care needs. Inpatient HIT applications and workflows must support facilitated communication and continuity among patients' primary care providers, families, and inpatient care teams as well as (real-time) interoperability between inpatient and medical home clinical data systems.

Hospitalists and nursing and affiliate staff (such as pharmacists) are central to the inpatient care process. The progressive compartmentalization of health care has separated clinical responsibilities for transitional and inpatient care: emergency physicians for emergent care, hospitalists for general inpatient and observation-unit services, neonatologists and intensivists for critical care services, specialists for specific problems and procedures, and nursing for inpatient unit management and patient care administration. Inpatient HIT tools must support the work of inpatient staff to organize patient care, facilitate communication, and make care transitions (including shift change, admission, transfer, and discharge) safe while reinforcing staff roles in patient care1723  (including issues of training and certification requirements2426  for pediatric care).

Medication delivery and patient care transitions are 2 inpatient processes that are vulnerable to errors and are the focus of current research and development of information technologies.

Medication delivery is a set of common inpatient processes consisting of a series of role-based functions and handoffs. Certain environments and processes have higher risk because of a higher likelihood and/or impact of errors, but at the core:

  1. A prescriber determines a patient's need for a drug regimen; specifies a medication and its dosage, form, route, and frequency; and then generates a formal order for the regimen and transcribes it for transmission to the pharmacist.

  2. The pharmacist receives and checks the order; consults patient data and the prescriber (when needed) for errors and clarifications; makes certain independent decisions on form, route, and dose adjustments; and prepares and dispenses drug doses and instructions.

  3. Drug doses are delivered to the inpatient unit nurse, who accepts and stores the drug doses; retrieves, administers, and documents drug doses to the patient according to the original order/schedule and pharmacy instructions; and makes certain independent decisions within practice scope (such as with “as-needed” orders or optional administration routes [oral versus rectal]).

During an inpatient stay, patients undergo numerous care transitions, including admission (from emergency departments, transport services, and physician offices), discharge (to home or other facilities), and/or transfer to different locations within the institution for tests (imaging), procedures (surgery), and special levels of care (postanesthesia recovery care). Patients in transit (away from the “home” inpatient unit) may have needs, including life (ventilator) and environmental (temperature regulation for preterm infants) support, maintenance of scheduled and continuous medical care, physical transport, patient-location tracking, and contingencies that must be anticipated and coordinated before transition. Information (in the form of notes, orders, and other documentation) accompanies personnel until the patient reaches his or her destination, where transition (handover) occurs.

The most common transition is the transfer of care responsibilities (handovers, handoffs, or sign-outs). Physicians, nurses, consultants, and ancillary staff members transfer responsibilities in parallel (physician to physician, nurse to nurse, etc) and, in most cases, asynchronously according to shift and call schedules. Higher rates of handovers of information, authorization, and responsibility are associated with higher risks of incomplete or incorrect information transfer but may be necessary because of residency hour requirements.27  Currently identified transition problems include needs for medication reconciliation and structured and interactive information transfers during handovers.

The consideration of adopting HIT for clinical use involves assessments of both the clinical and institutional environment and of available products.

Within any clinical environment or workflow, HIT adoption is high-risk change that must be managed carefully. In assessing HIT-adoption initiatives, stakeholders should consider HIT applications globally, in terms of the anticipated technical and adaptive changes that will be needed for adoption,28  including the ways that information will be presented, communicated, and used; downtime and recovery procedures; anticipated benefits; and how these changes will be measured. These considerations (plus others, including the political climate for change) and the presence or lack of answers can focus and guide efforts in securing resources and expertise.

Institutional awareness about specific HIT products gained through interchange with similar institutions can help reduce trial-and-error. Beyond sharing of knowledge about technology (hardware, software, interoperability with other systems, messaging), information assurance (data confidentiality, integrity, and availability), and accessibility/usability requirements (including the ability to override CDS) that a system must meet, institutional leaders involved with HIT decisions should communicate, not only with other institutions but with vendors and workers from all levels involved in using HIT applications. Site visits to external deployments can help decision-makers to gain familiarity with products, to assess a product's applicability to specific work environments, and to learn from the experience of their peers with products, vendors, and the adoption process. A “community-of-practice”29  approach encourages information sharing and dissemination about HIT adoption among practitioners (as well as others) and provides firsthand experiences of current users that can impart information on challenges and shortcomings that new customers need to make informed decisions. Collective formal and informal knowledge forums30  will be needed for specific applications if informed HIT adoption is to increase.

Computerized Provider Order Entry

Context, Purpose, and Functions

CPOE31  provides support for prescribers at the prescribing/ordering step of the medication-delivery process, with the purpose of standardizing and ensuring completeness in orders for drugs, tests, and procedures. CPOE interfaces promote standardization through default options32  and guide prescribers in creating and formatting structured orders through an electronic interface. CPOE differs from stand-alone prescription writers by an electronic data connection (excluding fax) to a pharmacy information system. In most cases, inpatient CPOE is linked to CDS, which improves its ability to reduce errors.33 

Pediatric-Specific Features

CPOE for pediatric inpatients should provide:

  • universal weight/body surface area–based dosing (with standard and consistent units of measurement (eg, metric) to prevent conversion and calculation errors);

  • drug dictionaries with pediatric-specific dose ranges and alerts that include single-dose, daily-dose, and cumulative-dose decision support, including lifetime cumulative dose for chemotherapies;

  • drug-dosing decision support that is contextual for pediatric-specific health issues that can include neonatal, renal, oncology, and other illness or wellness states;

  • automated calculations and automatic dose limits/caps for larger patients;

  • medication-reconciliation tools;

  • pediatric-specific order sets;

  • ability to link vaccination ordering to current immunization schedules; and

  • linkage to pediatric-appropriate nutrition, laboratory, radiology, and other ancillary service orders (eg, orders linked to pediatric-specific tests [smaller blood volumes]).

Clinical expertise by pediatricians, pediatric nurses, and pediatric pharmacists familiar with both HIT and pediatrics must guide pediatric CPOE implementation. Specific pediatric medication-delivery processes pose specific challenges in error reduction because of the potential for increased errors or increased impact of errors as follows:

  • continuous intravenous infusions, because of the immediate and dynamic impact of administered drugs and complex calculations that change in critically ill patients, benefit from in-line calculators that determine dosing and appropriate standard concentration choices (per Joint Commission regulations34 ) of drugs35,36 ;

  • pediatric chemotherapy, because of the narrow therapeutic indices and acute and cumulative effects of drugs as well as complex schedules that are prone to interruption as a result of changes in patient condition, is an area of research and development of management and decision-support tools37,38 ; and

  • total parenteral nutrition (a special case of continuous intravenous infusion), because of the complexity of rules and calculations and schedule-critical dependence on timed laboratory results and order, may benefit from in-line calculators with automated rules to avert incorrect dosing, interactions, precipitation of solutes, and other costly errors.39 

CDS: Clinical Calculators

Context, Purpose, and Functions

Automated calculation (of drug doses, dates, etc) eliminates manual computation errors, especially in high-stress situations40  such as cardiopulmonary resuscitation of a child. For cases in which parameters (such as weight and height) are known, precalculated charts may provide an alternative.4143  The primary failure point for calculators is manual numerical entry (decimal, unit errors), which must be considered in the design and evaluation of interfaces and user training.

Pediatric-Specific Features

Because possible pediatric weights may vary over orders of magnitude, the wide range of allowed values may facilitate decimal errors and evade detection. Incorporation of independent and redundant checks (automated and human) into workflow to mitigate this type of error is an important consideration of design.

CDS: Electronic Prescribing Systems

Context, Purpose, and Functions

Electronic prescribing systems are designed help clinicians to generate paper or electronic medication prescriptions. The use of CDS, default options, and improved legibility offer the potential for improved patient safety.44  In the hospital environment, these applications are usually used in the discharge process.

Pediatric-Specific Features

Features and requirements are similar to the CPOE requirements discussed previously.

CDS: Management Systems

Context, Purpose, and Functions

Management systems can provide high-level decision support by applying clinical and business rules to information processes across different but related systems (such as laboratory, imaging, and hospital admission systems) to improve prevention, therapy, and efficiency. In conjunction with CDS at CPOE interfaces, these tools can provide users with situational awareness of patient and hospital status. Examples of management tools include electronic whiteboards (census displays),45  antimicrobial restriction programs (decision support to reduce inappropriate antibiotic use),46  and early notification systems for infection risks for patient cohorting.47  The specification of rules requires close interaction of clinicians and developers to specify alerts of high impact and to avoid “alert fatigue.”48 

Pediatric-Specific Features

Systems have been devised to provide alerts for respiratory syncytial virus and rotavirus.49  The extension and linkage of such systems beyond hospitals to public health information systems may have value as resistant organisms previously confined to inpatient settings migrate to the community.50,51 

CDS: Reference (or Teaching) Materials

Context, Purpose, and Functions

Automatic or on-demand linkages of patient-specific data (from EHRs)52  and general medical knowledge (from formularies or electronic textbooks and handbooks) can aid decisions and help physicians in training.

Pediatric-Specific Features

Application-specific pediatric reference data should be checked by pediatric domain experts for conflicts with accepted norms from trusted data sources. Institutions should decide on “final authority status” of specific resources to resolve discrepancies. Many standard texts and references are available in multiple electronic formats (online, CD-ROM, handheld devices), and availability of trusted pediatric-specific information resources should be coordinated with a pediatrician and a hospital medical librarian. In institutions where children receive care on a partial basis, a core library (which may be available as an online subscription package, either commercially or through organizations such as the AAP or the Centers for Disease Control and Prevention), should be established and maintained. The AAP publishes authoritative policies on most pediatric issues53  and on infectious disease diagnosis and management in children (the Red Book online).54  The Centers for Disease Control and Prevention publishes current immunization schedules as well as surveillance data for influenza, respiratory syncytial virus, and rotavirus in the Morbidity and Mortality Weekly Report.

Pharmacy Information Systems

Context, Purpose, and Functions

Pharmacy information systems55  support the dispensing step of the medication-delivery process, with the purpose of providing inventory selection and management and decision support for pharmacists and a redundant check for dosing, drug-allergy, and drug-drug interaction errors and for other pharmacology problems (such as solute precipitation in intravenous solutions). Pharmacology information systems may be linked to or require prompts for data from laboratory information systems (or from previous drug orders) and may be partially automated (such as in creation of standard-concentration intravenous solutions or parenteral alimentation solutions).56 

Pediatric-Specific Features

Because most of the details of pharmacy preparation of drug doses are invisible to prescribers and nurses, the most valuable component of a pediatric pharmacy information system is a qualified and experienced pediatric pharmacist and pharmacy staff57  who actively participate in clinical care of inpatients (such as daily work rounds).58,59  This expertise provides an additional layer to error catching and safety in medication ordering; however, neither CPOE nor pharmacy information systems may be effective in directly preventing medication-administration errors.57  Essential expertise also provided by pediatric pharmacists is knowledge that populates (weight/body surface area) drug-dose range tables and alerts for pediatrics.

Administration Tools: Radio Frequency Identification, Bar Coding, Smart Pumps, Patient-Controlled Anesthesia, and Medication-Administration Records

Context, Purpose, and Functions

The administration step is the last step before a prescribed/ordered medication dose is given to the patient. The substeps of administration (usually performed by a nurse within inpatient environments) include receipt of drug doses from the pharmacy, storage of medication doses before final delivery, scheduled dose retrieval and preparation, identification of patient/drug/dose/form/route (“5 rights”), and final dose delivery. Radio frequency identification6062  and bar-coding63,64  systems are used to verify and record identification of patient and drug dose and to track inventory. “Smart” infusion pumps programmed for specific workflows with appropriate drug doses and alerts may be useful in pediatrics65  but require caution in deployment because of poor compliance with alerts by human operators.66,67  Electronic medication-administration records link administration tools such as radio frequency identification, bar coding, and smart pumps to documentation and tracking of drugs and are used by multiple members of the medical team,68  and usability by nursing is an important factor in success.69 

Pediatric-Specific Aspects

The 2006 Joint Commission mandate for universal use of standardized concentrations in continuous infusion medications70  created a debate among pediatric intensivists, particularly neonatologists, about fluid overload in extremely low weight infants. Hierarchical task analysis of neonatal infusion ordering/administration concluded that use of standardized admixtures could be associated with a higher risk of errors than ad hoc (“rule of 6”) admixtures in patients in critical condition who require frequent adjustments in infusion rates.71  Because of the feedback from this debate, the Joint Commission extended a transition period (until 2008) for pediatric/neonatal acute care if certain safeguards, including the use of “smart” pumps, were in place.72,73  A published description of the implementation process of standard concentrations for neonatal care includes allowances for nonstandard concentrations,74  with key knowledge being the lowest infusion rate allowed by the pump.

Errors in expressed human milk administration (wrong mother, wrong infant, wrong milk, wrong expiration date) in the NICU have been described with suggested methodologies for reducing their incidence.75,76  In addition to system design to prevent such errors, bar-coding systems have been developed, explored, and advocated77  as a means of tracking and ensuring correct administration of human milk.

Certain “high-alert” medications are associated with an increased risk of causing harm to patients78  when involved in errors. Approaches to these medications include proactive monitoring and redundant checks to prevent errors79  in addition to the use of technology. Pediatric patient-controlled analgesia and patient-controlled analgesia by proxy pose challenges to implementation, and inpatient protocols should be developed in consultation with specialists in pediatric pain control.80 

Electronic Health Records

Context, Purpose, and Functions

EHRs are a central structure for patient-specific data documentation. Their multiple roles include facilitating communication among providers, standardizing medicolegal documentation of care, historical record archiving and retrieval, and coordination of care. They can facilitate centralized clinical communication and documentation among hospitalists, primary care providers in medical homes, consultants, and emergency care providers. They also will start to hold artifacts of historical significance over time, such as records of patients who will become persons of public importance as well as historical trends in disease and wellness. They form the basis for medication reconciliation and may support personal health records to inform and empower patients and families about their care. Important technical functions of EHRs include interoperability of data elements, connectivity to other electronic records, and information assurance (according to established standards). Essential in their implementation is effective user training to prevent misuse that may lead to errors.

Pediatric-Specific Features

Pediatric functions in an EHR have been articulated in an AAP policy statement81  and include:

  • immunization management (recording data, linking to immunization systems, decision support);

  • growth tracking (graphing and percentile calculation);

  • medication dosing (dosing by weight, dose-range checking, safe and convenient dose rounding, age-based decision support, dosing for the school day);

  • patient identification (prenatal identifiers, newborn identifiers, name changes, ambiguous gender);

  • norms for pediatric data (numeric; nonnumeric; complex normative, such as blood pressures; gestational age); and

  • privacy (adolescent, foster/custodial care, consent by proxy, adoption, guardianship, emergency treatment).

Technical standards and certification criteria for inpatient systems are still in development.

Ancillary Information Systems: Laboratory and Radiology (Imaging) Information Systems

Context, Purpose, and Functions

Laboratory and radiology information systems may exist independently or may be integrated with other inpatient information systems. They allow the ordering, managing, processing, billing, and result reporting for laboratory or imaging services. Interoperability and connectivity with inpatient systems (CPOE, EHRs, electronic medication-administration records) is usually limited to single hospitals but may be a safety issue in related institutions that share clinical care of a patient82  during a single inpatient stay.

Pediatric-Specific Features

Pediatric-specific features are similar to those outlined for the EHR. Pediatric/age-specific norms for parameters and result reporting for radiologic and laboratory tests are critical.

Ancillary Information Systems: Admission, Discharge, and Transfer Systems

Context, Purpose, and Functions

Admission, discharge, and transfer systems track and facilitate the patient flow throughout the hospital by providing correct and unique patient identifiers for other clinical information technology systems for clinical care and billing.

Pediatric-Specific Features

Pediatric-specific issues that may contribute to increased errors include identification of individual infants in multiple births, mother-infant link, the ability to register patients before arrival (especially for critical and emergency patients), and reconciliation of alerts across information systems.

Standardized Handoffs, Whiteboards, and Patient-Tracking Tools

Context, Purpose, and Functions

Standardized care transitions have been identified as a national patient safety goal.83  Within inpatient settings, types of transitions include:

  • admissions and discharges;

  • transfers to other units within the same institution; and

  • handoffs of care (shift change).84 

Each transition involves an exchange of information, responsibility, and authority from a provider (or team of providers) to another and involves a complex interaction of communication and dialogue between the sender and receiver in the transition process. The level of interactivity depends on a variety of factors including the acuity and intensity of care, the uncertainty of the patient's status, the specialty, the level of care, and the experience of the provider (supervising attending, hospitalist, resident, intern). An important aspect of transition is the provision of an appropriate time and location for transition, protected from the interruptive nature of care environments.85  Models for handoff transitions and for creating standard checklists and for handoffs have been published.8688  HIT applications that support the handovers or transfers include electronic patient records, electronic whiteboards, and personal information tools that allow organization, management, and transfer of patient-specific task information.

Pediatric-Specific Features

Drivers for this area of efficiency and patient safety are medication discrepancies at sign-out89  and the restriction of resident work hours.27,90  A general structured template for transitions developed at an academic pediatric program has been proposed and is based on the mnemonic “PEDIATRIC”88 :

  • Problem list

  • Expected tasks to be done

  • Diagnostic one-liner

  • If/then contingency plans

  • Administrative data/advance directive

  • Therapeutics

  • Results and other important facts

  • Intravenous access/invasive devices/procedures

  • Custody and consent issues

Other approaches may be preferred in specific specialties or units (such as a systems-based approach used in pediatric and neonatal intensive care).

A proposed advantage of electronic data in HIT systems is data reuse.91  Advantages of electronic data in this regard include reduction of costs and effort of storage and retrieval; however, technical limitations to realizing the full advantage include:

  • Current technical ability to convert legacy print information into an electronically usable form. Optical character-recognition technology is limited in its capability to convert handwriting into computer-usable text. Legacy paper documents are typically scanned as photographic images for inclusion into electronic records. Limitations of this format include difficulty searching documents by text matching (other than by reading them) unless documents are labeled. The assignment of scanned records to the correct patient is challenging, and bar-code technologies have been used to aid in the process.92  EHRs may contain many such scanned documents, which are electronically inaccessible and of little added value other than for (manual) searching.

  • Default values on clinical forms (such as review of systems and physical examination) are intended to ensure completeness for quality assurance and billing. However, when the printed or retrieved versions of the contents of such forms are generated, very long notes with many negatives (pertinent and extraneous) result in low information “signal-to-noise” ratios and reduce clinical usefulness of form data. The value of notes generated from structured data has been improved with the addition of narrative text,93  which may be richer (or different) than structured data entry.94  In addition, “copy-and-paste” behaviors that allow providers to generate notes from previous entries may result in inflated notes and persistent propagation of errors.95 

Effective solutions are difficult, and considerations should include which product options (such as optical character-recognition conversion) to use and how data-input forms should be designed.

HIT purchasers and clinicians want assurances that the systems they purchase and use will provide needed technical functions and interoperate with other systems securely. To accomplish these goals, public-private processes are in development to define standards for HIT products and evaluate which systems meet them. Efforts aimed at certifying EHRs and their networks (including CPOE) have been implemented by the Certification Commission for Healthcare Information Technology and the Leapfrog Group.15,96,97  The current list of certifications for pediatric HIT functions is small (limited to pediatric ambulatory EHRs) but growing.

The accessibility of data afforded by electronic information systems creates new types of medicolegal liabilities. Increased availability of personal health data from multiple locations creates the potential for information breaches and confidentiality violations. New federal rules extend discovery to electronic information beyond the patient record, including e-mails, electronic business records, archived data, and administrative metadata on the origins and times of records.98  Electronic clinical records can facilitate discovery of practice deviations and record alterations,99  and converted legacy records, although they may have limited clinical value, may be admissible, although their paper counterparts may have long been discarded.

Language and literacy barriers may add to the complexities of care in non–English-speaking populations and may contribute to poor outcomes. Preformatted patient information sheets may not match the needs of patients,100,101  which may be missed by providers. The special needs of these patients and families include cultural competence by providers (including knowledge of language and health literacy issues) and information tools (such as personal health records and information sheets) adjusted to patient needs (including forms and scripts that ensure true informed consent).

For children with special health care needs, special communication needs may include extended discussions to ensure access to timely and appropriate care. An indirect effect of inpatient HIT adoption for minority populations may ultimately be related to the financial barriers of access and where families seek care. Low HIT-implementation rates in institutions where these patients receive care may reflect health disparities that are only part of the complex issues of the effects of poverty on children and their care.102 

The adoption, incorporation, and use of HIT in inpatient settings to ensure patient safety where children receive care goes beyond consideration of available technical products. Pediatricians and child health advocates interested in adopting HIT for inpatient care must be aware of the technical and adaptive considerations that go into its successful acquisition, implementation, and deployment.

HIT adoption involves a global consideration of local institutional issues including:

  • existing safety problems and outcomes that are to be improved with HIT;

  • organizational structure and clinical process changes that will be required, including the work of implementation and the costs of adoption, deployment, use, and maintenance; and

  • cultural and political factors that facilitate and block the changes.

Pediatric-specific HIT adoption involves familiarity with collective experience and knowledge.

  • Similar institutions with the same problems, experiences, and data can be key in providing input and experiences.

  • Specific products, their functions, and pediatric-centered features must be evaluated.

  • Shared information resources can be consulted to aid evaluation and decision-making.

HIT adoption involves expertise in clinical informatics among the following:

  • pediatric clinicians (physicians, nurses, pharmacists) with information technology experience in analysis, implementation, and evaluation of systems;

  • organizational change managers versed in information technology transitions in clinical settings; and

  • pediatric and institutional leaders who understand the goals and values of health care improvement and clinical information technology adoption with regard to the health needs of children, including those with special health care needs.

Introduction of HIT may significantly improve clinical performance, reduce costs, and reduce workloads; however, every HIT-system implementation will invariably introduce new and sometimes unforeseen errors and challenges.

Mark M. Simonian, MD, Chairperson

Joseph H. Schneider, MD, MBA, Vice Chairperson

Mark A. Del Beccaro, MD, Policy Chairperson

Kristin A. Benson, MD

Donna M. D'Alessandro, MD

Willa H. Drummond, MD, MS

George R. Kim, MD

Michael Leu, MD

Gregg C. Lund, DO

Eugenia Marcus, MD

Alan E. Zuckerman, MD

S. Andrew Spooner, MD, MS, Immediate Past Chairperson

Timothy H. Hartzog, MD

Christoph U. Lehmann, MD

Partnership for Policy Implementation

Jennifer Mansour

All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

1
Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM, Sheridan T. Reducing the frequency of errors in medicine using information technology.
J Am Med Inform Assoc.
2001
;
8
(4):
299
–308
2
Institute of Medicine, Committee on the Quality of Health Care in America.
To Err Is Human: Building a Safer Health System.
Kohn LT, Corrigan JM, Donaldson MS, eds. Washington, DC: National Academies Press; 2000
3
Leapfrog Group. Computerized Physician Order Entry. Available at: www.leapfroggroup.org/for_hospitals/leapfrog_hospital_survey_copy/leapfrog_safety_practices/cpoe. Accessed October 15, 2008
4
Beuscart-Zéphir MC, Pelayo S, Anceaux F, Meaux JJ, Degroisse M, Degoulet P. Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process.
Int J Med Inform.
2005
;
74
(7–8):
629
–641
5
King WJ, Paice N, Rangrej J, Forestell GJ, Swartz R. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients.
Pediatrics.
2003
;
112
(3 pt 1):
506
–509
6
American Hospital Association.
Forward Momentum: Hospital Use of Technology.
Chicago, IL; American Hospital Association; 2005. Available at: www.aha.org/aha/content/2005/pdf/FINALNonEmbITSurvey105.pdf. Accessed May 6, 2008
7
Ash JS, Gorman PN, Seshadri V, Hersh WR. Computerized physician order entry in U.S. hospitals: results of a 2002 survey.
J Am Med Inform Assoc.
2004
;
11
(2):
95
–99
8
Schumock GT, Nair VP, Finley JM, Lewis RK. Penetration of medication safety technology in community hospitals.
J Med Syst.
2003
;
27
(6):
531
–541
9
Lehmann CU. Medical information systems in pediatrics.
Pediatrics.
2003
;
111
(3):
679
10
Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors.
J Am Med Inform Assoc.
2004
;
11
(2):
104
–112
11
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors.
JAMA.
2005
;
293
(10):
1197
–1203
12
Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system [published correction appears in Pediatrics. 2006;117(2):594].
Pediatrics.
2005
;
116
(6):
1506
–1512
13
Reason J. Human error: modules and management.
BMJ.
2000
;
320
(7237):
768
–770
14
Health Level Seven, Pediatric Data Standards Special Interest Group, Child Health Functional Profile Workgroup. Child Health Functional Profile. Available at: www.hl7.org/Library/Committees/pedsdata/HL7%5FChildHealth%5FEHRFunctionalProfile%5FVersion%5F1%5F0%5FFinal%2Epdf. Accessed May 21, 2008
15
Certification Commission for Healthcare Information Technology. Certification Commission for Healthcare Information Technology. Certification Commission Approves CCHIT Certified 08 Ambulatory EHR Criteria, Cardiovascular and Child Health Options Debut, May 20, 2008. Available at: www.cchit.org/about/news/releases/2008/Certification-Commission-CCHIT-Certified-Ambulatory-EHR-Cardiovascular-Child-Health.asp. Accessed October 15, 2008
16
Kohl CD, Schott C, Verveur D, Linderkamp O, Knaup-Gregori P. Can an EPR support the concept of family-centred, individualized developmental care of premature infants and newborns?
Stud Health Technol Inform.
2007
;
129
(pt 1):
73
–77
17
Krugman SD, Suggs A, Photowala HY, Beck A. Redefining the community pediatric hospitalist: the combined pediatric ED/inpatient unit.
Pediatr Emerg Care.
2007
;
23
(1):
33
–37
18
Freed GL, Brzoznowski K, Neighbors K, Lakhani I; American Board of Pediatrics, Research Advisory Committee. Characteristics of the pediatric hospitalist workforce: its roles and work environment.
Pediatrics.
2007
;
120
(1):
33
–39
19
Rappaport DI, Pressel DM. Pediatric hospitalist comanagement of surgical patients: challenges and opportunities.
Clin Pediatr (Phila).
2007
;
47
(2):
114
–121
20
Simon TD, Eilert R, Dickinson LM, Kempe A, Benefield E, Berman S. Pediatric hospitalist comanagement of spinal fusion surgery patients.
J Hosp Med.
2007
;
2
(1):
23
–30
21
Connolly B, Mahant S. The pediatric hospitalist and interventional radiologist: a model for clinical care in pediatric interventional radiology.
J Vasc Interv Radiol.
2006
;
17
(11 pt 1):
1733
–1738
22
Rideout K. Evaluation of a PNP care coordinator model for hospitalized children, adolescents, and young adults with cystic fibrosis.
Pediatr Nurs.
2007
;
33
(1):
29
–35
23
Ellis JA, McCleary L, Blouin R, et al. Implementing best practice pain management in a pediatric hospital.
J Spec Pediatr Nurs.
2007
;
12
(4):
264
–277
24
Lye PS, Rauch DA, Ottolini MC, et al. Pediatric hospitalists: report of a leadership conference.
Pediatrics.
2006
;
117
(4):
1122
–1130
25
Freed GL, Uren RL, Hudson EJ, et al. Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging.
JAMA.
2006
;
295
(8):
905
–912
26
McClain N, Richardson B, Wyatt JS.A. profile of certification for pediatric nurses.
Pediatr Nurs.
2004
;
30
(3):
207
–211
27
Cull WL, Mulvey HJ, Jewett EA, Zalneraitis EL, Allen CE, Pan RJ. Pediatric residency duty hours before and after limitations.
Pediatrics.
2006
;
118
(6). Available at: www.pediatrics.org/cgi/content/full/118/6/e1805
28
Kim GR, Lehmann CU. Editorial: conceptual toolboxes for adopting pediatric health information technology.
COCIT News.
2006
;
5
(2):
10
. Available at: www.aapscot.org/fall2006.pdf. Accessed May 6, 2008
29
Wenger E, McDermott R, Snyder WM.
Cultivating Communities of Practice: A Guide to Managing Knowledge
. Boston, MA: Harvard Business School Press; 2002
30
American Academy of Pediatrics, Council on Clinical Information Technology. EMR review Web site. Available at: www.aapcocit.org/emr. Accessed May 6, 2008
31
Lehmann CU, Kim GR. Computerized provider order entry and patient safety.
Pediatr Clin North Am.
2006
;
53
(6):
1169
–1184
32
Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options to improve health care.
N Engl J Med.
2007
;
357
(13):
1340
–1344
33
Kuperman GJ, Bobb A, Payne TH, et al. Medication-related clinical decision support in computerized provider order entry systems: a review.
J Am Med Inform Assoc.
2007
;
14
(1):
29
–40
34
The Joint Commission. Goal 3B. In: Facts About the 2007 National Patient Safety Goals. Available at: www.jointcommission.org/NewsRoom/PressKits/AnnualReport/ar_facts_hapnpsgs.htm. Accessed October 15, 2008
35
Lehmann CU, Kim GR, Gujral R, Veltri MA, Clark JS, Miller MR. Decreasing errors in pediatric continuous intravenous infusions.
Pediatr Crit Care Med.
2006
;
7
(3):
225
–230
36
Apkon M, Leonard J, Probst L, DeLizio L, Vitale R. Design of a safer approach to intravenous drug infusions: failure mode effects analysis.
Qual Saf Health Care.
2004
;
13
(4):
265
–271
37
Kim GR, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis.
Arch Pediatr Adolesc Med.
2006
;
160
(5):
495
–498
38
Robinson DL, Heigham M, Clark J. Using failure mode and effects analysis for safe administration of chemotherapy to hospitalized children with cancer.
Jt Comm J Qual Patient Saf.
2006
;
32
(3):
161
–166
39
Lehmann CU, Conner KG, Cox JM. Preventing provider errors: online total parenteral nutrition calculator.
Pediatrics.
2004
;
113
(4):
748
–753
40
Blackledge CG Jr, Veltri MA, Matlin C, Sparkes W, Lehmann CU. Patient safety in emergency situations: a Web-based pediatric arrest medication calculator.
J Healthc Qual.
2006
;
28
(2):
27
–31
41
Lubitz DS, Seidel JS, Chameides L, Luten RC, Zaritsky AL, Campbell FW. A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group.
Ann Emerg Med.
1988
;
17
(6):
576
–581
42
Nieman CT, Manacci CF, Super DM, Mancuso C, Fallon WF Jr. Use of the Broselow tape may result in the underresuscitation of children.
Acad Emerg Med.
2006
;
13
(10):
1011
–1019
43
Luten RC, Zaritsky A, Wears R, Broselow J. The use of the Broselow tape in pediatric resuscitation.
Acad Emerg Med.
2007
;
14
(5):
500
–501; author reply 501–502
44
Gerstle RS, Lehmann CU; American Academy of Pediatrics, Council on Clinical Information Technology. Electronic prescribing systems in pediatrics: the rationale and functionality requirements.
Pediatrics.
2007
;
119
(6). Available at: www.pediatrics.org/cgi/content/full/119/6/e1413
45
Xiao Y, Schenkel S, Faraj S, Mackenzie CF, Moss J. What whiteboards in a trauma center operating suite can teach us about emergency department communication.
Ann Emerg Med.
2007
;
50
(4):
387
–395
46
Thursky KA, Buising KL, Bak N, et al. Reduction of broad-spectrum antibiotic use with computerized decision support in an intensive care unit.
Int J Qual Health Care.
2006
;
18
(3):
224
–231
47
Kac G, Grohs P, Durieux P, et al. Impact of electronic alerts on isolation precautions for patients with multidrug-resistant bacteria.
Arch Intern Med.
2007
;
167
(19):
2086
–2090
48
van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry.
J Am Med Inform Assoc.
2006
;
13
(2):
138
–147
49
Chen ES, Wajngurt D, Qureshi K, Hyman S, Hripcsak G. Automated real-time detection and notification of positive infection cases [poster].
AMIA Annu Symp Proc.
2006
:
883
. Available at: www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=1723850. Accessed October 15, 2008
50
Jeyaratnam D, Reid C, Kearns A, Klein J. Community associated MRSA: an alert to paediatricians.
Arch Dis Child.
2006
;
91
(6):
511
–512
51
Stankovic C, Mahajan PV. Healthy children with invasive community-acquired methicillin-resistant Staphylococcus aureus infections.
Pediatr Emerg Care.
2006
;
22
(5):
361
–363
52
Cimino JJ. Use, usability, usefulness, and impact of an infobutton manager.
AMIA Annu Symp Proc.
2006
:
151
–155
53
American Academy of Pediatrics. AAP policy Web site. Available at: http://aappolicy.aappublications.org. Accessed May 6, 2008
54
American Academy of Pediatrics, Committee on Infectious Diseases. AAP Red Book online. Available at: http://aapredbook.aappublications.org. Accessed May 6, 2008
55
Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals.
Pharmacotherapy.
2002
;
22
(2):
134
–147
56
Combeau D, Rey JB, Fontan JE, Nouaille-Degorce B, Brion F. Baxa MicroMacrocompounder for parenteral nutrition solutions in a pediatric hospital.
PDA J Pharm Sci Technol.
1999
;
53
(5):
226
–230
57
Wang JK, Herzog NS, Kaushal R, Park C, Mochizuki C, Weingarten SR. Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry.
Pediatrics.
2007
;
119
(1). Available at: www.pediatrics.org/cgi/content/full/119/1/e77
58
Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
JAMA.
1999
;
282
(3):
267
–270
59
Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units.
Arch Intern Med.
2003
;
163
(17):
2014
–2018
60
Roark DC, Miguel K. RFID: bar coding's replacement?
Nurs Manage.
2006
;
37
(2):
28
–31
61
Nagy P, George I, Bernstein W, et al. Radio frequency identification systems technology in the surgical setting.
Surg Innov.
2006
;
13
(1):
61
–67
62
Young D. Pittsburgh hospital combines RFID, bar codes to improve safety.
Am J Health Syst Pharm.
2006
;
63
(24):
2431
, 2435
63
Cummings J, Bush P, Smith D, Matuszewski K; UHC Bar-Coding Task Force. Bar-coding medication administration overview and consensus recommendations.
Am J Health Syst Pharm.
2005
;
62
(24):
2626
–2629
64
Sakowski J, Leonard T, Colburn S, et al. Using a bar-coded medication administration system to prevent medication errors in a community hospital network.
Am J Health Syst Pharm.
2005
;
62
(24):
2619
–2625
65
Chuo J, Lambert G, Hicks RW. Intralipid medication errors in the neonatal intensive care unit.
Jt Comm J Qual Patient Saf.
2007
;
33
(2):
104
–111
66
Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients.
Crit Care Med.
2005
;
33
(3):
533
–540
67
Leape LL. “Smart” pumps: a cautionary tale of human factors engineering.
Crit Care Med.
2005
;
33
(3):
679
–680
68
Staggers N, Kobus D, Brown C. Nurses' evaluations of a novel design for an electronic medication administration record.
Comput Inform Nurs.
2007
;
25
(2):
67
–75
69
Barber N, Cornford T, Klecun E. Qualitative evaluation of an electronic prescribing and administration system.
Qual Saf Health Care.
2007
;
16
(4):
271
–278
70
Joint Commission on Accreditation of Healthcare Organizations. 2007 hospital/critical access hospital national patient safety goals. Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_hap_cah_npsgs.htm. Accessed May 6, 2008
71
Brannon TS. Ad hoc versus standardized admixtures for continuous infusion drugs in neonatal intensive care: cognitive task analysis of safety at the bedside.
AMIA Annu Symp Proc.
2006
:
862
72
Swanson A. Nix the six: raise the bar on medication delivery.
Newborn Infant Nurs Rev.
2006
;
6
(4):
230
–236
73
The Joint Commission. 2006 national patient safety goals: home care applicability grid. In: 20062007 Comprehensive Accreditation Manual for Home Care. Oakbrook Terrace, IL: The Joint Commission; 2006:NPSG-9. Available at: www.jointcommission.org/NR/rdonlyres/883E2035-F862-4698-8379-2A5B3C959ACB/0/06_NPSG_ome_grid.pdf. Accessed May 6, 2008
74
Hennessy SC. Developing standard concentrations in the neonatal intensive care unit.
Am J Health Syst Pharm.
2007
;
64
(1):
28
–30
75
Drenckpohl D, Bowers L, Cooper H. Use of the six sigma methodology to reduce incidence of breast milk administration errors in the NICU.
Neonatal Netw.
2007
;
26
(3):
161
–166
76
Dougherty D, Giles V. From breast to baby: quality assurance for breast milk management.
Neonatal Netw.
2000
;
19
(7):
21
–25
77
CHICA-Canada.
Position Statement: Handling of Expressed Breast Milk (EBM) in Acute Care Settings
. Winnepeg, Manitoba, Canada: CHICA-Canada; 2006. Available at: www.chica.org/pdf/EBM.pdf. Accessed May 6, 2008
78
Institute for Safe Medication Practices.
ISMP's List of High-Alert Medications
. Horsham, PA: Institute for Safe Medication Practices; 2007. Available at: www.ismp.org/Tools/highalertmedications.pdf. Accessed May 6, 2008
79
The Joint Commission. Focus on five: high-alert meds.
Jt Comm Perspect Patient Saf.
2001
;
1
(1):
11
80
Kenagy A, Turner H. Pediatric patient-controlled analgesia by proxy.
AACN Adv Crit Care.
2007
;
18
(4):
361
–365
81
Spooner SA; American Academy of Pediatrics, Council on Clinical Information Technology. Special requirements of electronic health record systems in pediatrics.
Pediatrics.
2007
;
119
(3):
631
–637
82
Keatings M, Martin M, McCallum A, Lewis J. Medical errors: understanding the parent's perspective.
Pediatr Clin North Am.
2006
;
53
(6):
1079
–1089
83
The Joint Commission. Goal 2E: 2008 national patient safety goals hospital program. Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm. Accessed May 6, 2008
84
Clancy CM. Care transitions: a threat and an opportunity for patient safety.
Am J Med Qual.
2006
;
21
(6):
415
–417
85
Behara R, Wears RL, Perry SJ, et al. A conceptual framework for studying the safety of transitions in emergency care. In:
Advances in Patient Safety: From Research to Implementation
. Vol. 2, Concepts and Methodology. Rockville, MD: Agency for Healthcare Research and Quality;
2005
:
309
–321
86
Streitenberger K, Breen-Reid K, Harris C. Handoffs in care: can we make them safer?
Pediatr Clin North Am.
2006
;
53
(6):
1185
–1195
87
Nemeth C, Kowalsky J, Brandwijk M, et al.
Distributing Cognition: How Hand-Off Communication Actually Works
. Chicago, IL: University of Chicago, Cognitive Technologies Laboratory; 2005. Available at: www.ctlab.org/documents/ASA2005%20Handoffs%20POSTER.pdf. Accessed May 6, 2008
88
Arora V, Johnson J. National patient safety goals: a model for building a standardized hand-off protocol.
Jt Comm J Qual Patient Saf.
2006
;
32
(11):
646
–655
89
Arora V, Kao J, Lovinger D, Seiden SC, Meltzer D. Medication discrepancies in resident sign-outs and their potential to harm.
J Gen Intern Med.
2007
;
22
(12):
1751
–1755
90
Landrigan CP, Czeisler CA, Barger LK, et al. Effective implementation work-hour limits and systemic improvements.
Jt Comm J Qual Patient Saf.
2007
;
33
(11 suppl):
19
–29
91
Safran C, Bloomrosen M, Hammond WE, et al. Toward a national framework for the secondary use of health data: an American Medical Informatics Association White Paper.
J Am Med Inform Assoc.
2007
;
14
(1):
1
–9
92
Massengill SP. Image-based document management systems for medical records.
Top Health Rec Manage.
1992
;
12
(3):
40
–48
93
Jones SJ, Lyons RA. Routine narrative analysis as a screening tool to improve data quality.
Inj Prev.
2003
;
9
(2):
184
–186
94
Los RK, van Ginneken AM, Roukema J, Moll HA, van der Lei J. Why are structured data different? Relating differences in data representation to the rationale of OpenSDE.
Med Inform Internet Med.
2005
;
30
(4):
267
–276
95
Hirschtick RE. A piece of my mind. Copy-and-paste.
JAMA.
2006
;
295
(20):
2335
–2336
96
Classen DC, Avery AJ, Bates DW. Evaluation and certification of computerized provider order entry systems.
J Am Med Inform Assoc.
2007
;
14
(1):
48
–55
97
Leapfrog Group. New guide for hospitals on computerized physician order entry (CPOE) gives hospitals much needed resource. Available at: www.leapfroggroup.org/news/leapfrog_news/97902. Accessed May 6, 2008
98
Sorrel AL. Updating digital discovery: it's all on record. Am Med News. 2007. Available at: www.ama-assn.org/amednews/2007/07/02/gvsa0702.htm. Accessed May 6, 2008
99
Certification Commission for Healthcare Information Technology.
CCHIT Certified Electronic Health Records and Other Safety Enhancing Technologies: Medical Legal Risk Management Benefits, Pitfalls and Safeguards
. Chicago, IL: Certification Commission for Healthcare Information Technology; 2007. Available at: www.cchit.org/files/wpCCHITMalpractice.pdf. Accessed May 6, 2008
100
Leyva M, Sharif I, Ozuah PO. Health literacy among Spanish-speaking Latino parents with limited English proficiency.
Ambul Pediatr.
2005
;
5
(1):
56
–59
101
Lo S, Sharif I, Ozuah PO. Health literacy among English-speaking parents in a poor urban setting.
J Health Care Poor Underserved.
2006
;
17
(3):
504
–511
102
Simpson L, Owens PL, Zodet MW, et al. care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by income.
Ambul Pediatr.
2005
;
5
(1):
6
–44