- The majority of EHR companies have developed solutions targeting the needs of inpatient and ambulatory organizations and workflows of primary care providers. Allscripts, Cerner Corporation, Epic Systems, and other large enterprise companies offer a variety of EHR solutions to suit healthcare organizations ranging from large health systems and integrated delivery networks (IDNs) to rural hospitals and small physician practices.
While health IT innovations have expanded the breadth of EHR functionality to address an array of industry demands, they remain limited in specialty care settings. Pediatricians in particular have grown increasingly frustrated with the lag in EHR innovation related to pediatric care.
“We’re still asking for basic functionality just to recognize that a patient is a child,” Community Care of North Carolina (CCNC) Deputy Chief Medical Officer and pediatrician Marian Earls, MD, told EHRIntelligence.com.
Editor's Note: A previous version of this article incorrectly implied Earls began working at CCNC after the organization recieved its CHIPRA grant.
Earls has been involved in the effort to improve pediatric-friendly EHR functionality since 2010. She and CCNC Pediatric Program Manager Kern Eason first began exploring pediatric EHR functionality after CCNC received a five-year federal grant under the Children’s Health Insurance Program Reauthorization Act (CHIPRA) to develop pediatric-specific EHR content and functionality.
Eason was tasked with evaluating the Model Child EHR Format, which was originally commissioned by CMS and AHRQ and developed by research firm Westat. The model format comprised a gap analysis of areas where traditional EHR systems fell short of delivering functionality necessary for effective pediatric care delivery.
“We said, let’s look at gaps that are specifically in pediatric systems,” said Eason. “What makes systems out there now inadequate for pediatric healthcare delivery? This massive gap analysis was my first study when I came on board.”
Developed by a national team including Duke and Intermountain Health, the model format demonstrated how many EHR systems have overlooked the needs of younger patients. All told, the model format included over 560 requirements to fill gaps in approximately 25 topics.
“We identified gaps in terms of access to information that was outside of the practice, birth information, and development screening — lots of information about growth and development charting and documentation,” said Eason.
“Our approach was to see how closely we can tie our work to quality outcomes we’re trying to promote,” he continued. “So we used that lens to begin our evaluation and we repackaged the requirements in the model format around some of those quality activities. That really gave us an opportunity to ask not only EHR vendors that we were partnering with about their capabilities around quality improvement tools, but also to frame that conversation for practicing clinicians about their challenges.”
CCNC then shifted its focus to working with EHR companies and pediatricians to identify areas where EHR technology required improvements to better support pediatric care. Without money to offer EHR companies in exchange for participating in the project, Eason and Earls needed to find a practical business case to motivate developers to get on board.
The Business Case for Pediatric-Friendly EHR Templates
Fortunately for CCNC, several EHR companies saw value in getting feedback from physicians at a variety of practice types about their EHR technologies.
About 33 healthcare organizations signed on to provide feedback about the ways EHR functionality can better support pediatric care.
“We worked with practices of various sizes,” said Eason. “We wanted practices in rural communities, urban communities — so it was really spread all over the state. All the way from solo provider practices to big practice systems like Cornerstone Health.”
Allscripts, eClinicalWorks, ReLi Med, and pediatric-specific EHR developers Office Practicum and Physician's Computer Company were among the EHR companies that opted to participate in the project.
“My sell to the vendors was: This is an opportunity to get direct, specific feedback from pediatric practices and they want to help you improve the functionality of your product,” said Eason.
“The draw for vendors was just to do the right thing by understanding their role in supporting the care of pediatric patients,” he continued. “That was a big eye opener for vendors who hadn’t designed their system with that in mind.”
Some pediatric-specific EHR companies also engaged with CCNC’s work.
“For the two big pediatric specific EHRs, they wanted to understand how well their system stood up to the format,” Eason stated. “They did a really good job across the board. But some areas — particularly around support for quality improvement — needed work.”
In addition to assisting EHR companies with identifying areas where their product offerings needed improvement, CCNC also helped healthcare organizations identify problems with EHR use among providers.
“Sometimes the reality was that the vendor indeed could not provide a functionality,” said Earls. “And occasionally it was about the practice not knowing how to use functionality.”
Though there exists a business case for addressing gaps in pediatric functionality, Earls said ONC can also play a role in compelling health IT companies to develop pediatric-friendly EHR systems.
Leveraging Regulatory Pressures to Drive EHR Innovation
ONC got involved with CCNC’s work around 2015, with Earls and CCNC aiming to spur the federal agency to develop health IT certification requirements that addressed the needs of pediatricians.
“In terms of incentivizing, we were hoping there would be ONC requirements for vendors about pediatric EHR systems,” she said.
CMS and ONC worked with research firm RTI International to identify the top priorities EHR companies need to keep in mind when addressing the needs of pediatricians.
“When CHIPRA was ending, CMS gave the contract to RTI to take the data from both states involved in the project and try to consolidate,” said Earls. “They consolidated those 600 or so requirements into about 46 requirements. ONC was interested in that format. They called it the 2015 priority list.”
Since developing the 2015 priority list, CCNC has continued to work with ONC to create developer guidance for pediatric-friendly EHR functionality. Earls has worked also worked with the American Academy of Pediatrics (AAP) to find ways to enable pediatricians to use structured EHR data for quality improvement.
“We focused on our quality improvement areas because that had meaning to pediatricians,” said Earls. “They were trying to do better around childhood obesity and asthma. It made them more relevant when we clustered them that way.cThen there was a whole set of requirements that was the general doing business as a pediatrician like weight based dosing which without questions people needed to have happen.”
ONC and CCNC have continued to work together to address these priorities over the past two years. In October 2017, Earls worked with ONC and AAP at a meeting centered on health IT for pediatrics.
“We looked at the eight priorities that AAP had given them as a starting place,” said Earls.
Priorities included using biometric specific norms for growth curves and growth charts for children, weight-based dosing, ability to document all guardians and care givers, and ability to associate the mother’s demographic with the newborn, among others.
Earls and Eason agreed that regulatory pressures will likely serve as the motivating factor compelling EHR companies to improve functionality in these identified priority areas.
“We want ONC or another regulatory body to say — you must have this functionality to be a certified pediatric EHR — or for quality incentive payment models to require practices to be able to showcase their good work or use data to drive quality improvements,” said Eason. “That’s where the impetus will come from.”
Coupled with a compelling business case, regulatory pressures could yield significantly improvements for pediatric-specific EHR templates in the near future. Though pediatricians will reap the most value out of these EHR functionality, specialty-specific EHR innovation could have far-reaching positive implications for patient care delivery across the industry.
Applying Innovative EHR Functionality Across Patient Populations
While CCNC’s project maintains a specific focus on pediatric-friendly EHR functionality, some functionality pediatricians want could benefit providers from a variety of specialties.
“We talked about social determinants of health,” said Eason, “How do you screen for that, and how do you deliver support for families around transportation and housing and other things that are a factor in care? EHR systems don’t have a good way of tracking referrals to community agencies around those types of concerns.”
Pediatricians are by no means the only care providers interested in incorporating social determinants of health data into EHR systems.
Recently, a Texas health information exchange (HIE) — HASA — launched a pilot project with San Antonio-based healthcare organization Methodist Healthcare Ministries to link social determinants of health data to patient EHRs. The project aims to reduce emergency care visits for all patient populations affected by challenges with transportation, housing, or education.
HASA and Methodist Healthcare Ministries’ interest in linking social determinants of health data to patient EHRs in one example of the healthcare industry’s growing interest in addressing social determinants of health across patient populations and specialties for more efficient care delivery.
Beyond EHR integration of social determinants of health, EHR companies participating in the project may discover other functionality that could be applied more broadly. CCNC found developers were eager to find gaps in pediatric functionality that indicated larger problems with EHR systems in general.
“They looked to cherry-pick those things for immediate work that could be useful across the age spectrum,” said Eason.
Fostering collaboration between EHR companies and specialty care providers may reveal new ways to innovate and improve EHR technology for all users.