Opportunity on the Horizon to Improve Health IT Safety for Children

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New federal criteria for electronic medical records used in the care of children, due out as soon as this month, provide a golden opportunity to make digital records more effective for the youngest and often most vulnerable patients.

While the switch from paper records to electronic health records (EHRs) over the past decade has brought great benefits, the design and layout of EHRs—and the way that doctors and nurses use them—have created some safety hazards, from missing important test results and drug allergies to ordering the wrong medication.

The upsides of EHRs in the care of young patients are many. These electronic systems can capture pediatric-specific data, such as whether a child has been screened for lead exposure, is up-to-date on vaccines, and is meeting appropriate developmental milestones. They can also carefully track key indicators, such as whether a child’s heart rate, weight, and height fall within the normal range for the child’s age. Weight, in particular, can be significant for drug dosages and treatment in children, especially for premature babies and other vulnerable patients.

Yet these types of EHR uses, among others, are the very factors that can increase the potential for unintentional harm—especially for children. In one case, in 2013, a 16-year-old patient in California was inadvertently given 38 times the appropriate amount of an antibiotic; the physician didn’t realize that the EHR’s default setting multiplied the amount entered by the patient’s weight. As a result, the patient suffered a near-fatal grand mal seizure.

In addition, many EHRs are programmed to raise alerts of potentially unsafe drug interactions or allergies every time a doctor prescribes medicine for a patient through the system. While these alerts are important and can save lives, doctors can become inured to them when they are repetitive and unnecessary—leading medical staff to reflexively ignore the alerts and thus miss new and valid notifications of potential problems. This “alert fatigue” is one of many ways in which the complex interaction between clinicians and digital records can contribute to unintentional patient harm.

As part of the 21st Century Cures Act, which became law in December of 2016, Congress charged the Office of the National Coordinator for Health Information Technology (ONC) with establishing criteria for the development of EHRs used in the care of children, giving it a chance to address these types of issues. As it issues its draft policies, ONC should focus on rules to better monitor and test EHRs—including safety evaluations of high-risk functions such as weight-based drug dosing in pediatric care—that go beyond current requirements for EHRs and focus on the issues that emerge in the care of children. 

Ideally, such tests would include the doctors, nurses, and other workers who use EHRs every day in clinical settings. And while ONC criteria typically apply to the testing of electronic records only before they are implemented many health care facilities request custom changes to the systems they buy—so the vendors who create the products, as well as the health care providers who use them, should also test for safety after the systems are deployed. Such post-implementation testing would help to identify unanticipated problems after customization and allow users to address pediatric-specific problems that emerge.

Electronic health records have done much to modernize health care in the U.S., but the rapid adoption of new systems has posed unforeseen risks for all patients, including children. The federal government now has an opening to help avert the safety challenges associated with the design and use of EHRs. ONC should do its part to protect children from unnecessary harm by ensuring that EHR systems are rigorously tested for safety.

Dr. Josh Rising, a pediatrician, directs health care programs at The Pew Charitable Trusts, and Ben Moscovitch manages Pew’s health information technology project.

This article was originally published in The Hill on April 6, 2018.