Pediatric Informatics: Computer Applications in Child Health (Health ...

11 Clinical Practice Guidelines: Supporting Decisions, Optimizing Care 157
Center at Yale New Haven Hospital functions as a resident continuity clinic and
uses the Centricity (GE Medical Systems, Fairfield, CT) ambulatory electronic
health record system.
Following a careful parsing of the guidelines, supplemented with input from
Pediatric Respiratory Medicine experts, a set of data collection templates and
forms that provide guideline-based advice were designed and refined. An example
of system operation is:
A pediatric patient (Willy Wheeze) with identified chronic asthma comes for
an appointment for health maintenance. His mother notes that he recently experienced
his first asthma exacerbation that required a trip to the Emergency Room.
The primary care pediatrician (Dr. Jones) clicks a button that adds the asthma
management forms to the electronic health record health maintenance templates
that are presented for the visit. The asthma forms prompt Dr. Jones to ask about the
frequency of wheezing, cough, chest tightness, etc. As Dr. Jones records Willy’s
mother’ responses, a rule-based template calculates, per the NHLBI guidelines, the
severity level of Willy’s asthma. The frequency of Willy’s symptoms indicates his
asthma severity is mild persistent.
Dr. Jones next inquires about Willy’s level of asthma control, based on answers
to questions about missed school and emergency department visits. Results of
pulmonary function testing (PFTs) are also recorded. The decision support system,
using data from the history and PFTs, indicates that Willy’s control is suboptimal.
A third panel of questions prompts questions about asthma triggers and activities
the family has put into place to diminish Willy’s exposure.
The system summarizes findings and returns that Willy’s asthma is mild persistent
and suboptimally controlled. Dr. Jones considers the assessments, considers
overriding the suggestions and notes her reasoning in modifying or accepting the
assessments. The system recommends a series of appropriate interventions based
on the guideline, including rescue and controller medications. The system also
notes that inhaler propellants will be changing in the near future and will require
modification and refresher training for patients. Dr. Jones selects appropriate
medications from a list and gets additional information on options offered by an
onscreen “Info-button.” Dr. Jones clicks on her selections, which are automatically
added to Willy’s EHR medication list as prescriptions are prepared for electronic
transfer to the pharmacy. An individualized asthma action plan according to
NHLBI guidelines is automatically prepared and printed to which Dr. Jones can
add additional information.
References
1. Bosson JL, Labarere J. Determining indications for care common to competing guidelines by
using classification tree analysis: application to the prevention of venous thromboembolism
in medical inpatients. Med Decis Mak. 2006;26(1):63–75.
2. Burgers JS, Grol R, Klazinga NS, Makela M, Zaat J. Towards evidence-based clinical
practice: an international survey of 18 clinical guideline programs. Int J Qual Health Care.
2003;15(1):31–45.