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

326 M.M. Simonian
24.4 Case Study (Hypothetical)
Billy D. is a 15 year old who lives with his parents and two younger sisters. His
mother and father both work in sales and have challenges bringing their children to
the pediatrician’s office for scheduled visits. Recently, Billy’s parents have noted a
drop in his grades and a loss of interest in other activities.
They consult Dr. S. via secure e-mail (through her online practice portal). They
have used this in the past and have found it to be a very convenient and confidential
adjunct to their long relationship with Dr. S. Dr. S. reviews their message on her
daily “e-mail rounds” and considers a differential diagnosis that she shares with the
parents via return secure e-mail. In her reply, she explains her concerns, providing
additional information by linking to resources from her practice portal: pamphlets
from the American Academy of Pediatrics and materials she has written. She asks
the parents to complete a validated online questionnaire to screen for behavior
problems, depression and substance abuse. They complete the questionnaire that
afternoon and the portal Web service alerts Dr. S. by pager when their answers
have been submitted. On reviewing their responses, Dr. S. narrows her differential
diagnosis of depression and substance abuse, and contacts Billy’s mother via phone
to discuss the results, requesting that the parents bring Billy in for a face-to-face
visit that evening. When Billy comes in, Dr. S. assesses that he is not suicidal and
discusses the possibility of a drug screen (consulting the AAP guideline), to which
Billy consents. The results of the drug screen are made available to Billy and his
parents the following day through their online personal health record (also available
through the practice portal) with a follow up visit scheduled. That morning,
Dr. S. receives a secure e-mail from Billy, in which he would like to know how to
get condoms. Dr. S. replies that Billy should self-schedule a visit that day to pick
up condoms and education on their proper use and the risks of pregnancy, sexually
transmitted diseases and HIV.
Billy’s youngest sister, Sally, was discovered to have insulin-dependent diabetes
a year previously and is currently on an insulin pump as part of a clinical trial. Their
endocrinologist sends summaries of his consultations to Dr. S’s electronic health
record as well as to the study coordinator via secure messaging attachments. The
parents carry copies of these electronic summaries from their personal health record
for Sally on a “smart” card whenever they travel.
During Sally’s initial diabetic management on the pump, she had a severe low
blood sugar while on a family trip out of town. She was rushed to a local emergency
department from which the emergency physician accessed her medical and drug
information from her “smart” card through a standard reader and was able to get
trend information from her insulin pump. Sally was admitted to the hospital’s
pediatric observation unit where the pediatric hospitalist, Dr. R., using information
from the Medical Home Web service of her PHR (as authorized by her parents),
contacted her endocrinologist for guidance on managing and adjusting her insulin
pump. The endocrinologist, viewing the trend information from a secure message
from Dr. R., was able to specify a modification that made a full inpatient admission
unnecessary. Dr. R.’s detailed summary of Sally’s care, including data from