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

Chapter 32
Developing Pediatric Data Standards
S. Trent Rosenbloom and Joy Kuhl
Objectives
To provide a clinical rationale for clinical data standards
To give a brief overview of the types of data standards
To illustrate the use of data standards in implementing a growth chart into an
electronic record system
32.1 Introduction and Background
A major goal of Electronic Health Record (EHR) systems is to collect, store, and
make available high-quality clinical information to healthcare providers whenever
and wherever it is needed. 1 This clinical information can help inform decision
making, as well as supply data for research and drive quality assessment. To support
clinical decision making, EHR systems typically make available many types
of clinical information, including lists of a patient’s allergies, medications, or
diagnoses, the results from laboratory testing and narrative documents expressing
healthcare providers’ clinical observations and impressions. 2–5 The methods used by
EHR systems to aggregate and display clinical information can impact healthcare
providers’ workflow and decisions related to patient care. 2,5,6
For example, a single medical center may use more than one laboratory for testing
blood, including a central laboratory and one in the emergency department. In
the case that the child with abdominal pain has her blood tested for inflammation
in the emergency department, and then has the same test in clinic the next day as
follow-up with her physician, the physician would likely expect that the results
are aggregated together in the EHR system. If the results from the emergency
department are not easily seen alongside the results from the follow-up testing,
the physician may not see them and may request additional subsequent testing
and withhold any change in therapy while awaiting those results. A physician
concerned that the abdominal pain may be due to a serious illness, such as appendicitis,
may obtain a CT scan or ultrasound rather than waiting for a third blood
test result. If, by contrast, the results are all displayed together in the EHR system,
C.U. Lehmann et al. (eds.), Pediatric Informatics: Computer Applications 415
in Child Health, Health Informatics,
© Springer Science + Business Media, LLC 2009