Well-child care is a service fundamental to pediatrics, representing nearly half of healthcare visits made by children in the USA.1
These visits are designed to encompass a variety of health-promoting and disease-preventing services, including growth and development assessments, screens for subtle or asymptomatic disease, and delivery of services such as immunizations.2
Because preventive service delivery to children is neither procedure-oriented nor hospital-based, the relative cost per visit is small compared to other medical problems encountered in the healthcare system. However, the 19.8 million children under the age of five in the USA should have each received 13 well-child visits by the time they reach school age.2
Therefore, the magnitude and potential impact of childhood preventive services delivery is large.
The importance of preventive care has been widely emphasized, and a growing body of preventive services is routinely proposed by various expert panels and professional organizations.2
They range all the way from newborn metabolic and hearing screening to counseling 5 year olds about head-injury prevention through bike-helmet use. As these recommendations proliferate, a growing body of research continues to document the benefits of these preventive services on such diverse topics as injury prevention,7
healthy sleep habits,12
and infant iron-deficiency.14
Despite the widely accepted importance of preventive services, mounting evidence suggests that the provision of these services is suboptimal, even for services for which there is ample evidence and broad support. Among a Medicaid population for example, only one-fifth of children received preventive and developmental services that met a basic threshold of quality.16
A national survey of parents found that more than 94% of parents reported one or more unmet needs for parenting guidance, education, or screening by pediatric clinicians of recommended services.17
Overall, rates of delivery for basic preventive services are typically <50%.17
Some would argue that these figures are generous, as studies indicate that most clinicians overestimate the level of preventive care they provide, especially screening tests that they give their patients.18
When physicians are asked to describe the challenges in providing preventive services, they are quick to provide a convincing list of barriers commonly faced in pediatric settings.20
In an attempt to provide a framework which categorizes these barriers into groups, Cabana et al
performed a meta-analysis on 76 articles which described one or more problems physicians faced while adhering to care guidelines.21
Three barriers most consistently identified in this study relate to time constraints, problems inherent in case finding and prioritization, and a lack of clinician self-efficacy.
Much of the time required to provide preventive care services is spent attempting to assess risk, as care guidelines are often lengthy and complex, and may not apply to the individual circumstances of each patient. According to the US Preventive Services Task Force, when care givers place the greatest emphasis on understanding each patient's risk profile, they can significantly reduce the number of unnecessary interventions.4
As a result, many guidelines attempt to define an explicit, focused list of historical and demographic risk factors to facilitate rapid recognition of risk. To further reduce provider work burden, many of these risk factors are bundled into standardized screening instruments which can be completed by patients or their families.22–25
However, providers are still left to determine who receives each of these instruments, and must also score and/or interpret the results.
A great deal of research indicates that clinical reminders provided to physicians and other care givers at the point of patient care are superior to other methods of affecting clinical practice. However, reminders are typically delivered today by computerized physician order-entry systems or inpatient noting systems.26–31
Unfortunately, for many outpatient preventive services, a reminder at the time of note writing or order entry is often too late, as these events frequently take place after the physician has completed the visit. ‘Just-in-time’ information delivery requires that a reminder be delivered at the time the physician is making a decision, and this is often while they are conversing with a patient. Computers within exam rooms may not be a satisfactory solution, as they can be expensive and susceptible to damage by curious pediatric patients. Computers can also slow the patient encounter and negatively impact the content of physician–patient communications.32
In fact, at our institution, which houses one of the most successful electronic medical record systems in the world, pediatricians have long been resistant to the introduction of computers in their clinics for these reasons.
Child Health Improvement through Computer Automation (CHICA) system
CHICA is a decision-support and electronic medical record system for pediatric health maintenance and disease management. CHICA also serves as a front end for data exchange with the Regenstrief Medical Record System.33
It can also work as a standalone application or be coupled with any other clinical information system. CHICA's primary user interface consists of two sheets of paper that collect handwritten responses to dynamically generated questions and clinical reminders while easily integrating into clinic workflow.34
These forms are created by CHICA and tailored to the individual patient. The forms, called adaptive turnaround documents (ATDs), are scanned, and data are read by optical character recognition and optical mark recognition software. CHICA uses a library of Arden Syntax36
rules that utilize data from the RMRS and CHICA record systems to determine what information should be printed on each ATD. CHICA also uses a global prioritization scheme to determine which information is most relevant for inclusion on the printouts.37
This effectively constrains the number of topics that CHICA recommends be addressed to a feasible number for any given patient encounter.
When a patient checks into the clinic, our clinic appointment system sends a registration HL7 message to alert CHICA to begin generating the first of two ATDs. This first form, called the ‘prescreening’ form (PSF), captures data from both clinic staff and parents before the patient is seen by a physician. This form has a section for nurses to enter morphometrics, vital signs, and other data. In addition, the PSF contains 20 questions selected by CHICA to ask a child's family (). These 20 questions are typically answered by the patient's parent while in the waiting room of the clinic. Data obtained through this form are merged with previously existing data and analyzed to generate a second ATD, known as the ‘provider worksheet’ (PWS). This PWS is tailored to the individual patient and contains up to six reminders which are based on the merged data of the PSF and existing electronic medical records (). Each reminder contains a ‘stem,’ introducing the reason for the prompt and between one and six ‘leaves’ which consist of check boxes allowing the physician to document their responses to the prompt. Some answers to questions on the PSF might also result in CHICA printing a ‘just in time’ handout (JIT). These JITs can provide additional advice to the physician (eg, a depression screening tool) or to the patient (eg, an asthma action plan or educational handout). The JIT prints at the same time as the PWS and is placed on the chart for the physician's use during the encounter.
Child Health Improvement through Computer Automation (CHICA) prescreening form (tuberculosis screening questions have been highlighted).
Child Health Improvement through Computer Automation (CHICA) physician worksheet.
The purpose of this study was to explore CHICA's ability to implement screening guidelines. We specifically wanted to see how CHICA would affect the screening of patients for the following two conditions:
- Iron-deficiency anemia38
- –The American Academy of Pediatrics recommends blood hemoglobin or hematocrit tests for all 9–15-month-old children who demonstrate nutritional risk factors such as drinking cow's milk before 1 year of age, consuming a low-iron diet, drinking low-iron formula, or being born prematurely.39
- –Guidelines also exist for the placement of purified protein derivative tests for children. Risk factors indicating that a child should be screened include the following: exposure to someone with tuberculosis (TB), travel to a high risk country, someone else in the home having traveled to a high risk country, or exposure to anyone who is themselves at high risk for TB.41