Chapter 6: Electronic Health Records and Clinical Decision Support

INTRODUCTION

Over the last 50 years, the electronic health record (EHR) has emerged as a critical tool in the delivery of safe, efficient, quality healthcare. EHR systems have evolved from basic single-office databases into sophisticated applications capable of managing clinical documentation, laboratory results, images, and other patient data across care settings as well as providing decision support to promote safe patient care, reduce errors, and support adherence to practice guidelines. Data captured within the EHR are used to support nearly every aspect of patient care, including related billing and auditing activities. Increasingly, these data are also being used for quality improvement and research.

Hospitalists and the patients whom we treat stand to benefit greatly from well-implemented EHRs that provide tools to review growth data and immunization histories, to identify when vital signs and laboratory values exceed normal parameters for age, and to deliver age-, weight-, and condition-appropriate decision support for medication dosing and management. However, most commercially available EHR systems were designed with adult patients in mind. Configuring these systems to care for children often requires additional customization, which can translate to the need for hospitalists to invest time working with EHR implementation teams to ensure that safe, efficient, quality pediatric care can be delivered. This is especially important for hospitalists who work in pediatric units within larger adult-centered hospitals. In this chapter, we provide a brief background of EHR systems, discuss the role of clinical decision support (CDS) tools in delivering safe, efficient, quality pediatric hospital care, and review important patient safety considerations for hospitalists who may be asked to participate in the design, implementation, or optimization of an EHR.

ELECTRONIC HEALTH RECORDS

HISTORY OF HOSPITAL MEDICAL RECORDS

The practice of keeping medical records is one of the cornerstones of medicine. Hippocrates, the ancient Greek physician and father of Western medicine, famously kept and advocated for the use of medical records as early as the fifth century BC.¹ These earliest medical records were chronological accounts of individual patient cases and served as important tools in the initial understanding of the natural history of diseases, patient outcomes, and sharing of knowledge among practitioners. Such physician-based records dominated medical documentation for centuries and relied on the diligence of the conscientious physician to accurately document, maintain and preserve this information.

In the mid-nineteenth century, the emergence of record keeping in hospitals represented an early attempt to organize patient information primarily for tracking cases and billing.² Some saw the additional value of the aggregate information from the hospital population for improving patient care. In 1863, social reformer, nurse, and statistician Florence Nightingale described the challenges presented by the limitations of medical record keeping at that time: