Neonatal Informatics—Dream of a Paperless NICU: Part Five: Putting “IT” All Together

Abstract

The promise of computer-assisted neonatal intensive care unit (NICU) medical management is an intellectually global challenge. In early 2009, President Obama presented a “carrot and stick” plan to accelerate use of electronic health records. Financial incentives are offered to early adopters who meaningfully use certified systems; penalties begin in 2015 for those who do not. NICU critical care environments are extremely difficult to computerize because clinical data are time-dependent and highly variable, use repeated measures of many different elements, and run in real-time. Effective clinical computerization requires translation of complex human thinking models into software bits and bytes. All efforts require a logical, stepwise approach to designing effective databases and systems, and no existing system is currently adequate. Creating meaningful computerization for a busy NICU remains an ongoing challenge. On a daily basis, bedside visit and other care-related notes that outline the patient's condition, medications, treatments, nutrition, new problems, care being provided, plans, and family updates must be generated by physicians or neonatal nurse practitioners (NNPs). Clinical data management in NICUs is currently a “mixed model.” Real-time information management by typing is extremely difficult for hands-on critical caregivers, both in paper records and in computer systems. Workarounds involving paper remain the most common current practice in many institutions (including the scrub pants’ notational workaround). Medicolegal and service billing rules require documentation, and hundreds of different approaches are used, none of which is “certified.” Vendors’ old databases and newer databases designed by nonengineering individuals for clinical documentation tend to have significant technical problems that limit usability. In the future, good database design using modern techniques and technology should improve the situation. Direct download from devices and laboratories to local real-time systems is on the horizon, as is voice recognition for neonatal applications. However, for this year and through 2011, NICUs are not on the radar. Industry and political focus remains on administrative and population “quality management” functionality, now known as “meaningful use.” Emerging drafts of criteria for 2011 incentive payments formally excluded all hospitalists and infants younger than age 2 years from eligibility. Head circumference, respiratory rate, and temperature are not official parts of the vital signs specifications criteria for testing. The dream of a paperless NICU remains only a dream.