Electronic Documentation in Pediatrics: The Rationale and Functionality Requirements

Author:

O’Donnell Heather C.12,Suresh Srinivasan3,Webber Emily Chui,Alexander Gregg M.,Chung Sandy Lee,Hamling Alexander M.,Kirkendall Eric S.,Mann Ann M.,Sadeghian Reza,Shelov Eric,Wiesenthal Andrew M.,

Affiliation:

1. Department of Pediatrics, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York;

2. Pediatric Physicians’ Organization at Children’s Hospital, Boston Children’s Hospital, Brookline, Massachusetts; and

3. Divisions of Health Informatics and Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania

Abstract

Clinical documentation is a fundamental component of the practice of medicine. It has significantly evolved over the past decade, largely because of the growth of health information technology and electronic health records. Although government agencies and other professional organizations have published position statements on the structure and use of electronic documentation, few have specifically addressed the documentation needs for the care of children. A policy statement on electronic documentation of clinical care by general pediatric and subspecialist providers by the American Academy of Pediatrics is needed. This statement provides insight on the unmet needs of key stakeholders to direct future research and development of the electronic media necessary to enhance the wellness of children and improve health care delivery. It also addresses the challenges and opportunities for efficient and effective clinical documentation in pediatrics.

Publisher

American Academy of Pediatrics (AAP)

Subject

Pediatrics, Perinatology and Child Health

Reference20 articles.

1. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians;Kuhn;Ann Intern Med,2015

2. The future state of clinical data capture and documentation: a report from AMIA’s 2011 Policy Meeting;Cusack;J Am Med Inform Assoc,2013

3. The future of health IT innovation and informatics: a report from AMIA’s 2010 Policy Meeting;McGowan;J Am Med Inform Assoc,2012

4. Dufendach KR, Eichenberger JA, McPheeters ML; Agency for Healthcare Research and Quality. Core functionality in pediatric electronic health records. Available at: https://effectivehealthcare.ahrq.gov/topics/pediatric-ehr/technical-brief. Accessed January 10, 2018

5. Health Level Seven International. HL7 EHR Child Health Functional Profile (CHFP), release 1. Available at: www.hl7.org/implement/standards/product_brief.cfm?product_id=15. Accessed January 10, 2018

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