Bio

Clinical Focus


  • Pediatrics
  • Pediatric Hospital Medicine

Academic Appointments


Administrative Appointments


  • Program Director, Clinical Informatics Fellowship, Stanford University Medical Center (2014 - Present)
  • VP of Analytics, Stanford Children's Health (2012 - Present)
  • Chief Medical Information Officer, Stanford Children's Health (2010 - Present)
  • Medical Director, Clinical Informatics, Stanford Children's Health (2007 - 2010)
  • Physician Lead, Clinical Informatics, Stanford Children's Health (2004 - 2007)

Honors & Awards


  • Letter of Teaching Distinction, Stanford University School of Medicine, Office of the Dean (2011, 2012, 2013)
  • Top 25 Clinical Informaticist, Modern Healthcare (2010, 2011, 2012)
  • Faculty Fellows Leadership Program, Stanford University School of Medicine (2010)

Professional Education


  • Board Certification: Clinical Informatics, American Board of Preventive Medicine (2014)
  • Board Certification, Clinical Informatics, American Board of Preventive Medicine (2014)
  • Board Certification: Pediatrics, American Board of Pediatrics (2004)
  • Residency:Stanford University School of Medicine (2004) CA
  • Internship:Stanford University School of Medicine (2002) CA
  • Medical Education:UC Davis School of Medicine (2001) CA
  • M.S., UC Davis, Medical Informatics (2000)
  • B.S., UC San Diego, Molecular Biology (1996)

Community and International Work


  • Faculty Consultant

    Partnering Organization(s)

    Vermont Oxford Network

    Location

    US

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

  • Roatan Volunteer Pediatric Clinic, Honduras

    Partnering Organization(s)

    Global Healing

    Populations Served

    Latino, Carribean Garifuna

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    Yes

Research & Scholarship

Current Research and Scholarly Interests


Clinical Informatics is the scientific field concerned with the application of information technology to the delivery of healthcare services. In my administrative role as Chief Medical Information Officer (CMIO) at Stanford Children's Health, I oversee the Clinical Informatics and Analytics departments. I am responsible for the implementation and optimization of a comprehensive electronic medical record (EMR) system including computerized physician order entry (CPOE) with clinical decision support (CDS), patient-engaging technologies like personal health records (PHR), and our enterprise data warehouse (EDW).

Together with colleagues in the department, our applied informatics research focuses on rigorously evaluating the best ways to implement and optimize health information technology to benefit the patients we serve at Stanford Children's Health. Specific areas of focus include 1) the impact of health IT on pediatric and obstetric quality/safety 2) advancing clinical decision support through closed-loop analytics, and 3) the intersection of health IT and medical education. Results of this work have been published in peer-reviewed journals like the New England Journal of Medicine, BMJ, Pediatrics, and Applied Clinical Informatics.

Projects


Teaching

2013-14 Courses


Graduate and Fellowship Programs


Publications

Journal Articles


  • Refocusing medical education in the EMR era. JAMA : the journal of the American Medical Association Pageler, N. M., Friedman, C. P., Longhurst, C. A. 2013; 310 (21): 2249-50

    View details for DOI 10.1001/jama.2013.282326

    View details for PubMedID 24302083

  • Evidence-Based Medicine in the EMR Era NEW ENGLAND JOURNAL OF MEDICINE Frankovich, J., Longhurst, C. A., Sutherland, S. M. 2011; 365 (19): 1758-1759

    View details for DOI 10.1056/NEJMp1108726

    View details for Web of Science ID 000296762800003

    View details for PubMedID 22047518

  • Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System PEDIATRICS Longhurst, C. A., Parast, L., Sandborg, C. I., Widen, E., Sullivan, J., Hahn, J. S., Dawes, C. G., Sharek, P. J. 2010; 126 (1): 14-21

    Abstract

    Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates.The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital.We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80,063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17,432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation.After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008-0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%-40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.

    View details for DOI 10.1542/peds.2009-3271

    View details for Web of Science ID 000279431000003

    View details for PubMedID 20439590

  • Use of Electronic Medical Record-Enhanced Checklist and Electronic Dashboard to Decrease CLABSIs. Pediatrics Pageler, N. M., Longhurst, C. A., Wood, M., Cornfield, D. N., Suermondt, J., Sharek, P. J., Franzon, D. 2014; 133 (3): e738-46

    Abstract

    We hypothesized that a checklist enhanced by the electronic medical record and a unit-wide dashboard would improve compliance with an evidence-based, pediatric-specific catheter care bundle and decrease central line-associated bloodstream infections (CLABSI).We performed a cohort study with historical controls that included all patients with a central venous catheter in a 24-bed PICU in an academic children's hospital. Postintervention CLABSI rates, compliance with bundle elements, and staff perceptions of communication were evaluated and compared with preintervention data.CLABSI rates decreased from 2.6 CLABSIs per 1000 line-days before intervention to 0.7 CLABSIs per 1000 line-days after intervention. Analysis of specific bundle elements demonstrated increased daily documentation of line necessity from 30% to 73% (P < .001), increased compliance with dressing changes from 87% to 90% (P = .003), increased compliance with cap changes from 87% to 93% (P < .001), increased compliance with port needle changes from 69% to 95% (P < .001), but decreased compliance with insertion bundle documentation from 67% to 62% (P = .001). Changes in the care plan were made during review of the electronic medical record checklist on 39% of patient rounds episodes.Use of an electronic medical record-enhanced CLABSI prevention checklist coupled with a unit-wide real-time display of adherence was associated with increased compliance with evidence-based catheter care and sustained decrease in CLABSI rates. These data underscore the potential for computerized interventions to promote compliance with proven best practices and prevent patient harm.

    View details for DOI 10.1542/peds.2013-2249

    View details for PubMedID 24567021

  • Core drug-drug interaction alerts for inclusion in pediatric electronic health records with computerized prescriber order entry. Journal of patient safety Harper, M. B., Longhurst, C. A., McGuire, T. L., Tarrago, R., Desai, B. R., Patterson, A. 2014; 10 (1): 59-63

    Abstract

    The study aims to develop a core set of pediatric drug-drug interaction (DDI) pairs for which electronic alerts should be presented to prescribers during the ordering process.A clinical decision support working group composed of Children's Hospital Association (CHA) members was developed. CHA Pharmacists and Chief Medical Information Officers participated.Consensus was reached on a core set of 19 DDI pairs that should be presented to pediatric prescribers during the order process.We have provided a core list of 19 high value drug pairs for electronic drug-drug interaction alerts to be recommended for inclusion as high value alerts in prescriber order entry software used with a pediatric patient population. We believe this list represents the most important pediatric drug interactions for practical implementation within computerized prescriber order entry systems.

    View details for DOI 10.1097/PTS.0000000000000050

    View details for PubMedID 24522227

  • Association between Maintenance Fluid Tonicity and Hospital-Acquired Hyponatremia. journal of pediatrics Carandang, F., Anglemyer, A., Longhurst, C. A., Krishnan, G., Alexander, S. R., Kahana, M., Sutherland, S. M. 2013; 163 (6): 1646-1651

    Abstract

    To evaluate whether the administration of hypotonic fluids compared with isotonic fluids is associated with a greater risk for hyponatremia in hospitalized children.Informatics-enabled cohort study of all hospitalizations at Lucile Packard Children's Hospital between April 2009 and March 2011. Extraction and analysis of electronic medical record data identified normonatremic hospitalized children who received either hypotonic or isotonic intravenous maintenance fluids upon admission. The primary exposure was the administration of hypotonic maintenance fluids, and the primary outcome was the development of hyponatremia (serum sodium <135 mEq/L).A total of 1048 normonatremic children received either hypotonic (n = 674) or isotonic (n = 374) maintenance fluids upon admission. Hyponatremia developed in 260 (38.6%) children who received hypotonic fluids and 104 (27.8%) of those who received isotonic fluids (unadjusted OR 1.63; 95% CI 1.24-2.15, P < .001). After we controlled for intergroup differences and potential confounders, patients receiving hypotonic fluids remained more likely to develop hyponatremia (aOR 1.37, 95% CI 1.03-1.84). Multivariable analysis identified additional factors associated with the development of hyponatremia, including surgical admission (aOR 1.44, 95% CI 1.09-1.91), cardiac admitting diagnosis (aOR 2.08, 95% CI 1.34-3.20), and hematology/oncology admitting diagnosis (aOR 2.37, 95% CI 1.74-3.25).Hyponatremia was common regardless of maintenance fluid tonicity; however, the administration of hypotonic maintenance fluids compared with isotonic fluids was associated with a greater risk of developing hospital-acquired hyponatremia. Additional clinical characteristics modified the hyponatremic effect of hypotonic fluid, and it is possible that optimal maintenance fluid therapy now requires a more individualized approach.

    View details for DOI 10.1016/j.jpeds.2013.07.020

    View details for PubMedID 23998517

  • Medical Education in the Electronic Medical Record (EMR) Era: Benefits, Challenges, and Future Directions ACADEMIC MEDICINE Tierney, M. J., Pageler, N. M., Kahana, M., Pantaleoni, J. L., Longhurst, C. A. 2013; 88 (6): 753-757
  • A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Pediatrics Carspecken, C. W., Sharek, P. J., Longhurst, C., Pageler, N. M. 2013; 131 (6): e1970-3

    Abstract

    Despite advances in electronic medication order entry systems, it has been well established that clinicians override many drug allergy alerts generated by the electronic health record. The direct clinical consequences of overalerting clinicians in a pediatric setting have not been well demonstrated in the literature. We observed a patient in the PICU who experienced complications as a result of an extended series of non-evidence-based alerts in the electronic health record. Subsequently, evidence-based allergy alerting changes were made to the hospital's system. Incorporating clinical evidence in electronic drug allergy alerting systems remains challenging, especially in pediatric settings.

    View details for DOI 10.1542/peds.2012-3252

    View details for PubMedID 23713099

  • Embedding time-limited laboratory orders within computerized provider order entry reduces laboratory utilization*. Pediatric critical care medicine Pageler, N. M., Franzon, D., Longhurst, C. A., Wood, M., Shin, A. Y., Adams, E. S., Widen, E., Cornfield, D. N. 2013; 14 (4): 413-419

    Abstract

    : To test the hypothesis that limits on repeating laboratory studies within computerized provider order entry decrease laboratory utilization.: Cohort study with historical controls.: A 20-bed PICU in a freestanding, quaternary care, academic children's hospital.: This study included all patients admitted to the pediatric ICU between January 1, 2008, and December 31, 2009. A total of 818 discharges were evaluated prior to the intervention (January 1, 2008, through December 31, 2008) and 1,021 patient discharges were evaluated postintervention (January 1, 2009, through December 31, 2009).: A computerized provider order entry rule limited the ability to schedule repeating complete blood cell counts, chemistry, and coagulation studies to a 24-hour interval in the future. The time limit was designed to ensure daily evaluation of the utility of each test.: Initial analysis with t tests showed significant decreases in tests per patient day in the postintervention period (complete blood cell counts: 1.5 ± 0.1 to 1.0 ± 0.1; chemistry: 10.6 ± 0.9 to 6.9 ± 0.6; coagulation: 3.3 ± 0.4 to 1.7 ± 0.2; p < 0.01, all variables vs. preintervention period). Even after incorporating a trend toward decreasing laboratory utilization in the preintervention period into our regression analysis, the intervention decreased complete blood cell counts (p = 0.007), chemistry (p = 0.049), and coagulation (p = 0.001) tests per patient day.: Limits on laboratory orders within the context of computerized provider order entry decreased laboratory utilization without adverse affects on mortality or length of stay. Broader application of this strategy might decrease costs, the incidence of iatrogenic anemia, and catheter-associated bloodstream infections.

    View details for DOI 10.1097/PCC.0b013e318272010c

    View details for PubMedID 23439456

  • Immunization registries in the EMR Era. Online journal of public health informatics Stevens, L. A., Palma, J. P., Pandher, K. K., Longhurst, C. A. 2013; 5 (2): 211-?

    Abstract

    The CDC established a national objective to create population-based tracking of immunizations through regional and statewide registries nearly 2 decades ago, and these registries have increased coverage rates and reduced duplicate immunizations. With increased adoption of commercial electronic medical records (EMR), some institutions have used unidirectional links to send immunization data to designated registries. However, access to these registries within a vendor EMR has not been previously reported.To develop a visually integrated interface between an EMR and a statewide immunization registry at a previously non-reporting hospital, and to assess subsequent changes in provider use and satisfaction.A group of healthcare providers were surveyed before and after implementation of the new interface. The surveys addressed access of the California Immunization Registry (CAIR), and satisfaction with the availability of immunization information. Information Technology (IT) teams developed a "smart-link" within the electronic patient chart that provides a single-click interface for visual integration of data within the CAIR database.Use of the tool has increased in the months since its initiation, and over 20,000 new immunizations have been exported successfully to CAIR since the hospital began sharing data with the registry. Survey data suggest that providers find this tool improves workflow and overall satisfaction with availability of immunization data. (p=0.009).Visual integration of external registries into a vendor EMR system is feasible and improves provider satisfaction and registry reporting.

    View details for DOI 10.5210/ojphi.v5i2.4696

    View details for PubMedID 23923096

  • Rights and responsibilities of electronic health records (EHR) users caring for children. Archivos argentinos de pediatria Sittig, D. F., Singh, H., Longhurst, C. A. 2013; 111 (6)

    View details for PubMedID 24196758

  • Reducing Mortality Related to Adverse Events in Children PEDIATRIC CLINICS OF NORTH AMERICA Shin, A. Y., Longhurst, C. A., Sharek, P. J. 2012; 59 (6): 1293-?

    Abstract

    Since the launch of the 100,000 Lives Campaign by the Institute for Healthcare Improvement (IHI), preventing medical adverse events to reduce avoidable mortality has emerged as a central focus for health care providers, institutions, regulators, insurance companies, and patients. Evidence-based interventions targeting the 6 interventions in the campaign have been associated with a reduction in preventable hospital deaths in the United States. The generalizability of the IHI's campaign to the pediatric population is only partly applicable. Pediatric experiences with rapid response teams and preventing central-line infections parallel the published experience of adults, with promise to significantly reduce preventable pediatric mortality.

    View details for DOI 10.1016/j.pcl.2012.09.002

    View details for Web of Science ID 000312618600007

    View details for PubMedID 23116526

  • Special Requirements for Electronic Medical Records in Adolescent Medicine JOURNAL OF ADOLESCENT HEALTH Anoshiravani, A., Gaskin, G. L., Groshek, M. R., Kuelbs, C., Longhurst, C. A. 2012; 51 (5): 409-414

    Abstract

    Adolescents are a group likely to seek and, perhaps, most likely to benefit from electronic access to health information. Despite significant advances in technical capabilities over the past decade, to date neither electronic medical record vendors nor many health care systems have adequately addressed the functionality and process design considerations needed to protect the confidentiality of adolescent patients in an electronic world. We propose a shared responsibility for creating the necessary tools and processes to maintain the adolescent confidentiality required by most states: (1) system vendors must provide key functionality in their products (adolescent privacy default settings, customizable privacy controls, proxy access, and health information exchange compatibility), and (2) health care institutions must systematically address relevant adolescent confidentiality policies and process design issues. We highlight the unique technical and process considerations relevant to this patient population, as well as the collaborative multistakeholder work required for adolescent patients to experience the potential benefits of both electronic medical records and participatory health information technology.

    View details for DOI 10.1016/j.jadohealth.2012.08.003

    View details for Web of Science ID 000310353300002

    View details for PubMedID 23084160

  • Internet Access and Attitudes Toward Online Personal Health Information Among Detained Youth PEDIATRICS Gaskin, G. L., Longhurst, C. A., Anoshiravani, A. 2012; 130 (5): 914-917

    Abstract

    To assess Internet access and usage patterns among high-risk youth involved in the juvenile justice system, and to determine if health information technology tools might play a useful role in more actively engaging this population in their health care.A sample of 79 youth between the ages of 13 and 18 years old underwent a structured interview while detained in a large, Northern California juvenile detention facility. After an institutional review board-approved assent/consent process, youth discussed their typical Internet use when not detained, as well as their attitudes toward online access to their personal health information (PHI).Detained youth from predominantly underserved, minority communities, reported high levels of access to the Internet while outside of the detention setting, with 97% reporting using the Internet at least once per month and 87% at least weekly. Furthermore, 90% of these youth expressed interest in accessing their PHI online and sharing it with either parents or physicians.Detained adolescents describe unexpectedly high usage of the Internet and online resources when they are outside of the juvenile hall setting. These youth show an interest in, and may benefit from, accessing their PHI online. Further studies are needed to understand the potential health benefits that may be realized by engaging this population through online tools.

    View details for DOI 10.1542/peds.2012-1653

    View details for Web of Science ID 000310505900061

    View details for PubMedID 23090346

  • Integrating the home management plan of care for children with asthma into an electronic medical record. Joint Commission journal on quality and patient safety / Joint Commission Resources Patel, S. J., Longhurst, C. A., Lin, A., Garrett, L., Gillette-Arroyo, J., Mark, J. D., Wood, M. S., Sharek, P. J. 2012; 38 (8): 359-365

    Abstract

    Asthma exacerbation is one of the most common causes for pediatric hospitalization. One of the three Joint Commission quality measures--which has proven the most challenging--addresses the provision of a home management plan of care (HMPC) for discharge of pediatric inpatients with a primary diagnosis of asthma. A user-friendly electronic medical record (EMR)-generated HMPC was developed and implemented at Lucile Packard Children's Hospital (LPCH) Palo Alto, California, an HPMC needed to be completed before entry of an inpatient discharge order.A cohort study using historical controls was conducted in 2010-2011. Patients were eligible to receive an HMPC if they were between the ages of 2 and 17 years old at discharge, had a length of stay < 120 days, were not enrolled in clinical trials, and had the primary discharge diagnosis of asthma. These patients were identified by the EMR if this diagnosis was listed in the diagnosis list or problem list or if the asthma admit/discharge order set was initiated.Compliance with the HMPC increased from 65.3% for the 39 months (April 1, 2007-June 30, 2010) before integration of the HMPC into EMR to 93.7% for the 18 months after integration (July 1, 2010, through December 31, 2011); p < .0001. Users of the EMR-integrated HMPC found it to be significantly easier to complete, less time-consuming, and less prone to potential errors or omission.Lessons learned at LPCH included the need for a continuous surveillance and improvement model, which resulted in several iterations of the HMPC; the importance of soliciting user input, which resulted in improvements in work flow; and consistent support from the quality management and information technology departments, which are crucial to eliminating barriers and facilitating improvement.

    View details for PubMedID 22946253

  • Health information technology and patient safety BRITISH MEDICAL JOURNAL Longhurst, C. A., Landa, H. M. 2012; 344

    View details for DOI 10.1136/bmj.e1096

    View details for Web of Science ID 000300881600008

    View details for PubMedID 22349580

  • Neonatal Informatics: Optimizing Clinical Data Entry and Display. NeoReviews Palma, J. P., Brown, P. J., Lehmann, C. U., Longhurst, C. A. 2012; 13 (2): 81-85

    Abstract

    Displaying the vast amount of clinical data that exist in electronic medical records without causing information overload or interfering with provider thought processes is a challenge. To support the transformation of data into information and knowledge, effective electronic displays must be flexible and guide physicians' thought processes. Applying research from cognitive science and human factors engineering offers promise in improving the electronic display of clinical information. OBJECTIVES: After completing this article, readers should be able to: Appreciate the importance of supporting provider thought processes during both data entry and data review.Recognize that information does not need to be displayed and reviewed in the same way the data are entered.

    View details for PubMedID 22557935

  • Impact of an EMR-Based Daily Patient Update Letter on Communication and Parent Engagement in a Neonatal Intensive Care Unit. Journal of participatory medicine Palma, J. P., Keller, H., Godin, M., Wayman, K., Cohen, R. S., Rhine, W. D., Longhurst, C. A. 2012; 4

    Abstract

    To evaluate the impact of using electronic medical record (EMR) data in the form of a daily patient update letter on communication and parent engagement in a level II neonatal intensive care unit (NICU).Parents of babies in a level II NICU were surveyed before and after the introduction of an EMR-generated daily patient update letter, Your Baby's Daily Update (YBDU).Following the introduction of the EMR-generated daily patient update letter, 89% of families reported using YBDU as an information source; 83% of these families found it "very useful", and 96% of them responded that they "always" liked receiving it. Rates of receiving information from the attending physician were not statistically significantly different pre- and post-implementation, 81% and 78%, respectively (p = 1). Though there was no statistically significant improvement in parents' knowledge of individual items regarding the care of their babies, a trend towards statistical significance existed for several items (p <.1), and parents reported feeling more competent to manage information related to the health status of their babies (p =.039).Implementation of an EMR-generated daily patient update letter is feasible, resulted in a trend towards improved communication, and improved at least one aspect of parent engagement-perceived competence to manage information in the NICU.

    View details for PubMedID 23730532

  • Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital APPLIED CLINICAL INFORMATICS Hahn, J. S., Bernstein, J. A., MCKENZIE, R. B., King, B. J., Longhurst, C. A. 2012; 3 (2): 175-185

    Abstract

    Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children's Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution.

    View details for DOI 10.4338/ACI-2012-02-CR-0003

    View details for Web of Science ID 000317183500003

    View details for PubMedID 23620718

  • Neonatal Informatics: Transforming Neonatal Care Through Translational Bioinformatics. NeoReviews Palma, J. P., Benitz, W. E., Tarczy-Hornoch, P., Butte, A. J., Longhurst, C. A. 2012; 13 (5): e281-e284

    Abstract

    The future of neonatal informatics will be driven by the availability of increasingly vast amounts of clinical and genetic data. The field of translational bioinformatics is concerned with linking and learning from these data and applying new findings to clinical care to transform the data into proactive, predictive, preventive, and participatory health. As a result of advances in translational informatics, the care of neonates will become more data driven, evidence based, and personalized.

    View details for PubMedID 22924023

  • An evidence-based approach to activating your EMR. Healthcare informatics : the business magazine for information and communication systems Grisim, L. M., Longhurst, C. A. 2011; 28 (12): 47-?

    View details for PubMedID 22233021

  • A 15-Year-Old Girl with Dysphagia, Failure to Thrive PEDIATRIC ANNALS Ryan, C., Khan, M., Delgado, E., Berquist, W., Longhurst, C. 2011; 40 (8): 397-400

    View details for DOI 10.3928/00904481-20110708-05

    View details for Web of Science ID 000305740900005

    View details for PubMedID 21815600

  • Impact of electronic medical record integration of a handoff tool on sign-out in a newborn intensive care unit JOURNAL OF PERINATOLOGY Palma, J. P., Sharek, P. J., Longhurst, C. A. 2011; 31 (5): 311-317

    Abstract

    Objective:To evaluate the impact of integrating a handoff tool into the electronic medical record (EMR) on sign-out accuracy, satisfaction and workflow in a neonatal intensive care unit (NICU).Study Design:Prospective surveys of neonatal care providers in an academic children's hospital 1 month before and 6 months following EMR integration of a standalone Microsoft Access neonatal handoff tool.Result:Providers perceived sign-out information to be somewhat or very accurate at a rate of 78% with the standalone handoff tool and 91% with the EMR-integrated tool (P < 0.01). Before integration of neonatal sign-out into the EMR, 35% of providers were satisfied with the process of updating sign-out information and 71% were satisfied with the printed sign-out document; following EMR integration, 92% of providers were satisfied with the process of updating sign-out information (P < 0.01) and 98% were satisfied with the printed sign-out document (P<0.01). Neonatal care providers reported spending a median of 11 to 15 min/day updating the standalone sign-out and 16 to 20 min/day updating the EMR-integrated sign-out (P = 0.026). The median percentage of total sign-out preparation time dedicated to transcribing information from the EMR was 25 to 49% before and <25% after EMR integration of the handoff tool (P < 0.01).Conclusion:Integration of a NICU-specific handoff tool into an EMR resulted in improvements in perceived sign-out accuracy, provider satisfaction and at least one aspect of workflow.

    View details for DOI 10.1038/jp.2010.202

    View details for Web of Science ID 000289982300003

    View details for PubMedID 21273990

  • Computerized Physician Order Entry With Decision Support Decreases Blood Transfusions in Children PEDIATRICS Adams, E. S., Longhurst, C. A., Pageler, N., Widen, E., Franzon, D., Cornfield, D. N. 2011; 127 (5): E1112-E1119

    Abstract

    Timely provision of evidence-based recommendations through computerized physician order entry with clinical decision support may improve use of red blood cell transfusions (RBCTs).We performed a cohort study with historical controls including inpatients admitted between February 1, 2008, and January 31, 2010. A clinical decision-support alert for RBCTs was constructed by using current evidence. RBCT orders resulted in assessment of the patient's medical record with prescriber notification if parameters were not within recommended ranges. Primary end points included the average pretransfusion hemoglobin level and the rate of RBCTs per patient-day.In total, 3293 control discharges and 3492 study discharges were evaluated. The mean (SD) control pretransfusion hemoglobin level in the PICU was 9.83 (2.63) g/dL (95% confidence interval [CI]: 9.65-10.01) compared with the study value of 8.75 (2.05) g/dL (95% CI: 8.59-8.90) (P < .0001). The wards' control value was 7.56 (0.93) g/dL (95% CI: 7.47-7.65), the study value was 7.14 (1.01) g/dL (95% CI: 6.99-7.28) (P < .0001). The control PICU rate of RBCTs per patient-day was 0.20 (0.11) (95% CI: 0.13-0.27), the study rate was 0.14 (0.04) (95% CI: 0.11-0.17) (P = .12). The PICU's control rate was 0.033 (0.01) (95% CI: 0.02-0.04), and the study rate was 0.017 (0.007) (95% CI: 0.01-0.02) (P < .0001). There was no difference in mortality rates across all cohorts.Implementation of clinical decision-support alerts was associated with a decrease in RBCTs, which suggests improved adoption of evidence-based recommendations. This strategy might be widely applied to promote timely adoption of scientific evidence.

    View details for DOI 10.1542/peds.2010-3252

    View details for Web of Science ID 000290097800002

    View details for PubMedID 21502229

  • Sociotechnical Challenges of Developing an Interoperable Personal Health Record Lessons Learned APPLIED CLINICAL INFORMATICS Gaskin, G. L., Longhurst, C. A., Slayton, R., Das, A. K. 2011; 2 (4): 406-419

    Abstract

    OBJECTIVES: To analyze sociotechnical issues involved in the process of developing an interoperable commercial Personal Health Record (PHR) in a hospital setting, and to create guidelines for future PHR implementations. METHODS: This qualitative study utilized observational research and semi-structured interviews with 8 members of the hospital team, as gathered over a 28 week period of developing and adapting a vendor-based PHR at Lucile Packard Children's Hospital at Stanford University. A grounded theory approach was utilized to code and analyze over 100 pages of typewritten field notes and interview transcripts. This grounded analysis allowed themes to surface during the data collection process which were subsequently explored in greater detail in the observations and interviews. RESULTS: Four major themes emerged: (1) Multidisciplinary teamwork helped team members identify crucial features of the PHR; (2) Divergent goals for the PHR existed even within the hospital team; (3) Differing organizational conceptions of the end-user between the hospital and software company differentially shaped expectations for the final product; (4) Difficulties with coordination and accountability between the hospital and software company caused major delays and expenses and strained the relationship between hospital and software vendor. CONCLUSIONS: Though commercial interoperable PHRs have great potential to improve healthcare, the process of designing and developing such systems is an inherently sociotechnical process with many complex issues and barriers. This paper offers recommendations based on the lessons learned to guide future development of such PHRs.

    View details for DOI 10.4338/ACI-2011-06-RA-0035

    View details for Web of Science ID 000208686800002

    View details for PubMedID 22003373

  • Neonatal Informatics: Computerized Physician Order Entry. NeoReviews Palma, J. P., Sharek, P. J., Classen, D. C., Longhurst, C. A. 2011; 12: 393-396

    Abstract

    Computerized physician order entry (CPOE) is the feature of electronic medical record (EMR) implementation that arguably offers the greatest quality and patient safety benefits. The gains are potentially greater for critically ill neonates, but the effect of CPOE on quality and safety is dependent upon local implementation decisions. OBJECTIVES: After completing this article, readers should be able to: Define the basic aspects of CPOE and clinical decision support (CDS) systems.Describe the potential benefits of implementing CPOE associated with CDS in a neonatal intensive care unit (NICU).

    View details for PubMedID 21804768

  • Implementing an Interoperable Personal Health Record in Pediatrics: Lessons Learned at an Academic Children's Hospital. Journal of participatory medicine Anoshiravani, A., Gaskin, G., Kopetsky, E., Sandborg, C., Longhurst, C. A. 2011; 3

    Abstract

    This paper describes the development of an innovative health information technology creating a bidirectional link between the electronic medical record (EMR) of an academic children's hospital and a commercially available, interoperable personal health record (PHR). The goal of the PHR project has been to empower pediatric patients and their families to play a more active role in understanding, accessing, maintaining, and sharing their personal health information to ultimately improve health outcomes. The most notable challenges proved more operational and cultural than technological. Our experience demonstrates that an interoperable PHR is technically and culturally achievable at a pediatric academic medical center. Recognizing the complex social, cultural, and organizational contexts of these systems is important for overcoming barriers to a successful implementation.

    View details for PubMedID 21853160

  • Neonatal Informatics: Information Technology to Support Handoffs in Neonatal Care. NeoReviews Palma, J. P., Van Eaton, E. G., Longhurst, C. A. 2011; 2011 (12)

    Abstract

    Communication failures during physician handoffs represent a significant source of preventable adverse events. Computerized sign-out tools linked to hospital electronic medical record systems and customized for neonatal care can facilitate standardization of the handoff process and access to clinical information, thereby improving communication and reducing adverse events. It is important to note, however, that adoption of technological tools alone is not sufficient to remedy flawed communication processes. OBJECTIVES: After completing this article, readers should be able to: Identify key elements of a computerized sign-out tool.Describe how an electronic tool might be customized for neonatal care.Appreciate that technological tools are only one component of the handoff process they are designed to facilitate.

    View details for PubMedID 22199463

  • Vitamin D-Deficient Rickets in a Child With Cow's Milk Allergy NUTRITION IN CLINICAL PRACTICE Pearson, D., Barreto-Chang, O., Shepard, W. E., Greene, A., Longhurst, C. 2010; 25 (4): 394-398

    Abstract

    This article describes the case of a 16-month-old Hispanic male toddler with cow's milk allergy living in northern California who was admitted to a children's hospital for weight loss and markedly elevated levels of serum alkaline phosphatase and parathyroid hormone. At a routine outpatient well-child visit, his mother expressed concern about a decrease in his appetite and activity level. A detailed diet history revealed that breast milk was his primary source of nutrition during his first year of life and he had not been given supplemental vitamins. With attempts to introduce cow's milk formula, he had developed a rash and swelling around the mouth. Shortly after his first birthday, his mother weaned him from breast milk and introduced unfortified rice milk as a palatable milk substitute. Upon admission he was pale and lethargic; his laboratory studies were remarkable for elevated serum alkaline phosphatase and parathyroid hormone and low levels of phosphorus, 25-hydroxy-vitamin D, and ferritin. Lower extremity radiographic studies were consistent with rickets. After 5 weeks of therapy with vitamin D(3) and iron, his serum 25-hydroxy-vitamin D level normalized. Within 12 weeks following therapy, the child demonstrated significant clinical improvement, with resolution of growth failure and bone reossification. His activity level had returned to normal. This case emphasizes the importance of adequate vitamin D intake for children with special attention to those who might have nutrition deficiencies attributable to milk allergy.

    View details for DOI 10.1177/0884533610374199

    View details for Web of Science ID 000283800100011

    View details for PubMedID 20702845

  • Improved physician work flow after integrating sign-out notes into the electronic medical record. Joint Commission journal on quality and patient safety / Joint Commission Resources Bernstein, J. A., Imler, D. L., Sharek, P., Longhurst, C. A. 2010; 36 (2): 72-78

    Abstract

    In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed.A printable sign-out report was implemented within the EMR system at a tertiary academic children's hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey.The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process.EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.

    View details for PubMedID 20180439

  • Development of a Web-based decision support tool to increase use of neonatal hyperbilirubinemia guidelines. Joint Commission journal on quality and patient safety / Joint Commission Resources Longhurst, C., Turner, S., Burgos, A. E. 2009; 35 (5): 256-262

    Abstract

    The 2004 American Academy of Pediatrics (AAP) guidelines for management of hyperbilirubinemia in the newborn infant at > or =35 weeks of gestation recommend that clinicians systematically asses the risk of severe hyperbilirubinemia before hospital discharge. Using the guidelines requires access to the printed nomograms, calculation of the infant's age in hours, and manual plotting of total bilirubin results. The combination of a common clinical problem with the existence of guidelines for best practice is an ideal target for clinical informatics tools to help improve compliance. A Web-based clinical decision support tool was developed on the basis of a combination of published data and linear extrapolation to automate the hour-specific risk stratification nomogram and phototherapy nomogram.After BiliTool, the clinical decision support tool that contained the AAP clinical guidelines, was made publicly available, Web-site usage was monitored. An online survey composed of 10 multiple-choice, Likert-scale, and yes-no questions was made available.The number of site visits has increased over time. Of the 469 respondents to the survey, 297 respondents considered themselves tool "users".Rapid uptake and high ratings for clinical utility confirm that Web-based clinical decision support tools are in high demand and may increase use of clinical guidelines. Given the risk of human error with manual age calculation and nomogram plotting, this tool may also decrease the likelihood of medical errors, particularly with integration into the electronic medical record. Concomitant release of Web-based decision support tools with clinical guidelines would optimize the guidelines' adoption and implementation. Also, the integration of BiliTool into the electronic medical record may serve as a model for integrating other Web-based clinical decision support tools.

    View details for PubMedID 19480378

  • Alphanumeric paging in an academic hospital setting AMERICAN JOURNAL OF SURGERY Nguyen, T. C., Battat, A., Longhurst, C., Peng, P. D., Curet, M. J. 2006; 191 (4): 561-565

    Abstract

    To determine whether implementation of an alphanumeric-paging system would improve physician work environment.Surveys were distributed to all general surgery residents, faculty, and nurses before and after implementation of an alphanumeric-paging system. Housestaff also kept a detailed log of paging activity before and after the intervention.User satisfaction with the paging system was measured using a Likert format survey. Interruptions to patient care and pages requiring a call back were tracked using paging logs.Physician perceptions of the capability of text paging before the intervention were high and did not differ significantly postintervention. For nursing staff, postintervention perceptions of the text-paging system were significantly more positive than preintervention, especially with regard to perceived improvements in patient care (54.1% versus 81.6%, P < .05). Residents' paging logs reflected significantly decreased interruptions to patient care after the intervention (28.2% versus 46.9%, P < .05), with less pages requiring a call back (100% versus 73.6%, P < .05).Study participants rated the alphanumeric-paging system highly. Text-paging technology has the potential to reduce interruptions in patient care and improve physician work efficiency and satisfaction.

    View details for DOI 10.1016/j.amjsurg.2005.06.037

    View details for Web of Science ID 000236508800024

    View details for PubMedID 16531156

  • Perceived increase in mortality after process and policy changes implemented with computerized physician order entry PEDIATRICS Longhurst, C., Sharek, P., Hahn, J., Sullivan, J., Classen, D. 2006; 117 (4): 1450-1451

    View details for DOI 10.1542/peds.2005-3048

    View details for Web of Science ID 000236540500088

    View details for PubMedID 16585351

  • Index of suspicion PEDIATRICS IN REVIEW Agarwal, S., Trucco, S., Longhurst, C., Sectish, T. C., Karadsheh, M., Defendi, G. L., Karadsheh, M. 2004; 25 (10): 364-369

    View details for Web of Science ID 000232154200005

    View details for PubMedID 15466138

  • A practical guideline for calculating parenteral nutrition cycles. Nutrition in clinical practice Longhurst, C., Naumovski, L., Garcia-Careaga, M., Kerner, J. 2003; 18 (6): 517-520

    Abstract

    Both physiologic and psychological reasons for cycling total parenteral nutrition (TPN) have been well established. Despite widespread acceptance of this practice, the only previously published method for calculating TPN cycle rates is inherently flawed.A mathematical formula was derived to facilitate reliable calculation of cyclic TPN flow rates as a function of total volume and cycle time. A publicly accessible website was subsequently developed to expedite rapid determination of TPN cycles.A fail-safe method of calculating TPN cycle flow rates can be expressed as F = V/(4T-10), where F is equal to the basal flow rate (mL/h), T is equal to the desired cycle time (hours), and V is equal to the total volume of TPN (mL) to be delivered in 24 hours. The basal flow rate and twice the basal flow rate are used for the first and last 2 hours of the TPN cycle, and the remainder of the cycle runs at 4 times the basal flow rate. TPN cycles may be easily calculated online using this formula at http://peds.stanford.edu/tpn.html.We have developed a fail-safe method of calculating TPN cycle flow rates that will consistently deliver the desired volume and have made an online implementation of this formula publicly available.

    View details for PubMedID 16215087

  • Isolation of Leclercia adecarboxylata from an infant with acute lymphoblastic leukemia CLINICAL INFECTIOUS DISEASES Longhurst, C. A., West, D. C. 2001; 32 (11): 1659-1659

    View details for Web of Science ID 000168588500027

    View details for PubMedID 11340546

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