Dr. Greg Janos Imagines What’s Possible
Dr. Greg Janos, executive medical director of St. Luke’s Children’s Hospital, imagined the future in the writing that follows. During our coffee chat at Shoreline last week, I promised to post his “Imagine” essay, which first appeared in our January ”News from St. Luke’s Children’s Hospital” publication.
Imagine. Sometime in the hopefully not-so-distant future …
A 2-year-old boy presents to the St. Luke’s Children’s Hospital emergency department with a two-day history of vomiting, intermittent abdominal pain, and lethargy. He has been a patient of St. Luke’s and its primary care network since birth, so his entire medical history is stored in myStLuke’s, St. Luke’s electronic medical record.
The triage nurse sees him within five minutes of arrival, because his doctor has made an electronic referral through the electronic medical record to the emergency department and indicated a high level of urgency. The nurse enters the triage data into the EMR, noting the presence of abdominal pain, fever, and a rapid pulse and respiration. Predictive modeling software integrated with the EMR immediately generates a risk score consistent with a surgical abdomen. The nurse acts promptly on this information and triages the patient to urgent care; the boy is seen by a physician within 10 minutes of arrival.
The ED physician examines the patient’s EMR records, which reveal a significant past medical history. The child was born full term by prearranged C-section at the special delivery unit at St. Luke’s Boise, because of a prenatally diagnosed neck mass and the likelihood of airway obstruction at birth. A prescheduled surgical resection was performed very shortly after birth. The child was immediately transferred to the neonatal intensive care unit for further care.
The baby was extubated three days later, and five days after birth, was ready for transfer to the St. Luke’s Meridian NICU close to the family’s home. The baby went home two weeks after birth with a set of easily understandable discharge instructions provided by an assigned coordination of care nurse who also provided instructions on accessing all the electronic medical records at home. The follow-up exams were scheduled by the parents at home via the EMR’s myChart application.
The patient’s past medical history is also significant for recurrent vomiting from gastroesophageal reflux (GER), with periods of irritability and slow weight gain between six months and one year of life. The baby’s GER was managed entirely by his St. Luke’s primary care pediatrician with the help of a GER management template embedded within the EMR. The GER management template is an evidence-based protocol developed by the Children’s Hospital GI division and Department of Pediatrics and Family Medicine.
After performing a history and physical exam and entering the findings into the EMR, the ED physician is immediately presented with a differential diagnosis and a list of web links to obtain brief consults from the literature on each potential diagnosis.
The ED physician orders blood work and abdominal X-rays because of the concern for a possible intestinal obstruction and dehydration. The new data from the abdominal X-ray is added to the EMR, which now indicates that this child has an 85 percent chance of intussusception, a telescoping of the intestines upon itself, causing blockage. Furthermore, the chances of a barium enema reduction are 92 percent, a figure based on an examination of all patients with suspected intussusceptions seen at St. Luke’s Children’s and 15 other large children’s hospitals which have shared their data to form a large pediatric data warehouse through the Children’ Hospital Association.
This information resonates strongly with the physician’s experience and is reviewed on the EMR with family members, who agree with treatment. The patient undergoes a successful barium enema reduction of the intussusception within 45 minutes of entry to the emergency department, utilizing a reduced radiation protocol adopted by St. Luke’s Children’s and verified by a number of other children’s hospitals.
The primary care physician receives immediate feedback in the form of a video-based instant message from the radiologist once the procedure is complete. At discharge from the ED, the family is reminded by the nurse through the EMR that their son is also due for a follow-up immunization in their doctor’s office in two months.
Once home, the family receives a single bill for all services and a set of performance indicators that indicate how well their child was cared for. They are prompted to visit the St. Luke’s website to compare outcomes of care at St. Luke’s Children’s with other institutions. They are comforted that St. Luke’s Children’s has one of the shortest times to resolution for intussusception of any children’s hospital in the country. On the website, they read more about myStLuke’s, a system that helps St. Luke’s doctors and nurses perform their work accurately, safely, and expeditiously.
St. Luke’s Health System: Transforming Health Care. Exceptional experience of care. Exceptional outcomes.
Tags: accountable care, best practices, Dr. David Pate, Dr. Pate, electronic health records, electronic medical record, Idaho, st. luke's, St. Luke's Health System, transformation
While I appreciate the advanced processes envisioned here, I believe we may have missed a possible step with this scenario.
A patient like this would most likely be observed on the pediatric floor overnight (a common practice with our pediatric surgeons, due to a higher rate of recurrence with the reduction method used) to ensure the intussusception did not recur and that he could tolerate PO intake.
Cullen has an excellent point. There will always be children with reduced intussusception that will need admission overnight for observation and/or for the rare possibility of recurrence. Those patients with dehydration or electrolyte imbalances, ongoing poor oral intake, or prolonged obstruction with complications will need hospital observation.
However, the goal of any effective, efficient clinical pathway or care model for intussusseption is early identification and prompt successful reduction. Experience at children’s hospitals across the country is showing that many children with prompt effective treatment who don’t have underlying complicating factors can be observed and safely sent home, thus avoiding unneeded admission.
In conjunction with the utilization of myStLukes as a powerful tool to assist and expedite care, the adoption by the clinical team of best practice pathways and algorithms of care that are supported by evidence may allow us to better stratify patients with respect to risk and determine those that are best suited to short stay observation versus admission.
This is the essence of clinical integration: using clinical teams, in many cases multispecialty, to design more effective and safe models of care, testing them and constantly trying to reduce variability and improve outcomes.