Q&A With Daniel Nigrin

by Daniel Nigrin

January 29, 2007

Practicing physician and IT innovator Dr. Daniel Nigrin discusses hisexperiences at Children’s Hospital Boston and the special challenges thatface the pediatric specialty.

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Healthcare Technology: Children’s Hospital
Boston deployed high-speed Internet connections
to all patients’ rooms. How are
those connections being utilized?

DN: Incredibly frequently and well. Sometimes
it’s the patients themselves who are
using the connections,whether they have
chronic disorders and need to spend long
periods of time in the hospital, like patients
with cystic fibrosis or oncology disorders; it
helps to break up long days to be able to use
the Internet. The other way they are used is
by kids who need to connect back to their
classrooms with Internet connectivity and a
webcam; suddenly the kid who needs to
spend three or four weeks in the hospital
can “spend time” back in his classroom.
Lastly, as a pediatric institution, parents can
also stay connected,which enables the parent
to be with the child during hospitalization
while not falling so far behind with
work, or simply communicating with other
family members. So the ability for the parent
to stay connected has been a huge plus.

HCT: Initially the hospital simply provided
the Internet connection. Is the hospital
now providing computers as well?

DN: Not globally.We don’t do it for every
patient or every room, but there are sections
where we provide computers. In our oncology
unit and our bone marrow transplant
unit,we provide computers. They are also
set up in an area we call the Center for
Families,which is available to all.We also
have several laptops that rotate among the
inpatient floors. To extend the program, in
addition to having a wired connection at
every bed space,we have wireless access for
patients and families, at no charge, throughout
the entire organization. All of the ambulatory
waiting areas, lobbies, cafeterias and
many inpatient spaces have wireless access.

HCT: Using wireless devices in a hospital
was once thought to conflict with medical
devices. Have those fears been allayed?

DN: Not completely, and that is why I said
there is wireless connectivity in “many” but
not all of the inpatient spaces. There is no
patient and family wireless connectivity in
our intensive care units, for example, specifically
because it would be impossible to
test every laptop or other device a family
might use. And with the equipment there,
those end-user devices need to be formally
tested to ensure they’re safe.We have been
extremely careful in how we’ve deployed
this patient and family wireless network.
HCT: Is there a danger in allowing
patients and families too much access to
their own medical information?
DN: Danger is a bit of a strong word, but
there are certain risks. On the positive side
first, it’s empowering for patients to access
their record directly and to get that information;
it is helpful in the long run. But in
certain situations you do need to interpret
the information for patients rather than just
letting them see it on their own. For example,
there are often test results that are just
outside of the normal range, or maybe even
significantly outside of the normal range.
But there are also often extenuating circumstances
that might explain why the abnormal
reading is okay or insignificant for the
situation. Yet the patient, who doesn’t have
that context or explanation to go along with
the lab result is not going to understand
this, and will be alarmed. This is also the
case with other various sorts of medical documentation. Physicians use a different
language in many instances to describe
things, and that can be rather scary-sounding
if you don’t know what the terms mean.
So as we roll out things like personal health
records and access to seeing pieces of their
own information in their charts, we do it
carefully – and only when we can provide
context and explanation to patients.

HCT: Children’s Hospital Boston was one
of the pioneers of personal health records.
How is that concept evolving and what are
the newest applications like?

DN: We’re definitely pushing forward. The
concept you’re referring to was formerly
called PING, which has been renamed
Indivo Health. It’s a personally controlled
medical record, and we’re now ramping
up to do much more than the pilot efforts
we’ve been involved in previously.We’re
gearing up to making it a formal component
of a patient portal. Basically, in the
near to midterm we plan to offer this to
every one of our patients that we see here
at Children’s. This will give them the ability
to enter their own data and comments
into their own health record. Plus they’ll
be able to import data into that record
from the Children’s system.

Another one of the really exciting things
we’re doing with Indivo Health involves
Massachusetts being part of one of the NHIN
pilot projects, the national efforts in which
the government awarded four contracts to
different regions in the country with the
notion of pushing forward national interoperability
of health records. One of the groups
is a collaborative between Massachusetts;
Indianapolis; and Mendocino County, Calif.

The idea is that medical records would be
accessible to authorized people in any one of
those places so that if, for example, I were
delivered unconscious to the ER in Mendocino
or Indianapolis, a healthcare provider
there could look up my data, determine my
medical history and needs from institutions
where I received care in Massachusetts.
So what we’re doing with Indivo Health is
that we’re actually plugging these personal
health records into this national interoperability
infrastructure. The idea is that if I
walk up to an ED in Indianapolis, not only
can they get my Massachusetts General
Hospital information but they can also get
my personal health record information.
That’s enormously helpful.

HCT: How has all of this broad collection
of data been impacted by technology?

DN: It’s unbelievable how much more of
one’s healthcare record is now entered
into an electronic system and processed
in some way. Using pediatrics growth
charts as an example, those things used
to be plotted manually on a curve. Now
just the height and weight are entered,
and the plot as well as various other
growth parameters are calculated automatically.
In some situations when a child
is being evaluated for a specific disorder,
other nonstandard growth charts might
be used, and so the same data is just plotted
automatically on a different chart. All
of this can now be done without picking
up pen and paper.

So technology is really facilitating
many of the steps. In the area of immunizations,
one of the struggles we have is
getting children who are behind caught
up. That is getting simpler now that we
have reminder systems for primary care
practices. There can be alert flags for the
practice if a child is due for an immunization
and hasn’t come in. Now we can also
get quick summaries for patients who are
behind that list catch-up doses of various
immunizations for that child. Those things
can be very complex since the guidelines
change all the time. So automating those
processes is extremely helpful and can
improve the care.

HCT: Why is pediatrics more technically
challenging than other specialties?

DN: The biggest challenge I always talk
about is medication ordering, for both
inpatient and outpatient care. One of the
problems is that you have an extreme
range of patient size. In pediatrics there
are premature children who are born
at less than a pound, all the way to
your hulking 200-pound football player.
Obviously, doses of medications vary dramatically
with each of those scenarios.
One of the greatest challenges in pediatrics
is to assist the clinician in correctly
prescribing a medication for this wide
array of patients. Technology has greatly
enhanced these processes.

Another subtlety of medication ordering
where technology has been very beneficial
is for the calculation of fluids in
small kids, which plays into the dosages
that need to be prescribed. In the premature
child I mentioned, or in cases of kidney
failure, patients are extremely sensitive
to fluids and can get fluid-overloaded
easily. You don’t think about it, but medications
that are given by IV are packaged
as a fluid, and if you don’t count that fluid
in a child’s total daily fluid intake, you can
easily fluid overload a small child or a
renally insufficient child.

Lastly, I’d like to mention the linking of
records. For newborns, it’s not just the child’s
record you need; you need to get visibility
into the mom’s record. You also might want
to link father to child, or sibling to sibling,
and so on, basically establishing a good family
pedigree in an electronic system. This will
become even more important as genetic
testing becomes more commonplace. All of
those things are challenging but extremely
important for pediatrics.

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