Q&A With Daniel Nigrin
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.
