by David C. Kaelber, M.D., Ph.D., M.P.H., FAAP,
and Jane Im, M.D., FAAP
A 5-day-old was seen in clinic for her newborn visit.
She had been born at another health care system that
was not affiliated with the clinic.
In the old days, the clinic visit would have been
complicated by the frustrating and time-consuming
process of obtaining written consent from the parent/
guardian to view the infant’s medical records, faxing
the record request form to the other health care system
and waiting for a return fax. Alternatively, the doctor
could assume “nothing of continued consequence had
happened during the birth admission” or could ask the
mother if “anything significant had happened during
the birth admission.”
Fortunately, the two health care systems were con-
nected through a health information exchange. Hence,
it was a relatively seamless process to obtain access to
the entire record from the health system where the
child was born, including labs, provider notes, vital sign
readings and weight measurements, and to pull that
information into the electronic health record (EHR)
where the patient was currently being seen.
This example describes the best-case scenario for electronic health information exchange. When it works,
electronic health information exchange has been shown
to reduce unnecessary and duplicate testing, imaging
and admissions, and increase provider efficiency.
Tens of millions of patient documents are exchanged
monthly throughout the United States, both within
EHRs of the same vendor and between EHRs of different vendors. However, several challenges remain.
One of the major challenges, especially in pediat-
rics, is the lack of a universal identifier. In the example
above, the two systems were not automatically able
to identify the patient because she was
registered under a different name in
each system — one that was tied to the
mother’s name in the hospital system
where the child was born and the other
that was the child’s full legal name in
the second health care system. In this
case, a brief phone call was needed to
match the patient in both systems.
Secondly, electronic health information exchanged often contains only a
summary document, which may be referred to as a Continuity of Care Document, Continuity of Care Record or
Consolidated Clinical Document Architecture. Because these are generic
summary documents, they sometimes
leave out pieces of information that
may be important for a specific patient
or, conversely, may include too much
information, making it hard to find
the pertinent information. Sometimes
having the “raw” information is more
helpful than having the summary.
Another challenge with electronic health information exchange is discrete information integration and
reconciliation. Conceptually, we want to know all the
medications a patient was prescribed, all the immunizations received and all of his allergies and problems.
Electronic health information exchange can present all
of this outside information, but it needs to be integrat-
ed and reconciled. The integration and reconciliation
process sometimes can take a significant portion of
the visit, and duplicate information may not be easy
to eliminate. Also, many pharmacy benefit plans pro-
vide prescription fill information through electronic
health information exchange, which can be helpful in
some clinic situations. However, this additional piece
of information must be integrated into clinic visits that
already are too short.
The example described illustrates “pull” electronic
health information exchange in which a pediatrician or
health care system manually or automatically searches
for patient information in other systems.
“Push” electronic health information exchange, also
called direct messaging, is evolving. This is a type of secure, Health Insurance Portability and Accountability
Act-compliant email that can be embedded in an EHR,
whereby a pediatrician or health care system can “push”
or send a message to another pediatrician or health
system. For example, a message can be sent to notify a
pediatrician that his or her patient has been admitted
to another health care system, or a specialist can send
a message notifying the primary care pediatrician in
another health care system of consultation results.
Hopefully, every point of care for children in the
United States (and internationally) one day will have
seamless electronic health information exchange that
will allow all health care professionals to provide
higher-quality and more efficient and cost-effective
One example of this is a case of viewing the growth
chart for an older boy who recently was seen in clinic.
The patient was identified automatically through the
vendor-based health information exchange as having
data in another health care system. Weight and height
measurements from the other health care system were
automatically imported and integrated into the clinic’s
EHR to generate a single growth chart using different
colors to represent the internal (dark blue) and external (light blue) growth measurements (see figure). All
that was required was to follow a normal workflow of
reviewing growth charts at well-care visits, and all of
the information from the multiple health care systems
was automatically presented.
Dr. Kaelber is a member
of the AAP Council on
Clinical Information Technology. Dr. Im is a member
of the AAP Section on Hospital Medicine.
©2017 Epic Systems Corporation. Used with permission.
Growth chart for an older child shows weights that were integrated
from different health care systems. Internal measurements are in dark
blue and external measurements are in light blue.
Oral diseases are among the most common
chronic conditions patients face. Yet primary care
providers may have only minimal training to evaluate, diagnose and manage oral contusions.
The Smiles for Life Oral Health App is designed
to assist primary care providers in formulating diagnoses in real-time with the help of user-friendly
diagnostic modules and a risk assessment tool.
The diagnostic modules cover a wide variety of
oral health needs for patients of all ages, including
tooth lesions, mucosal lesions and oral emergencies.
The app also includes a risk assessment tool developed by the Academy to help primary care providers
during health supervision visits. The tool has been
endorsed by the National Interprofessional Initiative on Oral Health. Through a series of questions,
the tool provides narrowed-down information on
signs/symptoms and management. A photo gallery
of tooth and oral soft tissue findings also is available.
The app was developed by the Society of Teachers
of Family Medicine group on oral health, with a
wide range of authors, reviewers and photo contributors. It is free and available for both Android and
iOS devices at http://bit.ly/2mwB9Ht.
If you would like to share a first-hand experience using technology, such as software, program, app, widget,
etc., to improve patient care or practice management,
email submissions of 250 words or less to Vanessa Short
Oral health app designed for primary care clinicians
from the AAP Division of Quality