Medical journals hand washing

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Electronic health record (EHR) systems are increasingly being adopted in pediatric practices; however, requirements for integrated growth charts are poorly described and are not standardized in current systems. Electronic health record (EHR) systems are increasingly being adopted by all categories of health care providers,1,2 including those caring for children.
The VUMC includes the Vanderbilt Children's Hospital (VCH), a 196-bed academic inpatient tertiary care facility with large local and regional primary referral bases. Height growth chart for a hypothetical nearly nine-year-old boy who has experienced a growth delay.
An institutionally developed CPOE system (1994–1995) had been in wide use throughout the VUMC and VCH since 1997.
The electronic growth charts were designed to allow them to reuse anthropomorphic data collected through routine workflows and documented into the EHR system. The EHR system modeled growth charts by using the data tables and equations presented by the NHCS on the CDC Web site.20 The data tables on the CDC Web site include age- and gender-specific values that correspond with the 3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th, and 97th percentiles for weight, height, and head circumference.
While the EHR system rollout to the pediatric clinics was driven and organized by the clinic administration and by “clinical champions,” there was no specific rollout or training on the EHR system–based growth charts. Growth chart usage was defined as a mouse-click on a link that would cause the EHR system to display a growth chart and was independent of whether a user entered anthropomorphic measurements into the system. During the three-year observation period, covering July 2001 through June 2004, the VUMC cared for 143,672 patients aged 0 to 21 years old.
Rates of weight and stature values entered into the electronic health record (EHR) system before and after the EHR system was implemented in the pediatric clinics, starting September 2002 (vertical line). System users accessed the electronic growth charts a total of 128,022 times between January 29, 2002, when the charts were first introduced, and June 30, 2004. We found that pediatric providers readily adopted electronic growth charts when the charts were integrated into an EHR system.
We found that because EHR systems can manipulate clinical data, perform calculations, and adapt to user preferences and patient characteristics, users expected greater functionality than from paper-based records, such as an ability to calculate percentiles, growth velocities, and predicted growth. The need for automated electronic growth charts may be even greater in subspecialty practices that evaluate and treat growth disorders, such as pediatric endocrinology. Based on our experiences, we have learned that implementing basic pediatric growth charts into EHR systems is relatively straightforward from a technical standpoint and may enhance adoption of such systems by pediatricians. In addition, and informed by our experiences with EHR system users and from discussions with members of the AAP Council on Clinical Information Technology and members of the Health Level-7 Pediatric Data Special Interest Group, we have compiled a list of desiderata for EHR system–based growth charts, reported in Table 1. In the May 2010 issue of the Archives, Venugopal and Murrell1 described a 31-year-old man who showed rapid clearance of cutaneous warts after having received 3 doses of a recombinant quadrivalent human papillomavirus (HPV) vaccination. Leave only one space after periods or other punctuation marks (unless otherwise instructed by your instructor). In the upper left-hand corner of the first page, list your name, your instructor’s name, the course, and the date. 6.    Period are placed after the parenthetical citation, however question marks, commas, and exclamation points are placed within the quotation marks followed by a period after the parenthetical citation.
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You can use this cartoon doctor clip art on whatever project of yours that requires an image of a cartoon doctor. The authors integrated growth chart functionality into an EHR system being developed and installed in a multispecialty pediatric clinic in an academic medical center. The VUMC and VCH annually care for over 86,000 pediatric patients through more than 11,000 inpatient and 231,500 outpatient encounters. For discrete data points, users can display the value, date, percentile, and standard deviation score and the patient's age on the date that the measurement was made with a mouse click. Note that the subject's height is below the third percentile for a chronologic age of 8.75 years, while the height is between the 25th and 50th percentiles for his physiologic age (measured by a hand radiograph for bone age and indicated on the growth chart with an X).
With a goal of replacing paper-based processes, an institutionally developed EHR system was formally installed through all VUMC clinics (except Ophthalmology) between September 2001 and June 2004. As part of standard intake processes at the VUMC, growth measurements were obtained in most pediatric outpatient settings.
From these values, the EHR system generated a connected plot for each percentile curve, with age along the x-axis and the anthropomorphic measurement values along the y-axis. The EHR system plotted specific patient values on the growth curves and could be triggered to display the value for Z and the calculated percentile for each point (Fig.

To ensure that users knew about and could access the electronic growth charts, links were placed to them from multiple places within the graphical user interface of the EHR system.
Upon receiving Institutional Review Board approval, we screened EHR system logs for growth chart usage and administrative databases for visit rates to the VCH and to the VUMC pediatric clinics that monitored growth most closely. These patients contributed 755,802 outpatient clinic visits (20,994 per month), 95,066 emergency department visits (2,641 per month), and 35,244 admissions to the VCH (979 per month).
As would be expected, prior to electronic growth chart implementation in February 2002, there were fewer than ten values per weekday for weight, stature, and head circumference entered into the EHR system for pediatric patients. Among growth chart accessions, 81% were by physicians and nurse practitioners, 14% by nurses and patient care technicians, and 5% by students, ancillary personnel, nutritionists, pharmacists, and others.
The EHR growth charts described in this article were designed to translate the AAP's functional requirements and other features requested by users into a tool that could be readily accessed by providers during their normal workflow. Systems having greater functionality may be more efficient and more readily adopted by health care providers, but may also be more expensive to develop and more complicated to use.
In these settings, automated growth charting may improve the diagnostic accuracy and follow-up of complex medical conditions involving growth, such as growth hormone deficiency, hypothyroidism, congenital adrenal hyperplasia, and disorders of puberty. However, users of EHR system–based growth charts may expect such charts to have greater functionality than the paper-based growth charts they replace, including having the ability to reuse previously documented measurements and to calculate derived values such as percentiles and growth velocities.
While the growth chart functionality outlined by these desiderata may be desired for EHR systems supporting pediatric practice, necessary growth chart functions may vary depending on user subspecialty and patient diagnosis.
We herein describe a severely immunosuppressed woman who experienced a similarly substantial regression of widespread cutaneous warts following vaccination with a quadrivalent HPV-6, -11, -16, and -18 vaccine.
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The VUMC also offers graduate medical education and residency training in 53 subspecialty areas to more than 650 house officers and fellows every year.
The system automatically plots individual patient weight, height, and head circumference measurements on the relevant charts. By selecting two data points, users can trigger the system to calculate and display a growth velocity for the interval between the two points.
At the upper right margin of the chart, the child's adult parental heights are displayed based on their percentiles of adult height for gender (Fa, Mo, with percentile values extrapolated from the CDC height for age tables), and a mid-parental height (MPH) percentile is presented.
The EHR system was designed to be used by physicians, housestaff, nurse practitioners, nurses, and other ancillary staff for management of patient data, including clinical documentation, review of notes, testing results, lists of problems, medications and allergies, and clinical messaging among health care providers.
In general pediatric clinics, for example, weight and stature are recorded for all children, and head circumference for children younger than 36 months of age. In addition, the CDC data tables include constants for the Box-Cox transformation power (L), the median (M), and the standard deviation (S) for anthropomorphic measurements by categories of age and gender.
In addition, the electronic growth charts were demonstrated at weekly support meetings and to staff and physicians from clinics requesting information.
Because the data sources stored system-usage and patient visit information differently, we were unable directly to calculate percentages of patient visits in which the growth charts were used. Of the visits to outpatient clinics, an average of 2,771 per month were to the clinics that monitored pediatric growth most closely.
To accomplish this, the charts used available anthropomorphic measurements that were routinely entered into the EHR system, were easily accessible to EHR system users, displayed reference population-based curves, and allowed the underlying data to be reused for calculating growth velocities, percentiles, and growth targets. Our experiences demonstrate that it is possible to take high-level functional requirements made by clinical subspecialty organizations and specific functional needs outlined by users and iteratively develop EHR system components to meet them.
These desiderata should serve as a framework for system developers, clinical users, and evaluators as they consider the functionality of growth charts implemented in EHR systems. If you copy and paste phrases from an article, you should put quotation marks around what you copied to remind yourself that it’s a direct quote. Only indent the first line of the quotation by a half inch if you are citing multiple paragraphs. We would highly appreciate a link back to this webpage if you plan on using this clip art online.

Add this clip art to your medical journals, websites, presentations, reports, school projects, etc. By the end of the observation period, users accessed the growth charts an average 175 times per weekday, compared to 127 patient visits per weekday to the sites that most closely monitored pediatric growth.
At the VCH, the following clinics were identified as those that monitored pediatric growth most closely and used growth charts as part of their routine workflows: primary care pediatrics, endocrinology, gastroenterology, neurology, and specialty clinics for patients with Down syndrome and spina bifida. It also can plot data points linked together with lines or as discrete dots, with or without the date of measurement, according to user preference.
A table showing the growth data from two user-selected points, including their percentiles, standard deviation scores, and the growth velocity between them, is superimposed. The electronic growth charts were initially developed and integrated into the EHR system at the end of January 2002, before the subsequent formal EHR system rollout to the pediatric clinics in September 2002. To encourage clinic staff to enter anthropomorphic measurements directly into the EHR system, most VUMC clinics installed computer workstations in each patient room. System users received minimal training on the growth charts as part of their overall one-hour EHR-system training classes.
We calculated summary usage statistics and performed comparative analyses using the Wilcoxon rank-sum test for nonparametric distributions and tested for trends using time series analyses that incorporated moving average and autoregressive terms as well as structural components correcting for patient volume, gender, and age. By the end of the observation period, system users accessed the EHR growth charts on average 175 times per weekday (compared to 127 patient visits per weekday to the clinics that most closely monitored pediatric growth, above, and the 488 weight values entered per weekday institution-wide).
Many of the values were also available to other EHR component systems; for example, percentiles calculated for the growth charts could also be imported automatically into clinical documents such as progress notes. This approach may serve as a model for developers customizing EHR systems to achieve the necessary functionality to be useful in pediatric practices. Otherwise, we would highly appreciate a link back to this webpage if you plan on using this clip art on your online projects. A link back to this webpage is required if you plan on redistributing this clip art otherwise we would highly appreciate if you can provide a link to this webpage if you plan on using this clip art online. Although a link back to this webpage is not required, we would highly appreciate it though if you can add a link back to this webpage if you plan on using this clip art online.
Because EHR systems and integrated growth charts can manipulate data, perform calculations, and adapt to user preferences and patient characteristics, users may expect greater functionality from electronic growth charts than from paper-based growth charts. We have developed and deployed automated electronic growth charts via an EHR system in wide use at Vanderbilt University Medical Center (VUMC).
In these clinics, most direct patient care is provided by attending physicians and nurse practitioners, although housestaff and medical students may also spend time on academic rotations there. Quick links available at the top of the charts also allow users to superimpose on the growth charts parental height percentiles with a calculated mid-parental height point and to plot stature against skeletal age measurements in addition to chronologic age. Based on system-user feedback, the growth chart functionality was expanded to include additional features in July 2003. In addition, developers created a simple computerized intake form that allowed staff (such as nurses or patient care technicians) easily to select a scheduled patient and then document the patient's vital signs, anthropomorphic measurements, medications and allergies, and problem list information, all directly into the EHR system.
This combined functionality allowed pediatric providers easily to adopt the EHR growth charts and may have helped them to accept the EHR system. If your quote is more than 4 lines long, you must indent the entire quote three times.  The quote is still double spaced.
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The growth charts incorporated many of the functional requirements outlined by the AAP as well as others requested by EHR system users. Since 1994, the VUMC has also developed and implemented a number of patient care information systems, including a clinical data repository, an EHR system18 now available through the Internet, and a computerized provider order entry (CPOE) system19 available throughout the medical center.
For clinics that monitor growth closely, patient intake processes were modified to include documentation by staff of patient anthropomorphic measurements directly into the specialized intake form rather than on paper.
All analyses were performed using Stata SE, version 8.0 (Stata Corporation, College Station, TX).
In addition, users entered a total of 178 bone age measurements and 621 pairs of parental heights into the EHR system between July 2003 and June 2004. Health care providers in several pediatric clinics voluntarily adopted the electronic growth charts. Once entered into the system, anthropomorphic measurements were immediately available to other users and applications, including integrated electronic growth charts and clinical documentation tools.
To advance the discussion about EHR growth chart characteristics and to inform potential developers and users of automated growth charts, we report our design, implementation, and usage experiences. Growth charts and growth data tables may also be printed for parents, referring health care providers, or to document the need for or efficacy of treatments to third-party payers.
The EHR system also stored weight, stature, and head circumference measurements entered into the CPOE system and historical values entered as needed by system users.

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