Information regarding health care of children is highly demanded and valued by parents, and a wide variety of information sources are available to parents and pediatricians. Some examples of child health information include printed handouts, parentheld health records, advice and triage by telephone, and prerecorded audiotaped information. These information sources should be considered part of patient instructions and thus should be considered in a medical as well as a legal context.
This article reviews a variety of materials and services that are intended to inform parents about recommended health care for children. Innovative systems that can improve clinical efficiency and ensure that children receive preventive services are highlighted, and the implications for malpractice risk reduction are discussed.
PARENT-HELD HEALTH RECORDS
A variety of child health records are kept by parents, such as vaccination records or general health records sufficient for participation in organized educational, camping, or sporting activities. More complete parent-held health records are used in many countries. In France, one particularly innovative program has been developed by the Ministry of Social, Health, and Urban Affairs. The "Carnet de Sante" ("Health Notebook")1 is provided to each child bom in France once the birth is registered. The Carnet de Sante contains records of family medical history, clinical examinations conducted between the neonatal period and age 16, growth charts, immunizations administered, hospitalizaron summaries, blood type and transfusion history, and blanks for emergency telephone numbers. The Public Health Code requires that results of three visit records (8-day, 9-month, and 24-month examinations) be submitted to the local health ministry. A certificate of health is then issued, which authorizes access to additional government provided health services. An assessment of risk factors to the child's health is made and extra assistance offered to families in need. Similar parent-held health record programs exist in England, Germany, Austria, New Zealand, and Canada.
Few parent-held health records programs as comprehensive as the Carnet de Sante have been implemented in the United States. One such program, however, called Partners in Health Care (PHC), has been instituted in several communities. The goal of PHC is similar to that of the Carnet de Sante: to ensure that all children receive timely, continuous, and comprehensive preventive health services.
Partners in Health Care is based on the assumption that the health status of children requires coordination of efforts by parents, health providers and community heaíth planners. Parents need information about when and how to access care, eg, when to take their children in for immunizations or for serious illnesses and how to carry out the recommendations of health providers. Health providers benefit from organized records of previous care as well as having recommended professional guidelines readily available.2 Although guidelines such as anticipatory guidance and screening tests have long been available, they may be overlooked or not documented.
The community also has responsibilities to ensure the health of children. While most communities and states make health services available to those who cannot afford private health care, few communities are able to monitor the health care of all children regardless of the provider. As a result, public health concerns such as underimmunization and injuries may not be addressed due to the lack of specific and timely data.
The means toward achieving the PHC goal is based on two elements: The Denver Child Health Passport and a tracking and feedback system built around the Passport.
The Denver Child Health Passport is a parentheld, loose leaf bound 10l/iX6H-inch notebook that provides a comprehensive method of recording clinic visits. Passport sections intended for parents are printed in black and written at the sixth grade reading level. These sections include instructions and sections to be completed by a parent (eg, concerns and developmental observations). Physician portions (physical examination, immunization and screening test records, diagnosis, and treatment provided) are printed in red.
Additional pages in the Passport include: problem lists, lists of allergies and medications, a health summary chart (adapted from the American Academy of Pediatrics guidelines for health supervision), delivery and newborn nursery data, family history, demographic information, well-child visit clinic records (2 weeks to 6 years), growth and developmental data, illness visit forms, consult forms, and dental visits. Supplemental pages are available to keep the record current if parents forget to bring the child's Passport to a visit.
Clinical record pages are printed on self-copying paper affording three copies. One is for the parent to keep as a permanent log of the child's health care. The second copy is for the physician's clinical record. The physician detaches that copy along a fenestrated line, removes the covering of a glue strip, and places it into the child's chart. Since most of the record consists of checklists, only minimal writing is required to complete the physician portion. The third copy is used in the tracking phase of PHC.
The Passport also contains age-specific health suggestions pages. These single copy pages, also fenestrated along the ring-bound side, can be removed from the Passport at the end of the visit to remind parents about health promotion in the areas of nutrition, safety, development, and general health. These pages also have a location to write the date, time, and provider for the next scheduled appointment. At home, parents remove the health suggestion pages and place them on a metallic surface using the Passport magnet. In this way they serve as daily reminders of ways to promote the child's health and general well-being.
Tracking System/Community Coordinator
To help ensure that children receive health services in a timely fashion, a tracking system should:
* register all children in a given population,
* remind parents to keep recommended appointments,
* inform health providers of illegible records, missed appointments, services inadvertently omitted, or consults not received, and
* serve as a community-wide database to assist health planners in identifying health problems, such as low rates of immunization.
Three Colorado communities (Canon City, Salida, and Colorado Springs) and one Illinois community (Quincy) are using the Passport tracking software to perform these functions in their community.
Options With the PHC Program
One option for the physician is to use the Passport without the tracking system. Use of the Passport alone provides the pediatrician with a well-organized record, reminders of recommended preventive services, a tool for parent education, appointment reminders, lists of health problems, allergies and medications, and a health summary chart. Parents like the ability to organize all of their child's health records in one location. A second option is to use the Passport with the tracking system to give the physician additional benefits such as parent reminders of appointments, physician reminders of missed appointments, or care that was inadvertently omitted or not documented.
The tracking program can be a tool to evaluate individual performance for comparison with other physicians in the community, thereby alerting the physician to areas that he or she may want to improve. The tracking program also can be used in conjunction with other health tracking efforts. In Colorado, for example, a software conversion makes the PHC immunization database readable by the statewide immunization registry. In addition, the immunization information can be assessed by the Clinical Assessment Software Application (CASA) developed by the Centers for Disease Control and Prevention.
Support for the parent-held health record programs should be organized at the community level. Costs of the Passport program include: the Passports ($30 per copy), supplemental pages, coordinator time, and marginal office staff time. Grants from community and child health-promoting organizations and insurance (both medical and malpractice) have supported the existing programs. Some physicians purchase the Passports for their patients, while some medical insurance companies reimburse doctors for the Passport. Information about the Passport can be obtained by calling Denver Developmental Materials (800-419-4729).
Printed educational materials have an important role in pediatrie care. Most pediatricians use single handouts relevant to the concerns of one visit. Some practices, however, provide several key handouts to new patients or provide collections of handouts in office booklets.
Evidence from the limited research that has been conducted to date suggests written patient educational handouts improve preventive care3 but may not increase parent knowledge when given out a single time."1 Expert opinion and anecdotal experience, however, hold that patient educational handouts have numerous benefits.5 Handouts increase physician and nurse productivity by decreasing time for written or verbal instructions and decreasing unnecessary telephone calls. Written information is believed to encourage parents to manage minor illnesses at home. Handouts are believed to increase the amount of information used by parents at the times when they need that information. Handouts can provide written instructions that otherwise would be impractical to write out every time by hand. Detailed treatment instructions, follow-up plans, and information about medication side effects and interactions help to ensure successful outcomes.
Printed handouts can increase the number of people who receive detailed information and increase compliance with treatment regimens. Because ill children often have multiple caretakers, pediatricians should encourage parents to make the printed information available to these additional persons. Providing extra copies of handouts facilitates this transmission of information.
Handouts can serve to prompt physicians in subjects outside of their area of expertise. For example, handouts may help in the difficult areas of behavior problems, developmental and educational disabilities, or food allergy diets.
Providers should document each handout given, information that was added to the handout and, if applicable, that the handout was reviewed with the parent. Handouts should provide indications of worsening of the condition that should prompt the parent to recontact the provider or bring the child back in.
Software to make computer-generated handouts is available to pediatricians. The advantages of computerized handouts include lack of storage space requirements, ease of organization, and ease with which patient-specific information such as drug dosages or preferred methods of care can be added. In some offices, computerized handouts take slightly more provider time to get to the parent than printed handouts.
The Pediatrie Advisor is one computerized clinical handout system available. Information regarding the Pediatrie Advisor is available by calling (800) 2378401 or at the Internet address firstname.lastname@example.org. Other organizations providing extensive pediatrie handouts include the American Academy of Pediatrics (800-433-9016), Charming L. Bete Co Ine (800-628-7733), and ETR Associates (800-3214407).
TELEPHONE TRIAGE AND ADVICE
Health information provision by telephone is a time-consuming and stressful part of pediatrie practice, both during and after office hours. Instructions for pediatrie care by telephone have been handled in numerous ways in the past, often with little standardization or supervision by health professionals. In an era of managed care and capitation, it is increasingly important that telephone triage be highly effective in determining which patients need to be seen and the lowest cost site compatible with good clinical outcomes to which they may be referred. For telephone triage and advice to be cost effective, it needs to be carried out, in most cases, by nonphysicìans. Telephone triage must have an increased emphasis placed on educating families regarding self-care and the appropriate use of the health-care system. Written guidelines or protocols are available and probably should be used by most nonphysicians who perform telephone triage. Careful documentation of the call is important. Symptoms, parental observations, recommendations, and a follow-up plan should all be recorded. Following a telephone contact by a call center, a summary of the call should be sent (by mail OT by fax) to the physician's office to be included in the permanent patient record.
In an attempt to improve quality, efficiency, and documentation of telephone triage and advice for child health care, a computerized system, The Pediatrie Telephone Triage and Advice System (PTAS), was developed at The Children's Hospital in Denver, Colorado.6 The PTAS system has been implemented in the After-Hours Program (AHP) in Denver, which currently provides after-hours telephone management for 97% of private practice pediatricians in the Denver metropolitan area and 75% of pediatricians in the state of Colorado. Soon the PTAS will be piloted as a 24-hour triage and advice system in Colorado.
Trained nurses use the PTAS decision-making algorithms that, based on the presenting complaint and responses to a series of questions, determine the urgency and level of care needed. Home-care advice, medication advice, and health information are imbedded within the computerized system and are easily accessed by the triage nurse. Algorithms are based on the telephone management protocols written by Barton Schmitt.7 Prior to the introduction of the computerized algorithms in January 1996, the AHP used protocols in written form for 7 years. A previous report of the management of 107,938 after' hour calls demonstrated no adverse medical outcomes and a high degree of subscribing physician (100%) and parent (96% to 99%) satisfaction.5 For more information about the Pediatrie Telephone Triage and Advice System, call National Health Enhancement Ine at (800) 345-3342.
PRERECORDED AUDIOTAPED INFORMATION
Although direct counseling and printed materials have been the predominant vehicles of health education in pediatrics, an innovative approach for conveying information is the use of audiotapes. In November 1995, a new system using the telephone for patient education, the Parent Advice Line, was offered to physicians affiliated with The Children's Hospital in Denver. The Parent Advice Line is a collection of prerecorded messages on 275 pediatrie topics in the areas of acute illness, behavior, development, newborn care, health supervision, and adolescent care. The goal of the Parent Advice Line is to provide pre-recorded information and self-care guidance in a highly accessible manner, 24 hours a day. The system has the potential to reach those parents who do not read handouts, are not visual learners, or are reluctant to ask questions of a provider. Topics of the audiotapes are chosen based on the types of calls received in a pediatrie practice during the day or after-hours, and the information provided is consistent with handouts and telephone triage and advice information as discussed previously. Topic directories are provided through participating physician offices. Patient access to the system is obtained by entering an access code (unique to each physician or practice) and then a number from the directory corresponding to the subject desired. Hardware for the Parent Advice Line is intended to be based in a central location such as a hospital or a large health maintenance organization. The cost to physicians in Denver is only the cost of the topic directories (22 cents each).
A variety of evaluations of the Parent Advice Line are currently in progress. Initial data suggest that approximately 40% of families who receive a Parent Advice Line directory use the service within 3 months. In addition, many parents using the Parent Advice Line state that a call to the child's provider was avoided by information given. For more information about the Parent Advice Line, call National Health Enhancement Ine at (800) 345-3342.
Conditions Related to Child Health Information That Increase Risk for Malpractice Claims
RISK MANAGEMENT AND CHILD HEALTH INFORMATION
Good communication between provider and parent is the foundation for reduction of the risk of pedi' atric malpractice lawsuits.8·9 The importance of communication extends to the clinical setting of routine outpatient office visits, which is the third most common risk area for pediatricians.10 Good communication skills include the ability to organize and use medical information systems properly.11 Parent-held medical information, organized handout information, and telephone encounter records can minimize conditions in which malpractice claims arise (Table).
Parents who maintain detailed health records of their children may assume greater responsibility for several of the conditions listed in the Table. For example, parent-held records may be more easily available to consultants than office-based or hospital records. Parent-held records may be more legible since many of the entries are check-off boxes instead of written findings. They also may be more complete due to parent participation or because they prompt the provider to complete elements of the record such as health problems and allergy or medication lists. Thus, parent-held records may enhance communication. The results may be improved patient care and increased parental satisfaction, both of which decrease risk of liability.
Handout information can reduce risk by providing more complete instructions for the parent. Handouts allow individuals other than the person bringing in the child to have more complete knowledge of the treatment plan. Physicians are prompted by handouts to give complete advice for complex patient problems or in areas outside of their direct expertise. Malpractice risk may be reduced through documentation of which handout was given, what additions were made to the printed information, and whether a provider reviewed the information with the parent.
Organized telephone triage and advice systems may reduce liability by employing and training régistered nurses to use authoritative protocols rather than depending on the advice of individuals with variable amounts of experience and training. In addition, in the Denver experience, good documentation of telephone information received from parents and recommendations made by triage nurses has effectively countered five complaints against the After-Hours Program, which might otherwise have led to lawsuits (B. Schmitt, personal communication). The ability to easily collect and store data regarding all telephone encounters is an important asset of the Pediatrie Telephone Triage and Advice System.
Organized systems of child health information or instructions such as parent-held health records, handouts, telephone triage and advice systems, and audiotapes can enhance pediatrie practices. Parent-held health records facilitate the complete provision of preventive health services and communication with other health providers. Handouts enhance the access to information for parents and other care providers of children with complicated medical problems. Telephone triage and advice systems can organize a major part of pediatrìe practice in a way that provides cost-effective and competent advice. Clinical information on audiotape systems may reduce unnecessary calls to an office practice. To reduce risk, physicians should maintain awareness of information available to parents and patients, document completely, confirm parent understanding of information, and check for additional information needs. Systems for child health information will become more sophisticated and integrated with computerized office functions and electronic information sources available in die home. With this integration, cost effectiveness and health outcomes will be enhanced.
The authors thank William Frankenburg, MD1 for his review of this manuscript, and the Copie Insurance Company Foundation for its support of the Partners in Health Care Program.
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Conditions Related to Child Health Information That Increase Risk for Malpractice Claims