Impact of an EMR-Based Daily Patient Update Letter in a NICU

Abstract and Introduction

Abstract

Objective: To evaluate the impact of using electronic medical record (EMR) data in the form of a daily patient update letter on communication and parent engagement in a level II neonatal intensive care unit (NICU).

Study Design: Parents of babies in a level II NICU were surveyed before and after the introduction of an EMR-generated daily patient update letter, Your Baby's Daily Update (YBDU).

Results: Following the introduction of the EMR-generated daily patient update letter, 89% of families reported using YBDU as an information source; 83% of these families found it "very useful", and 96% of them responded that they "always" liked receiving it. Rates of receiving information from the attending physician were not statistically significantly different pre- and post-implementation, 81% and 78%, respectively (p = 1). Though there was no statistically significant improvement in parents' knowledge of individual items regarding the care of their babies, a trend towards statistical significance existed for several items (p < .1), and parents reported feeling more competent to manage information related to the health status of their babies (p = .039).

Conclusion: Implementation of an EMR-generated daily patient update letter is feasible, resulted in a trend towards improved communication, and improved at least one aspect of parent engagement—perceived competence to manage information in the NICU.

Introduction

Parents of newborns in the Neonatal Intensive Care Unit (NICU) are thrust into an unfamiliar environment, where health care providers may use medical terminology the parents don't understand. Educating NICU parents about their babies and engaging them in the care of their newborns is a challenge:^[1] in addition to trying to learn what to expect each day in the NICU, parents are adjusting to having delivered a critically ill infant, getting to know their new baby, and may be experiencing the role of being a parent for the first time.

The information families receive about their baby's medical care and health status can vary substantially.^[2] This information is dependent upon the health care provider's position, communication style, knowledge, and availability to update the families, as well as the parents' availability and desire to speak with care providers. On a given day during a baby's NICU stay, some families receive a thorough daily report from multiple providers (nurse, nurse practitioner, or doctor), while others may get only minimal information. When contact is made with a provider, the information communicated might range from a quick general description about the day's events, to a detailed account of the previous 24 hours, but one that doesn't reveal the "big picture."

However, when NICU parents are more knowledgeable about their baby's health status and medical care, they are better equipped to be more involved in the hands-on care of their baby and to contribute to medical decision-making regarding their infant. Programs aimed at increasing parent engagement have been shown to decrease NICU length of stay, improve parent well-being and satisfaction, and to be beneficial for the NICU care team.^{[3 4]}

Electronic Medical Records (EMRs) increase providers' access to information, but the use of EMRs to improve communication with parents has been limited. Providing access to a child's electronic chart (via a patient portal or personal health record,^[5] for example) allows access to clinical data, but may not provide meaningful interpretation, or a clear sense of the patient's overall condition.^[6] Nonetheless, approaches that increase access to clinical data have been shown to increase patient and provider satisfaction.^[7]

Providers and the Family Advisory Council from the NICU at St. Barnabas Medical Center represent one example of using information technology to improve family access to clinical information via daily updates generated by the EMR which, anecdotally, were well received by parents.^[8] Inspired by the promise of this work, we developed an EMR-generated daily parent update, Your Baby's Daily Update (YBDU), and hypothesized that its implementation would increase parent engagement by improving communication and increasing parents' knowledge and understanding of their babies' health status.

Authors and Disclosures

Table 1. Source of Information.*
	Pre-Intervention (n=31)	Post-Intervention (n=27)
Nurse (%)	31 (100)	26 (96)
Doctor (%)	25 (81)	21 (78)
Rounds (%)	15 (48)	11 (41)
Internet (%)	6 (19)	6 (22)
Written Materials (%)	13 (42)	10 (37)
Bulletin Board (%)	4 (13)	3 (11)
Your Baby's Daily Update (%)	n/a	24 (89)

Jonathan P. Palma, MD
Jonathan P. Palma, MD, MS completed both his subspecialty fellowship training in newborn intensive care and a master's degree in biomedical informatics at Stanford in 2012. In addition to his clinical responsibilities as Clinical Assistant Professor of neonatology, he also holds an administrative appointment as Medical Director of Clinical Informatics and Analytics at Lucile Packard Children's Hospital. His work focuses on enhancing the efficacy, safety, and quality of care using health information technology.

Heather Keller
Heather Keller is a Lead Parent in the Department of Family-Centered Care at Packard Children's Hospital at Stanford. She is the mom of twin boys born prematurely at 26 ½ weeks, and spent 15 weeks in Packard Hospital's Neonatal Intensive Care Unit (NICU) in 2003. As a result of this experience, she joined the FCC department in 2004. In her role, she mentors current NICU families, and is involved in various quality improvement efforts alongside NICU healthcare providers and throughout the hospital. She enjoys bringing her perspective as a parent to various hospital projects.

Margie Godin, RN
Margie Godin, RN currently holds a position at Lucile Packard Children's Hospital at Stanford as a Clinical Informatics Manager. Margie began her career in clinical informatics in 2007. Initially her role was supporting the Neonatal and Perinatal units, focusing on CPOE and clinical documentation. Over time, her responsibilities have expanded and currently she is accountable for our Perinatal Services as well as supervises two Clinical Informatics Leads who support our Acute Care, Oncology, Perioperative, NICU, PICU and CVICU, plus all ancillary and ambulatory services. Margie and her team collaborate with these departments to enhance patient safety, operational efficiency, quality of care and outcome measurements.

Karen Wayman, PhD
Karen Wayman, PhD is the LPCH Endowed Director of Family Centered Care, Department of Family-Centered Care, Lucile Packard Children's Hospital.

Ronald S. Cohen, MD
Ronald S. Cohen, MD, is Clinical Professor of Pediatrics at Stanford University, and Director of the Packard Intermediate Care Nursery at Lucile Packard Children's Hospital. He is a graduate of Columbia University College of Physicians & Surgeons, trained at UCSF and Stanford, and is Medical Director of the Mothers' Milk Bank of San José, California. Before coming to LPCH, he was Chief of Neonatology and Director of the NICU at Santa Clara Valley Medical Center in San José for over 17 years.

William D. Rhine, MD
William D. Rhine, MD, is Professor of Pediatrics, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine.

Christopher A. Longhurst, MD, MS
Christopher A. Longhurst, MD, MS is the Chief Medical Information Officer, Department of Information Services, Lucile Packard Children's Hospital at Stanford, and Assistant Professor, Division of Systems Medicine, Department of Pediatrics, Stanford University School of Medicine.

Competing Interests
The authors declare that no competing interests exist.