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Child Health Improvement through Computer Automation (CHICA) System

Known as the CHICA System, the Child Health Improvement through Computer Automation is both a computerized decision-support system and an electronic medical record (EMR) for pediatric preventative care and disease management. CHICA integrates into the high volume workflow of IU School of Medicine’s pediatric practices by implementing age-appropriate screening of patients in the waiting room via a tablet and then combining this information with electronic medical record data to generate patient-specific recommendations and reminders for the physician.

How CHICA Works

When a patient is registered in the clinic, CHICA accesses the patient’s medical record and selects 20 questions to ask the patient. These questions are displayed on an electronic tablet that is given to the patient or proxy to complete in the waiting room. This innovative decision-support system can interface with any electronic health record to capture patient-reported concerns, risks and outcomes, and pass these as alerts and reminders to physicians.  Since 2004 the system has served over 47,000 patients and has been the subject of multiple National Institutes of Health, Agency for Healthcare Research and Quality, Centers for Disease Control, and foundation grants, resulting in over 30 peer-reviewed publications.

Randomized controlled trials have shown that CHICA improves screening for tuberculosis, anemia, depression, tobacco exposure, asthma and developmental disorders. CHICA also covers a wide range of other issues, including domestic violence, food insecurity, housing insecurity, substance use, sexual behaviors, sleep problems, obesity management, diabetes, hypertension management, television watching, literacy, dental care, vision screening and vaccinations. Decision support for these topics is covered by more than 400 rules that screen the patient, alert the clinician, produce printed materials for patients and track appropriate protocols of care over time. This system facilitates implementation of clinical guidelines and is now being planned for expansion into adult medicine clinics at Eskenazi Health.

CHICA Initiatives and Current Projects

At patient registration, CHICA receives demographics, vital signs and medical history data via HL7v2 messages from the practice’s electronic medical record. The clinician can interact with the CHICA web based interface through a link within the electronic medical record. CHICA automatically creates a plain text note that can be inserted into the medical record when the clinician submits the CHICA electronic physician worksheet.

CHICA collects a rich set of clinical data from both patients and providers. Because it implements evidence based guidelines from the American Academy of Pediatrics and United States Preventative Services Task Force, it collects data for quality measures that go way beyond the Healthcare Effectiveness Data Information Set (HEDIS). CHICA is actively working with hospital systems and payors to use the rich data collected by CHICA to streamline the meaningful use and quality measure reporting for hospital systems that use CHICA.

As commoditized hardware infrastructure becomes more mature, cost effective and secure, developers are exploring the technical challenges of moving the CHICA software from a server hosted internally within a hospital system to servers hosted on commercial commoditized hardware. A functional prototype of CHICA is running on Amazon Web Service and developers are exploring the necessary measures to ensure protected health information is secure and HIPAA regulations are met.

CHICA has been used exclusively in general pediatrics clinics but developers are working to retool the system for use in subspecialty clinics also. With funding from a National Institutes of Health grant, developers have created a program for pediatric gastroenterology that will serve as a model for future development of CHICA subspecialty platforms.

Funded by the Agency for Healthcare Research and Quality, the objective of this project is to revise the existing CHICA ADHD Module to improve the identification and management of pediatric anxiety. ADHD and anxiety can mimic each other or co-exist. Pediatricians may benefit from the automation of this process to ensure children with disruptive behaviors are evaluated for the possibility of ADHD, anxiety or both. Physicians, clinic personnel and families are engaged in the design and troubleshooting of this workflow to ensure it meets the needs of physicians and families alike.

The CHICA Medical Legal Partnership study seeks to address upstream non-medical determinants of health to mitigate downstream health disparities by: (1) screening children for unmet social and legal needs that may adversely impact their families’ health; (2) alerting physicians to those needs; and (3) generating informational handouts and social work/legal referrals as needed. Funded by the Agency for Healthcare Research and Quality, the study examines the impact of the medical legal partnership module on the identification and mitigation of unmet health-harming legal needs, evaluates physician and patient/caregiver satisfaction with the module and evaluates the impact of the module on patient healthcare utilization.

The Bright Futures guidelines from the American Academy of Pediatrics includes extensive guidance on the primary care screening and preventive care of teenagers.  However, primary care physicians are often uncomfortable or unfamiliar with these recommendations.  CHICA Adolescent is a module built on Bright Futures and is being studied in a randomized controlled trial involving primary care pediatricians and adolescence specialists.

Constipation is a common reason for referral to pediatric gastroenterology subspecialists. With funding from the National Institutes of Health, the CHICA Constipation module is designed to help primary care pediatricians with the management of challenging cases of constipation to see if it will reduce the need for expensive subspecialty services.

With the recent dramatic increase in childhood obesity, the incidence of type II diabetes (formerly known as adult onset diabetes) has also risen dramatically.  Although the American Diabetic Association has published guidelines on how to screen for this condition, most general pediatricians are not following the recommendations. The CHICA Type 2 Diabetes module identifies overweight and obese children and screens for risk factors that would indicate the need for diabetes screening.  CHICA aids the pediatrician in following these screening recommendations. Researchers are studying whether screening is improved with the introduction of this CHICA module.

The HPV vaccine is recommended for all young men and women in their early teens, and although it is safe and effective, vaccination rates are lower than they should be. Research suggests that a parent’s decision to vaccinate or not is strongly driven by the advice provided by their physicians. Researchers are studying whether prompts from CHICA, suggesting specific wording, can increase vaccine uptake. A related study is examining whether an educational video shown on a tablet triggered by CHICA can increase HPV vaccine rates.

One of the most common challenges young parents face is nighttime awakening of a baby who is hard to get back to sleep. Pediatricians commonly counsel on this topic. In the CHICA Night Waking module, researchers are studying how physicians typically counsel families and optimal ways to screen automatically for this problem.

Obstructive sleep apnea is a common, potentially dangerous, and under recognized problem in pediatrics that usually presents with snoring. Although the American Academy of Pediatrics has published evidence based screening guidelines, most pediatricians are not familiar with them. Pilot work with the obstructive sleep apnea module found that about 9% of children snore, and about 40% of snoring children are at risk for sleep apnea. However, only a fraction of these children are referred for evaluation, and the likelihood of evaluation depends heavily on which physician the child sees. The Obstructive sleep apnea module is intended to automate the screening process and help physicians with referral of children who need to undergo sleep studies.

In collaboration with Indiana University Health and funded by the Riley Children’s Foundation, developers are formulating a child health data core that will tap into the IU Health Enterprise Data Warehouse to create opportunities to use “big data” to improve care and follow-up of vulnerable newborns.