Automation of the identification of Child Abuse Cases in the EMR
King Faisal Specialist Hospital & Research Center

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Before the Child Abuse identification workflow was automated at the King Faisal Specialist Hospital and Research Center (KFSHRC), there was a total reliance on paper-based documentation. As strict confidentiality had to be observed at all times, all documents were external to the EMR and kept securely locked away. The unwanted effect of this was that frontline staff, particularly in emergency and in critical situations, did not always have access to it at the right times and in the right places. This meant in practice that potentially serious situations occurred and although tragedies were often avoided, these were not completely unavoidable. One seminal event occurred when a child was seen in the Emergency Unit for what was initially a minor ailment. Through a combination of being very busy and not having access to the all-important records for the child, he (the child) was discharged by the physician, having been prescribed the appropriate medication. However, the child was discharged back into the care of his abuser and, sadly, when he was later re-admitted he succumbed to his injuries Subsequent investigations showed that the child in question was a known victim of abuse but the procedures and policies that were in place were not able to function properly because the critical information needed by the clinicians to make informed and safe decisions was not available. As a result of this case, the Paediatric Department and the head of the Child Advocacy Committee (CAC) approached the Medical and Clinical Informatics Department (MCI) to seek a solution to make sure that such a set of circumstances could not happen in the future. The subsequent deliberations led to the identification of key problems and recommendations for overcoming them. First and foremost, it was found that relevant paper records were not always available in emergency and other situations. Even when documentation existed, it was not readily available without the going through of a number of laborious procedures. Apart from ensuring that there was better communication between teams and clinicians, the primary solution was found in the adoption and use of an electronic system that was readily and easily available at all times, one which would increase awareness of child abuse cases but which would not compromise confidentiality.

B. Strategic Approach

 2. What was the solution?
In order to show how the new process, which was formulated by a team from the Medical and Clinical Informatics Department (MCI), is significantly different from previous practices, it is relevant to show how the previous system operated in terms of its workflows and responsibilities: Workflow and responsibilities under the previous system 1. If there were suspicions of child abuse, this would be reported by health care providers to a duty social worker. 2. The child in question would be admitted for observation as an in-patient to the Paediatric Unit. 3. A full medical and other history was compiled. 4. A full physical examination of the child would take place. 5. If necessary, diagnostic tests would be requested and carried out. 6. If child abuse was confirmed, a relevant form would be completed and a full report forwarded to the Ministry of Health. 7. The child’s name was kept on a list locked in the Child Advocacy Committee (CAC) Chairman’s office, along with the relevant documents. 8. The child would then be discharged to a safe environment, preferably to the care of a family member. 9. The case would subsequently be followed up and reported on by social workers. As can be seen, the system was thorough but this thoroughness was limited by the fact that important information was not readily available if the child subsequently became at risk again, in other words if he or she again came into contact with their abuser. A variety of options were investigated and considered to resolve these weaknesses. These options were framed within a number of tools and methods which included Power Chart, First Net and Discern Rules. This led to revised workflows and responsibilities as outlined below: 1. If there were suspicions of child abuse, this would be reported by health care providers to a duty social worker. 2. The child in question would be admitted for observation as an in-patient to the Paediatric Unit. 3. A full medical and other history was compiled. 4. A full physical examination of the child would take place. 5. If necessary, diagnostic tests would be requested and carried out. 6. If child abuse was confirmed, a relevant form would be completed and a full report forwarded to the Ministry of Health. 7. A list of all reported and confirmed Child Abuse Cases is kept by the CAC Chairperson or their designee. The CAC Chairman will enter a specified problem in the patients EMR in the Problem List. 8. If the patient is admitted to the Emergency Unit, the specific documented problem will trigger a Discern Alert that will place an automated order, called “CARE PATIENT” on the patient’s electronic chart. 9. This order will trigger an icon on the Tracking Board in the Emergency Unit (First Net Application), called ‘CARE PATIENT,’ evoked by the event of the new order placed by the System. 10. When the health care provider sees the ‘CARE PATIENT’ alert, the patient is evaluated and managed in accordance with a modified hospital IPP procedure (the hospital IPP was aligned with this new workflow/procedure). 11. Awareness is further ensured and improved as each time a nurse or physician accesses the patient electronic medical record, they will see a pop-up alert to remind or inform them of the fact that the patient has a history of being previously abused 12. Relevant health care providers have been trained by in-service sessions and by information bulletins.

 3. How did the initiative solve the problem and improve people’s lives?
The uniqueness of this initiative comes from the fact that it uses modern technology to overcome a number of fundamental flaws in the previous system, flaws which had been shown to have the potential to lead to fatal consequences for defenceless and vulnerable children. Where there were, in the past, wide gaps which could be subject to human errors, there is now technology which has so far proven incapable of leading to such errors. The creative and innovative approaches that have enabled the overall success of the new system include: • The use of a codified entry system through a selected problem list that becomes a part of an automated electronic health record. • An automatic trigger which provides an unmistakable warning to any person with authorised access that the patient has been categorised as being a victim of child abuse. • Ongoing alerts ensures early and appropriate actions • The maintaining of ethical standards with regard to confidentiality of electronic medical records. • Health care providers are empowered through a system which is clear, consistent and in line with the best medical practices and policies.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The responsible authority, KFSHRC, has a standard implementation strategy and this was at the core of the implementation methodology that was adopted for this initiative. The first part of this strategy involved the following steps: • Collecting data from relevant departments and other sources • A thorough work flow analysis was conducted by the MCI team • The team also conducted a Gap Analysis, which considered all different options and possibilities As a result of these initial steps, the following three options were identified by the team as a short list: Option 1 – All of the documentary information could be entered into electronic medical records using Power Form, which would be completed by the relevant social worker. From this point, Discern Rules could be utilized and the rest of the workflow could be automated by the use of Tracking Board. Option 2 – All of the relevant information could be entered through Power Note by the Attending Physician. The rest of the flow described in Option 1 would then continue (the utilization of Discern Rules and the automation of the rest of the workflow through Tracking Board). Option 3 – This involves capturing the codified problem in the Problem List through physician documentation, and then utilizing the Discern Rules and automated events in the Tracking Board to automate the remainder of the workflow. An evaluation of the three options led to a conclusion that the first two held significantly more potential for human error for this reason, it option 3 was chosen. Following this choice, a number of further steps towards implementation were taken. These included: • The demonstration of the principles underpinning the system to stakeholder departments within the healthcare system by the MCI Team. • The designing of the future workflow in conjunction with health care partners and stakeholders. • The establishment of quality measures within the implementation and monitoring design for the system, which were aligned with a benefits realisation survey (again, this was done in collaboration with healthcare partners and stakeholders). • Refinement of the selected option following the receipt of feedback from relevant departments. • Training of all health care providers working in the affected areas, including Physicians and Nurses for the Emergency and Inpatient Units. • Existing policies and procedures were amended and updated to accommodate the new system and reflect the required workflow practices. • The new workflow was implemented within the Production Domain. • Post implementation quality measures were enacted, along with benefits realization assessments.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Employees from two key institutions were primarily responsible for the design and implementation of the initiative. These are the King Faisal Specialist Hospital and Research Centre (KFSHRC) medical staff and those from the Medical and Clinical Informatics Department (MCI), albeit that stakeholders and partners from other parts of the Hospital and from other health offices and departments were also involved. The staff involved from KFSHRC included subject matter experts/specialists, the Head of the Child Advocacy Committee, social workers as a group and physicians. Those from MCI included the Project Sponsor, the Project Executive, the Project Manager, the Benefits Coordinator, the Change Management Specialist and the IPP Coordinator.
 6. How was the strategy implemented and what resources were mobilized?
The human resource costs were met entirely by existing employees from a number of agencies. These can be divided into two areas of speciality – those who are within the healthcare for child abuse victims and those who provided the technical expertise. Because these two areas met at points of practicality, cohesion and collaboration was at the core of the success of the initiative and this was encapsulated in the person of Aqila Almattar, who was the Project Manager overseeing the initiative. With regard to clinical and medical expertise, the human resources utilised were subject matter experts that included physicians, nursing staff, social workers and the Head of the Clinical Advocacy Committee. On the technical side, Adele Sandeman was the Application Specialist whose responsibilities included designing, building and validation of the PowerChart aspects of the Project, as well as technical training, implementation and benefits realization. Another Application Specialist, Fahad Alogaili, had responsibility for FirstNet as the resource that was used for building Tracking Board. Dianne Aker took on the role of Systems Manager and with it the responsibilities associated with changes to Internal Policies and Procedures. The design, implementation and initial monitoring and evaluation of the initiative lasted for approximately one year and no external funding was requested or offered. It was felt (and subsequently justified) that there were sufficient resources, financial, human and technical, that were internally available to cover all aspects of the initiative.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
A number of successful outputs can be cited for this initiative, but far and away the most important, and therefore the overwhelming success story that emerges from it is the fact that perhaps the most vulnerable and at risk groups within society – abused children – can be saved in terms of further serious psychological and physical damage, or even in terms of their lives. The simple fact of an automatic pop-up within the normal routines of patients being dealt with at accident and emergency centres or other departments opens guaranteed avenues of safety from further harm for these victims. Following on from this, the initiative means that appropriate and ongoing care can be provided not only with regard to immediate caring needs but also through the social care system by following defined policies and procedures. The initiative and its implementation, along with the training provided to health care workers, means that there is increased awareness not only of the signs of child abuse but also of the potential seriousness of individual cases. Thus, there is an enhanced potential for earlier identification through normal and routine medical channels of abuse cases and their subsequent management. There is also the matter of efficiency –as a result of automation, pop-ups will automatically appear when medical records are electronically accessed. There is no longer a need for staff to spend time looking for notes and paper documents either as a matter of routine or even to ‘make sure’ when there are any elements of doubt. In the ways described above, health care staff are effectively empowered and part of this empowerment comes from them being able to work within a paradigm of new and optimized workflow standardized care, which improves compliance with the defined policies and procedures outlined, and which can be adjusted and ‘fine tuned’ over time as monitoring through statistical analysis and informal and formal surveying of stakeholder employees continues.

 8. What were the most successful outputs and why was the initiative effective?
Several significant points should be made with regard to this initiative which on the one hand positions it within a specific and very important area of monitoring and evaluation and on the other makes it critical that specific standards, ethical and moral, are maintained. Monitoring within ethical standards are at the core of the Child Advocacy Committee. During the course of internal meetings of this committee, standards are monitored and evaluated to ensure that compliance with policies and procedures are upheld in each individual case. Thus, while the policies and procedures exist within the design and functions of the initiative, they are regularly monitored and evaluated from a specifically ethical stance by review of cases. As well as this, the Medical and Clinical Informatics Department (MCI) produces quarterly reports which monitor the Discern Alerts to ensure that they are still operating to the standards set and that they are within their operational design framework.

 9. What were the main obstacles encountered and how were they overcome?
The most challenging problem encountered by the initiative in terms of design and implementation was how to automate the process without compromising the identity of an abused child. The sensitivity of these cases allied with the culture of Saudi Arabia meant that confidentiality was the prime concern and this fact limited many of the options available for development. The problem was overcome by the use of a non-specific codified problem that is documented on these children’s Problem List in their electronic medical records (EMR’s) (The signal in this area is ‘Negative Life Event in Childhood, Unspecified’). This documented problem in turn triggers discern rules which place a non-specific order of ‘Care Patient’ on the patients’ order profile for an Emergency Encounter in the EMR. This order in turn triggers a new event icon, called ‘Care Patient’ in the First Net application that displays on the Tracking Board. Although this icon is viewable to all staff in the Emergency Unit, it is non-specific. Staff are all trained to understand what the specific icon means and what to do when it displays. The Documented Problem also triggers a pop-up message: “CARE PATIERNT” when nurses and physicians enter the EMR for all encounters. A further obstacle, which also concerned confidentiality, was the limitation of Cerner tools because some of the available options did not have the required ability to ensure the integrity of confidentiality for child abuse cases. No security could be satisfactorily built around Power Forms or Power Notes and, if used, the information would be viewable to anybody with access to the patient’s EMR. With patient confidentiality being the primary concern throughout, the risk of stigmatising children superseded any other operational consideration and so these options were excluded from the implementation of the initiative.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Since going live on 3rd December 2011, there have been no reported cases of child abuse which have come to light through the system that now exists, where such a child did not receive the proper management and care as outlined in the internal policies, procedures and protocols. As previously mentioned, prior to the initiative, there had been such cases, with one in particular shocking society generally. In this case, a child was brought to the Emergency Unit at KFSHRC for minor injuries. For a number of reasons, there was a systemic failure in not recognising that the child was a registered victim of child abuse and he was discharged following the prescription of appropriate medication. Following his discharge, this boy again suffered at the hands of his abuser, to the extent that when he was next brought to the hospital he had such severe injuries that he died. This effectively meant that not only the most weak and vulnerable in society – child abuse victims – could not be certain of future care provision and protection when they required help, but also that members of society could not fully place their trust and their belief in a public healthcare system that was, through no fault of its own, apparently unable to guarantee the safety of children. The fact that the new system has shown that it can provide that protection and is able to ensure that child abuse will be recognised when it re-occurs, and when children require help with injuries (no matter how minor), is a means for rebuilding the important trust that citizens and society place in public healthcare systems. It also means that because the new system is efficient, less time is wasted by healthcare staff and this time can be spent in improving provision in other areas. Although there were occasions when staff had been unable to check paper records, on others they would have spent much time seeking and checking such records unnecessarily. Now, with absolute trust in the reliability of the new system, there is no need to be concerned by checking every case because the system does that for the key staff members involved. By changing the key areas of the then existing work flows that were causing the problem but keeping those that worked well, and by ensuring that confidentiality was a cornerstone of the new system, the public can be reassured and can again have faith in the public health care system. However, it would be facile to suggest that it has been possible to absolutely measure this change in public perception of a public healthcare system that is undergoing very significant wider changes in how it operates and in how it is funded. What can be said is that the monitoring of the system has shown that it does work, it does protect, and that in time significant numbers of child abuse victims will benefit from it.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The first point that can be made with respect to sustainability in economic and financial terms is that the funding for the new system has been met internally and there are no additional ongoing costs, other than support and monitoring. Apart from technical support, the monitoring of the system for child abuse is within existing frameworks and within existing committees. The second (more economic) sustainability point is that the system is efficient and has therefore made healthcare staff more efficient. This is not only within the staff of the Emergency Department at KFSHRC but also within the wider healthcare community that is concerned with child abuse, for example social workers. Child abuse is societally and culturally unacceptable in most if not all modern nations and cultures. This is nowhere more true than within the culture of Saudi Arabia, which is not only steeped within the caring traditions of Islam but is also a society which carries a strong sense of responsibility for the maintaining of major holy places that are at the core of the Muslim Religion. Thus, the new system is entirely aligned with the society and the culture of Saudi Arabia. With regard to environmental, institutional and regulatory sustainability, the environment must be better and must be healthier if it is one where child abuse is reduced and where ongoing abuse is identified and dealt with. With regard to institutions and regulations, it has been noted elsewhere that the new system has been developed within strict medical ethical guidelines, policies, procedures and regulations. This can be and will be sustained through the offices of the Child Advocacy Committee. Each healthcare system will have its own procedures and policies for ensuring that original and ongoing child abuse is identified and appropriately dealt with. In this sense, the initiative holds the key to be adapted to any existing system if that system has the same or similar systemic weaknesses that were identified at KFSHRC. This is true at national, regional and international levels and it is anticipated that the initiative will, in time, be adopted across the nation. At a regional level, the initiative has been presented at the Regional Users Group Conference and internationally at the Cerner Health Conference. The initiative was well received on both occasions and considerable interest was shown. It is believed that versions of the system have been or are in the process of being developed and implemented.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Several key lessons have been learned and one very important one is that areas of sensitivity, where the weakest and most vulnerable members of society are at risk, should particularly be the subject of regular assessment and evaluation with regard to existing risks. Although this initiative has been successful and has closed a considerable gap in care, it is a matter of sadness and deep regret that it was motivated by a tragedy rather than by rigorous risk assessment. A second lesson learned is that by looking at individual components of a workflow rather than at a system as a whole, specific areas of weakness can be identified. Once they have been identified, they can – in this modern era – often be resolved by the use of existing technology. The adoption of such technology can, furthermore, be a catalyst for further and perhaps unanticipated ancillary gains, for example in terms of productivity and efficiency. The recommendations for the future stem, in this case, from the lessons learned. These are that management and management teams as well as healthcare professionals should be encouraged to be participative in innovation and should be encouraged to proactively seek improvements in the levels and quality of healthcare that they can provide to users, particularly to those who are the most weak and the most vulnerable in society.

Contact Information

Institution Name:   King Faisal Specialist Hospital & Research Center
Institution Type:   Government Agency  
Contact Person:   OSAMA ALSWAILEM
Title:   CIO  
Telephone/ Fax:  
Institution's / Project's Website:  
E-mail:   sabdulmuniam@kfshrc.edu.sa  
Address:   KFSHRC; HITA; MBC 27-1
Postal Code:   11211
City:   Riyadh
State/Province:   Riyadh
Country:  

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