Reducing the Need for Non-Preventive Healthcare Utilization in the First Month of Life
Weight loss is normal for healthy newborns in the first few days, especially for those exclusively breastfed, until mothers begin to produce copious amounts of milk about two to five days after giving birth. While this dip in weight is normal, it can be stressful for parents and family members and can also have health consequences, because weight loss that is more pronounced than normal can lead to hyperbilirubinemia and dehydration.
Taken together, these problems are frequent barriers to a healthy first month of life and cause the majority of neonatal readmissions.
A new study at UC San Francisco called Healthy Start is using the electronic health record (EHR) to guide management of newborn weight loss from the very first day after birth to prevent health problems for infants.
The Healthy Start study aims to deliver decision support to health care providers caring for newborns that helps them reassure parents about normal newborn weight loss patterns, and decide whether their weight loss is more than expected.
“We hope the study will improve decision-making about whether supplemental feeding or other interventions might be warranted,” said Valerie Flaherman, MD, MPH, an associate professor of Pediatrics at UCSF and the lead author of the study.
A Better Way to Access Information
The Newborn Weight Tool (NEWT) is a web-based application that provides clinicians with hour-by-hour newborn weight loss nomograms to assist in early identification of those on a trajectory for adverse outcomes.
NEWT was developed by Ian Paul, MD, M.Sc. at Penn State Hershey Children’s Hospital; Flaherman, lead investigator of Healthy Start; and Michael Kuzniewicz, MD, MPH, a neonatologist at UCSF Benioff Children’s Hospital San Francisco.
But clinicians wishing to use the nomogram for patient management were required either to exit the electronic health record to use a browser for manual data entry, or to engage IT support at their institution for a complex EHR-specific build.
The Healthy Start study has dramatically simplified the implementation and usage of NEWT by integrating it directly into APeX (UCSF Health’s EPIC-based EHR system) and automating data collection using an external integration platform.
How the Study Works
The study enrolls all healthy newborns at UCSF in a randomized, controlled trial that assigns each newborn’s EHR record to display the NEWT nomogram automatically with pre-populated weight values, or to show newborn weights in the usual manner in the chart, with NEWT available for access by the clinician outside the EPIC environment.
The study will evaluate a range of options including guideline-concordant feeding recommendations, exclusive breastfeeding, and readmission rates.
“The project is using exciting technology called SMART on FHIR to bring information from an external website into the workflow of UCSF clinicians, by prepopulating that website with information from the patient currently being viewed in EPIC, and then displaying that website in an EPIC module so clinicians don’t have to leave the EHR to see it,” said Mark Pletcher, MD, MPH, director of the UCSF Clinical and Translational Science Institute’s Informatics and Research Innovation program. “This technology also makes it relatively easy to share and duplicate the implementation at other medical centers.”
So far, the intervention has been running smoothly as planned.
Many micro clinical decisions are made daily in a newborn nursery. “Although each decision could be small and have small consequences for each infant, there are 4 million infants born each year in the U.S. so even changes with slight consequences have potential for a large impact on population health,” said Flaherman. “Randomized trials in this area may be able to greatly improve public health, while avoiding negative consequences.”
In the future, the team also hopes to study the effect of our FHIR-enabled NEWT technology on newborns nationwide in a larger, cluster randomized trial conducted in partnership with the Better Outcomes through Research for Newborns (BORN) Network.
Building the Program
The Healthy Start program was launched as a pilot project of the UCSF Clinical and Translational Science Institute’s Learning Healthcare Systems initiative.
CTSI launched this initiative in partnership with UCSF’s Chief Health Information Officer, Chief Innovation Officer, Chief Quality Officer, Enterprise Information Analytics Program, and Institutional Review Board to award innovative EHR demonstration projects, such as Healthy Start, and evaluate their effectiveness in randomized controlled trials.
The group’s goal is to advance UCSF as a Learning Healthcare System, as envisioned by the Institute of Medicine and the NIH Collaboratory, which aims to embed clinical trials within the healthcare delivery system for continuous improvement and knowledge generation
UCSF’s CTSI is a member of the Clinical and Translational Science Awards network funded through the National Center for Advancing Translational Sciences (grant Number UL1 TR000004) at the NIH Health