1125 - Cerebral Palsy Hip Surveillance at Texas Children's Hospital: Using the Electronic Medical Record (Epic) to Drive a Hospital Systems Best Practice

Case Diagnosis:
Evidence-based care promotes continuous hip surveillance in children with Cerebral Palsy (CP) as best practice. Without a national health registry, structured implementation is widely variable. We are using the electronic medical record (EMR) to systematically prompt surveillance.



Case Description:
An interdisciplinary team consisting of Complex Care, Orthopedics, Radiology, Radiology Technology, PM&R, Epic Builder and Population Health staff has created a Cerebral Palsy (CP) Hip Surveillance Process at Texas Children's Hospital (TCH). Within our EMR, Epic, we developed x-ray surveillance schedules driven by risk stratification based on the Gross Motor Function Classification System (GMFCS) levels and consensus recommendations from the Pediatric Orthopedic Society of North America. Program elements include an X-ray order set, a standardized radiology reading template, a series of Best Practice Alerts (BPAs) for initiating and sustaining surveillance schedules throughout a child's growth and a referral path to orthopedics. Training sessions based on the information needs of various stakeholders were developed for content dissemination.

Discussions: After identification of appropriate stakeholders, we met to build consensus on the use of a single AP pelvis x- ray, solely for the purpose of surveillance, to replace the previously utilized 2 view pelvis x-ray. We chose to focus interpretation on Migration Percent, set standards for adequacy of positioning, identifying skeletal maturity and created a reading template reflecting these priorities. Within Epic we built BPAs prompting surveillance initiation at age 2 and assignment of a GMFCS level for all children with a CP diagnosis in their problem list. Subsequent scheduled surveillance is driven by GMFCS level and hip stability with surveillance stoppage driven by hip stability and skeletal maturity.

Conclusions: Benefits or our process include reduced patient radiation exposure, improved adherence to consensus x-ray surveillance schedules, more consistent quality and interpretation of x-rays over time, and more appropriately timed orthopedic referral.