对于普通的电子病历，小儿科医生会觉得不方便，他们还需要：immunization management, growth tracking, medication dosing, data norms, and privacy in special pediatric populations.
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There are some functional areas that are so critical to the care of infants, children, and adolescents that their absence results in the system impeding quality pediatric care.

Immunization Management
Recording Immunization Data
The ability to record multiple immunizations efficiently is critical for pediatric health maintenance activities. State and federal regulations add a complexity to the process of recording immunization administration that is absent for medications. Systems designed to record adult immunizations and other medications naturally allow the practitioner to record data such as the manufacturer, lot number, date, site, route of administration, and expiration date. The nature of immunization practices in children adds some requirements to this list, in particular, data required by the Vaccines for Children (VFC) program5 and the National Childhood Vaccine Injury Act (NCVIA) of 1986 (42 USC §§300aa-1–300aa-34).6,7 The VFC program, a federal program by which eligible children are provided vaccine at no charge, requires providers to maintain a separate stock of vaccine, to assess eligibility for the program, and to submit reports to the program. All of these activities require support from the information system used to track immunization data. The NCVIA has numerous implications for immunization data recording. Among these is the requirement to deliver to the parent (or equivalent health decision-maker) a vaccine information statement (VIS) and to record when it was given and which version of the VIS was given. The NCVIA also mandates that health care providers report adverse events associated with vaccines; although this applies equally to adult providers, automation of this reporting capability would be of particular interest to child health care providers, who give the bulk of vaccines. The Centers for Disease Control and Prevention's National Immunization Program (www.cdc.gov/nip) specifies these information-management requirements in detail. EHR systems also need to manage the record of consent for vaccine administration. Vaccine refusal8 by a parent or patient requires the recording of refusal reasons and recording of which refused vaccines were offered.

Linking to Immunization Information Systems
Most states and several local jurisdictions have electronic immunization-information systems or registries.9–11 The EHR should allow interoperability with these systems, including the ability to download, upload, and synchronize a child's immunization history. Some technical standards already exist for immunization information system functions and communications with them.12,13

Immunization Decision Support
Systems for encoding rules about which immunizations are due and when they are projected to be due in the future have been in existence for years.14 For an EHR system to fully support pediatric practice, it must be able to take previous immunization data and derive, at the point of care, logical conclusions about the currency of immunization and recommend the appropriate immunizations. This functionality requires an understanding of the individual antigens present in each vaccine and analysis of when, in what form, and at what age in the child's life each antigen was—or was supposed to be—administered. There may also be local variations in this functionality based on local epidemiology. These functions might be built into the system or be derived from immunization registries or third-party programs accessed via a network. If the logic is built into the EHR system itself, there should be a way to easily update the logic to reflect changes to immunization rules and to handle new vaccines and new antigen combinations.

Growth Tracking
Graphical Representation
Child health care providers make important judgments about a child's health by visual inspection of a plot of a child's body measurements (usually weight, height, head circumference, BMI) over time. Plots show the progression of measured values over time against curves of predicted growth or percentile curves. Ideally, the visual plot should be visible at the top level of an individual record or require minimal effort for viewing. The EHR system should allow the representation of percentile curves from a usual source (Centers for Disease Control and Prevention [www.cdc.gov/growthcharts]) or other sources that may provide these curves for special populations.15 The system should allow magnification ("zooming") of the plot to allow inspection of areas of the plot in which measurements have been frequently made. Users ought to be able to derive growth-velocity data from 2 selected data points. The system should distinguish height from length. Also, the system should accommodate corrections for preterm birth in the graphical display of body measurements.

Percentile Calculations
In addition to representation of body measurements, the percentile value of any particular body measurement against a defined distribution is desirable. Such percentile values should be calculated and displayed at the time of data entry. Percentile values should also be available for decision-support functions of the EHR system.

Medication Dosing
Dosing by Body Weight
The predominant method for calculating pediatric drug dosages is to compute them on the basis of body weight. When a current body weight is available, the EHR system should be able to incorporate it into the prescribing process and suggest doses on the basis of accepted references. Failing this, the EHR system should make weight visible in all displays associated with drug dosing. When a current body weight is not available, the system should react to this appropriately by requesting its input. For medications that require adjustment of dose as the child's weight increases, the intended dosage per unit of body weight should be recordable and maintained as an aspect of the prescription. Systems should be able to determine if a body weight obtained in the past is too old to be used in decision support (eg, last month's weight would be appropriate for an adolescent but not a neonate). Entries of height, weight, and head circumference should be checked against age-based norms so that users can be warned of possible errors. As in adult care, medication dosing by body surface area or ideal weight should also be available; however, the equations for the estimation of body surface area and ideal body weight in children are different from those in adult care.

Dose-Range Checking
With or without dosing decision support, an EHR system should be able to check drug doses posthoc by using accepted pediatric references and advise the user when no pediatric references exist.

Rounding to Safe and Convenient Doses
Many medications for infants and young children are supplied in liquid form. Because parents and other caregivers must measure a volume of liquid for each dose of medication, child health care providers must compute a volume for each dose, round it to a convenient volume, and spend time educating caregivers on the proper volume to administer. EHR systems that facilitate prescribing should support prescriptions expressed in the volume of drug to be administered and avoid expressing the prescription solely in terms of the mass of the drug.

Age-Based Dosing Decision Support
For the case in which dosing guidelines or formulary benefits vary with age or gestational age,16 the system should incorporate those data into its decision support.

Dosing for the School Day
Pediatricians must often write prescriptions in which the medication is divided in 2 labeled packages—one for home administration and one for administration during the day at school, child care, or another care setting. EHR systems should provide the capability to generate instructions to the pharmacy to dispense a medication in this way.

Patient Identification
Newborn Identification
Although many EHR systems depend on the use of a government-issued identification number (usually the Social Security number), newborn infants do not receive these numbers for a significant period of time after birth. EHR systems should allow the registration of patients without such identifiers and allow retrieval of information on the basis of any temporary identifiers that may be used.

Prenatal Identifiers
An EHR system that allows storage of prenatal data (eg, from a fetal imaging procedure) should allow the logical connection of these data to the postnatal record once the child's record is established in the system.

Name Changes
Infants undergo name changes because of changes in family structure or the need to change the temporary name assigned at the birth hospital. Because clinical data are connected to the old names, EHR systems need to support retrieval of data via search on previous names.

Ambiguous Sex
In the case of a child with ambiguous genitalia, an EHR system ought to allow the assignment of sex as unknown and to operate normally until the sex of the patient is assigned.

Norms for Pediatric Data
Numeric Data
Norms for almost all numeric data (such as laboratory results, body measurements, scores on standardized assessments, and vital signs) change as the child grows. For many of these data, norms change continuously with age, so it is insufficient to provide merely a handful of normative ranges. Developers should assume that all numeric data collected in a pediatric context have changing norms over the lifespan and should provide ways of flagging abnormal values at any age. Percentile values and z scores (number of SDs from the mean) should be available for those few data for which the distributions are known, such as height, weight, head circumference, and BMI.

Nonnumeric Data
Whenever an EHR system distinguishes normal from abnormal in nonnumeric data (eg, flagging the presence of a physical sign as abnormal), it should consider age in the interpretation of normality. For example, if "unable to feed self" is considered to be a universally abnormal finding in the interpretation of a functional assessment, then the system is not taking the functional capabilities of young children into account.

Complex Normative Relationships
Not all normative data are based solely on age. In the case of blood pressure, normative values are determined by age (to the nearest month), gender, and height percentile.17 Similarly, peak flow meter norms depend on age, height, and gender.18 Methods for flagging abnormal values that are based on age alone are insufficient for blood pressure and peak expiratory flow and may be insufficient for other measurements in pediatric patients.

Gestational Age
For neonates, chronologic age (expressed simply as the time since birth) is insufficient for medication-prescribing decision support, normative ranges for laboratory data, normative definitions for physical examination findings, and guideline-application support. Gestational age, chronologic age, and corrected age are each unique and important ways to present age of a neonate16; EHR systems need to record each of these expressions for age and allow for their use in decision support.

Privacy
Adolescent Privacy
Laws about age of consent vary from state to state19 and according to presenting problem.20–22 Adolescents who present for treatment of mental health disorders, for example, may consent to their treatment at an earlier age than the age of majority in most states.19,23 Some states also have laws regarding parental notification whereby interpretation is based on the patient's age and presenting problem.24 Practices that serve adolescents typically have policies with respect to what portion of an adolescent's care should be handled with special privacy protections (eg, in some jurisdictions, the adolescent must give explicit permission for the parent to review his or her records). These privacy protections may require the flagging of protected information. Therefore, EHR systems should support privacy policies that vary by age and according to presenting problem and diagnosis and be flexible enough to handle the policies of individual practices. Furthermore, if an EHR system handles record-keeping for consent for treatment, it should provide for the recording of assent for treatment (from an underaged adolescent or child) combined with parental informed permission25,26 as well as consent for treatment (from an adolescent) combined with a record of parental involvement.25 The separation of the patient's consent and the parent's or guardian's consent is particularly important in the area of testing for drugs of abuse.27 Pregnancy is another area in which the records of patient and parental consent, assent, and permission may be less straightforward than in adult care.28

Children in Foster or Custodial Care
When a child is removed from the care of his or her parents, as in the case of foster care, complex issues of confidentiality of medical information arise.29 Licensed foster parents may consent to routine medical and dental treatment for minors placed with them pursuant to a court order or with the voluntary consent of the person having the legal custody of the minor. The pediatrician should document the authority of a foster parent to give consent to medical treatment by obtaining a copy of the court order. Parents who no longer have custody may still have the right to access their children's medical records and be involved with health care decisions unless their parental rights have been terminated. EHR systems that purport to manage consent for treatment and information access will need to be able to record these details.

Consent by Proxy
Children often present for nonurgent health care in the company of an adult who is not the custodial parent or guardian. The best way to prevent confusion about consent for care in this situation is to record the custodial parents' wishes as to which adult can consent to which child's care and under what limitations.30 EHR systems that manage consent for treatment should support this sort of data-recording.

Adoption
Records of children who are undergoing adoption proceedings or who have been adopted may need special privacy handling, as in a case where state law offers special protections for the identity of adoptees. The EHR systems should allow flagging of these data for special privacy protection. In some states, the preadoption record may need to be separated entirely from any postadoption record by using 2 distinct patient identities.

Guardianship
The identity of a child's guardian and guarantor, although most commonly the parent, can become complicated outside the bounds of the "typical" 2-parent household. The EHR system must provide the flexibility to indicate the broad variety of adults in the child's life who may play some role in medical or financial decision-making. The system should draw a distinction between the patient's guardian and his or her financial guarantor. In those cases in which a court has appointed a guardian for a minor, the ability of the guardian to consent to medical treatment depends on the type of treatment being sought and the scope of authority the court has granted. If more than routine care is required, the pediatrician should document the authority of the guardian to give consent by obtaining a copy of the official certified letters of guardianship. The EHR system should support this record-keeping.

Emergency Treatment
When EHR systems support the recording of consent and assent for treatment, they should be flexible enough to allow for the emergency treatment of minors, in which the parent or legal guardian may be absent, and the usual procedures for consent must change.20