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Growth records are essential in the assessment of every child. Chronic diseases impact growth, so deviation from expected norms act as an early warning signal that something is wrong and medical investigation is required. Paediatricians and other health professionals have used them since the 1970s as a core tool to monitor children's development and well-being.

They plot three key body parameters of the individual child - height, weight and head circumference - against national growth trajectories with this information then used to reflect illness or highlight other medical issues such as obesity which is a major issue today.

Aneurin Bevan University Health Board provides acute, community, mental and child health services from five sites for 693,000 people in South Wales, approximately 21% of the total Welsh population. In 2012 Aneurin Bevan was the first health board in NHS Wales to procure an electronic document and records management system (EDRMS) from CCube Solutions. The new growth charts application is fully integrated with this and accessed using a portal called Clinical Work Space (CWS).

Clicking on a button within the individual patient record launches the growth chart on a desktop PC. Authorised staff can then add in updated growth measurements into a dialogue box which automatically updates the chart displayed.

A pilot was started in June 2014 with the system fully implemented and in widespread use by October 2014. Children visiting Aneurin Bevan University Health Board are not issued with paper charts anymore. Within nine months of 'go live', growth data is available for 11,000 children.

INTEGRATING GROWTH CHARTS WITH EMR
Given the wholesale move to electronic patient records three years ago, a way of effectively managing children's growth records was required for two main reasons:

• Growth charts were the last paper documents in use and had to be circulated around multiple sites - in some sense, negating the value of installing a computer-based medical records system;
• Growth charts are dynamic documents which change constantly. Printing out individual graphs, adding a dot(s), scanning and then storing the chart again in the EDRMS was not practical given the time and impact on readability. Using a spreadsheet as an alternative was also considered cumbersome.
Aneurin Bevan University Health Board worked in close partnership with CCube to implement an IT solution using its eForms module which allows staff to record data points over a long period of time.

Dr. Tom Williams, consultant paediatrician (retired) and the clinical lead on the electronic growth records project, explains: "I've been involved in NHS IT for many years - this is not just about digitising a process. IT must supplant existing activities but over this improve them, which is what we are doing with our electronic growth charts application."

To develop the system, Aneurin Bevan University Health Board and CCube Solutions licensed national growth data from the Medical Research Council to create the background charts. The individual child's development information is then 'overlaid' on top, with the actual data held in a Microsoft SQL database not embedded in the chart. Architecting the solution like this means easy integration with other clinical or research systems, enabling data to be re-used simply without wasteful IT support and integration costs.

OPERATIONAL AND CLINICAL BENEFITS
The electronic growth charts solution developed offers a range of benefits:

Simplicity. The easy to use desktop system means it is straightforward for nurses, clinicians and other health professionals to input growth data in clinic such that they are enthusiastic about doing so. Charts are available for children aged 0 to 2, 0 to 4 and 0 to 18 years old, along with charts for sufferers of Down Syndrome who have a different growth trajectory.

Additional features developed include the ability to display on the chart the "target height range" for a child (what they might reach in adult life) based on entered data of parental height, and the display of "bone age".

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