Child-at-Risk Electronic Medical Record Alert

Northern NSW Local Health District (NNSWLHD) developed a unique alert system for at-risk children and pregnant women that is integrated into the patient’s electronic medical record (eMR).


To improve information sharing among clinicians, departments and agencies regarding suspected child abuse and neglect in NNSWLHD.


  • Provides an efficient, standardised process to flag at-risk children and at-risk pregnant women across all services in the local health district.
  • Places the child at the centre of clinical decision making and improves health outcomes.
  • Alerts clinicians to the possibility of harm in assessments and the need for referrals to support services.
  • Enhances collaboration and information sharing between departments and agencies.
  • Improves the timeliness of response to concerns about at-risk children and at-risk pregnant women and reduces morbidity.
  • Empowers clinicians by showing that one clinician’s actions can help the next clinician respond to the child’s or pregnant woman’s risk.
  • Allows child protection and healthcare agencies to target high-risk families and maximise scarce resources.
  • Complies with NSW Health Policy Directives on file flagging (2012_069 and 2013_007).


In 2015, child protection was NNSWLHD’s number one corporate risk. There were instances where clinicians failed to communicate suspected child abuse and neglect of patients, to each other and relevant agencies. In addition, many child death reviews and commissions of inquiry recommended improved information sharing within and between agencies as a strategy to prevent harm to vulnerable children.

It was determined that NNSWLHD needed an information sharing system that improved health and safety outcomes for at-risk children and pregnant women. An international literature search was undertaken to identify whether other countries had implemented a successful child-at-risk alert system that could be adopted for use in NSW. Results showed that the United Kingdom had developed a system that allows staff to identify vulnerable families at the point of contact with the health service. It will be rolled out across England by 2018 and improves communication about risk factors for children1.

In addition, a study in 2014 by Pittsburgh Children’s Hospital in the United States tested whether triggers embedded in the eMR could alert clinicians to the possibility of physical abuse and found that alerts can achieve this aim with both high sensitivity and specificity2.


A child-at-risk alert was developed by the statewide eMR team and integrated into the existing eMR system. It provides clinicians with timely access to a patient’s child protection status and allows them to identify any pre-existing wellbeing concerns for the child or pregnant woman. It also allows staff to view the patient through a child-at-risk lens when providing healthcare services to people whose eMR has been flagged.

Managers and staff across all clinical streams were engaged in the development of the alert system, including paediatric, emergency department, mental health, drug and alcohol, Aboriginal health, community child and family health services in NNSWLHD. Staff were consulted by: invitation to join a reference group; seeking submissions from staff on the suitability of an alert system to their clinical practice; and providing information to team managers and executive directors of health service groups.

As a result, 40 senior managers attended four consultation sessions and a training roadshow was delivered in 14 locations. These comprised 56 sessions of 45 minutes each, which trained 1100 staff on how to apply the alert in the eMR. A helpdesk was also available for staff who needed help with using the child-at-risk alert system.

The child-at-risk alert is applied to the eMR by the clinician who has wellbeing concerns and reported the child or pregnant woman to the NSW Health Child Wellbeing Unit or the NSW Health Child Protection Helpline. The alert takes less than 60 seconds to apply and is designed to be easily understood by clinical, nursing and administration staff. Once the alert is applied to the eMR any clinician accessing that record can see the alert. When a clinician sees a child-at-risk alert, they can do three things:

  1. talk with the family about any referrals to additional services they may need
  2. share information with other agencies if appropriate
  3. consider relaxing missed appointment or fail to attend rules, if the family misses an appointment.

The eMR alert is available to all local health districts in NSW. A registration tool was developed to monitor uptake and use of the system by staff. A training presentation and quick reference guide with screenshots were also made available for staff looking to use the system in their health service.

Project status

Sustained – The project has been implemented and is sustained in standard business.

Key dates

July 2013 – July 2018

Implementation sites

The project has been implemented across all sites in NNSWLHD.


Mid North Coast Local Health District


A formal evaluation on the efficacy of the child-at-risk alert system will be undertaken in 2017-18 in partnership with a national research organisation. This will determine its impact on clinical decision making. As of August 2017, 1717 alerts have been applied in the eMR. The information sharing system has produced excellent clinical outcomes, including the following:

  • clinician-initiated case reviews of children who have several child-at-risk alerts on their eMR
  • escalation of cases to the Department of Family and Community Services (FACS), where there appears to be an ongoing risk and no apparent change to the child’s situation
  • clinicians who have acquired additional information about the family from the NSW Health Child Wellbeing Unit and referred a child they wouldn’t normally have, or re-reported a child to FACS
  • action has been taken to help at-risk infants as young as one week of age, as well as children with multiple alerts involving exposure to domestic and family violence, drug use and neglect.

Feedback provided by staff show that clinicians have changed their normal practice as a direct result of seeing an alert placed on a child. Individual case planning meetings for children where several alerts have been applied also indicate that the alert has contributed to improved outcomes for children. Reports generated directly from the eMR Cerner system show that a range of clinicians are using the alert system, from medical officers and social workers, to nurses and allied health therapists.

The system has been able to accommodate modern reforms, such as flagging children at risk of domestic violence as part of the NSW Government’s It Stops Here Domestic and Family Violence Framework. This demonstrates the system’s ability to respond to emerging service delivery requirements. The project has been presented at several statewide meetings by invitation and there is interest from other local health districts to implement it in their facilities. There are no ongoing or additional costs to health services and training is provided within routine child protection training, making it completely sustainable.

Lessons learnt

There is no doubt that the successful uptake of this tool by clinicians was due to the executive sponsorship of the project. Senior managers of NNSWLHD were informed of the project, invited to express their views and show staff they endorsed it by supporting their attendance at the training. It is highly recommended that the executive team endorse implementation across all services that will use the alert. It is also important to teach staff how to apply the alert and ensure there is governance in place for reviews, cancellations and renewals of the alerts.


  1. The Author(s) & Low D. The child protection information sharing project (CP-IS): electronic information sharing to improve the assessment of known vulnerable or at-risk children. Adoption & Fostering 2016;40(3):293-96. DOI:
  2. Berger R, Saladino R, Fromkin J et al. Development of an electronic medical record-based child physical abuse alert system. Journal of the American Medical Informatics Association, 2017;0(0):1-8. DOI: 10.1093/jamia/ocx063.

Further reading


Rosemaria Flaherty
Child Protection Manager
Grafton Community Health Centre
Phone: 02 6641 8702


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