OB APR Extensions Detailed Proposal

1. Proposed Profile: OB APR Extensions Detailed Proposal

• Proposal Editor: Anne Diamond and Tone Southerland
• Profile Editor: Tone Southerland
• Date: November 2008
• Version: N/A (Wiki keeps history)
• Domain: Patient Care Coordination (PCC)

Summary

This proposal requests the continuation/completion of work on the Antepartum Record Summary.

2. The Problem

Pieces that require attention include:

• Pregnancy history (additional pregnancy-specific elements)
• Physical exam (additional pregnancy-specific elements)
• Consent(s) Notification Element(s) – likely these will belong to the existing plans of care section in the Antepartum Summary. These are NOT the actual consent documents.
• Psycho-social elements
• Infection History Section (couldn’t find this section – I believe it was left out)

3. Key Use Case

Basic Antepartum Record Use Case from Antepartum Record Summary

This use case reflects the course of care during an uncomplicated pregnancy.

Pre-condition

The patient’s obstetrician sees the patient for her initial and subsequent prenatal visits. During the initial and/or subsequent prenatal visits information is collected and may be updated within the office Electronic Health Record (EHR), these include:

• Patient demographics
• Menstrual history
• Obstetric history
• Medical history including surgical history, psych-social history
• Genetic history and screening/Teratology counseling
• Infection history
• Family history
• Initial and subsequent physical examination
• Medications
• Problems and risk factors for preterm birth
• Allergies
• Prenatal visit information
• Prenatal Laboratory results

Documentation of patient education and counseling

Plans for care

The information collected during the patient’s prenatal visits make up the components which are included in the patient’s Antepartum Record.

Event(s)

Scenario 1

At a specified time an initial and/or subsequent patient Antepartum Record is transmitted by the patient’s prenatal care provider EHR to the intended facility for delivery. The intended facility of delivery health information system receives the transmitted initial and/or subsequent patient Antepartum Record.

Scenario 2

At a specified time the initial and/or subsequent patient Antepartum Record registry information is transmitted by the patient’s obstetrician EHR to a registry. The facility of delivery health information system queries the registry repository for the applicable patient’s Antepartum Record(s). A request is made for the patient’s Antepartum Record. The applicable system which contains the patient’s Antepartum Record then makes available the patients Antepartum Record information to the requesting facility of delivery.

Post-condition

The received patient Antepartum Record can be viewed and/or imported into the facility for delivery health information system to facilitate patient care by healthcare professional at the time of delivery for the mother and newborn.

4. Standards & Systems

• CCD ASTM/HL7 Continuity of Care Document
• CDAR2 HL7 CDA Release 2.0
• ACOG AR American College of Obstetricians and Gynecologists (ACOG) Antepartum Record
• LOINC Logical Observation Identifiers, Names and Codes
• SNOMED Systemized Nomenclature for Medicine
• DSG Document Digital Signature
• NAV Notification of Document Availability

5. Technical Approach

Existing actors

There are two actors in the APS profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is to be consumed by a Content Consumer.

Impact on existing integration profiles

Completing the work on the Antepartum Record would be a significant step towards creating a more complete Antepartum Summary IHE profile for healthcare professionals to utilize in their exchange/sharing of Antepartum records.

6. Support & Resources

A copy of an Antepartum record is available at: http://www.acog.org/acb-custom/aa128.pdf

9. Tech Committee Evaluation

Effort Evaluation (as a % of Tech Cmte Bandwidth):

• 35% for ...

Responses to Issues:

See italics in Risk and Open Issue sections

Candidate Editor:

TBA