Antepartum Record Proposal

1. Proposed Profile: Antepartum Record

• Proposal Editor: Tone Southerland, Greenway; Jason Colquitt, Greenway; Larry McKnight, Siemens; Anne Diamond, ACOG; Jan Meyers, HCA; Mike Jolley, UHIN; Nancy Brazelton, University of Utah.
• Profile Editor:
• Date: November 2007
• Version:
• Domain: Patient Care Coordination

Summary

There are over 4 million births in the United States each year. Obstetric patients must have a complete summary of antepartum care available for all care providers and for labor and delivery staff. Incomplete information can be a danger to the mother and child and result in injury, inadequate treatment or undesirable outcomes. One study estimates that one-third of all adverse outcomes is a result of poor communication among obstetric providers.

The aggregated information contained in a patient's antenatal record should be available across multiple care settings. The current practice is to copy the paper chart at various times during the pregnancy and transport the copies to the hospital the patient intends to use for delivery.

Expansion of the Antepartum Summary would provide the capability to electronically communicate pertinent patient history, treatment, lab and imaging information collected over the course of a (40 week) pregnancy to care providers and institutions (ambulatory, hospital, specialists, etc. via perinatal, ambulatory and inpatient EHR systems.

2. The Problem

There does not now exist in the industry a standardized integration profile to allow for the exchange of antepartum record information (specifically the data elements from ACOG Forms A, B, D and E) between healthcare professionals.

Current practice is to copy the (paper) chart at various times during the pregnancy (as at 28 weeks and at 36 weeks of completed gestation), and transport the copies of the chart to the hospital the patient intends to use for delivery. Should the patient arrive prior to the chart copy arriving, or if the chart (or information within the chart) is missing on presentation of the patient to Labor and Delivery (a frequent occurrence), often the staff or clinicians repeat laboratory or imaging studies. This results in unwarranted and duplicative tests, is wasteful of time and resources, and leads to dissatisfied patients.

• The History & Physical and Summary of OB-specific ambulatory visit data does not contain a complete record of the relevant OB-specific information contained within antepartum records and more specifically ACOG Form A.
• Currently, in order to extract antepartum record summary information from an EMR system and import it into a hospital system, it requires one or more expensive customized interfaces. It is preferable to have a standardized extract of antepartum record summary information from an EMR system for a referring physician to submit to the place of intended delivery and/or actual delivery.
• The CCR/CCD format is not conducive to transmitting clinical information unique to prenatal care such as history of past pregnancies, genetic history, etc.

The existing IHE antepartum summary profile requires minimal coding associated with the structure data that limits the ability to aggregate this data and analyze clinical trends. It is preferable by hospitals to utilize more coded data (e.g. SNOMED CT) entries.

3. Key Use Case

Obstetric patients in labor and admitted to Labor and Delivery must have a complete summary of their antepartum ambulatory care available at the time of admission to evaluate and / or ameliorate risk. This same data is required at any visit to Labor and Delivery for any other problems or special needs a patient may require.

During the 40 weeks of a typical pregnancy duration, the patient will have an initial History and Physical Examination, followed by repetitive office visits with multiple laboratory studies, imaging (usually ultrasound) studies, and serial physical examinations with recordings of vital signs, fundal height, and the fetal heart rate. As the patient is seen over a finite period in the office, aggregation of specific relevant data important to the evaluation of the obstetric patient upon presentation to Labor and Delivery is caputured on paper forms. The antepartum record contains the most critical information needed including the ongoing Medical Diagnoses, the Estimated Due Date, outcomes of any prior pregnancies, serial visit data on the appropriate growth of the uterus and assessments of fetal well being, authorizations, laboratory and imaging studies. This data must all be presented and evaluated upon entry to the Labor and Delivery Suite to ensure optimal care for the patient and the fetus.

Although the patient and her care provider may plan for a vaginal (natural) method of delivery, there is a substantive chance the delivery route may be surgical, requiring anesthesia and post-surgical care.

Current practice is to copy the patient's (paper) chart at various times during the pregnancy (as at 28 weeks and at 36 weeks of completed gestation), and transport the copies of the chart to the hospital the patient intends to use for delivery. Should the patient arrive prior to the chart copy arriving, or if the chart (or information within the chart) is missing on presentation of the patient to Labor and Delivery (a frequent occurrence), the staff or clinicians repeat laboratory or imaging studies. This results in unwarranted and duplicative tests, is wasteful of time and resources, and leads to dissatisfied patients. Further, missing or incomplete information about the patient’s clinical status may create a situation where critical information is unavailable to clinicians, which may ultimately result in an injury, inadequate aftercare or other undesirable outcome.

Significantly, a large portion of patients arrive in L&D without complete documentation. In one recent U.S. study , ~70% of patients (with paper charts) arrived in L&D without their current medical record being available. While only one hospital was involved in this study, one can see the extent of the issue, with pregnant patients possibly going to a different hospital than planned (preterm labor, rapid labor and unable to make it to the planned delivery hospital, or visiting a distant city), moving mid-care, or with a covering physician (rather than the primary obstetrician) on call.

In a Swedish study done in the 1990’s, critical data on paper records were incomplete from 45 to 87.5% of the time. Thus, availability of current medical records remains a significant problem for most hospital Labor and Delivery units; availability of key information electronically will significantly enhance patient safety.

4. Standards & Systems

• CCD ASTM/HL7 Continuity of Care Document
• CDAR2 HL7 CDA Release 2.0
• ACOG AR American college of Obstetricians and Gynecologists 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

• History and Physical (including menstrual, past pregnancy, medical history and relevant social history)
• Summary of OB-specific Ambulatory Visit Data (completed in 2007)
• Obstetric related Laboratory Reports
• Obstetric related Imaging Reports
• Obstetric related Consultation Reports
• Non Stress Test (NST) Reports
• NST Waveforms (may be covered by DICOM)
• Patient Consent Forms for Performance of Procedures
• Payer Authorization Forms

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. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described below, and is out of scope of this profile. A Document Source or a Portable Media Creator may embody the Content Creator Actor. A Document Consumer, a Document Recipient or a Portable Media Importer may embody the Content Consumer Actor. The sharing or transmission of content or updates from one actor to the other is addressed by the use of appropriate IHE profiles described in the section on Content Bindings with XDS, XDM and XDR.

6. Support & Resources

• American College of Obstetricians and Gynecologists (ACOG)
• Greenway
• HCA
• Intermountain Healthcare
• Utah Health Information Network (UHIN)