Antepartum Record Proposal

Antepartum Record

Scope

The initial work on Part I of the (APS) was completed in 2007 on ACOG forms C and F. This proposal requests continuation of the APS into the next logical steps (Forms A, B, D, and E). Obstetrical 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. As the patient is seen over a finite period in the office, aggregation of specific relevant data is important to the evaluation of the obstetrical patient upon presentation to Labor and Delivery. During the 40 weeks of a typical pregnancy duration, the patient will have had 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. The original New OB History & Physical, 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 must all be presented and evaluated upon entry to the Labor and Delivery Suite to ensure optimal care for the patient and the fetus. While for labor patients the planned method of delivery may be vaginal (natural), there is a substantive chance the delivery route may be surgical, requiring anesthesia and post-surgical care. 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. In addition, clinicians taking care of patients presenting to the emergency department with medical and/or obstetrical related conditions oftentimes do not have pertinent information to adequately care for patients based on current and past medical conditions.

There does not exist in the industry a standardized integration profile to allow for the exchange of structured antepartum record information (specifically ACOG forms A,B, D,E) between healthcare professionals. o 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. o Currently, in order to extract antepartum record summary information from an EMR system and import it into our hospital systems 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. o The CCR/CCD format is not conducive to transmitting clinical information unique to prenatal care such as history of past pregnancies, genetic history, etc. o The existing IHE antepartum summary profile requires minimal coding associated with the structure data which 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. Example: To use coded data in the previous pregnancy history values placed in the comments and complication column contents as contained on ACOG form A. Affiliated and employed HCA physicians and mid-level providers who desire to exchange structured patient antepartum record information with our hospitals (Specifically include ACOG Form A,B,D,E into the existing structured IHE antepartum summary).

We are especially interested in piloting this in the six hospitals in our Utah market in cooperation with our EHR/EMR vendors, local prenatal care providers, the three other major hospital systems in the urban Utah market, and the Utah Health Information Network (UHIN). HCA would eventually integrate this into 120 hospitals providing perinatal services.

Key Use Case

Practitioners who would use the information contained in the APS: Obstetrician, Perinatologist, Family Physician, Certified Nurse Midwife, Anesthesiologist, Labor and Delivery staff, Pediatrician, Hospitalist, Perioperative staff, Social Work, Covering physician, Emergency Physicians, or other medical specialists. Use case: Pregnant diabetic patient is seen by obstetrician in office for initial visit. An ultrasound is performed to determine gestational age. The patient is sent for perinatology consult as a high risk patient. Obstetrician transmits preauthorization insurance information, labs and anticipated route of delivery to perinatologist and hospital. The patient returns to perinatologist biweekly for blood testing and ultrasounds when necessary in addition to regular ob visits. Perinatologist reports back to obstetrician after each visit. Complete H&P, imaging and additional labs are performed during patient’s regular visit with he obstetrician. The patient arrives at labor and delivery at the hospital. Obstetrician completes the admission H&P, Allergies, Medications, and includes the data prepared or ordered by the perinatologist, and makes it available to L&D. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The charge nurse for L&D documents that the complete collection of documents needed is available. Pt’s obstetrician delivers by Cesarean Section after anesthesia. The Post-Partum discharge planning is notified and assures that there is a suitable environment with appropriate support for post-delivery after-care. Information is available for pediatrician. Patient can incorporate H&P into her own and her newborn’s PHR.

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

Discussion

o Including ACOG Form A, B, D, E within the already created Antepartum Summary (APS) 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 summary records.