Antepartum Summary Extension - All ACOG Forms

1. Proposed Profile: Antepartum Summary Profile Extension

• 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

A pregnant diabetic patient is seen by her obstetrician in the office for a prenatal care. An ultrasound is performed to determine gestational age. The patient is sent for perinatology consult as a high-risk patient. Her obstetrician transmits preauthorization insurance information, labs and anticipated route of delivery to perinatologist and hospital. The patient returns to her perinatologist biweekly for blood testing and ultrasounds when necessary in addition to regular ob visits. The perinatologist reports back to the obstetrician after each visit. Complete History and Physical, imaging and additional labs are performed during patient’s regular visit with her 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.

The patient’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. Delivery information, i.e. birth weight, APGAR scores, type of delivery, etc is available for pediatrician. The patient can then incorporate H&P into her own and her newborn’s PHR.

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.

6. Support & Resources

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