Latest revision as of 07:15, 27 August 2010

Introduction

This is a draft of the Antepartum Record Profile (APR) supplement to the PCC Technical Framework. This draft is a work in progress, not the official supplement or profile.

Profile Abstract

The Antepartum Record Profile (APR) is based on data elements from prenatal records currently in common use, and includes the following documents:

Antepartum History & Physical – The initial assessment and physical
Antepartum Summary – Summary of the most critical information
Antepartum Laboratory – Laboratory Evaluations
Antepartum Education – Education Record

Additional commonly used forms not included in this profile are:

A patient generated obstetric medical history
A postpartum form

A sample form showing the data elements may be found at: http://www.acog.org/acb-custom/aa128.pdf

This profile defines the implementation of HL7 CDA documents to represent these data elements along with the XDS, XDR and XDM bindings. This profile also defines mechanisms to group them into a single logical folder.

Glossary

The following elements are found in the Antepartum History & Physical document of the Antepartum Record:

Abortion, Induced (AB, Induced): Number of induced abortions by patient. An induced abortion is a deliberate termination of pregnancy.
Abortion Spontaneous (AB, Spontaneous): Number of spontaneous abortions by patient. A spontaneous abortion is a natural loss of the products of conception.
Ectopic pregnancy: Number of ectopic pregnancies by patient. An ectopic pregnancy is the development of a fertilized ovum outside the uterus, as in a Fallopian tube.
Estimated Date of Delivery(EDD)/Estimated Date of Confinement(EDC): Date of anticipated delivery (confinement).
Final/Corrected Estimated Date of Delivery (EDD): Corrected EDD/EDC based upon parameters such as ultrasound, first auscultation of fetal heart tones, etc.
Full term: Number of babies the mother has delivered that were between 37 and 42 completed weeks of gestation.
Living Children: Number of living children of patient
Multiple births: Number of deliveries of more than one baby by patient
Premature: Delivery between 20 and 36 6/7 weeks gestation
Stillbirth: An infant delivered without signs of life after reaching mid-second trimester to full term gestational age. In the US this is usually after 20 or greater weeks gestation. In the UK this has been reported as an infant delivered without signs of life until after 24 weeks gestation.
Total Pregnancies: Number of total pregnancies

Antepartum History & Physical - Menstrual History

Birth Control Pills (BCP): Oral contraceptives.
Frequency: Duration of the monthly menstrual cycle; from first day of menses to the first day of next menses.
hCG+: Human Chorionic Gonadotropin pregnancy test.
LMP (last menstrual period): Date measured as the first day of the patient's most recent menstrual period.

Approximate (month known) - Patient is unsure of exact date but can offer an approximate date.
Definite - Patient can say with certainty the date of her last menstrual period.
Final - Finally agreed upon date of last menstrual period.
Unknown - Patient does not know the date of her last menstrual period.

Menarche: Age at onset of initial menstrual period.
Menses Monthly: Menses is the monthly flow of blood and cellular debris from the uterus that begins at puberty and ceases at menopause.
Normal Amount/duration: Last menstrual was typical in amount and duration.
Prior Menses: Date of most recent menstrual period.

Antepartum History & Physical - Past Pregnancies

Anesthesia: The loss of the ability to feel pain caused by administration of a drug or other intervention.
Artificial Reproductive Technology (ART) Treatment: Fertility procedures in which both eggs and sperm are handled in the laboratory (in vitro) to establish a pregnancy.
Autoimmune disorder: An autoimmune disorder is a condition in which the body attacks its own tissues. (ACOG)
Birth weight: Weight of infant at birth.
Delivery Date: Date of delivery of patient's previous pregnancies.
DES: Diethylstilbesterol
D (Rh) sensitized: Rh negative mother is sensitized to the Rh D antigen. A sensitized mother produces IgG anti-D (antibody) that crosses the placenta and coats D-positive fetal red cells which are then destroyed in the fetal spleen.
Gestational Age weeks: The number of weeks elapsed between the first day of the last normal menstrual period and the date of delivery.
Infertility: Infertility primarily refers to the biological inability of a man or a woman to contribute to conception. Infertility may also refer to the state of a woman who is unable to carry a pregnancy to full term.
Kidney disease: Kidney disease is either a declining or a sudden loss in renal function.
Length of labor: The interval between onset of contractions and childbirth.
Place of Delivery: Hospital name, city and state if known.
Preterm labor: Labor that begins before 37 weeks gestation.
Pulmonary (TB, Asthma): Diseases or disorders of the lungs, i.e. asthma, tuberculosis or other pulmonary problems.
Sex Male/Female: Sex of patient's previously delivered babies.
Type Delivery: Type of delivery in pregnancy: Vaginal (spontaneous, forceps, vacuum), Cesarean section (low-transverse, classical, low-vertical).
Urinary Tract Infection (UTI): A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract.
Uterine Anomaly: – Any uterine structural abnormalities.
Varicosities/Phlebitis: Swelling or inflammation of veins.

Antepartum History & Physical - Other elements:

Abdomen: Area of the body that lies between the chest and the pelvis and encloses the stomach, intestines, liver, spleen and pancreas
Adnexa: Appendages of the uterus which include the fallopian tubes, the ovaries and the supporting ligaments of the uterus.
BMI - Body Mass Index.: Measurement of the relative percentages of fat and muscle mass in the human body.
BP - Blood Pressure: Pressure exerted by the blood against the walls of the arteries, maintained by the contraction of the left ventricle, the resistance of the arterioles and capillaries, the elasticity of the arterial walls, and by the viscosity and volume of the blood.
Breasts: In humans, one of the paired regions in the anterior portion of the thorax. The breasts consists of mammary glands, the skin, the muscles, the adipose tissue and connective tissues.
Cervix: The lower, narrow end of the uterus, which protrudes into the vagina. (ACOG)
Diagonal Conjugate: The distance from the promontory of the sacrum to the lower margin of the pubic symphysis
Extremities: A bodily limb or appendage.
Fundus: The fundus of the uterus is the top portion of the uterus, opposite from the cervix. Fundal height, measured from the top of the pubic bone, is routinely measured in pregnancy to determine growth rates.
Gynecoid pelvic type: The normal female pelvis.
Heart: The hollow, muscular organ that maintains the circulation of the blood.
HEENT: Head, Eyes, Ears, Nose and Throat
Height: Measurement of stature
Lungs: Either of the pair of organs occupying the cavity of the thorax that effect the aeration of the blood.
Lymph nodes: Any of the accumulations of lymphoid tissue organized as definite lymphoid organs varying from 1 to 25 mm in diameter situated along the course of lymphatic vessels and consisting of an outer cortical and inner medullary part.
Rectum: The distal segment of the large intestine, between the sigmoid colon and the anal canal.
Sacrum: Triangular bone below the lumbar vertebrae.
Skin: Outer protective covering of the body
Spines: (Ischial Spines) Two parts of the maternal pelvis resulting from the bony processes projecting backward and medially from the posterior border of the ischium.
Subpubic arch: Arch formed by the conjoined rami of the ischia and pubic bones of the two sides of the body.
Teeth: one of the hard, calcified structures set in the alveloar processes of the jaws for the biting and mastication of food.
Thyroid: The thyroid gland. One of the largest endocrine glands in the body. This gland is found in the neck below the thyroid cartilage and at approximately the same level as the cricoid cartilage. The thyroid controls how quickly the body burns energy, makes proteins, and how sensitive the body should be to other hormones.
Uterus size: In pregnancy the uterine size is estimated in terms of weeks of gestation. e.g 12 weeks if the fundus reaches the top of the smphysis pubis or 20 weeks' gestation when the fundus reaches the umbilicus.
Vagina: The genital canal in the female, leading from the opening of the vulva to the cervix of the uterus.
Vulva: The external genital organs of the female, including the labia majora, labia minora, clitoris, and vestibule of the vagina.
Patient Weight: A measurement of mass.

The following terms are found in the Antepartum Laboratory document of the Antepartum Record:

1st Trimester Aneuploidy risk assessment (Free or Total): Non-invasive screening for chromosomal abnormalities, such as Down syndrome, performed in the first trimester. Screening tests that uses a combination of fetal measurements (crown rump length and nuchal translucency) and maternal blood tests for beta-human chorionic gonadotropin (hCG) and pregnancy associated plasma protein (PAPP-A) to determine risk for trisomy 21, trisomy 13 and trisomy 18.
2nd Trimester serum screening: Non-invasive screening test for chromosomal abnormalities, such as Down yndrome, trisomy 18, or open neural defects. Blood test to measure alpha-fetoprotein (AFP), estriol, human chorionic gonadotropin (hCG) [free or total], and inhibin-A.
Amniocentesis (Amnio): Percutaneous transabdominal puncture of the uterus during pregnancy to obtain amniotic fluid.
Amniotic Fluid (AFP) Test: A test to detect the presence of Alpha-fetoprotein in amniotic fluid.
Antibody screen: A blood test to detect antibodies against red blood cell antigens.
Anti-D Immune Globulin (RHIG): Anti-D antibodies given to prevent sensitization to the RhD antigen on red blood cells.
Blood type: Test to determine blood group, i.e. A, B, AB or O
Chlamydia Test: Test done to detect the bacterium, Chlamydia trachomatis.
Cystic Fibrosis Screening Test: Test to detect gene mutations that cause cystic fibrosis.
Chorionic Villi Sampling (CVS): A method of sampling the cells of the placental chorionic villi, done either transabdominally or transcervically.
D (Rh) Antibody screen: A blood screening test for presence of IgG antibodies to the Rh D antigen on red blood cells.
D (Rh) type: A blood test to detect the presence of the Rh D red blood surface antigen.
Diabetes screen: Laboratory test to screen for gestational diabetes.
Familial Dysautonomia: Autosomal disorder of the peripheral and autonomic nervous systems limited to individuals of Ashkenazic Jewish descent; clinical manifestations are present at birth and include diminished lacrimation, defective thermoregulation, orthostatic hypotension, fixed pupils, excessive sweating, loss of pain and temperature sensation, and absent reflexes; pathologic features include reduced numbers of small diameter peripheral nerve fibers and autonomic ganglion neurons.
Genetic Screening Test: Screening for genetic disorders, e.g. sickle cell, Thalassemia, Tay-Sachs, Canavan, cystic fibrosis, fragile X syndrome, or Duchenne’s muscular dystrophy.
Gonorrhea Test: Test to detect Neisseria gonorrhea
Group B Streptococcus Rectovaginal Culture (Group B Strep): A test to determine the presence of group B streptococcus (streptococcus agalactiae) in the lower genital tract in pregnant women.
GTT (if screen abnormal): Glucose Tolerance Test. Used to determine how quickly the body metabolizes blood sugar. Test to diagnose gestational diabetes mellitus.
HBsAg Test: Test for the detection of the surface antigen of the Hepatitis-B virus.
HCT/HGB/MCV

HCT- Hematocrit – A blood test measuring the percentage of red blood cells found in a given volume of whole blood.
HGB- Hemoglobin – A blood test measuring the level of the protein carrying oxygen in red blood cells.
MCV - Mean corpuscular volume - The average volume of red blood cells calculated from the hematocrit red blood cell count

Hemoglobin Electrophoresis: A blood test done to measure the different types of hemoglobin. The test can detect abnormal levels of hemoglobin such as that found in sickle cell anemia.
HIV Test: A test to detect for the presence of antibodies to the human immunodeficiency virus.
HIV Counseling: Discussion with pregnant patient regarding Human Immunodeficiency Virus/ HIV status, risks and prevention strategies.
Karotype: Test done on cells/tissue to identify and evaluate the number, shape, and size of chromosomes.
MSAFP - Maternal Serum Alpha-Fetoprotein: A screening blood serum test on the mother for to determine the level of alpha-fetoprotein.
Multiple marker screening test: A maternal blood serum screening test for the detection of Down syndrome, trisomy 18, and neural tube defects in the fetus. The following analytes are measured: alpha-fetoprotein, human chorionic gonadotriopin, estriol, and inhibin-A. When the first three analytes are used, this is also called a maternal serum triple screen or a maternal serum quad screen when all four analytes are used.
Pap test: Cervical cytology test to determine abnormal cells of the cervix.
PPD Skin Test: - Mantoux test with purified protein derivative to screen for exposure to tuberculosis.
Rubella Test: A blood test to detect the presence of antibodies against the rubella virus (German measles).
Tay-Sachs Screening Test: A blood test done to measure the amount of beta-hexosaminidase A or B activity in serum or white blood cells, or for the most common DNA mutations causing Tay Sachs disease.
Ultrasound: A radiologic study using sound waves used in the assessment of gestational age, size, growth, anatomy, and blood flow of a fetus or in the assessment of maternal anatomy and blood flow.
Urine Culture: A Test that it used to detect the presence of bacteria or other organism in the urine.
Urine Screen: A physical, chemical, and / or microscopic examination of the urine. It may be used to screen for / or to detect abnormal kidney function, kidney stones, urinary tract infections, or substance abuse.
Varicella: A blood test to detect the presence of anti-varicella antibodies.
VDRL (Venereal Disease Research Laboratories): A blood test to screen for the presence of antibodies against Treponema pallidum, the bacteria that causes syphilis.

The following terms are found in the Antepartum Education document of the Antepartum Record:

First Trimester

Alcohol: Discussion with patient about past and present use of alcohol and the perinatal implications of continued use during pregnancy; referral to treatment program if appropriate.
Anticipated Course of prenatal care: Discussion with the patient on the scope of care that will be performed in the office, lab work that may be performed, signs and symptoms that should be reported, anticipated schedule of visits, physician coverage of labor and delivery.
Childbirth classes/hospital facilities: Discussion with the patient on educational programs available for childbirth and hospital choice.
Domestic violence: Screening/Discussion with patient regarding physical threats/abuse/safety concerns; referral to appropriate counseling, legal and/or social advocacy program if appropriate.
Environmental/Work hazards: Discussion with patient about potential exposures to environmental agents at work, home, or locations that may affect pregnancy.
Exercise: Discussion with patient on appropriate level of exercise activities during the pregnancy.
Illicit/Recreational drugs: Discussion with patient about past and present use of illicit or recreational drugs and the perinatal implications of continued use during pregnancy; referral to treatment program if appropriate.
Indications for ultrasounds: Discussion with patient regarding reasons ultrasound test will be performed during pregnancy.
Influenza vaccine: Discussion with patient of risks/benefits of influenza and influenza vaccine during pregnancy.
Nutrition and weight gain counseling, special diet: Information about balanced nutrition, ideal caloric intake and weight gain.
Risk factors identified by prenatal history
Seatbelt use: Discussion with patient on use of seatbelts.
Sexual activity: Discussion with the patient of sexual activity: concerns, restrictions, warning signs and/or safe sex practices.
Smoking counseling: Discussion with patient regarding smoking cessation and smoke exposure.
Tobacco (Ask,advise,assess,assist,and arrange): status; Advise patient to stop smoking; Assess patient's willingness to attempt to quit smoking; Assist patients who are interested in quitting by providing pregnancy specific cessation materials; Arrange follow up visits to track progress.
Toxoplasmosis precautions: Discussion with patient of risk factors for toxoplasmosis and precautions for avoiding/preventing infection.
Travel: Discussion with patient on travel precautions, if any.
Use of any medications (including supplements, vitamins, herbs or OTC drugs): Discussion with patient of risks/benefits/safety of any medications currently used by patient.

Second Trimester

Abnormal lab values: Discussion with patient of lab results that fall outside normal range and that may require further testing.
Domestic violence: Screening/Discussion with patient regarding physical threats/abuse/safety concerns; referral to appropriate counseling, legal and/or social advocacy program if appropriate.
Influenza vaccine: Discussion with patient of risks/benefits of influenza and influenza vaccine.
Postpartum family planning/tubal sterilization: Discussion with patient of intended postpartum contraception options, including tubal sterilization.
Selecting a newborn care provider: Discussion with patient to identify newborn care provider; referral to resources to help patient choose provider if none previously identified.
Signs and symptoms of preterm labor: Discussion with patient on risks, signs and symptoms of preterm labor.
Smoking counseling: Discussion with patient regarding smoking cessation and smoke exposure.

Third Trimester

Anesthesia/Analgesia plans: Discussion with patient to determine intended method of pain management/discomfort during labor and delivery.
Breast or bottle feeding: Discussion with patient of nutritional advantages/disadvantages of human breast milk, bottled formula; advise on available lactation consultation services.
Circumcision: Discussion with patient on circumcision of male newborn.
Domestic violence: Screening/Discussion with patient regarding physical threats/abuse/safety concerns; referral to appropriate counseling, legal and/or social advocacy program if appropriate.
Family medical leave or disability forms: Discussion with patient about any forms the patient will need completed for employment or insurance purposes.
Fetal Movement monitoring: Discussion with patient regarding her perception and assessment of fetal movement.
Influenza vaccine: Discussion with patient of risks/benefits of influenza and influenza vaccine.
Labor signs: Discussion with patient on signs of labor, i.e. contractions, membrane rupture, bleeding, etc.
Newborn education (Newborn screening, jaundice, SIDS, car seat): Prenatal discussion with patient of preventive public health screening procedures available to newborns; testing that will occur on baby after birth to screen for up to 30 disorders. Additional items may include infants risk for developing jaundice. Discussion of positioning of infant to reduce SIDS risk. Education regarding car seat safety.
Postpartum depression: Discussion with patient of signs of postpartum depression.
Postterm counseling: Discussion with patient of risks of pregnancy extending beyond 42 weeks.
Signs & Symptoms of Pregnancy-induced hypertension: Discussion with patient of signs and symptoms of hypertension.
Smoking counseling: Discussion with patient regarding smoking cessation and smoke exposure.
VBAC (Vaginal Birth After Cesarean) counseling: Discussion with patient of risks/benefits of vaginal birth after previous cesarean surgery.

History and physical have been sent to hospital: Notation of date and initials of person transmitting history and physical to hospital prior to delivery.
Tubal sterilization consent signed: Notation of date the consent form for tubal sterilization signed and the initials of person witnessing.

Open Issues

How does the XDS Folder structure need to be handled?
Several LOINC and SNOMED codes are in the process of being created. These codes are denoted by a preceeding "xx-" or "XX-" with an abbreviated description of the code following.

Closed Issues

For Antepartum Laboratory there is a LOINC code for Laboratory Studies (26436-6) - is this too general? Should a new code be requested specific to Antepartum labs? The concern is that this could cause mapping issues in an EMR that has other lab results that are considered to be specific to antepartum that would live under that same loinc section code. the IHE formatCode supplied in the XDS Metadata will identify this as an Antepartum Laboratory document so a LOINC code is not needed.

Volume I

Add the following bullet to the list of profiles

Antepartum Record - A folder of content profiles that contains the record of antepartum care including initial patient history and physical, recurring evaluations of mother and fetus(es), laboratory studies, patient education, and on-going plans of care.

Dependencies

Add the following row(s) to the list of dependencies

Integration Profile	Dependency	Dependency Type	Purpose
Antepartum Record	Sharing of Laboratory Reports (XD-LAB)	child	share laboratory results

Antepartum Record (APR)

The Antepartum Record Profile (APR) is based on the data elements from prenatal records currently in common use.

Obstetric patients in labor and admitted to the hospital or birthing facility optimally would 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 the birthing facility or hospital for any other problems or special care needs of the patient. The antepartum record optimally would be available in its entirety for appropriate continuity of care and legal concerns.

The aggregated record provides important information for all health care professionals who are part of the patient's obstetric care team. Patients may incorporate the data from this aggregated record into their personal health record. Administration staff may use data for billing and payment purposes.

A typical pregnancy duration is approximately 40 weeks. Patient care during that time includes an initial history and physical examination, followed by repetitive office visits with multiple laboratory studies, imaging/ ultrasound studies, and serial physical examinations. As the patient is seen over a finite period for care, aggregation of data relevant to the evaluation of the obstetric patient upon presentation to the birthing facility or hospital is commonly collected on paper forms. This antepartum record contains the most critical information needed to provide care for the patient during pregnancy, delivery and the post-partum period. This data must all be presented and evaluated upon entry to the birthing facility or hospital to ensure optimal continuity of care for the patient and the fetus.

Although the patient and her care provider may plan for a vaginal 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 at the birthing facility or hospital prior to the chart copy arriving, or if the chart (or information within the chart) is missing on presentation of the patient (a frequent occurrence), the care team must 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 which may ultimately result in an injury, inadequate aftercare, or other undesirable outcomes.

A large portion of patients arrive at the birthing facility or hospital without complete documentation. In one recent U.S. study, approximately 70 % of patients (with paper charts) arrived at the birthing facility 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 birthing facilities; availability of key information electronically will significantly enhance patient safety.

Use Cases

Use Case 1: Basic Antepartum Record Use Case

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.

Use Case 2: Antepartum Consultative Care

This use case reflects an example of perinatologist consultative prenatal care.

Pre-condition
The patient’s prenatal care provider sees the patient for her pregnancy in the ambulatory (office) setting. During the pregnancy, the patient is noted to have a medical problem requiring consultation with a maternal-fetal medicine specialist (perinatologist). The office obtains pre-authorization from the insurance payer for the consult and for the intended or anticipated route of delivery. Preauthorization information is transmitted to both the consultant and to the hospital.

Events
The patient is seen in the prenatal care provider’s office where a complete health history (e.g. medical and surgical history, psycho-social history) is obtained and recorded in the office EHR and sent to the consultive care provider office EHR. Data from the perinatologist’s consultation report is incorporated as appropriate. Laboratory and imaging reports ordered by the perinatologist consultant as well as the perinatologist’s consultation report are displayed electronically to the prenatal care provider. The prenatal care provider reviews the consultation report from the perinatologist’s office and imaging studies ordered by the perinatologist along with current recorded data. Physical exam reveals some abnormalities. The prenatal care provider orders additional laboratory studies, and sends the patient to the hospital or birthing facility.

When the laboratory results return, the prenatal care provider completes the admission history and physical, allergies, medications, includes the data prepared or ordered by the perinatologist, and makes it available to the hospital or birthing facility. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The care team assures the complete collection of documents needed is available and that there is a suitable environment with appropriate support for post-delivery after-care.

Post-condition
The pre-delivery history and physical and Antepartum Summary with appropriate relationships to the perinatologist consultation, and all the antepartum laboratory and imaging studies are available to the obstetrician and the hospital or birthing center personnel for incorporation into their respective EHRs. The history and physical is also available to the patient for viewing and incorporation into the patient’s PHR, and into the newborn baby’s PHR.

Use Case 3: Antepartum Collaborative Care

This use case reflects two-way transmission of data in an example of collaborative care.

Pre-condition
A pregnant diabetic patient is seen by her prenatal care provider in the office for prenatal care. An ultrasound is performed to determine gestational age. The patient is sent to a consultant (e.g. perinatologist) as a high-risk patient. Her prenatal care provider transmits preauthorization insurance information, labs and anticipated route of delivery to the consultant and/or hospital birthing facility.

Events
The patient returns to her consultant biweekly for blood testing and ultrasounds (when necessary) in addition to regular ob visits. The consultant 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 prenatal care provider.

The patient arrives at birthing facility. Prenatal care provider completes the admission history and physical, allergies, medications, and includes the data prepared or ordered by the consultant, and makes it available to the hospital birthing facility. This data includes an assessment of the patient’s health status, and the requisite data summarized from the antepartum care given. The care team documents that the complete collection of documents required is available.

Post-condition
The patient’s prenatal care provider 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's postpartum record is sent to the consultant for incorporation into the patient's record. The patient can incorporate the history and physical into her own personal health record and the newborn’s records into the newborn's personal health record.

Actors/Transaction

There are two actors in this 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 by section 3.7 Content Bindings with XDS, XDM and XDR found in the Patient Care Coordination Technical Framework

Antepartum Record Actor Diagram

Options

Antepartum Record Options
Actor	Option	Section
Content Consumer	View Option (See Note 1) Document Import Option (See Note 1) Section Import Option (See Note 1) Discrete Data Import Option (See Note 1)	PCC TF-1: 2.13.1 PCC TF-1: 2.13.2 PCC TF-1: 2.13.3 PCC TF-1: 2.13.4
Content Creator	Referral Option (See Note 1) Discharge Summary Option (See Note 1)	PCC TF-1: 2.13.5 PCC TF-1: 2.13.6

Note ¹: The Actor shall support at least one of these options.

Grouping

Content Bindings with XDS, XDM and XDR

It is expected that the transfers of care will occur in an environment where the physician offices and hospitals have a coordinated infrastructure that serves the information sharing needs of this community of care. Several mechanisms are supported by IHE profiles:

A registry/repository-based infrastructure is defined by the IHE Cross Enterprise Document Sharing (XDS) and other IHE Integration Profiles such as patient identification (PIX & PDQ), and notification of availability of documents (NAV).
A media-based infrastructure is defined by the IHE Cross Enterprise Document Media Interchange (XDM) profile.
A reliable messaging-based infrastructure is defined by the IHE Cross Enterprise Document Reliable Interchange (XDR) profile.
All of these infrastructures support Security and privacy through the use of the Consistent Time (CT) and Audit Trail and Node Authentication (ATNA) profiles.

For more details on these profiles, see the IHE IT Infrastructure Technical Framework.

Content profiles may impose additional requirements on the transactions used when grouped with actors from other IHE Profiles.

Cross Enterprise Document Sharing, Media Interchange and Reliable Messages

Actors from the ITI XDS, XDM and XDR profiles embody the Content Creator and Content Consumer sharing function of this profile. A Content Creator or Content Consumer must be grouped with appropriate actors from the XDS, XDM or XDR profiles, and the metadata sent in the document sharing or interchange messages has specific relationships to the content of the clinical document described in the content profile.

Notification of Document Availability (NAV)

A Document Source should provide the capability to issue a Send Notification Transaction per the ITI Notification of Document Availability (NAV) Integration Profile in order to notify one or more Document Consumer(s) of the availability of one or more documents for retrieval. One of the Acknowledgement Request options may be used to request from a Document Consumer that an acknowledgement should be returned when it has received and processed the notification. A Document Consumer should provide the capability to receive a Receive Notification Transaction per the NAV Integration Profile in order to be notified by Document Sources of the availability of one or more documents for retrieval. The Send Acknowledgement option may be used to issue a Send Acknowledgement to a Document Source that the notification was received and processed.

Document Digital Signature (DSG)

When a Content Creator Actor needs to digitally sign a document in a submission set, it may support the Digital Signature (DSG) Content Profile as a Document Source. When a Content Consumer Actor needs to verify a Digital Signature, it may retrieve the digital signature document and may perform the verification against the signed document content.

Content Modules

Content modules describe the content of a payload found in an IHE transaction. Content profiles are transaction neutral. They do not have dependencies upon the transaction that they appear in. The Antepartum Record Profile currently consists of four document content modules, with potentially more added in future work. One or more of these document content modules are required for the implementation of APR. For example, a system may choose to implement the Antepartum Summary the first year, and implement the additional content modules of Antepartum History & Physical, Antepartum Laboratory and Antepartum Education is following years.

Antepartum History and Physical

Antepartum Summary

Antepartum Laboratory

Antepartum Education

Process Flow

Antepartum Record Process Flow

This process flow diagram shows the movement of the antepartum record over the course of care for a pregnancy involving an ambulatory facility (obstetric provider), consultant and hospital (birthing facility). This diagram specifically excludes other infrastructure interactions for simplicity and readability. These infrastructure interactions may be found elsewhere in the framework.

Data from the patient's prenatal care aggregates into her electronic antepartum record by the obstetric provider. The antepartum record is then sent to a consultant who updates the antepartum record, and returns it to the obstetric provider. The electronic antepartum record is then sent to the birthing facility at the appropriate time(s). The consultant may also send the antepartum record directly to the hospital.

Difference between revisions of "Antepartum Record"