The use of an electronic health record (EHR) in a maternity shared-care environment

Abstract

Background The paper hand-held record (PHR) has been used as a successful and integral tool in maternity shared-care for many years. A pregnant woman carries her PHR with her and the care given is documented at each visit to either the General Practitioner (GP) or the hospital health care provider. Increasingly, patient electronic health records (EHR) are increasingly being implemented around the world. Implementing electronic records is often driven by government regulations or financial institutions predominantly in the USA, the UK and Denmark (1-3). EHRs are designed to enhance integration between patients and health care providers and contain information in a digital format that can be used by both patients and health care providers, from anywhere, at any time. In 2012, in alignment with the Australian National Personally Controlled EHR (PCEHR), the Mater Mothers’ Hospital (MH) developed and implemented a Mater Shared Electronic Health Record (MSEHR) in conjunction with GPs in a shared-care setting. Prior to the introduction of the MSEHR, maternity information was documented in a PHR. Research Design A comparative cohort, multimethod design was chosen using: 1. Quantitative extraction of evidence based, best practice variables: o To identify and compare the PHR and the MSEHR (for completeness of the specific evidence based, best practice variables, using a Pearson chi-squared analyses (or Fishers Exact tests for cell sizes less than 5). An alpha level of 0.05 was used to detect statistical significance. 2. Qualitative data collection, using face-to-face interviews and focus groups, coded manually using content analysis: o To explore and compare women’s experiences when using the PHR and the MSEHR, o To determine how the integration of care for health care providers differs between the PHR and the MSEHR. Results Completeness of best practice variables While neither the PHR nor the MSEHR completely captured all required best practice variables, use of an EHR demonstrated improved access to antenatal clinical information and provided greater adherence and completeness in collecting these variables. While the PHR recorded best practice variables, many of these were difficult to locate in a free text form and were only retrospectively found by an audit. The MSEHR has the capacity to further improve data capture by providing specific fields in which to enter the best practice variables. The variables not captured well in the MSEHR were due to absence of data entry fields. Experiences of women using the PHR and MSEHR Women unanimously talked about ‘liking’ the PHR and carried it with them, however many did not look through the whole document or in any detail, and so did not realise the full potential of the record. Most of the responses from women described the MSEHR favourably and most did complete the sign-up process to gain a log-in. Women reported a willingness to use the MSEHR but did not do so, due to lack of instruction or support. There were women who did not get their log-in to work but still considered the MSEHR to be an advantageous option over using the PHR and the ‘way of the future’. Health care providers and integration of care using a PHR and MSEHR GPs thought the PHR was a familiar document but with information that was not necessary for them. When GPs were asked about using the MSEHR, most comments were around frustration with getting access to the record. The MSEHR was reported to have too many steps to log-in or be very slow to open. GPs were keen to access discharge summaries through the MSEHR. Midwives and doctors were familiar with manually documenting maternity information on the PHR and thought it to be a good ‘journal’ or ‘diary’ of a woman’s pregnancy. Furthermore, when using the MSEHR, midwives and doctors talked about the duplication of having to enter data into one database system screen but open another system screen to view output. They also talked about data entry fields changing when modifications were made to the database, resulting in discrepancies with output. None of the hospital health providers were aware of the MSEHR from a woman’s perspective. Allied health did not use either the PHR or the MSEHR, but instead wrote their notes in a hospital chart. They did, however, consider both the PHR and MSEHR as useful tools to alert other care providers of a referral that had been made. Conclusions While outside the scope of this thesis, further work to encourage engagement of women and health care providers is needed to move the MSEHR system forward. For the MSEHR to be successful it is essential that future research ascertains the needs of women, workflow processes are revisited and modified with associated educational materials. Additionally ongoing training should be provided, computer compatibility and access issues both within hospital and with GP practices should be addressed, and stakeholder collaboration should continue.