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Keywords:

  • electronic health record;
  • perinatal data;
  • perinatal documentation;
  • change process;
  • perinatal quality;
  • perinatal technology

Poster Presentation

  1. Top of page
  2. Poster Presentation

Purpose for the Program

At the first Perinatal Work-Group meeting in 2002, physicians of a large, multihospital system established a perinatal electronic health record as a top priority. Soon after, the electronic health record became not only a company priority but also a national priority. The federal government established electronic health record standards and began incentivizing electronic health record development. Concurrently, quality measure groups and payers began demanding accurate, timely data that could be produced only with an electronic health record. This environment provided the opportunity for perinatal leaders of the system's 111 perinatal services around the country to begin the journey to an enterprise electronic health record.

Proposed Change

Perinatal nursing representatives began collaboration to establish documentation templates with standard data elements and reports. Expectations for documentation templates included the utilization of evidence when evidence was available; compliance with national regulatory standards and professional organization guidelines; and support for enterprise initiatives. Implementation of the documentation database at the first site highlighted the need for consistent education for end users, standard policies and procedures, and an established leadership structure to maintain the standard approach with future deployments. The second implementation demonstrated to information system and clinical leaders that a standard network and interfaces were imperative to reach the goal of an enterprise perinatal electronic health record. Contracts for volume purchases, utilization of wide area networks, and consistent network architecture and interfaces decreased financial investment while enhancing efficiency of design and implementation of the standard perinatal electronic health record.

Implementation, Outcomes, and Evaluation

Currently, 25 perinatal services have implemented the standard electronic health record. Eighty-eight perinatal services have committed to the installation of the perinatal electronic health record by December, 2012. Preimplementation assessments were completed for designated sites and postimplementation surveys will occur 90 days after implementation. Standard reports are generated by the facilities. Facilities report improved documentation and clinician satisfaction approximately 90 days after implementation. Documentation screens, technology, and resources will continue to be refined as obstetric provider documentation templates are created and additional interfaces are built.

Implications for Nursing Practice

The successful deployment of a perinatal electronic health record includes administrative support, clinical leadership, intradepartmental collaboration, and clinician engagement. Well-designed tools, such as project management and transition plans, network architecture, policies and procedures, and educational resources are also critical to success. Perinatal electronic health record standardization will promote quality care, provide data on 220,000 births annually, and provide lessons learned for other enterprise hospitals as well as other hospitals and systems on their electronic health record journey.