Joys of the Journey: Giving Birth to An Obstetrical Electronic Health Record

Purpose for the program: The purpose of this poster presentation is to share information surrounding the selection, implementation, and maintenance of an obstetrical electronic health record (EHR).  In October 2009, Albert Einstein Medical Center (AEMC) in Philadelphia switched from paper documentation to a clinical decision support system as the obstetrical electronic health record.  The realization and execution of this electronic health record will improve patient safety and allow AEMC to apply for Medicare and Medicaid incentive payments under new federal legislation called the American Recovery and Reinvestment Act (ARRA).  Additionally, the electronic health record that was chosen by the hospital will assist in meeting many of the compliance goals set by ACOG, AWHONN and The Joint Commission.

Proposed change: Implementation of this proposed change came about with some trial and error, and not necessarily from any formalized understanding of how decisions which were made in the planning stage would impact on the final product.  It took some time to understand that a broad, multidisciplinary approach was more helpful than working in silos as individual disciplines.  We have learned many valuable lessons on the journey to integrate a clinical documentation system with the provision of clinical care.

Implementation, outcomes and evaluation: AEMC now has the ability to track and trend clinical quality indicators and outcomes in real time to evaluate the level of safety and care provided.  The evaluation of these clinical measures has enabled us to think critically about how our team provides care, and improves practice and patient safety with a level of objectivity and accuracy that we did not previously have when using a paper and pencil closed chart review.

Implications for nursing practice: At this time, obstetrical electronic health records have yet to establish baseline parameters for specific nursing clinical indicators and outcomes.  Additional nursing research needs to be performed in this area to capture this information and provide a better understanding of how to improve those quality outcomes that are unique and evidenced based nursing practices.

Keywords: Electronic Health Record (EHR), Clinical documentation system, Clinical quality measures, Patient safety