Data Flow & Clinical Outcomes in a Perinatal Continuum of Care System

Integrated electronic health records (EHRs) between care settings allow for access to patient data regardless of location, and have the potential to reduce medical errors and increase patient safety. Without such integration, test results and clinical notes completed in one setting are often not available in the other. This issue is particularly striking in obstetrics where there is a critical, sometimes urgent, need to understand a pregnant patient’s course of care when being evaluated on labor and delivery. Exchanging data between obstetrical offices and the hospital can facilitate coordinated treatment; improve clinical decision making; reduce the underuse, overuse, and inappropriate use of medications and diagnostic tests; and reduce the incidence of negative birth outcomes for mothers and newborns.

This project studied the impact of a perinatal continuum of care information system on maternal and fetal outcomes, and on provider satisfaction and productivity. The study took place at the Lehigh Valley Health network in Pennsylvania consisting of three OB/gyn groups and the network’s main hospital, Lehigh Valley Hospital-Cedar Crest.

The specific aims of the project were as follows:

• Develop grounded theory to describe the process of effective implementation and integration of ambulatory EHR systems with hospital information systems. 
• Examine the change in data completeness (complete and accessible data) at the hospital and the individual practices. 
• Examine improvements in health outcomes, staff perceptions of patient safety, and patient and medical staff satisfaction, as well as changes in the productivity of primary care and inpatient physicians. 
• Triangulate the results of the quantitative and qualitative analyses to gain a deeper understanding of how to achieve benefits from an integrated EHR. 

The project was conducted in three phases. In phase I, the OB/gyn practice groups migrated from either paper records or an existing EHR to a common commercial EHR. Discrete data elements were interfaced over to the same vendor’s hospital perinatal information system. In phase II, visit summary documents, such as triage discharge summaries, were interfaced from the perinatal information system to the ambulatory EHR. In phase III, discrete clinical data elements collected during triage visits were interfaced from the perinatal information system to specific locations in the ambulatory EHR.

The impact of the system was evaluated using both qualitative and quantitative methods. Structured interviews were conducted with 75 providers, and data on transmission, physician productivity, birth outcomes, and provider and patient satisfaction were analyzed. The project team noted many lessons learned from the implementation, including:

• Clinician needs and demands vary by department and specialty, and must be weighed against organizational values and goals. 
• Simple interfaces, such as those with billing and scheduling systems, have data that is often not clinically relevant. 
• Workflow analysis is necessary to understand how and when clinicians use data, and whether processes might require redesign for maximal effectiveness. 
• Determining which data elements are necessary in the design of encounter templates is critical, including which may be entered via free text and which must be entered via structured data entry. 

The project team found an initial decrease in physician productivity and satisfaction during implementation and data integration, which subsequently increased over time. EHR integration led to a reduction in the severity of adverse birth events, such as harm to the mother or baby during delivery. The project found that while there was an initial learning curve, increased information enabled providers to identify problems and respond with more intensive care.

Full detail of lessons learned and results are described in the final report.