Implementing an electronic health record (EHR) in an obstetrical practice involves several unique considerations prior to making the conversion from a paper record to an electronic one.
When an ob/gyn practice is ready to go live using an EHR, you must decide how to document prenatal “revisit” patients. Do you just document new pregnancies in the EHR, or do you document all visits using the EHR on the first day of conversion? There are pluses and minuses to each approach.
The pluses of just starting new pregnancies in the EHR are:
1. The go-live or conversion is easier;
2. There is less of a slowdown in provider productivity.
The minuses of just starting new pregnancies in the EHR are:
1. Some patients are on paper and some are in the EHR so there is a dual system;
2. There may not be the necessary EHR trainer support present to assist with the documentation of revisits;
3. Some providers may continue to use paper because it is available.
However, there is also a middle ground: Your practice could elect to convert all existing prenatal patients under 20 weeks, for example, to the EHR and continue to document those prenatal patients past 20 weeks on paper. Alternatively, you might convert all existing prenatal patients that registered after a certain date (e.g. January 1st) to the EHR.
If the practice elects to pick a date and convert all patients to the EHR, it should be aware before making their decision, that there will be four weeks of hard work until every Ob revisit patient is entered into the EHR. After that four week period, providers should be efficient at quickly and correctly documenting OB revisits.
There are two very important caveats to any EHR implementation: One, there is no substitute for adequate training prior to go-live and two, converting all paper charts (abstracting the OB revisit patients) to the EHR requires adequate onsite support.
If the practice decides that going forward all notes for all patients will be entered into the EHR, the following suggestions may prove helpful:
1. Decide in advance on a time frame to retire the paper charts. Should this be after one prenatal visit or two?
2. After that, a written entry with today’s date can be made saying “see computer.” The paper chart can then be scanned into the EHR and archived.
3. Decide what items are to be documented by the nurse/MA such as: vital signs, LMP, urine dip, etc.
4. Decide what items should be entered by the provider.
5. In converting from a paper chart to an EHR for an established patient, the provider should verify that all information is accurate. The first note in the computer can summarize anything important from the paper chart.
6. In an EHR, lists such as allergies and problems should not be left blank/empty. An empty allergy list might mean “no allergies” or it might mean that no allergies were entered. This can be a potential patient safety issue so “no known allergies” should be positively noted rather than just having a blank list. In an EHR, the problem list should never be empty. More so than paper, it is unclear whether the list is empty because there are absolutely no issues or because someone failed to enter the problems. Entering “Normal multip, anticipate NSVD” lets the provider know the EHR information has been synthesized and summarized.
7. For obstetrical practices that participate in UDS reporting, the date of the first visit, the trimester first seen, and whether the first visit was here or elsewhere should be entered.
8. All information on the paper form does not need to be entered into the computer. Both the scanned chart and the EHR can be sent to Labor and Delivery. This is analogous to the current practice of sending a baseline chart to Labor and Delivery and then sending updates as the pregnancy advances.
With proper planning and provider/staff training, the implementation of an EHR into an Obstetrical practice can be a smooth and exciting transition.
B mode and 3D Ultrasound images of a fetal abdomen (35wks) revealing gallbladder calculi
This case study shows a 26 week gestation with a cystic mass close to the sacrum.
CC is a 31 year old primigravida who was referred for ultrasound at a community hospital due to suspected cardiac anomalies noted on a screening sonogram at her doctor's office. Due to concern about a probable cardiac abnormality an amniocentesis was performed at the local hospital.
Single umbilical artery color doppler, transverse scan of urinary bladder shows single umbilical artery (left), transverse section of umbilical cord showing only two vessels: one vein and one artery (right).
Normal 35 week pregnancy