Obstetrical EMR

The obstetrical electronic medical record is the sum of all the interactions of caregivers and pregnant patient throughout the antenatal, intra-partum, and subsequent post-partum time intervals. The complexity of the record has evolved over the past several decades just as the medical record in general has evolved. As US healthcare is transitioning to a comprehensive electronic medical record, so too the obstetrical component of healthcare is similarly changing.

History of Obstetrical Record

Obstetrical care has been acknowledged from antiquity, often known by the term midwifery. Records of early obstetrical practice were brief and succinct. As late as 1955 the sum total of a woman's prenatal obstetrical care could be completed on a few lines of 5 inch by 7 inch index card(1). The delivery record would be a single line in the hospital notes declaring the mother's age, race, parity and baby's weight and gender(2).

As the practice of obstetrics became more complex, so too the patient's obstetrical record evolved. The record began to take on additional significance as the record was viewed not only as an archive of care, but also as a legal tool to aid in medical malpractice defense. Standardize forms were offered by professional organizations to document not only care, but also Standard of Care. The American College of OB/GYN (ACOG) promoted standard paper forms that were adapted to the special requirements of obstetrical practice(3). Because of the wide influence of ACOG, these forms became the de facto standard for record keeping. These forms were modified over time to reflect changes of obstetrical practice. Presently ACOG forms, or local derivatives of the same, form the bulk of all obstetrical records in use today.

Development of the Electronic Medical Record

Use of computers in medicine can be seen as early as 1950's(4), but significant movement toward the integration of medical records and computer technology is first seen in the 1960's with the advent of Computer Stored Ambulatory Record (COSTAR) at Massachusetts General Hospital(5). This integration of computers and medical records results in the earliest forms of a medical record that not only contains the data of a paper record, but also exhibits unique characteristics that result from the electronic digital format.

The resultant data form is called the electronic medical record (EMR). By 1991 the Institute of Medicine (IOM) recognizes the importance and potential of this unique data form and strongly advocates for its use and development(6). Simultaneous technology developments supported further evolution of the EMR. The US military was involved with this process and had developed one of the earliest EMRs devoted to obstetrical care, Standard Record Obstetric Charting System STORC(7). By 2004 President G. W. Bush set a goal for national healthcare to utilize an EMR for all Americans(8). President B. Obama furthered this goal with the American Recovery and Reinvestment Act of 2009 which provided significant incentive for healthcare entities to meaningfully utilize EMRs for all patients(9).

Impetus to Certification of the Electronic Record

The incentives of ARRA were codified so that a three step process was required in order for a healthcare organization to benefit from government funds. Additionally a timetable was established so that healthcare organizations would receive incentives only if they achieve certain benchmarks by the specified deadlines The process required that, first, an EMR be certified by a government sanctioned entity declaring that the EMR met the requirements of ARRA. Second the healthcare organization using the EMR had to provide data to prove that the EMR was indeed being used in a clinically meaningful manner. And third, the healthcare organization had to apply for ARRA incentives according to the stipulated application process(10).

Special Requirements and Certification of Obstetrical Electronic Medical Record

The first, and arguably most influential certifying organization was the Certification Commission for Health Information Technology (CCHIT). CCHIT initiated the process of identifying the functional characteristics that would be found in an EMR worthy of CCHIT certification for purposes of ARRA incentive payments. CCHIT utilized a consensus building methodology to identify these important functional characteristics and first directed attention to the issue of the functional characteristics of a general ambulatory EMR(11). The consensus discussions revealed that stipulating the necessary and valuable functional characteristics of specialty charts was significantly more involved than specifying a general ambulatory EMR. As a result, CCHIT formally recognized that certain medical specialties needed a functional EMR with much different functionalities than a general ambulatory EMR. CCHIT therefore established more distant deadlines and extended the consensus building to individual medical specialties in order to establish functional EMR characteristics satisfying CCHIT certification above minimum federal standards.

Special Considerations of Obstetrical Electronic Medical Record

Women's Health was the ninth specialty recognized by CCHIT as requiring specialty based criteria for supplemental CCHIT certification(12). The voluntary Women's Health work group was assembled from internet applicants submitted March 16 through April 16, 2010. Soon thereafter the group began the process of establishing specialty based criteria for CCHIT certification and testing. Input was also solicited from professional organizations, including ACOG. The response of ACOG came by way of a influential detailed written exploration and identification of unique data forms intrinsic to OB/GYN clinical practice(13). The obstetrical component of Women's Health was opened for public comment on November 15, 2010 and closed on December 10, 2010. The final listing of necessary functional characteristics of a CCHIT certified obstetrical EMR was targeted to be released late spring of 2011 and was release May 17, 2011. The release specified 34 criteria, of which 24 are specified for CCHIT certification; 10 of the 34 criteria were noted for anticipated later requirements. The requirements acknowledge several of the unique data issues found in obstetrics including flow sheet data throughout gestation, gestational age dependent data points, two-patient data intrinsically and vitally entwined, wave-form data, imaging data, video data, data editing, and pregnancy specific medical conditions(14). Other components (e.g. Gynecology) of the Women's Health EMR may be addressed in the future.

The CCHIT Certified 2011 Women's Health (Obstetric Component) Certification Criteria can be found here:

www.cchit.org/certify/2011/cchit-certified-2011-ambulatory-ehr

A Town-hall webcast is slated for June 2, 2011 to discuss the new criteria.

Citations

1. Personal communication M. Hulst 1981
2. Personal observation, Yale New Haven Hospital, D. Meyer 1986
3. Web source 2011, www.acog.org/bookstore/Antepartum_Record_NCR_Version_P328.cfm
4. Carter, J.H.; Electronic Health Records, 2nd ed.; 2008, p 3.
5. Carter, op cit, p 7.
6. Carter, op cit, p 5.
7. Web source 2011, http://journals.lww.com/greenjournal/Fulltext/2000/12000/Ten_Goals_for_The_American_College_of.25.aspx
8. Carter, op cit, 295
9. Web source, 2011 http://www.docpatient.com/why/economic_stimulus.asp
10. Ray, A., EHR certification: What's the right course for you?, Missouri Hospital Association Webinar, Apri 25, 2011, p 7.
11. Web source, 2011, www.cchit.org/about
12. Web source, 2011, www.cchit.org/media/news/2010/11/public-comment-period-open-oncology-and-women’s-health-ehr-certifications
13. McCoy M.J.; Special Requirements of Electronic Medical Records in Obstetrics and Gynecology; Obstetrics and Gynecology vol 116, 1, July 2010 p 140.
14. Web source, 2011, www.cchit.org/certify/2011/cchit-certified-2011-ambulatory-ehr

Submitted by David Meyer