Sharing of clinical data in a maternity setting: How do paper hand-held records and electronic health records compare for completeness?

BMC Health Services Research

Shelley A Wilkinson¹  Julie Hepworth²  Claire Jackson³  Glenda Hawley³ 

[1] Department of Nutrition and Dietetics, Mater Health Services, South Brisbane 4101, Australia;School of Public Health & Social Work, Queensland University of Technology, Victoria Park Road, Kelvin Grove 4059, QLD, Australia;APHCRI Centre of Research Excellence in Primary Health Care Microsystems, School of Medicine, Discipline of General Practice, University of Queensland, Level 8 Health Sciences Building, Building 16/910, Herston, Brisbane 4029, QLD, Australia

关键词: Best Practice Variable;    Electronic health record (EHR);    Paper hand-held record (PHR);    General practitioner (GP);    Shared-care;    Maternity;   

Others  :  1089898
DOI  :  10.1186/s12913-014-0650-x

 received in 2014-09-08, accepted in 2014-12-11,  发布年份 2014

【 摘 要 】

Background

Historically, the paper hand-held record (PHR) has been used for sharing information between hospital clinicians, general practitioners and pregnant women in a maternity shared-care environment. Recently in alignment with a National e-health agenda, an electronic health record (EHR) was introduced at an Australian tertiary maternity service to replace the PHR for collection and transfer of data. The aim of this study was to examine and compare the completeness of clinical data collected in a PHR and an EHR.

Methods

We undertook a comparative cohort design study to determine differences in completeness between data collected from maternity records in two phases. Phase 1 data were collected from the PHR and Phase 2 data from the EHR. Records were compared for completeness of best practice variables collected The primary outcome was the presence of best practice variables and the secondary outcomes were the differences in individual variables between the records.

Results

Ninety-four percent of paper medical charts were available in Phase 1 and 100% of records from an obstetric database in Phase 2. No PHR or EHR had a complete dataset of best practice variables. The variables with significant improvement in completeness of data documented in the EHR, compared with the PHR, were urine culture, glucose tolerance test, nuchal screening, morphology scans, folic acid advice, tobacco smoking, illicit drug assessment and domestic violence assessment (p = 0.001). Additionally the documentation of immunisations (pertussis, hepatitis B, varicella, fluvax) were markedly improved in the EHR (p = 0.001). The variables of blood pressure, proteinuria, blood group, antibody, rubella and syphilis status, showed no significant differences in completeness of recording.

Conclusion

This is the first paper to report on the comparison of clinical data collected on a PHR and EHR in a maternity shared-care setting. The use of an EHR demonstrated significant improvements to the collection of best practice variables. Additionally, the data in an EHR were more available to relevant clinical staff with the appropriate log-in and more easily retrieved than from the PHR. This study contributes to an under-researched area of determining data quality collected in patient records.

【 授权许可】

   
2014 Hawley et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

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