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

Hawley, Glenda, Jackson, Claire, Hepworth, Julie and Wilkinson, Shelley A. (2014) 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, 14 1: . doi:10.1186/s12913-014-0650-x


Author Hawley, Glenda
Jackson, Claire
Hepworth, Julie
Wilkinson, Shelley A.
Title Sharing of clinical data in a maternity setting: how do paper hand-held records and electronic health records compare for completeness?
Journal name BMC Health Services Research   Check publisher's open access policy
ISSN 1472-6963
Publication date 2014-12-21
Year available 2014
Sub-type Article (original research)
DOI 10.1186/s12913-014-0650-x
Open Access Status DOI
Volume 14
Issue 1
Total pages 9
Place of publication London, United Kingdom
Publisher BioMed Central
Collection year 2015
Language eng
Formatted abstract
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.
Keyword Maternity
Shared-care
General practitioner
Paper hand-held record (PHR)
Electronic health record (EHR)
Best practice variable
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ
Additional Notes Article no. : 14:650

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2015 Collection
School of Medicine Publications
 
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Created: Tue, 24 Feb 2015, 11:13:47 EST by Mrs Glenda Hawley on behalf of Medicine - Royal Brisbane and Women's Hospital