EMRs and obstetrics

The use of Electronic Health Records (EHRs) has been quite variable from one specialty to another. Some specialties, like primary care specialties, seem more open to adopting EHRs, while others have had a different adoption experience. Even when adoption barriers – cost, implementation and workflow-disruption burdens – are minimized, variable adoption among different specialties are seen. Is this a function of the specialties themselves, or is it a function of the EHR tools currently available in the market?

An interesting case-study of EHR adoption can be seen among OB-Gyn’s. Even when an EHR is “given” to them, it is common to see EHR use for documenting gynecology visits (especially office-based, rather than hospital-based visits), whereas obstetrical visits are often written by hand on paper-based ACOG prenatal worksheets.

This pattern illustrates a fundamental weakness of how most currently-available EHRs are built. The general paradigm for chart-note capture followed by most EHRs is centered around SOAP notes, or other H&P notes – in other words, each visit is a stand-alone encounter. Of course, each such stand-alone notes need to be able to electively draw from summary items in the patient’s chart, like Past Medical History, medications lists, allergy lists, etc., and most EHR systems allow for such elective incorporation of summary data into a given note.

However, obstetrical documentation is a different workflow. The central document, the Antepartum Record, is not a one-encounter-at-a-time document; it is a cumulative document that persists across an episode of care (the 9 months of pregnancy). Each encounter appends items to the document, but everything that has gone before is carried forward for each encounter. At the end of gestation, then, the accumulated record is sent (usually faxed) to Labor and Delivery. A standardized form (the ACOG Antepartum Record) is therefore what works best – it does not help for every EHR system to create their own.

Building documentation tools (an EHR) that can create both stand-alone visit encounters (like office gynecology visits) as well as “episode-of-care” cumulative records (obstetrical visits) is a challenge. For us, it requires a non-trivial re-work of the back-end data structures. But it is necessary in order to build a tool that serves this kind of workflow well. Most EHRs have not effectively grasped this issue, and have approached obstetrical visits like other one-note-at-a-time visits. The result? It slows obstetricians down, and therefore it is not utilized (or resisted if utilization is forced). Obstetrical workflows can’t be addressed simply by adding “OB templates” to SOAP notes.

Recognizing this fundamental workflow issue is important, and is something much more easily addressed with a web-based EHR product that with something which is locally installed – changes and customization of the user experience is more readily achievable with web-based technology.

Episode-of-care cumulative recordkeeping is, in fact, a platform that can serve for other specialties whose workflows are similar – such as oncology, for example (where treatment protocols are episode-of-care based, and each encounter with various members of the treatment team needs to be appended to a cumulative document). As a result of building such an approach, several specialties who have to-date been slow to embrace EHR technology may well find their leading-edge tools something indispensable to daily work life. That is our hope, as we build this for obstetricians.

Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc.