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

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BMC Health Services Research

, 14:650

Quality, performance, safety and outcomes


BackgroundHistorically, 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.

MethodsWe 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.

ResultsNinety-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.

ConclusionThis 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.

KeywordsMaternity Shared-care General practitioner GP Paper hand-held record PHR Electronic health record EHR Best Practice Variable AbbreviationsPHRPaper hand-held record

EHRElectronic health record

GPGeneral practitioner

MHMaternity Health

Electronic supplementary materialThe online version of this article doi:10.1186-s12913-014-0650-x contains supplementary material, which is available to authorized users.

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Author: Glenda Hawley - Claire Jackson - Julie Hepworth - Shelley A Wilkinson


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