The Electronic Delivery Log: Redesign of Report Generation

Purpose:
DUHS continues to be a leader in the implementation of the Perinatal Electronic Medical Record. The delivery log provides obstetrical caregivers with information to be utilized in a variety of ways. This poster presents strategies to abstract clinical data to support research and clinicians.

Significance:
Historically, the RN was held responsible for documenting accurate and complete maternal and newborn delivery information. Information manually entered was often illegible and not always entered in a timely fashion leaving the log incomplete in some cases thus not allowing for clinical analysis.

Strategy and Implementation:
With the evolution of the Perinatal EMR in 2003, we are able to customize an existing form within our Perinatal EMR and create an electronic delivery log to meet the needs of the Health System. Data are extracted throughout the intrapartum period and populate fields in the log. The platform is an Excel format that readily supports ad-hoc queries. This enables us to support Health System trend analysis and business practices in both high and low risk settings, the academic medical center setting and the community hospital. The electronic log supports statistical analysis of delivery data such as infection rates, c/s rates as well as departmental and administrative statistics. In turn, we are able to share statistics with our obstetrical providers including local health departments. Duplicate documentation is eliminated. Collaborative, interdisciplinary documentation is achieved.

Evaluation:
Duplicate documentation was eliminated; Decreased potential for data error; Improved process for professional and technical billing and Birth Certificate preparation; Improved staff and provider satisfaction; Supports the Balanced Scorecard; Supports Health System reporting

Implications for Practice:
Log distribution is achieved thru secure protected health information network (PHI). Distribution takes places via email or hardcopy. Ten additional clinical reports are scheduled for release and distribution in 2009 to support research, business practices, and beside care givers.