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Information systems and audit in antenatal care
Insights
Computerizing obstetric records enhances patient care by reducing errors and tailoring management. True audit of care quality requires process evaluation, not just data collection.
Area of Science:
- Obstetrics
- Health Informatics
- Medical Auditing
Background:
- Antenatal booking records are crucial for risk assessment and tailoring pregnancy management.
- Current record-keeping methods, whether paper-based or shared-care, face challenges with information quality and human error.
- Effective patient management relies on accurate and comprehensive obstetric records.
Purpose of the Study:
- To propose on-line computerization of obstetric patient records as a superior system for managing pregnancy care.
- To highlight the benefits of user-friendly software with clinical decision support and error-reduction features.
- To differentiate between data collection and true audit in assessing the quality of obstetric care.
Main Methods:
- Development and implementation of a user-friendly, on-line computerized patient record system.
- Incorporation of branching programs for clinical action suggestions and 'error traps' for data accuracy.
- Discussion of operational effects and comparison with traditional audit methods.
Main Results:
- Computerized systems can be operated by staff with minimal training and are well-accepted by patients and healthcare providers.
- The proposed system enhances accuracy and provides clinical guidance, especially for high-risk pregnancies.
- Distinction made between descriptive statistics and process-based audit for quality assessment.
Conclusions:
- On-line computerization of obstetric records is presented as the optimal system for accurate, efficient, and tailored patient management.
- True audit of obstetric care quality necessitates evaluating the process of care, not merely collecting statistics.
- Further research may be needed to audit existing standards of care in obstetrics.
Abstract:
The obstetric record as initiated at the antenatal booking clinic essentially identifies the degree of risk engendered in that pregnancy so that consequent obstetric and paediatric management is tailored appropriately. Whether carried by the patient or based in the hospital with a summary carried by the patient (shared-care card), this record should be exhaustive, the emphasis being on quality, not quantity, of information recorded. To obviate human error in history-taking, patient management or record transcription, we believe on-line computerization of patient records with spin-off paperwork to be the only patient management system to fulfil the above criteria. User-friendly software can be designed with highly branching programmes which provide clinical action suggestions in high-risk cases. Various 'error traps' enhance the accuracy of information recorded. Such systems can be operated by medical and midwifery staff with minimal keyboard skills and are well accepted by patients and staff. Inexpensive and versatile microcomputer networks are excellent for such systems. The operational effects are discussed. Audit means different things to different people and one's view on the subject depends on which definition is selected. Obstetricians are quick to take credit for instituting audit in the form of local and national data collection exercises, such as statistics on perinatal mortality, birthweight, etc. While these exercises certainly constitute observational studies, they cannot be used to make conclusions about the quality of care. There is no sound inference that can be made from a review of information contained in amalgamated databases of hospital statistics. Audit, as properly defined, hinges on inference: the inference that the quality of care was or was not of a high standard. Descriptive statistics, therefore, can be used to generate hypotheses but should not be used as a form of audit, at least not in obstetrics. Auditing the quality of care involves a study of process. It therefore depends on the assumption that we know which practices maximize beneficial outcomes. This exercise is therefore only relevant when we have good evidence linking the process of care with these outcomes. In some cases the accepted standard against which the process of care can be compared is very obvious. In other cases, however, the accepted standard should itself be audited to ensure that it is based on sound evidence.