Implementation of a Regional Standardised Model for Perinatal Electronic Medical Records

Area of Science:

• Health Informatics
• Perinatal Care
• Public Health Systems

Background:

• Electronic health records enhance newborn care quality.
• Limited evidence exists on implementing perinatal electronic medical record (EMR) models.
• Standardization of maternal and newborn health data is crucial.

Purpose of the Study:

• To describe the development and implementation of a standardized electronic recording model for maternal and newborn health information.
• To evaluate the feasibility of a perinatal EMR model across a regional health care system.
• To assess the impact of a two-stage implementation strategy on data completion rates.

Main Methods:

• Development of a standardized electronic recording model for maternal and newborn care.
• Two-stage implementation process: initial introduction and strategy refinement.
• Monitoring implementation indicators and comparing completion rates using chi-squared tests.

Main Results:

• Stage 1 saw high electronic medical record creation for newborns but low staff form completion (36.7%-55.3%).
• Stage 2 implementation resulted in a statistically significant increase in form completion rates.
• A standardized discharge report was successfully provided to all newborns by the end of Stage 2.

Conclusions:

• Digitalization and standardization of healthy newborn care data in maternity wards are feasible across hospital networks.
• The implemented Perinatal Care Record (PCR) model in the Region of Murcia demonstrates a successful regional approach.
• A phased implementation and multidisciplinary agreement are key to stabilizing EMR models.