Enhancing Documentation of Contraception and Pregnancy Interest in the Rheumatology Clinic: A multi-site initiative

Appropriately addressing reproductive health requires that a provider know a patient's contraceptive method and interest in pregnancy; this information is often missing from rheumatology visit documentation.

A Learning Collaborative (LC) comprised of experts and clinical rheumatologists implemented data collections methods for reproductive health information during clinic visits. Patient-level data was extracted from the electronic medical record for community sites (Sites A, B, and C) and aggregate data was collected for up to 30 patients per month from academic sites (Sites D and E).

The LC included 5 clinics. The community sites created flagged, easy-to-access data-fields; this was not feasible at academic sites. Medical assistants documented patient information at Sites A and B; providers at Sites C, D, and E. Sites A and B had rapid and significant increases in documentation of contraception and pregnancy interest. Two providers at Site C significantly improved; others had modest increases. Contraception documentation increased at Site D but not Site E. Among 1,982 women in Sites A, B, and C, 48.6% had contraception documented, more frequently among younger patients, those with SLE, and those taking a teratogen. Pregnancy intention was documented in 50.1% of women, 9.5% of whom reported potential interest.

Routinely documenting contraception and pregnancy interest is feasible in academic and community rheumatology practices. Documentation is enhanced by flagged data fields and completion by medical assistants or very engaged providers.