The computerized perinatal database: are the data reliable?

Area of Science:

• Perinatal medicine
• Health informatics
• Clinical data management

Background:

• Computerized perinatal databases are essential for electronic birth certificate transmission.
• Assessing the accuracy of clinical data in these systems is vital for reliable healthcare information.
• The PC-Log system is utilized in Wisconsin for perinatal data collection.

Purpose of the Study:

• To evaluate the clinical data accuracy of the PC-Log computerized perinatal database.
• To compare data in PC-Log against paper medical records for correctness.
• To identify specific variables with high and low agreement in the database.

Main Methods:

• A random sample of 99 charts was selected from 893 births at a tertiary perinatal center.
• 32 key variables from the PC-Log database were compared to hand-abstracted data from paper medical records.
• Positive-predictive value (PPV), sensitivity, and specificity were calculated for various clinical variables.

Main Results:

• PC-Log demonstrated 100% PPV for eclampsia, prolonged rupture of membranes, pre-existing diabetes, cesarean section, and transports.
• Moderate to high agreement was observed for variables including abortion, congenital anomalies, gestational diabetes, maternal hypertension, and maternal employment.
• Poor agreement was noted for maternal ethanol use, and PC-Log lacked data on substance abuse and length of stay.

Conclusions:

• The PC-Log system exhibits good agreement for many clinical variables, supporting its use in perinatal data collection.
• Limitations exist for certain variables, necessitating careful review and potential improvements in data abstraction.
• While birth weight and Apgar scores showed strong correlation, the database requires further validation for comprehensive clinical accuracy.