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Electronic health records provide more complete information than paper-based records in labor and delivery units

Research Activities, June 2009, No. 346

The use of electronic health records (EHR) in obstetrical environments has lagged behind other clinical specialties that have already embraced the technology. In a study of the use of an EHR in a labor and delivery unit, Jeanne-Marie Guise, M.D., M.P.H. of Oregon Health and Science University, and colleagues found that electronic admission records contained more patient information when compared with paper records.

The researchers examined 250 paper-based and 250 EHR labor and delivery admission notes in a busy university hospital labor and delivery unit. The paper-based records were created during a 6-month period before the unit implemented an EHR system. All of the EHR admission notes studied were created after the system was in place for 1 year.

Paper-based admission notes were substantially more likely to be missing key clinical information when compared with the EHR. Data most likely to be missing included contractions (10 vs. 2 percent), membrane status (64 vs. 5 percent), bleeding (35 vs. 2 percent), and fetal movement (20 vs. 3 percent). The EHR also was more likely to contain complete information about factors used to calculate gestational age. Other data more likely to be missed in paper-based notes were fetal monitoring information, infection history, and laboratory data, such as blood type and Rh factor. When workflow was examined, both computer-related and direct patient care activities significantly increased following the EHR implementation.

Implementing an EHR system in labor and delivery units can improve patient safety and quality of care. EHRs have specific design features that may improve document completeness compared with paper-based records. For example, providers can use a single check box to indicate an entire category of patient history is negative. More research is needed to understand how certain safety features can affect aspects of labor and delivery care. The study was supported by the Agency for Healthcare Research and Quality (HS15321).

See "Examining the value of electronic health records on labor and delivery," by Karen B. Eden, Ph.D., Rosalia Messina, M.P.A., Hong Li, M.D., M.S.P.H., and others, in the September 2008 American Journal of Obstetrics & Gynecology 199, pp. 307.e1-307.e9.

Current as of June 2009
Internet Citation: Electronic health records provide more complete information than paper-based records in labor and delivery units: Research Activities, June 2009, No. 346. June 2009. Agency for Healthcare Research and Quality, Rockville, MD.