Source
Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA.
Abstract
OBJECTIVE:
The objective of the study was to evaluate the impact of an electronic health record (EHR) on documentation completeness and patient care in a labor and delivery unit.
STUDY DESIGN:
We conducted a pre- and postintervention study to compare documentation quality and workflow before and after EHR implementation. Documentation was compared using chi(2) and Fisher's exact tests. Objective observers measured workflow activities across all shifts before and after EHR implementation and activities were compared using Kruskal-Wallis tests and analysis of covariance.
RESULTS:
Paper admission records were significantly more likely to miss key clinical information such as chief complaints (contractions, membrane status, bleeding, fetal movement, 10-64% vs 2-5%; P < .0001) and prenatal laboratory results and history (Varicella, group B Streptococcus, human immunodeficiency virus, 26-66% vs 1-16%, P < .0001). Both direct patient care and computer activities increased after EHR implementation (2 vs 12 and 12 vs 17 activities/shift, respectively, P < .0001).
CONCLUSION:
The introduction of an obstetric EHR improved documentation completeness without reducing direct patient care.