Reducing errors and risk in a prenatal network with an electronic medical record.
In 2002 the Institute of Medicine called for implementation of information technologies in health care settings to improve quality of care and reduce the incidence of medical errors. Nowhere is this need more critical than in obstetrics. In recent years numerous electronic prenatal medical records have become available. To date there has been little literature to identify what constitutes the important features in these systems, nor research into whether these systems actually improve the quality of care or the outcome of pregnancies. In this article we will elucidate some of the features that we feel are critical if we are to achieve these goals. Some of these features are: (1) availability across a computer network so that providers can access the record in a variety of settings, (2) simplicity of the user interface to ensure provider compliance with the system, (3) an intelligent system to encourage completeness of documentation in the medical record, (4) a problem-oriented obstetric chart so that no issue is overlooked and each is adequately addressed, and (5) administrative features to allow evaluation to ensure improved quality of care. These features together, we believe, will help to minimize medical errors, improve patient outcomes and reduce liability exposure.
Bernstein
Peter S
PS
Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York 10461-2373, USA. pbernste@montefiore.org
Merkatz
Irwin R
IR
D003195:Computer Communication Networks; D005260:Female; D006753:Hospital Records / Q000592:standards; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D011247:Pregnancy; D011295:Prenatal Care / Q000592:standards*; D011787:Quality of Health Care; D014584:User-Computer Interface