Sharing of clinical data in a maternity setting: How do paper hand-held records and electronic health records compare for completeness?

BackgroundHistorically- the paper hand-held record (PHR) has been used for sharing information between hospital clinicians- general practitioners and pregnant women in a maternity shared-care environment. Recently in alignment with a National e-health agenda- an electronic health record (EHR) was introduced at an Australian tertiary maternity service to replace the PHR for collection and transfer of data. The aim of this study was to examine and compare the completeness of clinical data collected in a PHR and an EHR.MethodsWe undertook a comparative cohort design study to determine differences in completeness between data collected from maternity records in two phases. Phase 1 data were collected from the PHR and Phase 2 data from the EHR. Records were examined and compared for completeness of best practice variables collected- informed by local and national maternity guidelines. The primary outcome was the presence of best practice variables identified from the guidelines and the secondary outcomes were the differences in individual variables between the records.ResultsNinety-four percent of paper medical charts were available by audit in Phase 1 and 100% of records from an obstetric database in Phase 2. No PHR or EHR had a complete dataset of best practice variables. The variables with significant improvement in completeness of data documented in the EHR- compared with the PHR- were urine culture- glucose tolerance test (GTT)- nuchal screening- morphology scans- folic acid advice- tobacco smoking- illicit drug assessment and domestic violence assessment (p