Effect of clinical-decision support on documentation compliance in an electronic medical record

Abstract

Objective: To investigate the efficacy of enhancing an existing prompt system in our obstetric electronic medical record in regard to documentation of estimated fetal weights and indications for labor induction.

Methods: Preintervention rates of documentation of indications for labor induction and estimated fetal weight were established at two hospital sites that used the same obstetric electronic medical record system. A compliance adherence mechanism with an enhanced prompting system was installed at the intervention hospital. Changes in the percentage of records with completed documentation were then calculated at the intervention and control hospitals. Additionally, the effects of the intervention on the pattern of documentation of indications for labor induction and on the accuracy of estimated fetal weight were tested.

Results: In the intervention hospital, the documentation rate increased from 42% to 69.4% for indications for labor induction, and from 55.7% to 77% for estimated fetal weight (both P<.001) during the study period although the estimated fetal weight documentation rate did not reach the level seen at base in the control hospital (92.5%). In the control hospital, there were no significant changes in rates of estimated fetal weight during the study period, but there was a decrease in indications for labor induction documentation rates. The accuracy of estimated fetal weights did not change with the enhanced documentation compliance mechanism.

Conclusion: Increasing the frequency and modifying the methodology of prompts in an electronic medical record increased the documentation of both estimated fetal weight and indications for labor induction but did not lead to full compliance with documentation.

Level of evidence: I.