Patient safety is not a new concept in the world of medicine. Dating back to the origins of the Hippocratic oath of ‘do no harm’, it constitutes a core pillar of healthcare provision – wrapped around patient wellbeing and optimal outcomes, it is a promise we make to every patient for delivering our best at every stage of their ailment. It cannot be dismissed that during day-to-day medical practice, several errors can be a threat to patient safety. Fortunately, many of them are preventable – proven to impact health outcomes and burden healthcare resources. The topic of patient safety has grown massively over time, and many opportunities for safety nets have been identified in several settings. The aim is to make safe practice universal across all networks and for such an outcome, the standardization of practice can be pivotal.
Every patient and health condition demands a unique approach to providing safety in healthcare. With a lot of research and experience over decades, many standard practice guidelines have been established to guide care providers on best practices.
One such journey is pregnancy – the antenatal period is a vulnerable one for the mum and the baby, where the mother’s physiology changes dramatically. Each step in this journey has its challenges and benchmarks.
The story dates back to human existence, with generally accepted milestones and developments for a normal pregnancy. However, this equation can become complex with various maternal, child, or co-factors requiring a specialized approach. Health leaders have invested much in improving antenatal programs to attain the sustainable development goal of reducing maternal and newborn mortality.
Improving maternal outcomes across UAE
Emirates Health Services (EHS) has a vast network of health centers and facilities spread over six emirates in the UAE. We facilitate an average of 10,000 births annually. To support this cohort of patients, EHS has evidence-based policies and best practice protocols that guide our care providers to follow a process of optimal, comprehensive care for all pregnant women seeking women’s health services across our network. This comprehensive antenatal care program ensures the wellbeing of pregnant patients and facilitates safe delivery practices. EHS’s evidence-based antenatal care guidelines encapsulate different stages of the antenatal period and guide care providers toward a standardized method for managing patients ranging from standard to high-risk situations.
Our program aims to improve maternal health outcomes, standardize care practice, enhance the end user experience, and positively impact the overall healthcare quality for these patients.
Designing the new program
The Oracle Cerner team has worked with EHS experts to make this vision a digital reality. Their pregnancy care solution packages essential elements and many smart tools to manage pregnant women from the initial antenatal visit through labor and delivery up to postnatal care.
Primary healthcare is the entry point for all uncomplicated cases; they are the gatekeepers who closely monitor the population and identify those who require specialized care versus those who should be managed till they are transitioned to the secondary care setting. Primary healthcare providers are highly subscribed and would benefit from any support in creating ease of documentation, decision support, risk identification, patient monitoring, and more. We realized that there was a need for creating efficient mechanisms to reduce the documentation load on primary care physicians – to achieve this, Oracle Cerner Quick Visits were employed. A specific Quick Visit is designed for every antenatal visit aligned with different stages (weeks) of pregnancy, including standard documentation and visit-specific orders. This has reduced the documentation and cognitive load on our physicians, standardized our care practice and allowed greater interaction time between patients and providers.
Before the implementation of this program, even though we had a discrete and standard way of documentation, the adoption and review of the risks were low, and physicians had the practice of free-text documentation in their notes, which was not trackable and could not be tied to clinical decision support. There was no categorization of patients based on their pregnancy risk profile. We also required smart tools to support the standardization of clinical practice for all antenatal visits and implement our evidence-based escalation protocol when needed. The approach employed to execute this program was based on a framework of Identify and Notify, which encapsulates the various elements utilized in designing this project.
We used our Oracle Cerner EHR as the platform to implement this program, which has been designed after thoroughly analyzing patient antenatal journey and EHS protocols. It has the following major design elements:
- Adherence to practice: A rule has been created in the EHR that mandates reviewing of the risk factors form on every antenatal visit of the patient. This helps to ensure that patient’s risk is being assessed on every visit, their category has not changed from their previous visit, and they are still eligible to receive the appropriate management and care based on their risk profile.
- Compliance management – order sets: To ensure the standardized practice of patient management, trimester-specific multiphase order sets – including lab tests, medications, anomaly scans, etc. – were introduced.
- Minimum datasets: Discrete data documentation is a foundational requirement for creating data-driven workflows and measuring process/clinical outcomes. Creating value-driven data collection for patients and minimizing physician burnout is critical in defining a minimum dataset. Working with subject matter experts, we created minimum datasets for physician and nursing documentation, defining mandatory data elements that should be collected for each visit. This will create a rich data mine, which can generate evidence, analyze patterns, and drive research, leading to future enhancements/improvements in patient care.
- Patient education: Antenatal-specific education content according to trimester with guided documentation was implemented for antenatal nurses. This is a crucial step towards ensuring all patients are educated on the topics according to the defined policy for patient education, and the process is standardized across EHS.
- Patient data insights: All information documented for patient risk profiling becomes a part of the antenatal patient data insights. This includes patient demographics, risk profiles, antenatal journeys, and other relevant information.
- Risk assessment: A form has been created for risk factor documentation. This form is updated according to the latest EHS guidelines and includes many antepartum risk factors.
- Risk notification: Once risk has been identified in a pregnant patient, the information is visible to all clinicians accessing this patient’s chart for prompt notification. In every instance where the patient chart is opened, the physicians will be alerted to the patient’s current pregnancy risk category. The risk profile is stored in the patient’s file, and it can be seen by all clinicians across different EHS venues like the emergency department and labor/delivery room for the ongoing management and care of the patient.
- Risk profiling: Once a patient has documented a risk, their risk profile gets created on the system. If certain risks or problems like gestational diagnosis are not documented as ICD10-CM on documentation of the form, the system checks for availability and adds the problem if it was not already documented, ensuring consistency of data across the patient’s chart.
- Risk protocol implementation: The system has smart cues and prompts to incorporate the risk management protocols at EHS. Based on their latest risk stratification, an icon will be automatically triggered in the ED Tracking shell when high-risk pregnant patients are admitted to the emergency department. These icons can provide a clear view to any care provider about the patient’s risk category. This step ensures that high-risk pregnancies are prioritized, and proper protocols are followed based on the individual risks. Along with the icons, the system has clinical rules to notify the ED providers if they are opening any high-risk or critical-risk patient’s file.
- Risk stratification: Clinical decision support rules have been created that automatically generate a risk category for the patient based on their risk factors documentation by the physicians. The patients are categorized into risk levels based on the presence or absence of risk factors (critical/high/medium/low/none).
Data-driven insights for High-risk patients
This is an effort to identify early risks related to pregnancy and guide physicians in managing maternity patients based on their risk profiling. The program can help manage situations related to high-risk or critical pregnancies by guiding the next course of action based on the identified risks for effective management and care of the patient.
For the smooth and efficient transition of care, this program is integrated across all facilities in the EHS network through the Oracle Cerner EHR. This program has been designed to improve patient safety and standardize risk screening practice across all antenatal clinics in EHS PHCs.
Some accomplishments of this program include:
- Early risk identification on all screened
- Prompt notification for all patients identified to be at risk.
- The average time for referral to hospitals has been less than a week for high-risk patients, which aligns with the EHS benchmark.
- Smart algorithms ensured significant compliance to risk screening for all outpatient antenatal visits at EHS primary care facilities.
Due to its innovative design and high impact on patient safety practices, this program was awarded a Gold Award at the prestigious Middle East & North Africa Stevie Awards 2022.