MMPO Developing an electronic health record for mobile community based health practitioners. Dr Chris Hendry Executive Director Midwifery and Maternity Providers Organisation. www.mmpo.org.nz Chris on 021 655 355 Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

The Midwifery and Maternity Providers Organisation. The Midwifery and Maternity Providers Organisation (MMPO) was established by the New Zealand College of Midwives in 1997 to assist case loading (lead maternity carer) midwives with an efficient ‘ midwifery friendly ’ practice management service. We are now the largest Maternity Provider Organisation in New Zealand, with a membership of about 750 midwives throughout the country. We provide primary maternity ‘practice management’ support and advisory services as well as an integrated Maternity Practice Management System (MPMS) for those claiming on the Section 88 Maternity Notice. Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

The Midwifery and Maternity Providers Organisation.

The Midwifery and Maternity Providers Organisation (MMPO) was established by the New Zealand College of Midwives in 1997 to assist case loading (lead maternity carer) midwives with an efficient ‘ midwifery friendly ’ practice management service.

We are now the largest Maternity Provider Organisation in New Zealand, with a membership of about 750 midwives throughout the country.

We provide primary maternity ‘practice management’ support and advisory services as well as an integrated Maternity Practice Management System (MPMS) for those claiming on the Section 88 Maternity Notice.

The documentation requirements of midwives. Under the Section 88 Maternity Notice a Lead Maternity Carer (LMC) registers with a women to provide continuity of care from early pregnancy to 6 weeks following the birth. This includes inpatient care during labour and birth. There are at least 19 pieces of information which the midwife is expected to import or export to or from external agencies, as well as record information on an average of 20 visits per woman over this time. All of this takes place over a 9 month period for an average of 50 women per midwife. Our midwives work within 80 maternity facilities spread throughout the 21 DHBs. They all have unique documentation requirements! Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

The documentation requirements of midwives.

Under the Section 88 Maternity Notice a Lead Maternity Carer (LMC) registers with a women to provide continuity of care from early pregnancy to 6 weeks following the birth. This includes inpatient care during labour and birth.

There are at least 19 pieces of information which the midwife is expected to import or export to or from external agencies, as well as record information on an average of 20 visits per woman over this time.

All of this takes place over a 9 month period for an average of 50 women per midwife.

Our midwives work within 80 maternity facilities spread throughout the 21 DHBs. They all have unique documentation requirements!

Information sharing points . Pregnancy LMC Care LMC care Postnatally Hospital care Continuity of care by LMC Notification of pregnancy to GP or MW Antenatal scan & Blood tests. Antenatal assessment by LMC. (For some) Specialist consultation. 8 – 11 Antenatal visits with LMC. Booking into Hospital for Birth. Medical certificate to employer. Further scan and blood tests. Hospital admission (LMC). Labour & birth information. Postnatal inpatient care. Discharge from Hospital. Home base postnatal care (5 visits). Birth notification (BDM). New Born hearing screening Immunisation register. Antenatal HIV screening Cervical Screening register. Birth notification to GP. Referral to well child provider (at 2 weeks). Discharge from LMC to GP (6 weeks). Birth registration (BDM). Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

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Woman Midwife Midwifery outcome data Payment claim forms Womans clinical notes Midwifery Standards Review Women held notes HealthPac MMPO Maternity Notes provide copies of data, for the woman, the midwife and claiming information. Response of the profession with the MMPO. We developed up a set of maternity notes which intuitively work the midwife through the entire process of care enabling her to meet the various requirements. Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

We then worked with software developers to design a midwifery PMS The MMPO developed a comprehensive set of maternity notes (held by both the mother and her midwife), linked to an electronic practice management system . Taken together, the two components provide: a shared set of clinical notes agreed by the provider and recipient of care, a streamlined system for claim payments , a quality assurance mechanism for review of practice , a database for individual, practice and professional level outcomes monitoring. Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

We then worked with software developers to design a midwifery PMS

The MMPO developed a comprehensive set of maternity notes (held by both the mother and her midwife), linked to an electronic practice management system .

Taken together, the two components provide:

a shared set of clinical notes agreed by the provider and recipient of care,

a streamlined system for claim payments ,

a quality assurance mechanism for review of practice ,

a database for individual, practice and professional level outcomes monitoring.

National database Quality assurance Professional advice Maternity Practice Management system. Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

MMPO MMPO MMPO National database Quality assurance Professional advice Similarity between hard and soft copies Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

The incentive for use was the production of their Midwifery Standards Review Reports Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

The next step …..development of an electronic maternity record Midwives have access to a ‘remote’ version of our PMS and submit claims and associated data to our main database in Christchurch. The more adventurous had developed up ‘maternity notes’ in each section to use the PMS as a fully electronic record. The profession were concerned about the ‘risk’ of not having hard copy documentation on decision-making and specific information sharing between the woman and midwife. How would electronic ‘notes’ stand up to scrutiny by MOH auditors, HDC, ACC, Coroners Court and/or at a Health Practitioners Disciplinary review? Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

The next step …..development of an electronic maternity record

Midwives have access to a ‘remote’ version of our PMS and submit claims and associated data to our main database in Christchurch.

The more adventurous had developed up ‘maternity notes’ in each section to use the PMS as a fully electronic record.

The profession were concerned about the ‘risk’ of not having hard copy documentation on decision-making and specific information sharing between the woman and midwife.

How would electronic ‘notes’ stand up to scrutiny by MOH auditors, HDC, ACC, Coroners Court and/or at a Health Practitioners Disciplinary review?

We held a workshop with key informants to thrash out the issues and plot a way forward. Attendees included Legal representation, midwifery advisors, LMC midwives, software designer, GP software designer, MOH. First questions centred around: What information needs to be captured ? (We had worked that out through development of our maternity notes) What is acceptable practice around documentation ? ( We had the health Record Standard and Midwifery standards of Practice Handbook) What does a community based midwife need ? Mobility of data collection tool Subtle electronic data collection Safety of data Ability to transfer the record or part when needed. Other providers can contribute The woman can have access. Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

We held a workshop with key informants to thrash out the issues and plot a way forward.

Attendees included Legal representation, midwifery advisors, LMC midwives, software designer, GP software designer, MOH.

First questions centred around:

What information needs to be captured ? (We had worked that out through development of our maternity notes)

What is acceptable practice around documentation ? ( We had the health Record Standard and Midwifery standards of Practice Handbook)

What does a community based midwife need ?

Mobility of data collection tool

Subtle electronic data collection

Safety of data

Ability to transfer the record or part when needed.

Other providers can contribute

The woman can have access.

What about the legal requirements? How do practitioners maintain ‘progress notes’? Date Place of visit/method of communication Summary of discussion Assessment Opinion Action taken/plan Evaluation & follow up How would you provide evidence for audit and legal purposes? Need to develop an electronic record documentation standard This would be used for reference by the midwife Also used for audit purposes. Needs to be incorporated in Midwives Standards of Practice Handbook. Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

What about the legal requirements?

How do practitioners maintain ‘progress notes’?

Date

Place of visit/method of communication

Summary of discussion

Assessment

Opinion

Action taken/plan

Evaluation & follow up

How would you provide evidence for audit and legal purposes?

Need to develop an electronic record documentation standard

This would be used for reference by the midwife

Also used for audit purposes.

Needs to be incorporated in Midwives Standards of Practice Handbook.

What would a midwifery electronic record documentation standard look like? Use the Health Record Standard as a framework. Characteristics would need to consider: Should enforce best practice Must cater for shared and non-shared data. Requires an agreed minimum dataset. Provides an agreed common format: Level of detail Levels of sharing and access Levels of viewing and printing Requires automatic recording of date, time, author, changes, access, printing. Allows syncronisation between hard and soft copy. Enforces changes made by MOH, profession/best practice etc. Able to include scanned information Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

What would a midwifery electronic record documentation standard

look like?

Use the Health Record Standard as a framework.

Characteristics would need to consider:

Should enforce best practice

Must cater for shared and non-shared data.

Requires an agreed minimum dataset.

Provides an agreed common format:

Level of detail

Levels of sharing and access

Levels of viewing and printing

Requires automatic recording of date, time, author, changes, access, printing.

Allows syncronisation between hard and soft copy.

Enforces changes made by MOH, profession/best practice etc.

Able to include scanned information

Where to from here? Confirm the framework for documentation, using Section 88 & current MMPO Maternity Notes. Confirm the minimum dataset. Agree on a common practice of data gathering. Capture information in a secure way. Identify what information needs to be exported how and when. Establish principles guiding collection and transfer of information. Identify access rights and levels. Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

Where to from here?

Confirm the framework for documentation, using Section 88 & current MMPO Maternity Notes.

Confirm the minimum dataset.

Agree on a common practice of data gathering.

Capture information in a secure way.

Identify what information needs to be exported how and when.

Establish principles guiding collection and transfer of information.

Identify access rights and levels.

Next step for the MMPO in midwifery electronic record documentation standard Work with the College of midwives on the development of the electronic record documentation standard. Plan for increased use of the ‘remote’ PMS. Develop system access via phone technology. Trial use of digital pen technology. Work with PHOs and DHBs on data transfer. Supporting quality midwifery led maternity care for women in Aotearoa New Zealand

Next step for the MMPO in midwifery electronic record documentation standard

Work with the College of midwives on the development of the electronic record documentation standard.

Plan for increased use of the ‘remote’ PMS.

Develop system access via phone technology.

Trial use of digital pen technology.

Work with PHOs and DHBs on data transfer.