Interaction of Electronic Health Records and Vital Records Systems:

1. Interaction of Electronic Health Records and Vital Records Systems: Vermont Comparisons of EBRS Data with Hospitals’ OBNet System Data Cindy Hooley Vermont Department of Health Public Health Statistics

2. Acknowledgements Rich McCoy Center for Health Statistics Vermont Department of Health Jason Roberts Research & Statistics Section Vermont Department of Health Rachel Wallace-Brodeur Vermont Child Health Improvement Program University of Vermont, College of Medicine

3. Background: VT EBRS and OBNet 2003 – 2005 • Fletcher Allen Health Care (in partnership with Dartmouth Hitchcock Medical Center) developed a Web-based obstetrical delivery “registry” called OBNet. They planned to roll out the OBNet system to six hospitals and sell the application to the remaining VT hospitals. • OBNet application collected demographics, maternal and fetal risk factors, interventions, and outcomes. • Not a true “electronic health record,” but data entered real-time, point-of-service. • Users (physicians, nurses, medical records clerks, etc.) access screens and enter data based on their roles for patient care.

4. Background: VT EBRS and OBNet 2003 – 2005 • Fletcher Allen approached us to propose a partnership: 1) Vital Records assist OBNet to modify the application to meet all national standards and requirements for birth reporting and registration. 2) Vital Records excuse the “OBNet hospitals” from using the VT EBRS (to avoid double data entry). • Health Department leadership agrees to collaborate with OBNet, resulting in a two year development cycle. • Utilized the NAPHSIS use cases and the NCHS guidelines and materials and incorporated the 2003 Revision of U.S. standard birth certificate.

5. OBNet Hospitals VT EBRS Hospitals 6 Hospitals 57% of all births 6 Hospitals 40% of all births Users: Physician; Nurse; Medical Records Clerk; maybe others Users: Medical Records Clerk • Data entered directly into VT EBRS. • Transmitted when record is completed (doesn’t depend on patient discharge or nightly batch). • Data sent from OBNet system to VT EBRS using PHIN-MS based on xml schema. • Batch file nightly. • Only sent to VT EBRS after the patient is discharged.

6. VT EBRS and OBNet: Differences in Data Collection • OBNet interface: Information for the birth data “extract” to Vital Records is pulled from different OBNet screens (e.g., medical conditions are not “grouped” as on NCHS birth worksheets). • Users at the OBNet hospitals do not use the NCHS worksheets. • OBNet screens allow access based on “roles” – for example, a medical records clerk will not have access to all data elements for entry or edit checks. Responsibilities for completion of OBNet screens are decentralized. • OBNet had to make significant changes to accommodate national standards: • Force the user to visit each data element and mark “unknown” (so we know they didn’t skip the question). • Changed several items from default responses to state-required options.

7. VT EBRS and OBNet: Implementation and Beyond July 1, 2005 • Six hospitals begin collecting and transmitting birth record data to Vital Records using OBNet. Other hospitals submitting births using VT EBRS. 2006 – 2007 • Variety of defects and enhancements made to the OBNet. Many items found in the first year that did not meet our original requirements. • Collaboration was always positive, but OBNet was understaffed and therefore very slow to correct defects. Resulted in a lot of questionable data and extra “clean-up” of the births database by Vital Records.

8. VT EBRS and OBNet: Defects and Enhancements 2008 – 2009 • VDH changed font type and size for content (values) of all fields printed on legal birth certificates and implemented new concatenation rules to accommodate long names. • Increase in the number of married teens giving birth. Learned that OBNet had 2 questions for marital status on their worksheet and on the interface – caused confusion for moms and clerks! 1) Marital Status: Single, Married, Divorced. 2) Mother Married at time of Birth, Conception, or in Between? Yes, No, Unknown (what VDH wants). • Increase in the number of babies being transferred within 24 hours of delivery. Learned that response to this was being lumped with additional question about any transfer before being submitted from OBNet to VDH.

9. The Big Question • Four and a half years later (July 1, 2005 – December 31, 2009) more data available for comparison to answer the question: Is there a difference in the quality of birth data received directly from a hospital medical record compared to what is entered into an EBRS? • Can’t fully answer the question since OBNet is not a true electronic medical record, but it is close enough to provide some guidance as we pursue HL-7 standards for birth / death collection by electronic medical/health record systems and the transfer of data to a state’s EBRS / EDRS. • We continue to examine the data (small numbers in VT – approx. 6,000 births / year).

10. The Big Question Our hypothesis back in 2005 was that birth data from OBNet would be: 1) More accurate than EBRS (point of service rather than several days after the fact). 2) More complete than EBRS (less unknowns). 3) More timely than EBRS (more events reported w/in 10 days of the birth).

11. VT EBRS versus OBNet: Accuracy? • A significant difference was identified in the reporting of abnormal newborn outcomes and also for congenital anomalies when comparing hospitals that use VT EBRS compared to OBNet hospitals. Abnormal Conditions of the Newborn • Assisted Ventilation Immediately following delivery • Assisted Ventilation for more than 6 hours • NICU Admission • Newborn Given Surfactant • Antibiotics Received for Suspected Sepsis • Seizure/Neurologic Dysfunction • Significant Birth Injury Congenital Anomalies • Anencephaly • Meningomyelocele/Spina Bifida • Congenital Heart Disease • Congenital Diaphragmatic Hernia • Omphalocele • Gastroschisis • Limb Reduction Defect • Cleft Lip and/or Cleft Palate • Down Syndrome • Suspected Chromosomal Disorder • Hypospadias

12. Number of Infants Requiring Any Assisted Ventilation: Level 1 Hospitals 2005 Before OBNet Implemented* After OBNet Implemented *The “OBNet” hospitals are those that were using Vermont’s vital records’ birth system, but converted to OBNet after July 1st, 2005.

13. Number of Infants Requiring Any Assisted Ventilation: Level 1 Hospitals 2006-2009

14. Infants who received Surfactant: Level 1 Hospitals 2005 - 2009

15. Seizure / Neurologic Dysfunction: Level 1 Hospitals 2005 - 2009

16. Significant Birth Injury: Level 1 Hospitals 2005 - 2009

17. Any Congenital Anomaly: Level 1 Hospitals 2005 - 2009

18. Vermont Regional Perinatal Health Project (VRPHP) Study • VRPHP volunteered to do a small study from 2005 - 2007. • VRPHP asked three (3) OBNet hospitals to submit a small portion of the Birth Certificate data to them manually (on a worksheet) for an annual review of perinatal statistics. • The data was collected by a nurse using a worksheet provided by VRPHP. • This allowed for a comparison of the birth data reported to VRPHP on paper to the OBNet hospitals’ birth data submitted electronically to VDH. • The study substantiated the differences being noticed in the post-OBNet implementation.

19. Vermont Regional Perinatal Health Project (VRPHP) Study Total Transmitted by OBNet to VT EBRS: 2 Total Reported on Paper to VRPHP: 96 Total Transmitted by OBNet to VT EBRS: 15 Total Reported on Paper to VRPHP: 39

20. VRPHP Conclusions: Reasons for OBNet Underreporting • 1. Abnormal Conditions of Newborn and Congenital Anomalies are rarely entered into the OBNet application by the physician. • Physician may not consider it as “their role” and it has not been assigned or clarified for the nurse, nurse manager, or other staff to enter the information. • 2. OBNet hospitals are not using the NCHS worksheet. • Using their own worksheets and guidance documents, which may result in different interpretations for what qualifies as a confirmed condition, per the birth certificate standards.

21. VRPHP Conclusions: Reasons for OBNet Underreporting 3.Birth data items in OBNet that are incomplete are left to the medical records clerk to obtain and enter. An assumption is made that the medical records clerk will take care of it. • Medical and Health Information items on OBNet screens that the medical records clerk cannot access (re: not their assigned “role”). • VRPHP conclusion after meetings with the OBNet hospital staff: “…clerks are entering just the information from the parent worksheet….they assumed that the other information was being entered by OBs, thus they did not have to enter it.  When we presented this to the nurse managers, they had no idea that those fields were not being completed.”

22. VT EBRS versus OBNet: Accuracy, continued NCHS questioning the underreporting of “Non-vertex presentation”, a new checkbox item under Characteristics of Labor and Delivery when compared to responses for Method of Delivery. While we found this to be true in Vermont, it appears to be an issue only at hospitals using VT EBRS.

23. VT EBRS versus OBNet: Accuracy NCHS concerned about inconsistency in reporting “Was delivery w/ forceps attempted by unsuccessful” under Method of Delivery. Small numbers (39) in Vermont but significant differences found between VT EBRS records and OBNet records: For EBRS records, 7/1/05 – 12/31/09: 7.1% of records w/ failed forceps attempts were also coded with “forceps” as the final route of delivery. Further, 42.9% of failed forceps attempts were marked as “spontaneous” vaginal deliveries, a highly unlikely, if not inconsistent result. So, 50% of all records marked as “attempt at forceps delivery failed were miscoded. For OBNet records, NONE were miscoded.

24. VT EBRS versus OBNet: Accuracy NCHS concerned about inconsistency in reporting “Was delivery w/ vacuum attempted by unsuccessful” under Method of Delivery. Small numbers (181)in Vermont but differences found between VT EBRS records and OBNet records: 8.6% of EBRS records and 6.3% of OBNet records coded w/ failed vacuum attempt were coded as “vacuum” deliveries. 28.6%of EBRS records and 9.0% of OBNet records coded w/ failed vacuum attempt were coded as “spontaneous” vaginal deliveries. So, total of 37.1% EBRS and 15.3% OBNet records miscoded.

25. VT EBRS versus OBNet: Completeness? • Following is a chart showing rates of “unknowns” for selected items including those used in calculating bmi, weight gain, and smoking rates. • 10,534 hospital births reported via EBRS for 7/1/05 – 12/31/2009. • 15,953 hospital births reported via OBNet for same period.

26. VT EBRS versus OBNet: Completeness?

27. VT EBRS versus OBNet: Completeness?

28. VT EBRS versus OBNet: Timeliness? • We have observed that transmission of the birth certificate data from the hospital to the Vital Records’ birth reporting system occurs more often within 10 days of the event for OBNet hospitals than EBRS hospitals.

29. Conclusions OBNET • Receive more complete data (less unknowns) with OBNet for birth outcomes, complications, etc. because it is physician or nurse entering those fields. • Receive moreaccurate (consistent) data for method of delivery information because medical personnel enters those fields. • Receive lessaccurate data for abnormal conditions and congenital anomalies. Trend confirmed in VRPHP study appears to have continued through 2009; VDH may need to intervene with hospital/OBnet procedures. • Receive the data in a moretimely manner (higher % transmitted within 10 days of the birth). Doesn’t take as long to complete records EBRS • Receive more accurate data for abnormal conditions and congenital anomalies. If it’s there, clerk will find it?! • Receive lesscomplete data (more unknowns overall for more fields). • Receive the data in less timely manner.

30. Future Discussion / Topics • As software vendors prepare hospital or practice-based EHR systems to include data collection for states’ EBRS or EDRS reporting, those systems need to account for: • What (who) is the best source of the information? • Are the required data fields being populated with the best data source (e.g., data from mother’s worksheet)? • Have appropriate edit checks been put into place to ensure review of all data fields and minimize “unknowns” or blank/null fields? • Does the system integrate the use cases, standards and guidance from the National Association of Public Health Statistics and Information Systems (NAPHSIS) and the National Center for Health Statistics (NCHS)? • Is there capacity within the EHR to meet any state-specific requirements, depending on the jurisdiction’s laws, rules, and policies? (e.g., same sex parents; additional birth defects; hospice care question; etc.)

31. Questions / Comments? Cindy Hooley Vital Statistics Information Manager Phone (802) 651-1636 Email: cynthia.hooley@ahs.state.vt.us Richard McCoy Director, Vermont Center for Health Statistics Phone (802) 651-1862 Email: richard.mccoy@ahs.state.vt.us