Implementation of a regional standardised model for perinatal electronic medical records

Background: Electronic recording of newborn health information contributes to improving the quality of care. Nonetheless, there is limited evidence on the implementation of perinatal electronic medical records models. We describe the development and implementation of an electronic recording model that includes data on the health care provided to both the mother and the newborn, standardised for six hospitals of a regional health care system. Methods: The implementation process was developed in 2 stages. During stage 1, the tool was introduced in hospitals to stablish first contact with the healthcare staff. The second stage consisted in designing a new strategy to stabilise the model. Technical issues were fixed, and a new version was drawn up based on multidisciplinary agreement. Indicators to monitor implementation were measured in both stages and compared using the chi-squared test. Results: During stage 1, nearly every newborn got its electronic medical record with an appropriate connection to the mother’s data. However, certain forms that were meant to be filled in by staff were frequently neglected (completion rates: 36.7%-55.3%). In stage 2, there was a statistically significant increase in the completion rates of all these forms. As a result, a standardised discharge report was provided to every newborn at the end of stage 2. Conclusions: Implementation of perinatal electronic medical records that link maternal and neonatal data is complicated and experience in this area is limited. Here we describe the implementation process of a model that was reliable and standardised for an entire regional health care system.