Much native data, little longitudinal information: a model of information for the continuity of care, from prenatal assistance to the emergency in maternities
Resumo
Obstetric caring demands a continuous process of information sharing between health professionals. However, the lack of communication between points of assistance has allowed for an accumulation of local data without the benefits of data interoperability. The study’s objective is to develop an information model with essential obstetric data to foster the continuity of information. An exploratory research involved discussions of fictitious cases of obstetric emergencies and ninety electronic medical records (EMR) were used to validate the model. The minimum antenatal dataset entries was structured into nine sections, and fifty-six data entries. The development of an information model, based on the standard of interoperability, has the potential to overcome the informality of EMR.Referências
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Pan American Health Organization. eHealth in Latin America and the Caribbean: interoperability standards review. Washington, D.C.: PAHO 2016.
Spyropoulos B, Botsivaly M, Tzavaras A, Koutsourakis K. Extending the use of DRGs to estimate mean Home-Care cost by employing an adapted ASTM E2369-05 Continuity of Care Record. 2006 International Conference of the IEEE Engineering in Medicine and Biology Society [Internet]. IEEE; 2006 Aug; Available from: http://dx.doi.org/10.1109/iembs.2006.260323
Botsivaly M, Spyropoulos B, Koutsourakis K, Mertika K. Enhancing continuity in care: an implemantation of the ASTM E2369-05 Standard Specification for Continuity of Care Record in a homecare application. AMIA Annu Symp Proc. 2006;2006:66-70. PMID: 17238304; PMCID: PMC1839263.
Adler-Milstein J, DesRoches CM, Kralovec P, Foster G, Worzala C, Charles D, et al. Electronic Health Record Adoption In US Hospitals: Progress Continues, But Challenges Persist. Health Affairs [Internet]. Health Affairs (Project Hope); 2015 Dec;34(12):2174–80. Available from: http://dx.doi.org/10.1377/hlthaff.2015.0992
Santos MR, de Sá TQV, da Silva FE, dos Santos Junior MR, Maia TA, Reis ZSN. Health Information Exchange for Continuity of Maternal and Neonatal Care Supporting: A Proof-of-Concept Based on ISO Standard. Applied Clinical Informatics [Internet]. Georg Thieme Verlag KG; 2017;08(04):1082–94. Available from: http://dx.doi.org/10.4338/aci-2017-06-ra-0106
Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatric and Perinatal Epidemiology [Internet]. Wiley; 2001 Jan;15(1):1–42. Available from: http://dx.doi.org/10.1046/j.1365-3016.2001.00001.x
Rai RK. Tracking women and children in a Continuum of Reproductive, Maternal, Newborn, and Child Healthcare (RMNCH) in India. Journal of Epidemiology and Global Health [Internet]. Atlantis Press; 2014 Sep;4(3):239–43. Available from: http://dx.doi.org/10.1016/j.jegh.2013.12.006
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health [Internet]. Elsevier BV; 2014 Jun;2(6):e323–e333. Available from: http://dx.doi.org/10.1016/s2214-109x(14)70227-x
Tunçalp ?, Pena-Rosas J, Lawrie T, Bucagu M, Oladapo O, Portela A, et al. WHO recommendations on antenatal care for a positive pregnancy experience-going beyond survival. BJOG: An International Journal of Obstetrics & Gynaecology [Internet]. Wiley; 2017 Mar 9;124(6):860–2. Available from: http://dx.doi.org/10.1111/1471-0528.14599
Oladapo O, Tunçalp Ö, Bonet M, Lawrie T, Portela A, Downe S, et al. WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing. BJOG: An International Journal of Obstetrics & Gynaecology [Internet]. Wiley; 2018 May 15;125(8):918–22. Available from: http://dx.doi.org/10.1111/1471-0528.15237
Joint Initiative for Global Standards Harmonization Health Informatics Document Registry and Glossary. Standards Knowledge Management Tool 2014. Available from: http://www.skmtglossary.org/.
ABNT. Health informatics - Discharge Summary for continuity of care Part 1: Information model. Brasilia: Associação Brasileira de Normas Técnicas (ABNT); 2016.
Fakari FR, Simbar M, Modares SZ, Majd HA. Obstetric Triage Scales; a Narrative Review. Arch Acad Emerg Med. 2019 Jan 13;7(1):e13. PMID: 30847448; PMCID: PMC6377224.
openEHR Foundation. openEHR Architecture Overview. BASE Release 1.1.0, 2018. Available from: https://specifications.openehr.org/releases/BASE/latest/architecture_overview.html
International Organization for Standardization. Standard 13.606 Health informatics, Electronic health record communication. Part 1: Reference model. web: ISO; 2008. p. 108.
Santos MR, Bax MP, Peçanha C, editors. Codificando Arquétipos em linguagem ADL com base no modelo de referência da norma ISO 13606. X Workshop de Informática Médica; 2010.
World Health Organization. Birth and emergency preparedness in antenatal care. Intergrated Management of Pregnancy and Childbirth. [Internet]. Standards for Maternal and Neonatal Care, 2006. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/emergency_preparedness_antenatal_care.pdf
Beredugo L, Emmanuel L, Oniso J, Aluye-Benibo D. BIRTH PREPAREDNESS AND COMPLICATION READINESS IN AMASSOMA COMMUNITY OF SOUTHERN IJAW LOCAL GOVERNMENT AREA, BAYELSA STATE, NIGERIA. LAUTECH JOURNAL OF NURSING. 2018:160.
Maia TA, De Muylder CF, Reis ZSN. Archetype Development Process: A Case Study of Support Interoperability Among Electronic Health Record in the State of Minas Gerais, Brazil. Trends and Advances in Information Systems and Technologies [Internet]. Springer International Publishing; 2018;457–67. Available from: http://dx.doi.org/10.1007/978-3-319-77703-0_45
Kuhn IF. Abbreviations and acronyms in healthcare: when shorter isn't sweeter. Pediatr Nurs. 2007 Sep-Oct;33(5):392-8. PubMed PMID: 18041327
Yang P, Pan F, Liu D, Xu Y, Wan Y, Tu H, et al. The Development of Clinical Document Standards for Semantic Interoperability in China. Healthcare Informatics Research [Internet]. The Korean Society of Medical Informatics (KAMJE); 2011;17(4):205. Available from: http://dx.doi.org/10.4258/hir.2011.17.4.205
Bipartisan Policy Center. Clinician Perspectives on Electronic Health Information Sharing for Transitions of Care. 2012. Available from: https://bipartisanpolicy.org/wp-content/uploads/2019/03/Clinician-Survery_format-2.pdf
World Health Organization . WHO guideline: recommendations on digital interventions for health system strengthening. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.
Hawley G, Jackson C, Hepworth J, Wilkinson SA. Sharing of clinical data in a maternity setting: How do paper hand-held records and electronic health records compare for completeness? BMC Health Services Research [Internet]. Springer Science and Business Media LLC; 2014 Dec;14(1). Available from: http://dx.doi.org/10.1186/s12913-014-0650-x
Kenneweg J, Fritz F, Bruland P, Doods D, Trinczek B, Dugas M, et al. Multilingual Medical Data Models in ODM Format. Applied Clinical Informatics [Internet]. Georg Thieme Verlag KG; 2012;03(03):276–89. Available from: http://dx.doi.org/10.4338/aci-2012-03-ra-0011
Kushlan JA. Use and Abuse of Abbreviations in Technical Communication. Journal of Child Neurology [Internet]. SAGE Publications; 1995 Jan;10(1):1–3. Available from: http://dx.doi.org/10.1177/088307389501000101
Pan American Health Organization. eHealth in Latin America and the Caribbean: interoperability standards review. Washington, D.C.: PAHO 2016.
Spyropoulos B, Botsivaly M, Tzavaras A, Koutsourakis K. Extending the use of DRGs to estimate mean Home-Care cost by employing an adapted ASTM E2369-05 Continuity of Care Record. 2006 International Conference of the IEEE Engineering in Medicine and Biology Society [Internet]. IEEE; 2006 Aug; Available from: http://dx.doi.org/10.1109/iembs.2006.260323
Botsivaly M, Spyropoulos B, Koutsourakis K, Mertika K. Enhancing continuity in care: an implemantation of the ASTM E2369-05 Standard Specification for Continuity of Care Record in a homecare application. AMIA Annu Symp Proc. 2006;2006:66-70. PMID: 17238304; PMCID: PMC1839263.
Adler-Milstein J, DesRoches CM, Kralovec P, Foster G, Worzala C, Charles D, et al. Electronic Health Record Adoption In US Hospitals: Progress Continues, But Challenges Persist. Health Affairs [Internet]. Health Affairs (Project Hope); 2015 Dec;34(12):2174–80. Available from: http://dx.doi.org/10.1377/hlthaff.2015.0992
Santos MR, de Sá TQV, da Silva FE, dos Santos Junior MR, Maia TA, Reis ZSN. Health Information Exchange for Continuity of Maternal and Neonatal Care Supporting: A Proof-of-Concept Based on ISO Standard. Applied Clinical Informatics [Internet]. Georg Thieme Verlag KG; 2017;08(04):1082–94. Available from: http://dx.doi.org/10.4338/aci-2017-06-ra-0106
Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatric and Perinatal Epidemiology [Internet]. Wiley; 2001 Jan;15(1):1–42. Available from: http://dx.doi.org/10.1046/j.1365-3016.2001.00001.x
Rai RK. Tracking women and children in a Continuum of Reproductive, Maternal, Newborn, and Child Healthcare (RMNCH) in India. Journal of Epidemiology and Global Health [Internet]. Atlantis Press; 2014 Sep;4(3):239–43. Available from: http://dx.doi.org/10.1016/j.jegh.2013.12.006
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health [Internet]. Elsevier BV; 2014 Jun;2(6):e323–e333. Available from: http://dx.doi.org/10.1016/s2214-109x(14)70227-x
Tunçalp ?, Pena-Rosas J, Lawrie T, Bucagu M, Oladapo O, Portela A, et al. WHO recommendations on antenatal care for a positive pregnancy experience-going beyond survival. BJOG: An International Journal of Obstetrics & Gynaecology [Internet]. Wiley; 2017 Mar 9;124(6):860–2. Available from: http://dx.doi.org/10.1111/1471-0528.14599
Oladapo O, Tunçalp Ö, Bonet M, Lawrie T, Portela A, Downe S, et al. WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing. BJOG: An International Journal of Obstetrics & Gynaecology [Internet]. Wiley; 2018 May 15;125(8):918–22. Available from: http://dx.doi.org/10.1111/1471-0528.15237
Joint Initiative for Global Standards Harmonization Health Informatics Document Registry and Glossary. Standards Knowledge Management Tool 2014. Available from: http://www.skmtglossary.org/.
ABNT. Health informatics - Discharge Summary for continuity of care Part 1: Information model. Brasilia: Associação Brasileira de Normas Técnicas (ABNT); 2016.
Fakari FR, Simbar M, Modares SZ, Majd HA. Obstetric Triage Scales; a Narrative Review. Arch Acad Emerg Med. 2019 Jan 13;7(1):e13. PMID: 30847448; PMCID: PMC6377224.
openEHR Foundation. openEHR Architecture Overview. BASE Release 1.1.0, 2018. Available from: https://specifications.openehr.org/releases/BASE/latest/architecture_overview.html
International Organization for Standardization. Standard 13.606 Health informatics, Electronic health record communication. Part 1: Reference model. web: ISO; 2008. p. 108.
Santos MR, Bax MP, Peçanha C, editors. Codificando Arquétipos em linguagem ADL com base no modelo de referência da norma ISO 13606. X Workshop de Informática Médica; 2010.
World Health Organization. Birth and emergency preparedness in antenatal care. Intergrated Management of Pregnancy and Childbirth. [Internet]. Standards for Maternal and Neonatal Care, 2006. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/emergency_preparedness_antenatal_care.pdf
Beredugo L, Emmanuel L, Oniso J, Aluye-Benibo D. BIRTH PREPAREDNESS AND COMPLICATION READINESS IN AMASSOMA COMMUNITY OF SOUTHERN IJAW LOCAL GOVERNMENT AREA, BAYELSA STATE, NIGERIA. LAUTECH JOURNAL OF NURSING. 2018:160.
Maia TA, De Muylder CF, Reis ZSN. Archetype Development Process: A Case Study of Support Interoperability Among Electronic Health Record in the State of Minas Gerais, Brazil. Trends and Advances in Information Systems and Technologies [Internet]. Springer International Publishing; 2018;457–67. Available from: http://dx.doi.org/10.1007/978-3-319-77703-0_45
Kuhn IF. Abbreviations and acronyms in healthcare: when shorter isn't sweeter. Pediatr Nurs. 2007 Sep-Oct;33(5):392-8. PubMed PMID: 18041327
Yang P, Pan F, Liu D, Xu Y, Wan Y, Tu H, et al. The Development of Clinical Document Standards for Semantic Interoperability in China. Healthcare Informatics Research [Internet]. The Korean Society of Medical Informatics (KAMJE); 2011;17(4):205. Available from: http://dx.doi.org/10.4258/hir.2011.17.4.205
Bipartisan Policy Center. Clinician Perspectives on Electronic Health Information Sharing for Transitions of Care. 2012. Available from: https://bipartisanpolicy.org/wp-content/uploads/2019/03/Clinician-Survery_format-2.pdf
World Health Organization . WHO guideline: recommendations on digital interventions for health system strengthening. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.
Hawley G, Jackson C, Hepworth J, Wilkinson SA. Sharing of clinical data in a maternity setting: How do paper hand-held records and electronic health records compare for completeness? BMC Health Services Research [Internet]. Springer Science and Business Media LLC; 2014 Dec;14(1). Available from: http://dx.doi.org/10.1186/s12913-014-0650-x
Kenneweg J, Fritz F, Bruland P, Doods D, Trinczek B, Dugas M, et al. Multilingual Medical Data Models in ODM Format. Applied Clinical Informatics [Internet]. Georg Thieme Verlag KG; 2012;03(03):276–89. Available from: http://dx.doi.org/10.4338/aci-2012-03-ra-0011
Kushlan JA. Use and Abuse of Abbreviations in Technical Communication. Journal of Child Neurology [Internet]. SAGE Publications; 1995 Jan;10(1):1–3. Available from: http://dx.doi.org/10.1177/088307389501000101
Publicado
15/06/2021
Como Citar
TVQ, Sá; RALP, Aguiar; ZSN, Reis.
Much native data, little longitudinal information: a model of information for the continuity of care, from prenatal assistance to the emergency in maternities . In: SIMPÓSIO BRASILEIRO DE COMPUTAÇÃO APLICADA À SAÚDE (SBCAS), 21. , 2021, Evento Online.
Anais [...].
Porto Alegre: Sociedade Brasileira de Computação,
2021
.
p. 129-140.
ISSN 2763-8952.
DOI: https://doi.org/10.5753/sbcas.2021.16059.
