K2MS Athena™ provides an electronic patient note system spanning the whole of pregnancy.
K2’s commitment and enthusiasm to provide the complete maternity management system has resulted with the introduction of Athena™. With the emphasis based firmly on clinical utility, Athena™ generates contemporaneous notes at the point of care and realises the next stage in maternity electronic patient note system by being able to provide an EPN across the whole of pregnancy. By integrating seamlessly with K2MS Guardian™ it offers an obstetric risk management system enabling the full electronic capture of all patient data, crucial for providing an automated comprehensive auditing process to free valuable clinical resource.
With the lives of clinicians becoming increasingly demanding auditing and the compilation of management statistics now takes seconds, reducing the workload for staff by weeks and even months. Comprehensive auditing is essential for hospitals to achieve high CNST standards and recognition and, in response to this, every aspect of Athena™ is geared towards ensuring a paperless, comprehensive and invaluable clinical resource.
What is wrong with traditional attempts at maternity information systems?
Before setting out our vision and new approach to the electronic patient record, it is worth a quick look at the all too recognisable problems with traditional approaches. Does some of the following sound familiar?
Clinical interactions are handwritten on paper in the clinical notes and also subsequently entered again into the Maternity Information System. Multiple entry wastes time and is frustrating to clinicians.
The same data is handwritten many times on many different paper forms and entered many times in different computer systems. Repetition leads to transcription errors.
When a report is printed from the Maternity Information System the data is wrong and inconsistent. Reports are unreliable so they are not used to drive our Governance and Management processes. The data collected by the Maternity Information System cannot be used to improve patient care.
The data entered into the Maternity Information System is a repetition of data that has been recorded in the notes so sometimes people forget or don’t bother to enter it into the computer. When a report is printed the numbers don’t add up. We have no confidence in the data we produce.
Following the delivery, Midwives spend a lot of time, usually 40 minutes or more, sat at a computer with the handwritten notes in front of them transcribing information into an electronic form. This is a chore that is resented especially when a better use of midwifery time would be spent supporting the mother and newborn.
Electronic Patient Records are no more than Electronic forms that do not encourage clinician-patient interaction. They do not replace the handwritten notes which are still required to facilitate these interactions.
The computer systems don’t talk to each other so you go to different systems to find out the information needed; PAS, PACS, Lab, BloodGas, CTG, MIS, Baby Numbering, fetal medicine – all separate islands of information.
Audit is done by hand. We spend considerable time identifying which cases we want to look at then we have to order the notes from medical records. When they arrive we have patient notes everywhere and it takes a team (usually clinicians) to go through the notes to get the information we need. CNST audits are dreaded and are very hard work indeed. Valuable clinical resource is taken away from the clinical environment to undertake this work. It is so difficult for us to achieve and then maintain the higher standards of CNST and bring valuable savings to the Trust.
The Trust does not get paid for a significant part of the work we do because of our unreliable and incomplete electronic data. It is a real effort for our coders to profile the care we provide and produce our Hospital Episode Statistics.
The information department is responsible for compiling detailed reports for a number of important bodies for example the Commissioners, Care Quality Commission, CEMACH, National Screening Committee and Office for National Statistics and in Scotland, the Scottish Birth Record (SBR) and Scottish Perinatal and Infant Mortality and Morbidity Report (SSBID). Compiling these returns are never straightforward and are seldom accurate or complete.
Previous experience of maternity system procurement has invariably been a top down approach. The systems installed do not have a clinical focus nor do they meet our clinical needs. Much of the data is collected in the wrong form and our suppliers have not been interested in taking on board our local requirements and customisations. When they do they want to make significant charges which is felt to be unfair.
To mark our break from the past approaches we shall never again use the term, ‘Electronic Patient Record’. From now on we shall use the term, ‘Electronic Patient Notes’ (EPN) to emphasise that our new approach puts the clinician-patient interaction first and foremost from which all the benefits of the captured electronic information will then naturally flow.
Athena captures the patient’s notes electronically which means the electronic note IS the clinical record – it is not a duplication of the handwritten record, there is no handwritten record – the handwritten record is replaced. A system that can do this then unleashes the full benefit of captured electronic data that we have all known to be possible from computer systems but until now has been entirely illusive. The Electronic Patient Note enables the following to flow automatically:
Every clinician knows the importance of an accurate clinical record so now that the electronic record is the only record – it will be respected and treated with the same reverence as the former handwritten note. The Electronic Note is bound to be accurate.
Now that the Electronic Note is THE Note, there will be full data entry compliance and all relevant information is completed, for all patients.
We have all heard the adage, ‘rubbish in – rubbish out’ and it is true, but equally it is true to say, ‘You get out, what you put in’. The benefits of fully compliant, complete and accurate data means that all the information benefits of the electronic note can be realised. Information generation now becomes a bi-product of the process of giving care. No longer an added process, no longer an added burden.