Use of a microcomputer network for history taking in a prenatal clinic

Effect of using protocols on medical care: randomised trial of three methods of taking an antenatal history

OBJECTIVE

To compare the effectiveness of three methods of taking an antenatal history on the quality of obstetric care.

DESIGN

Randomised controlled trial.

SETTING

Antenatal clinic of St James's University Hospital, Leeds.

SUBJECTS

2424 women attending the hospital for the first (booking) visit.

INTERVENTIONS

Histories were taken by midwives using an unstructured paper questionnaire, a structured paper questionnaire (incorporating a checklist), or an interactive computerised questionnaire (incorporating 101 clinical reminders).

MAIN OUTCOME MEASURES

The number of clinical responses to factors arising from the antenatal booking history according to method of taking the history. Actions were categorised as medical and surgical, obstetric, personal, current symptoms and treatment, related to maternal age, and related to two common actions (cervical smear testing and dental hygiene) and were weighted for clinical importance by 10 obstetricians.

RESULTS

Overall the unstructured questionnaire generated 1063 actions, the structured questionnaire 1146, and the computerised questionnaire 1122. The clinical importance of these actions was lowest for the unstructured questionnaire (overall total value score 1987 v 2182 and 2110 for the structured and computerised questionnaires respectively). The structured questionnaire was better than the computerised questionnaire in the medical and surgical (total value score 191 v 184), obstetric (275 v 241), and personal (430 v 360) categories but inferior in the current symptoms category (179 v 191).

CONCLUSION

Structured questionnaires (computerised or paper) provide more and better information, and their use improves clinical response to risk factors. Computerised systems offer no further advantage in antenatal clinics.

Information systems and audit in antenatal care

The obstetric record as initiated at the antenatal booking clinic essentially identifies the degree of risk engendered in that pregnancy so that consequent obstetric and paediatric management is tailored appropriately. Whether carried by the patient or based in the hospital with a summary carried by the patient (shared-care card), this record should be exhaustive, the emphasis being on quality, not quantity, of information recorded. To obviate human error in history-taking, patient management or record transcription, we believe on-line computerization of patient records with spin-off paperwork to be the only patient management system to fulfil the above criteria. User-friendly software can be designed with highly branching programmes which provide clinical action suggestions in high-risk cases. Various 'error traps' enhance the accuracy of information recorded. Such systems can be operated by medical and midwifery staff with minimal keyboard skills and are well accepted by patients and staff. Inexpensive and versatile microcomputer networks are excellent for such systems. The operational effects are discussed. Audit means different things to different people and one's view on the subject depends on which definition is selected. Obstetricians are quick to take credit for instituting audit in the form of local and national data collection exercises, such as statistics on perinatal mortality, birthweight, etc. While these exercises certainly constitute observational studies, they cannot be used to make conclusions about the quality of care. There is no sound inference that can be made from a review of information contained in amalgamated databases of hospital statistics. Audit, as properly defined, hinges on inference: the inference that the quality of care was or was not of a high standard. Descriptive statistics, therefore, can be used to generate hypotheses but should not be used as a form of audit, at least not in obstetrics. Auditing the quality of care involves a study of process. It therefore depends on the assumption that we know which practices maximize beneficial outcomes. This exercise is therefore only relevant when we have good evidence linking the process of care with these outcomes. In some cases the accepted standard against which the process of care can be compared is very obvious. In other cases, however, the accepted standard should itself be audited to ensure that it is based on sound evidence.

The development and evaluation of a computerised antenatal questionnaire

A computerised questionnaire, for convenience entitled "PAM" (Programmed Aid for use in Midwifery), was created for use at the time of first antenatal assessment. The system required simple direct input by the expectant mother; and in response to a short descriptive letter, 73.4% of 349 women were prepared to try the new method. The response of 100 consecutive women who tried the system was further analysed. Seventy women liked PAM, four disliked the technique and the remainder had no strong feelings. Asked by the midwife which they would prefer, 46 women expressed a preference for the computer questionnaire and only nine would rather have had a traditional interview with a midwife asking the same questions. PAM or similar systems provide a new opportunity, both for research and as a means of reliably decentralizing the initial assessment of a pregnancy.

Computer applications in obstetrics

The potential impact of the computer on the practice of obstetrics has long been recognized and is slowly being realized. Computers are already essential in many administrative aspects of obstetrics and indispensable in data storage and analysis for clinical research. Emerging applications include computer systems for taking the perinatal history, storage and on-line interpretation of fetal monitor tracings, information retrieval for case management and research purposes, and computer-assisted instruction. Future applications offer possibilities of computerized consulting for support of obstetric decisions and sophisticated case simulations for continuing education.