Uso do prontuário eletrônico na assistência pré-natal às portadoras de diabetes na gestação

Resumo

Objetivo Apresentar e validar um registro eletrônico de saúde (RES) multifuncional para atendimento ambulatorial a portadoras de endocrinopatias na gestação e comparar a taxa de preenchimento de informações de saúde com o prontuário convencional.

Métodos Desenvolvemos um RES denominado Ambulatório de Endocrinopatias na Gestação eletrônico (AMBEG) para registro sistematizado das informações de saúde. O AMBEG foi utilizado para atendimento obstétrico e endocrinológico de gestantes acompanhadas no ambulatório de endocrinopatias na gestação na maternidade referência em gestação de alto risco na Bahia, no período de janeiro de 2010 a dezembro de 2013. Aleatoriamente foram selecionadas 100 pacientes atendidas com o AMBEG e 100 pacientes atendidas com prontuário convencional com registro em papel e comparou-se a taxa de preenchimento de informações clínicas.

Resultados Foram realizados 1461 atendimentos com o AMBEG: 253, 963 e 245 respectivamente, admissões, consultas de seguimento e puerpério. Eram portadoras de diabetes 77,2% e sendo 60,1% portadoras de diabetes pré-gestacional. O AMBEG substituiu, satisfatoriamente, o prontuário convencional. O percentual de informações clínicas registradas em ambos os prontuários foi significativamente maior no AMBEG: queixas clínicas (100 versus 87%, p < 0,01), altura uterina (89 versus 75%, p = 0,01), ganho de peso total (91 versus 40%, p < 0,01) e dados específicos sobre o diabetes (dieta, esquema de insulina, controle glicêmico e manejo de hipoglicemias) revelando diferença significativa (p < 0,01). A possibilidade de exportar dados clínicos para planilhas facilitou e agilizou a análise estatística de dados.

Conclusões O AMBEG é uma ferramenta útil no atendimento clínico a mulheres portadoras de endocrinopatias na gestação. A taxa de preenchimento de informações clínicas foi superior à do prontuário convencional.

Abstract

Objective To present and validate a multifunctional electronic medical record (EMR) for outpatient care to women with endocrine disorders in pregnancy and to compare health information data fill rate to conventional medical records.

Methods We developed an EMR named Ambulatory of Endocrine Diseases in Pregnancy (AMBEG) for systematic registration of health information The AMBEG was used for obstetric and endocrine care in a sample of pregnant women admitted to the maternity reference in high-risk pregnancies in Bahia from January 2010 to December 2013. We randomly selected 100 patients accompanied with AMBEG and 100 patients monitored with conventional consultation and compared the health information data fill rate of the electronic consultation to that performed using conventional medical records.

Results 1461 consultations were held, of which 253, 963 and 245 were first, follow-up and puerperium consultations, respectively. Most patients were pregnant women with diabetes (77.2%) and 60.1% were women with pre-gestational diabetes. The AMBEG satisfactorily replaced the conventional medical record. The percentage of registered information was significantly higher in the AMBEG: clinical symptoms (87% versus 100, p < 0.01), uterine height (89 versus 75%, p = 0.01), total weight gain (91 versus 40%, p < 0.01) and specific diabetes data (diet, insulin regimen, glycemic control and management of hypoglycemia) revealed a significant difference (p < 0.01). The ability to export data to worksheets greatly facilitated and accelerated the statistical analysis of the data.

Conclusions AMBEG is a useful tool in clinical care for women with endocrine diseases during pregnancy. The fill rate of clinical information was superior to that registered in conventional medical records.

Palavras-Chave

diabetes mellitus - gravidez em diabéticas - diabetes gestacional - sistemas computadorizados de registros médicos - doenças do sistema endócrino

Keywords

diabetes mellitus - pregnancy in diabetics - gestational diabetes - medical records systems - computerized - endocrine system diseases

Publikationsverlauf

Eingereicht: 31. Juli 2015

Angenommen: 14. Oktober 2015

Publikationsdatum:
30. Dezember 2015 (online)

• Referências

• 1 Metzger BE, Gabbe SG, Persson B. et al; International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010; 33 (03) 676-682
• 2 Law A, McCoy M, Lynen R. et al. The prevalence of complications and healthcare costs during pregnancy. J Med Econ 2015; 18 (07) 533-541
• 3 McIntyre HD, Gibbons KS, Flenady VJ, Callaway LK. Overweight and obesity in Australian mothers: epidemic or endemic?. Med J Aust 2012; 196 (03) 184-188
• 4 Morikawa M, Yamada T, Yamada T, Sato S, Cho K, Minakami H. Prevalence of hyperglycemia during pregnancy according to maternal age and pre-pregnancy body mass index in Japan, 2007-2009. Int J Gynaecol Obstet 2012; 118 (03) 198-201
• 5 Mayo K, Melamed N, Vandenberghe H, Berger H. The impact of adoption of the international association of diabetes in pregnancy study group criteria for the screening and diagnosis of gestational diabetes. Am J Obstet Gynecol 2015; 212 (02) 224.e1-224.e9
• 6 American Diabetes Association. (12) Management of diabetes in pregnancy. Diabetes Care 2015; 38 (Suppl): S77-S79
• 7 Conselho Federal de Medicina. Cartilha sobre Prontuário Eletrônico: a certificação de sistemas de Registro Eletrônico de Saúde. Brasília (DF): CFM; 2012
• 8 Reed M, Huang J, Graetz I. et al. Outpatient electronic health records and the clinical care and outcomes of patients with diabetes mellitus. Ann Intern Med 2012; 157 (07) 482-489
• 9 Conselho Federal de Medicina [Internet]. Resolução CFM n. 1638 de 9 de agosto de 2002. Define prontuário médico e torna obrigatória a criação da Comissão de Revisão de Prontuários nas instituições de saúde. 2002 (cited 2013 Apr 26). Available at: http://www.portalmedico.org.br/resolucoes/cfm/2002/1638_2002.htm
• 10 Nguyen L, Bellucci E, Nguyen LT. Electronic health records implementation: an evaluation of information system impact and contingency factors. Int J Med Inform 2014; 83 (11) 779-796
• 11 Ancker JS, Kern LM, Edwards A. et al; HITEC Investigators. Associations between healthcare quality and use of electronic health record functions in ambulatory care. J Am Med Inform Assoc 2015; 22 (04) 864-871
• 12 Kern LM, Edwards AM, Pichardo M, Kaushal R. Electronic health records and health care quality over time in a federally qualified health center. J Am Med Inform Assoc 2015; 22 (02) 453-458
• 13 Eggleston EM, Klompas M. Rational use of electronic health records for diabetes population management. Curr Diab Rep 2014; 14 (04) 479
• 14 Corser W, Yuan S. Mixed influence of electronic health record implementation on diabetes order patterns for Michigan Medicaid Adults. J Diabetes Sci Tech 2015
• 15 Reed M, Huang J, Brand R. et al. Implementation of an outpatient electronic health record and emergency department visits, hospitalizations, and office visits among patients with diabetes. JAMA 2013; 310 (10) 1060-1065
• 16 Jolles DR, Brown III WW, King KB. Electronic health records and perinatal quality: a call to midwives. J Midwifery Womens Health 2012; 57 (04) 315-320
• 17 Raglan GB, Margolis B, Paulus RA, Schulkin J. Electronic health record adoption among obstetrician/gynecologists in the United States: physician practices and satisfaction. J Healthc Qual 2015; [Epub ahead of print]
• 18 Doods J, Botteri F, Dugas M, Fritz F. EHR4CR WP7. A European inventory of common electronic health record data elements for clinical trial feasibility. Trials 2014; 15: 18
• 19 Burke HB, Sessums LL, Hoang A. et al. Electronic health records improve clinical note quality. J Am Med Inform Assoc 2015; 22 (01) 199-205
• 20 Kurtzman JH, Wasserman EB, Suter BJ, Glantz JC, Dozier AM. Measuring adequacy of prenatal care: does missing visit information matter?. Birth 2014; 41 (03) 254-261
• 21 National Academy of Science. Institute of Medicine. Key capabilities of an electronic health record system: letter report. Washington (DC): National Academies Press; 2003
• 22 Blumenthal D, Glaser JP. Information technology comes to medicine. N Engl J Med 2007; 356 (24) 2527-2534