Trifecta for Change: Enhancing Antenatal Care in Ontario TEC Talk May 27 th, 2013 Mari Teitelbaum Michael Pluscauskas, Sandra Dunn, Tracy Carr, Brenda Bonner, Douglas Cochen

2 BORN Ontario The best possible beginnings for lifelong health

3 Facilitation of Care: Access to Information Sarah, from Toronto, is having a weekend away with friends, she is 34 weeks pregnant Delivers unexpectedly at the London Health Sciences Centre How will the delivering obstetrician access her pregnancy health records?

4 Pregnancy in Ontario 140k women Midwife Family doctor Community obstetrician High risk obstetrician Nurse practitioner LMP Transmit Forms to Hospital Newborn Screening within 48 hrs of birth Ultrasound GBS Screening Pregnancy Care Reminders Prenatal Education Prenatal Screening Plan labour & birth Diabetes Screening Cared for by:Delivering:

5 Antenatal Forms Consistent care Facilitates communication Gold standard ✗ Up to 10% of the time the forms are missing – early delivery, unexpected location or lost ✗ Practices associated with the pathway change regularly

6 Prenatal Genetic Investigations First Visit(s): Early Prenatal Care Ultrasound 2 nd Test: Hb, ABO/Rh, Repeat ABS Fetal anatomy / morphology wks Dating scan wks (early if larger than dates) If 2 U/S, use 1 st for EDB IPS FTS NT MSS 1 hr GCT CVS / amnio declined or twins MSAFP Diagnostic and Screening Tests First Visit (s): Identify Risk Factors and Management Plan Adjust EDB Pregnancy Summary LMP: Certain Y/N Cycle q: Regular Y/N Contraceptive Type Last Used Gravida Term Premature Abortuses Living EDB by dates: Dating Method:  Dates  T1 US  T2 US  ART (e.g. IVF) Final EDB: Obstetrical History No. Year Sex M/F Gest. Age (weeks) Birth Weight Length of Labour Place of Birth Type of Delivery Comments re: pregnancy and birth Current Pregnancy BleedingY/NOccup / Environ RisksY/N Nausea, vomitingY/NDietary restrictionsY/N Smoking___cig/dayY/NCalcium adequateY/N Alcohol, street drugsY/NPreconceptual folateY/N Infectious Disease Varicella SusceptibleY/N STDs / HSV / BVY/N Tuberculosis riskY/N OtherY/N Psychosocial Poor social supportY/NFamily violenceY/N Relationship problemsY/NParenting concernsY/N Emotional / DepressionY/NRelig. / Cultural issuesY/N Substance abuseY/NFamily violenceY/N Family History: At risk population Y/N SOGC guidelines for screening options Repeat 1hr GCT in high risk -ve 2 hr GCT Value Administer Rh-IG Physical Examination HtBMIWtBP ThyroidN / AbNExternal GenitaliaN / AbN ChestN / AbNCervix, vaginaN / AbN BreastsN / AbNUterusN / AbN CardiovascularN / AbNSize: _____ weeks AbdomenN / AbNAdnexaeN / AbN Varicosities / Extrm.N / AbNOtherN / AbN High risk 1 hr GCT Second trimester screening (Quad) wks WEEKWEEK Medical HistoryGenetic History HypertensionY/NSurgeryY/NAt risk populationY/N EndocrineY/NBlood TransfusionY/NFamily History: Urinary tractY/NAnaesthetic compl.Y/NDevelopmental delayY/N Cardiac/PulmonaryY/NPsychiatricY/NCongenital anomaliesY/N Liver, hepatitis, GIY/NEpilepsy / NeurologicalY/NChromosomal disordersY/N Gynaecology / BreastY/NOtherGenetic disordersY/N Hem/ImmunologyY/N Subsequent Visits: Ongoing Prenatal Care (see next page) Soft Markers for Aneuploidy (see box above) Establish Risk + Counsel Previous C-Section : Consider VBAC vs. Repeat C-Section Laboratory Investigations Urine C&SHIVHBsAgABO VDRLSickle CellRh GC/ChlamydiaRubella ImmuneMCV Last PapAntibody ScreenHb Rh -ve Give Rh-IG (28wks) If father known, consider Rh test Father +ve Glucose intolerance Follow Canadian Diabetes Association Guidelines Diagnose Gestational Diabetes 1 AbN test Glucose Level AbN Placental Edge Overlap Abnormal Cervical Length Change Fetal Structural Anomaly EICF Soft Markers for Aneuploidy: establish risk + counsel Single umbilical artery Enlarged cysterna magna pelvis ≥ 5mm pyelectasis pelvis >10mm 3 rd trimester scan Mild ventriculomegaly Fetal anatomy review Neonatal u/s Grade 2, 3 echogenic bowel Expert review + further evaluation Choroid plexus cysts 35+ or MSS +ve or other soft markers Isolated + risk > 1/600 Fetal karyotyping Expert review Other Thickened nuchal fold Adjust EDB > 5 days discrepancy with LMP estimate > 10 days discrepancy with LMP date Finalize EDB If 1 st visit wks AbN level maternal serum marker SOGC Guidelines Consult OB to establish fetal surveillance plan 2 nd trimester screen for open neural tube defects 3 rd Trimester exam and follow-up re: need for C-Section Consult with specialist and genetic counselor Refer to tertiary ultrasound unit Repeat U/S, consider further imaging Assess preterm birth risk Value >10.3

7 A1A2 Pilot Project Launched in 2011, partnership between E-Health Ontario and BORN, the project had 3 Goals 1.Improve practitioner use of high quality clinical practice guidelines (CPGs) and pathways for antenatal care. (partnership of BORN and Centre for Effective Practice) 2.Automate the flow of data collected on A1/A2 to facilitate care to women who may arrive at an Ontario birthing hospital without an antenatal record 3.Enhance the quality of data available to support QI, system planning and surveillance of pregnancy and birth Participants –1 EMR Vendor (OSCAR) –4 family health teams –3 hospitals

8 Clinical Input

9 EMR Enhancements

10 System Enhancements BORN Registry BORN Registry

11 System Impact BORN Registry BORN Registry Population Organization Provider Individual

12 Trifecta: Pregnancy Pathway Value to the provider beyond what is in their chart Trusted & Authoritative Connection to the individual patient – clinical impact and outcomes Patient information available when and where it is needed Clinical pathway embedded in primary care practice Created by clinicians and subject matter experts using OMA standard forms

13 Pilot Learning 573 records in the BORN Information System Preliminary evaluation findings: ‘Good’* –Integration & Coordination of Care –Evidence-based Care & Patient Safety –Workflow Efficiency Critical Success Factors –Well defined scope –Governance –The Trifecta Many new opportunities!

14 So many to Thank eHealth Ontario Participating family health teams OSCAR Perinatal Services BC Centre for Effective Practice

15 Questions