Alberta Prenatal Record (PNR) Pilot - Protocol & FAQ - Alberta Health Services

Alberta Prenatal Record (PNR) Pilot – Protocol & FAQ

 BACKGROUND & PNR DEVELOPMENT

 The mission of the MNCY SCN is to bring together people, evidence, and data to
 achieve the best possible health outcomes for mothers, newborns, children, youth, and
 families within a sustainable, publicly funded health care system. With this in mind, the
 SCN established twelve priorities for the 2017-2020 transformational roadmap that are
 aimed at optimizing care practices, processes, and outcomes.
 One of these priorities includes the development of a Pregnancy Pathway (from
 preconception to the postpartum). The Antenatal component of this pathway has
 been developed to support consistency and continuity in care through the early
 identification and management of obstetrical risk factors.
 To support the development of this Antenatal Pregnancy Pathway, a critical review of
 the existing Alberta Prenatal Record was completed. This enabled a comparison of
 current practices with a thorough review of the evidence on modifiable risk factors,
 optimal number of visits based on risk, routine investigations, indicated treatments, and
 other topics relevant to prenatal care.
 The development of the 2018 PNR began in May 2017 and was based on a multi-
 phase, evidence- and consensus-based, collaborative process. This included:
 •   An international environmental scan of prenatal care resources;
 •   A content analysis of risk assessment sections in provincial prenatal records;
 •   A systematic literature review of epidemiological evidence;
 •   Stakeholder discussion within the Antenatal Pregnancy Pathways Working Group;
 •   Targeted expert consultation; and
 •   Broad provincial stakeholder feedback on record content and organization from
     physicians, nurses, midwives, researchers, public health professionals, decision-
     makers, etc.

 For more information about the PNR development process, you can view our
 presentation “The Changing Alberta Prenatal Record” posted on the MNCY website.

Alberta 2018 Prenatal Record (PNR) Pilot • 2

The MNCY SCN Core Committee ratified a ‘final’ trial version of the PNR in May 2018.
The 2018 PNR in its current form is 7 pages long, including a page of tools/resources
and a page for documentation overflow. A completion guide was subsequently
developed as a manual for the PNR to standardize the documentation of prenatal care
and to organize definitions, resources, and other considerations according to each data
element.
The overall goal of the new PNR is to facilitate the provision of comprehensive,
evidence-based prenatal care that supports continuity in approach among primary
care clinicians, midwives, and specialists across Alberta.

PILOT OBJECTIVE

The purpose of this pilot trial is to assess the feasibility, acceptability, and utility of
the 2018 Alberta PNR from the perspective of prenatal care providers. The trial is open
to primary care clinicians (family physicians, nurse practitioners, midwives, and
obstetricians) from metro, urban, and rural communities across Alberta.

PROPOSED METHOD

Timeline & Process (August 2018-June 2019)
We propose that the 2018 PNR be trialed on a small subset of patients beginning with
their initial prenatal visit through to birth. This will enable the collection of valuable and
detailed feedback about the 2018 PNR performance throughout the entirety of prenatal
care. Each clinic may decide whether they want to use the new PNR on all new
patients, or limit the use to a minimum of 5 patients.
 Pre-trial Preparation           • Orientation meeting with participating
 August 2018                       clinicians/clinics
 A pre-trial focus group meeting will be held in August 2018 via teleconference to
 provide a brief orientation to the 2018 PNR and the trial procedures, as well as
 address clinician questions and/or concerns.
 Trial Implementation            • Trial is initiated at each participating clinic
 September 2018                  • Survey for early-stage feedback

Alberta 2018 Prenatal Record (PNR) Pilot • 3

Beginning in September 2018, each participating clinician will trial the new PNR with a
minimum of 5 new obstetrical patients; however, the number of patients is at the
discretion of the provider and clinics may choose to use the form on all new patients.
A web-based survey will be administered to all participating clinicians 2 weeks after
trial initiation to gather first impressions on PNR feasibility and acceptability.
Evaluation Phase 1            • 1st round of meetings: early October 2018
October–December 2018         • 2nd round of meetings: late November 2018
                              • Review of PNR use/completion
By mid-October 2018, it is expected that clinicians will have completed the first
prenatal visit for each new patient ‘enrolled’ in the trial. Two rounds of focus groups
and key informant interviews will be conducted to collect feedback about PNR
feasibility, acceptability, and utility, with an emphasis on the initial health and risk
assessment and first half of pregnancy. Each round will require a 1 hour commitment
from trial leads at each participating clinic, and will be scheduled via teleconference.
All participating clinicians are welcome to attend the evaluation meetings (schedule
permitting), or are otherwise encouraged to forward their feedback to the trial leads. A
subset of redacted/de-identified PNRs will be reviewed to ascertain how the PNR is
used on patients with varying levels of risk (e.g., how items are interpreted, level of
completion). Ongoing feedback will be collected on whether clinicians wish to follow
their enrolled patients through to delivery using the new PNR.
Report                           • Trial report of findings and recommendations
January 2019
Data from the survey and evaluation meeting will be collated and analyzed to identify
strengths and weaknesses of the new PNR form and implementation process, as well
as recommendations for revisions. This information will be shared with all participating
clinicians and will be used to inform PNR changes and the provincial roll-out strategy.
Evaluation Phase 2              • 3rd round of meetings
April–June 2019                 • Formal evaluation regarding identification of risks,
                                   management/referrals, and outcomes
                                • Survey on trial participation
                                • Review of PNR use/completion
Recognizing that gestational age at the first prenatal visit may be between 10-20
weeks, it is expected that enrolled patients will have given birth (or be close to doing
so) by April 2019. A third round of focus groups and key informant interviews will be
conducted to collect remaining feedback about PNR feasibility, acceptability, and
utility, with an emphasis on the second half of pregnancy and delivery process. Each
round will require a 1 hour commitment from trial leads at each participating clinic,
and will be scheduled via teleconference. A subset of redacted/de-identified PNRs will
be reviewed to ascertain how the PNR is used. MNCY will also undertake a formal

Alberta 2018 Prenatal Record (PNR) Pilot • 4

 evaluation on the impact of the PNR and Antenatal Pathway on identification of
 obstetric risks, management and referrals, and key perinatal outcome indicators.
 Finally, we will administer a brief end-of-trial survey to collect information on clinician’s
 experiences with participating in the trial.

At any time during the pilot, clinicians have the right to withdraw their participation and
revert to using the existing Alberta PNR. Those who choose to withdraw will be asked to
provide their reasons for doing so in an effort to improve the form and/or implementation
for the future.

2018 PNR Format Availability

✓ EMR–QHR (Accuro): QHR has created and uploaded the 2018 PNR form into
Accuro EMR platform. Clinicians who use this platform (mainly obstetricians) should find
the form available to them at this time; instructions for locating the form are available.
✓ Paper: The 2018 PNR is available in hard copy format for manual charting. Hard
copies may be stored in the clinic or provided to the patient who will be responsible for
bringing their form to each visit. If the latter is preferred, clinicians may wish to scan the
form into the patient’s EMR after each visit to ensure that all information is stored
securely in one file. This process can be adapted as needed based on clinician
preference and clinic workflow.
✓ Electronic Fillable PDF: The 2018 PNR is available in a fillable PDF file that could be
loaded on a clinic’s shared drive and completed electronically, as well as printed as
needed. This option would require measures to ensure that patient information is secure
and only available to the prenatal care provider. Such measures may include password
protection and/or encryption for the shared drive or PDF file.
✗ EMR–Telus (Wolfe, Med Access, Practice Solutions): Work is underway with Telus
to create and upload the 2018 PNR into all three EMR platforms. There will be a
substantial cost associated with this as well as a minimum 3 month time frame for form
development. MNCY is awaiting a detailed cost and time quote from Telus, and is
currently seeking out funding sources to support this. However, at this time, the 2018
PNR is not available in Telus EMR platforms

Alberta 2018 Prenatal Record (PNR) Pilot • 5

EXPECTED OUTCOME

This pilot trial will be essential for identifying potential barriers and facilitators to full-
scale implementation of the 2018 PNR. Findings from the trial will be used to refine the
2018 PNR content or organization (and complementary resources, such as the
completion guide), and to optimize the implementation process for provincial rollout.

FREQUENTLY ASKED QUESTIONS

Has the 2018 PNR been tested previously with any patients?

No, the proposed trial will be the first time this form is being used with human patients.
We have had significant stakeholder involvement in the PNR development process–with
respect to both content and clinical utility (e.g., flow of care, organization)–which is
expected to facilitate the seamless implementation of the new form into patient care.

Which clinics in the province have agreed to participate in the PNR trial?

1. Family Practice: Urban Calgary Riley Park Clinic: Dr. Jan Ooi (lead), Dr. Lisa
    Coffey, Dr. Warren Stanich, Dr. Sanjeev Bhatla, Dr. Meagan Brown, Dr. Teresa
    Killam
2. Family Practice: Rural- Central Zone- Sundre: Dr. Michelle Warren (lead), Dr.
    Rob Warren, Dr. Carly Crewe, Dr. Jena Smith, Dr. Anthony Willmot, Dr. Alanna
    Bowie, Dr. Mark Diaz, Dr. Danielle Diaz
3. Registered Midwifery- Urban, Calgary: Patricia Lenstra
4. Registered Midwifery- Urban, Edmonton: Marie Tutt (lead), Jenna Chowick
5. OB/Gyn: Calgary, South Health Campus: Dr. James Watson
6. OB/Gyn South Zone: Medicine Hat: Dr. Duncan McCubbin
7. OB/Gyn: Edmonton Grey Nuns: Dr. Michael Bow
8. OB/Gyn: Edmonton- Lois Hole: Dr. Hajira Danial (lead)
9. OB/Gyn: Edmonton- Misericordia: Dr. Martine Roy
10. OB/Gyn: Central Zone (Red Deer); Dr. Chris Cham
11. OB/Gyn: North Zone- Grande Prairie: Grande Prairie, QEII: Dr. Christa Delacruz

Others interested in trialing but their EMR is not supported at this time:
12. Family Practice: Dr. Sanjeev Bhatla, Bowmont Clinic, Calgary (TELUS)
13. Family Practice: Dr. Kim Rogers, Rocky Mountain House Medical Clinic, Rocky
    Mountain House (TELUS.)
14. Family Practice: Dr. Kim Derouin, Low Risk Obstetric Clinic, Red Deer (TELUS)

Alberta 2018 Prenatal Record (PNR) Pilot • 6

We are striving to have a representation of rural, urban, and metro clinics, as well as a
mix of family practice, midwifery and specialist groups. This will ensure that the 2018
PNR is tested in different environments and with diverse clinic populations (e.g., levels
of obstetrical risk)

Does participation in the trial require duplicate charting on both the current and 2018
PNR?

No. The 2018 PNR incorporates virtually all of the information that exists in the current
record (see the Appendix for a detailed comparison), so there is very minimal risk for
loss of data or information according to the current standard. The 2018 PNR has
additional sections and data elements that are intended to enhance the scope and detail
of prenatal care information.

Are the staff at my birthing facility aware of the 2018 PNR and the upcoming trial?

Once the trial begins in September, we will connect with each participating clinic’s
birthing facility to socialize the staff to the 2018 PNR and provide a brief orientation on
where to locate the information they require for providing optimal care during childbirth.

Is patient consent required to ‘enroll’ in the pilot trial?

No. The pilot is a quality improvement initiative; therefore, it is exempted from ethics
review and will not require formal patient consent. Further, the 2018 PNR builds upon
the information standard in the current PNR, so the risks associated with patient
involvement is minimal. The decision to inform patients about the 2018 PNR pilot is at
the discretion of participating clinicians. If you wish to inform your patients, please let us
know and we can provide a brief patient handout template containing trial information.

Will clinicians be compensated for their voluntary participation in the trial?

Yes. Clinicians may be compensated through MNCY for their participation in the pre-
trial meeting and focus groups. Financial resources to support additional time required
for patient visits or clinic workflow due to participation in the trial are not available
however.

Who can I contact if I have any additional questions about the trial or the 2018 PNR?

Please contact Debbie Leitch, Executive Director of the MNCY SCN,
at debbie.leitch@ahs.ca.

Alberta 2018 Prenatal Record (PNR) Pilot • 7

Comparison of Current PNR and 2018 PNR Content

                  Current PNR                              Included in the 2018 PNR?
PAGE 1
Demographics: name, marital status, date of         Yes (Patient Demographics on page 1)
birth, age, occupation, ethnicity, language
Contact: address, phone number                      Yes (Patient Demographics on page 1)
Emergency contact information                       Yes (Patient Demographics on page 1)
Ethnicity baby’s father, partner information        Yes (Patient Demographics on page 1;
(name, occupation)                                  ethnicity of baby’s father addressed in
                                                    Genetic & Teratogen Risk on page 6)
Provider information: referring care provider,      Yes (Patient Demographics on page 1;
prenatal care provider, consultant, baby            newborn care provider is documented in
physician                                           Postpartum Follow-up on page 5)
Intended place of birth                             Yes (Labour & Delivery on page 5)
Obstetrical history: date, site, gestational age,   Yes (Obstetrical History on page 1)
hours in labour, delivery type, complications,
sex, birth weight, present health
Family history: diabetes, heart disease,            Yes (Initial Prenatal Health & Risk
hypertension, birth defects, mental illness,        Assessment-Medical on page 2, excluding
multifetal gestation, other                         mental illness, multifetal gestation, and birth
                                                    defects)
Hereditary/ethnic risk                              Yes (Genetic & Teratogen Risk on page 6,
                                                    with a summary in Initial Prenatal Health &
                                                    Risk Assessment-Genetic & Teratogen Risk
                                                    on page 2)
Medical history: asthma, autoimmune,                Yes (Initial Prenatal Health & Risk
bleeding disorder, heart, hypertension,             Assessment-Medical and Initial Prenatal
diabetes, thyroid, gastrointestinal, epilepsy,      Health & Risk Assessment-Psychosocial on
renal, gynecological, hepatitis/liver,              page 2; transfusion is documented in
HIV/AIDS, STI, tuberculosis, chicken                Obstetrical History-Risk Factors on page 1;
pox/vaccine, mental illness, assisted               assisted conception is documented in
conception, anesthetic problems,                    Pregnancy Summary on page 1)
transfusions, operations, other
Allergies                                           Yes (Allergies & Adverse Reactions List on
                                                    page 2)
Medications: folic acid, prenatal vitamins          Yes (Past/Current Medications List on page
                                                    2)
Environmental/occupational                          Yes (Initial Prenatal Health & Risk
                                                    Assessment-Lifestyle and Initial Prenatal
                                                    Health & Risk Assessment-Psychosocial on
                                                    page 2)
Social/cultural                                     Yes (Initial Prenatal Health & Risk
                                                    Assessment-Lifestyle and Initial Prenatal

Alberta 2018 Prenatal Record (PNR) Pilot • 8

                                                 Health & Risk Assessment-Psychosocial on
                                                 page 2)
Physical examination: weight, height, BMI,       Yes (Physical Exam on page 3, excluding
nutrition, head/neck, breast/nipples, heart,     nutrition)
chest, abdomen, spine/extremities, pelvic
exam/uterine size
Substance use: tobacco, alcohol, recreational    Yes (Initial Prenatal Health & Risk
drugs                                            Assessment-Lifestyle-Substance Use on
                                                 page 2)
Prenatal discussion topics                       Yes (Discussion Topics on page 6)
PAGE 2
Gravida, term, preterm, abortions (by type),     Yes (Pregnancy Summary on page 1)
living children, stillbirth, neonatal death
Pregnancy info: last menstrual period (LMP),     Yes (Pregnancy Summary on page 1)
cycle, estimated date of birth (by LMP and
ultrasound)
Investigations: pap smear, chlamydia,            Yes (1st Trimester Investigations and 2nd & 3rd
gonorrhea, urinalysis, urine C/S, hemoglobin,    Trimester Investigations on page 3)
ABO/Rh, red cell antibodies, HBsAG, rubella,
varicella, HIV, syphilis, gestational diabetes
screen, group B strep
Growth curve                                     Yes (Fetal Growth Chart on page 6)
Genetic investigations: counselled/declined,     Yes (Genetic Investigations on page 3)
rows
Rh-IG: counselled, 1st dose date, 2nd dose       Yes (Rh Immune Globulin on page 3)
date
Influenza vaccine                                Yes (Immunizations on page 3)
Maternal fetal assessments: date, weight,        Yes (Maternal Fetal Assessments on page 4,
urine, blood pressure, gestational age,          excluding cigarettes/day)
fundus, presentation, fetal heart rate, fetal
movement, cigarettes/day, next visit, initials
Fetal movement discussed, chart given            Yes (Discussion Topics on page 6)
Postpartum discussion topics                     Yes (Discussion Topics on page 6)
Newborn requires hepatitis B prophylaxis         Yes (Postpartum Follow-up on page 5)