Good work to those lucky obstetric professionals who have responded to the EFM IQ test so far. 91.3% got the first EFM IQ question right. Last week, however, it dipped to 57.8%. This week’s question is another easy one, especially for those attending the upcoming AWHONN California and Minnesota Section Conferences. Click to see how you stack up then visit us at the AWHONN events (we’re a sponsor) to check out how you did and get your “just rewards.”
PeriGen has just launched the Five Minute Challenge offering labor & deliver managers the chance to get a week’s worth of Starbucks. Simply schedule a short meeting and if we can’t tell you how we make great patient care easier to your satisfaction, we’ll hand you a $25 Starbucks gift card. Schedule your Challenge…
PeriGen is offering rewards for those able to answer
four quick, easy EFM IQ questions correctly. Click to try it!
The Journal of Healthcare Information Management has just published an article co-authored by PeriGen’s Emily Hamilton highlighting how administration of oxytocin was improved through the use of electronic fetal monitoring. Click to access
PeriGen brings the total number of births supported by PeriCALM advanced fetal monitoring solutions to 140,032.
Hospitals joining the PeriCALM family include Valley Health and JFK Medical Center serving New Jersey, University of Utah Hospital, Good Samaritan Hospital of Indiana, Riverside Medical Center serving Illinois, and Concord Hospital serving Concord, New Hampshire. For details, click here
The new features & fixes you asked for:
PeriGen is very committed to ongoing improvement of PeriCALM products, especially in answer to customer suggestions and needs. The newest release illustrates this. We’ve added features that enable more documentation on the strip, focusing specifically on your most time-sensitive observations. Documentation now includes systems assessments, pain scoring, and FHR interpretations.
Sites using Epic and those clients subscribing to the PeriCALM full documentation suite will see additional improvements. Here’s a summary of the new features added in release 03.18.02:
New tabs & fields on the tracing annotation dialog:
The following tabs and multi-select fields were added to the tracing annotation screens:
- Systems Assessment: Integumentary, Neurological, Cardiovascular, Respiratory, Gastrointestinal, Breast, Extremities, Psychological
- Risk Assessment: Fall Risk Assessment, VTE Risk Assessment, Skin Assessment, Hemorrhage Risk Assessment
- Recovery Room: Fundus (U+/-), Fundal Height, Uterine Tone, Bleeding Flow, Blood Clots, Bladder, Extremities Movement
These tabs and fields will provide additional flexibility to customers who wish to complement their OB documentation with the official EMR at the site. All additional fields are also included in the read-only Intrapartum Flowsheet view.
Additions/changes to existing fields on the tracing annotation dialog:
The following fields were added to the existing tabs of the tracing annotation screens:
- Maternal Assessment: Added Pain Scales and Interventions fields.
- Fetal Assessment: Added Category field.
- Exam: Added a read-only auto-calculated Bishop Scale (see below).
Added new auto-calculated Bishop Score field:
Under the Exams tab in the Add Annotation dialog, a new auto-calculated field was added. The Bishop Score is automatically calculated based on the values of its five components: Dilatation, Effacement, Station, Cervical Position, and Consistency. The calculation takes into account values observed up to one hour prior to the current exam. The Bishop Score is recalculated when one of the source values is changed. When a maximum score is reached for one of the components, though, it is used for the calculation regardless of its observed time.
A new Acquire Server service for better control of tracings acquisition processes:
The new Acquire Server Service will provide the capability to start and stop acquisition process from Windows Services subsystem as well as control and restart processes that are in an error state or down altogether. This will provide better flexibility to IT staff as well as increased resiliency of tracing Up-time for clinical staff.
GBS field added to the Admin Admission screen:
Starting with this version, a GBS field is added to the Admin Admission screen. This new field is identical to the one present in the Nursing Assessment under Prenatal and Labs section, and can be used as a Chalkboard column with color coding.
Support for Active Directory authentication:
PeriCALM Tracings can now be configured to authenticate users through Active Directory (AD). The PeriCALM Tracings group-based user privilege logic is maintained and only groups (new or existing) have to be replicated in AD to enable authentication. In AD mode, built-in users are only allowed to login when AD is unavailable. In AD mode, since PeriCALM Tracings does not manage or control user accounts, all internal fields that list users are converted to free-text fields
FOR DOCUMENTATION SUITE USERS
Additional fields in Nursing Assessment and Delivery Summary:
Several new fields were added and some existing fields modified to provide better Intrapartum charting coverage especially for customers using PeriCALM documentation to complement the EMR record. The printed reports were updated to reflect the additions and changes accordingly. See Release Notes for details.
FOR EPIC USERS
Support for Epic Single Sign-On using FileDrop protocol:
When used in collaboration with Epic, clinicians can now use the single sign-on module to automatically synchronize login/logoff events on a common workstation. The single sign-on capability assumes an Active Directory authentication configuration on both PeriCALM and Epic.
Record number of customers
join PeriCALM in 2014
PeriGen more than doubled its accounts this year with the addition of 29 new hospital accounts. Among those that we warmly welcome to the PeriCALM family are the following:
- University of Utah Hospital, a 425-bed, 3,469 annual birth facility
- JFK Medical Center, a facility with 2,835 annual births in New Jersey
- Good Samaritan Hospital, a 612 annual birth facility serving Indiana
- Grand Lake Health System, a 250 annual birth facility serving Ohio
- Riverside Medical Center, a 325-bed, 1,198 annual birth facility serving Illinois
- Concord Hospital, a 295-bed facility located in Concord, NH who has 1,300 births last year (including 17 twins)
- Little Colorado Medical Center of Arizona
- North Country Medical Center, a facility with 220 annual births serving northern Vermont
- Ridgecrest Regional Hospital , a 575 annual birth facility serving California
- Regional West Medical Center, a 185-bed, 800 annual birth facility serving Nebraska
- Terrebonne General Medical Center, a 312-bed, 2,200 annual birth facility in Louisiana
- Valley Health of New Jersey
- Capital Region Medical Center (University of Missouri)
- Baptist Health System, a 638-bed system serving Mississippi
I am so very excited to initiate a new newsletter which will enjoy regular circulation throughout our PeriGen family every quarter. Over time, we hope to engage some of PeriGen’s less shy clients as special contributors, and we are investigating interactive aspects as well. We hope to facilitate sharing across our customer base and provide a comprehensive view on practice across country and hopefully the world.
2014 has been quite a year for PeriGen.
It is shaping up to be the single best year in terms of sales of the PeriCALM platform, which is critical because the more hospitals that use PeriGen, the more feedback we receive to inform our product development efforts, and the more resources we can commit to bring those suggestions to light as commercialized software.
- We have added a record number of clients from across the country – and a corresponding number of EMRs with which we now have interface packages, such as Epic, McKesson, MediTech, Allscripts, Cerner, CPSI and others. (Click to see who has joined the PeriGen family.)
- We entered into an agreement with McKesson, to provide fetal surveillance systems to its Horizon client base and to jointly and exclusively develop comprehensive interfacing with Paragon.
- We also reached an agreement to provide Patterns clinical decision support, as well as PeriCALM Tracings, available on the Airstrip and Sense4Baby platforms, so those of you who are (or want to ) utilize Airstrip technologies will have that ability.
- Perhaps more immediately relevant, we have invested in more client-facing personnel and product management roles to strengthen our understanding of how customers use our solutions and, more importantly, where you see areas for improvement.
- We received a few new patents which we are busily developing as the backbone for new, commercial tools.
- Quite excitingly, we completed and released a new version of PeriCALM – version 03.18.02 – which includes significant infrastructure uplift in areas such as Active Directory support, it also resolves the root cause of or most universal support calls, so we expect user satisfaction to increase. (Click to see details on the new version of PeriCALM)
We are busy at working closely with a number of you to test or pilot some new offerings which will come to market in 2015 and continue to improve the level of data you have available to inform your clinical thinking.
After the New Year, I and my management team will make a concerted effort to get in the field to see and hear from as many clients as we can. I look forward to that opportunity.
Chief Executive Officer
by Emily Hamilton, MDCM
Senior Vice President, Clinical Research, PeriGen
“In the New Year, you carry all the experiences of the past years and that is the greatest power of every New Year! This year, you are less student and more master!”
~Mehmet Murat Ildan, Contemporary Novelist & Playwright
Just as individuals gain experience and wisdom on life’s journey, so do organizations, professions and companies. Experience helps because as professionals we are entrusted with responsibility both at a personal and organizational level to provide safe maternity care. Among the myriad of challenges crying for our attention, which ones are critical, have a chance for success, or bring the greatest benefit for our mothers, babies and their families? With the New Year beginning it is time to pause and reflect on some of the lessons learned and past accomplishments because they will help us plan our journey for the coming year. As you read on, note the clarity of insights gained by using “Big Data” and “Wide Lenses” for time and geography.
One of the United Nation’s Millennium Goals – to reduce child mortality, has brought us more reliable data on an important obstetrical topic: namely, intrapartum-related neonatal encephalopathy (IP-NE). On a world scale, intrapartum-related hypoxic events are estimated to have a huge impact – contributing to ¼ of neonatal deaths and ½ of late pregnancy stillbirths. They make the largest single-condition contribution to disability adjusted life-years. 1-4
When one examines progress over 20 years in multiple countries, steady incremental improvement is evident. Figure 1 shows the falling rates of IP-NE in regions including and most similar to the US1 Rates in all the other geographical regions were much higher. They all showed progressive descent fell except for the region of Sub-Saharan Africa.
Two other recent and large studies provide further important insights regarding the nature of IP-NE and related clinical care. 5, 6 Researchers in Sweden, where infant mortality rates are generally amongst the best in the world, examined 71,189 birth records to investigate the association between EFM patterns and neonatal outcome. 5 The rates of neonatal encephalopathy were very low at 1.1 per 1000 births. They concluded that moderate and severe encephalopathy was attributable to asphyxia in 60% of their NE cases and most evolved during labor.
Moving closer to home, Clark et al examined the effect of compliance vs non-compliance with an oxytocin administration protocol in 14,398 women undergoing induction of labor at HCA.6 Oxytocin misuse is a common finding in births with severe metabolic acidosis. 7-9 Furthermore, oxytocin misuse is a modifiable risk factor. In this most recent study compliance was associated with:
- Fewer admissions to the NICU (3.8% vs 5.2% P=0.01)
- Fewer low Apgar scores (4.9% vs 6.4% P=0.04)
- Fewer cesareans (15.8% vs 18.8% P<0.01)
Members of our own PeriGen family have experienced similar success stories. 10 MedStar Franklin Square Medical Center launched a highly successful IT initiative focusing on uterine tachysystole (overly frequent contractions). PeriCALM Patterns fetal monitoring software with built-in pattern recognition and specialized long-term graphical displays was introduced in 2011. At a glance any clinician could detect if uterine tachysystole (UT) was present, if it was transient or persistent, if it provoked fetal heart rate decelerations and see the Montevideo units as is shown in Figure 2.
This study involved the systematic re-examination of each 30-minute segment of tracing from all 10,518 monitored term labors. Comparing years before immediately before and after the introduction of PeriCALM Patterns they observed that:
- The rate of UT with oxytocin fell from 22.7% to 17.3% P<0.0001.
- Average duration of UT fell from 64 minutes to 54 minutes.
- Total time spent in UT fell by 36.5%.
Long term trends analysis is a key component of helping humans see significant trends and to anticipate what is about to happen. In psychological parlance this ability to assess current conditions and project the most likely development is known as situational awareness. In medical behavioral studies it is one of the key skills required across all acute care settings.
Computers are masters of rapid computation and efficient data visualization. Anecdotes from nursing staff related how the displays made easy it was to see when uterine tachysystole was present or even about to occur. Continuous calculations removed the subjectivity of choosing where to count the contraction rates. Quantitative data facilitated communication because predominant patterns were clearly evident. Nurses had the authority to stop oxytocin when uterine tachysystole occurred.
There is abundant evidence today that the human brain has a fixed functional capacity and that every mental task we perform detracts from our ability to do another at the same time. 11 Computers are very consistent at number crunching, that is counting, adding, measuring or doing exactly what they are programmed to do. In contrast, humans are very good at reasoning based on deep clinical understanding Clinicians will always have to integrate EFM tracing findings with other clinical information. That said, the repetitive analytic capacity of PeriCALM Patterns and its long-term displays are useful adjuncts for clinicians. This study demonstrated the synergistic effects of this technology and dedicated clinicians. Together they achieved an impressive reduction in UT.
In summary, what lessons have we learned?
Lesson 1. It is impossible to see progress in rare conditions using small samples over short periods of time. Rates derived from large data sets and trends over long periods are much more revealing.
Lesson #2. A substantial portion of NE arises and evolves during labor.
Lesson #3. The incidence of intrapartum-related NE, a devastatingly serious condition, is falling.
Lesson #4. Clinical actions matter. Oxytocin protocol compliance is associated with better neonatal condition and lower cesarean rates. Uterine tachysystole rates can be reduced.
Lesson #5. Computers and clinicians can be highly synergistic.
No one is suggesting that technology replace clinicians. However, computerization is useful for tasks like calculations, data visualization, reminders and communication thus freeing clinicians to focus applies their energy on higher level reasoning and clinical interventions.
Maternal child health care has come a very long way. Detractors of EFM often refer to randomized clinical trials conducted more than 30 ago that showed no neonatal survival benefit with EFM, although EFM use was associated with a substantial reduction in the incidence of neonatal seizures. In the largest of these studies, deaths or seizures occurred at an astonishing rate of 1 in 225.12 Today, intrapartum fetal death is exceedingly rare and moderate and severe IP-NE are estimated to occur in approximately 1.5/1000 births among the High-Income countries and 0.6/1000 specifically in the Swedish study. This achievement did not happen by chance. Concerted efforts on many fronts have contributed. It happened in part, because most clinicians did not adopt a defeatist attitude such as believing that the origins of IP-NE were beyond our influence or that EFM held no value. Rather these clinicians continued to find better ways to fine tune the imperfect tools that are available and improve our health care systems.
Healthcare informatics has also evolved. We have seen a maturation of software for basic hospital wide electronic medical records and convergence on a few products. With this accomplishment we have seen an increasing demand for the efficient overlay of smart modules with real clinical benefits. In parallel, the PeriGen experience has confirmed our belief that the most useful smart software applications are those that harness the power of computers to do what they do best especially in areas that humans find challenging or time consuming.
As for the New Year, we will continue to apply sound analytical methods on high impact clinical issues where objective quantitative analysis helps clinicians see critical factors or developing trends and intervene in a timely fashion. We have reached a new level in medical informatics and a very exciting one indeed. Stay tuned as we work to bring these ideas to the bedside.
1. Lee AC, Kozuki N, Blencowe H, Vos T, Bahalim A, Darmstadt GL, Niermeyer S, Ellis M, Robertson NJ, Cousens S, Lawn JE. Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990. Pediatr Res. 2013 Dec;74 Suppl 1:50-72. doi: 10.1038/pr.2013.206.
2. Wn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. Bull World Health Organ. 2005 Jun;83(6):409-17. Epub 2005 Jun 17.
3. Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? Int J Gynaecol Obstet. 2009 Oct;107 Suppl 1:S5-18, S19. doi: 10.1016/j.ijgo.2009.07.016
4. Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet. 1997 May 17;349(9063):1436-42.
5. Jonsson M, Agren J, Nordén-Lindeberg S, Ohlin A, Hanson U. Neonatal encephalopathy and the association to asphyxia in labor. Am J Obstet Gynecol. 2014 Dec;211(6):667.e1-8. doi: 10.1016/j.ajog.2014.06.027. Epub 2014 Jun 17.
6. Clark SL, Meyers JA, Frye DK, Garthwaite T, Lee AJ, Perlin JB. Recognition and response to electronic fetal heart rate patterns – impact on newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor. Am J Obstet Gynecol. 2014 Nov 22. pii: S0002-9378(14)02249-2. doi: 10.1016/j.ajog.2014.11.019. [Epub ahead of print]
7. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008 Dec;112(6):1279-1283.
8. Berglund S, Grunewald C, Pettersson H, Cnattingius S. Severe asphyxia due to delivery-related malpractice in Sweden 1990-2005. BJOG. 2008 Feb;115(3):316-323.
Jonsson M, Nordén SL, Hanson U. Analysis of malpractice claims with a focus on oxytocin use in labour. Acta Obstet Gynecol Scand. 2007;86(3):315-319.
10. Smith S, Bunting K, Hamilton E. Using Intelligent Electronic Fetal Monitoring Software to Reduce Iatrogenic Complications of Childbirth: A Case Study.J Healthc Inf Manag, in press
10. Rock D., Your Brain at Work: Strategies for Overcoming Distraction, Regaining Focus, and Working Smarter All Day Long Harper Business. Harper Collins, New York, NY.
12. MacDonald D, Grant A, Sheridan-Pereira M, Boylan P, Chalmers I. The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring. Am J Obstet Gynecol. 1985 Jul 1;152(5):524-39