The Institute of Medicine (IOM) report Crossing the Quality Chasm called for elimination of handwritten data and set a goal to implement a paperless electronic health record (EHR) before the end of the decade, citing evidence that the EHR improves health care quality, safety, and efficiency (IOM, 2001). The electronic format provides a record of clinical data that are legible, organized, complete, and accessible by multiple users across sites of care and episodes of care. In addition, the electronic records enable a database of clinical information that can be automatically analyzed. The IOM goal immediately reinforced and promoted the present efforts by the government, health care agencies, professional organizations, and industry partners to develop the EHR. The U.S. Department of Health and Human Services (DHHS) established two goals for the effective use of health information technology that are particularly relevant to obstetric patients and fetal monitoring: (a) informing clinical practice and (b) interconnecting clinicians (U.S. DHHS, 2006). Informing clinical practice aims to bring electronic data directly to the front-line providers, to reduce duplicative work, and to provide access to clinical data immediately (e.g., one-time entry of the mother’s expected delivery date that flows to all parts of the medical record simultaneously; immediate access to interpret and document on a fetal tracing). Interconnecting clinicians aims to promote sharing of data with interoperable standards, so information is portable and travels with the patient (such as immediate access to prenatal FHR assessments and diagnostics). The DHHS identified several key strategies to achieve these goals: adoption of the EHR, development of a Nationwide Health Information Network (NHIN) as the interoperable system for the secure exchange of health care information, and development of Regional Health Information Organizations (RHIOs) for local health information exchange. Collectively, these strategies will deliver the right information to the right person at the right time.

The transition to an EHR poses education and practice challenges for currently practicing obstetric
care providers, which can overwhelm the provider and subsequently compromise successful implementation. A multidisciplinary summit sponsored by the American Health Information Management Association addressed such training needs and listed specific actions for not only health care workers, but also employers, vendors, educators, and the government to promote workforce competencies (2006). This panel recommended that health care workers themselves identify knowledge gaps and seek ongoing professional development. Obstetric clinicians must recognize how the national agenda will shape EFM practice with clinical information systems and informatics.

Clinical information systems (CISs) are networks of computers that share clinical data in a digital format, typically bedside computer workstations connected to a central server. The CIS is the backbone or architecture for the paperless EHR. The use of CISs in obstetrics expanded in the 1990s with “perinatal systems” capable of transmitting and displaying the fetal tracings recording from all the bedside stations in the system on all the screens in the system (surveillance), and storing the tracings in an electronic format on an optical disk (archiving). Networks expanded to include remote transmission of the fetal tracings through an Internet connection or wireless device to and from settings outside the labor and delivery unit, such as antepartum testing units and ambulatory offices, on a desktop or hand-held device. Clinicians began documenting on the computer tracing. Gradually, the monitor paper was used less or turned off. This conversion from the traditional fetal monitor paper to a digital perinatal system challenges and changes the actual clinical workflow and requires substantial staff effort. Clinicians need to see direct benefits from the system. Initially, clinicians were most interested in the risk management benefit of what came to be known as “central monitoring,” or the display of all fetal tracings at a centrally located station. With central monitoring, clinicians could monitor tracings when a care provider could not be at the bedside. Quality assurance projects reported less loss of tracings with electronic storage. And soon, clinicians recognized the value of the CIS database functions, including documentation or data entry, data analysis (such as aggregation and trending), and data reporting.

Perinatal systems are niche systems, developed to meet the unique clinical needs in a specialty area. These small systems are generally not integrated or interoperable with the main CIS in the health care organization; however, industry engineers are addressing this constraint. These niche systems are needed as few general CISs have perinatal-specific documentation forms. Some unique issues to consider with perinatal CISs are the following: a direct application of the device on the patient (FHR monitor) requires approval by the U.S. Food and Drug Administration, one admission actually generates at least two admissions, all patients are transferred between units, and the litigation risk is high.