September 22, 2023

“How’s the baby?”

Jennifer Morrow doesn’t remember much after hearing her intake nurse ask about her son at her postpartum visit. Instead, she describes how she essentially “blacked out” after the awkward conversation that followed; her son, Matthew, had died shortly after his birth.

“This was after I notified the front desk of what happened when I handed them back my Postpartum Depression questionnaire–that my answer reflected infant death and that they make the staff aware,” Morrow said. “The receptionist kind of assured me that the staff knew.”

Morrow also assumed the nurse knew because Matthew’s death was expected; he had been diagnosed with a terminal condition at Morrow’s first ultrasound. When Morrow and her husband chose to continue the pregnancy, doctors told them to prepare for miscarriage or stillbirth due to “multiple fetal anomalies not compatible with life.” 

It was all there in Morrow’s chart. Surely, the nurse knew he had not survived.

Unfortunately, she did not. 

“After she asked how the baby was, I kind of choked,” Morrow said. “When I told her he died, I could see her scroll in her chart a little bit until she found the note.” 

Jennifer Morrow and her husband embrace their son, Matthew. Matthew was diagnosed with a terminal condition at Morrow's first ultrasound during the twelfth week of pregnancy; he died two hours after his birth on December 5, 2017, due to "multiple fetal anomalies not compatible with life." The cause of his condition is unknown as genetic test results were normal.

Tragically, Morrow’s story is not unique. According to a 2019 report from the Centers for Disease Control and Prevention (CDC), there are approximately 23,000 stillbirths* and 21,000 neonatal** deaths in the United States each year. While there are no reports or studies on the frequency of communication errors regarding stillbirths and neonatal deaths, a quick glance at social media reveals hundreds of other women reporting similar experiences:

"I called to set up my six-week postpartum appointment and they said congratulations and asked how [my son] was doing. I was shocked by the question, as if this had never happened before, making the isolation that I was already experiencing even worse." 
Nikki
"A nurse from my OB's office called me two weeks postpartum to ask how the baby was doing...[this was] after I called and told the front desk and a nurse and my OB that my son died in the NICU. I skipped my [postpartum] appointment because I couldn't deal with explaining again and again."
Cathy
"I had a 39-week stillbirth and my hospital record literally says 'baby had no complications and was discharged to home with mom.'" ... In hospital, they texted me 'congratulations' after I replied to their reminder for my appointment, which I was missing because I had just delivered my son."
Katrin

A grief and wellness coach, Morrow used to work at a sports medicine office that used electronic health records (EHR) systems. Following her experience, she was shocked to learn most systems contain no alerts or prompts specifically designed for stillbirths or neonatal deaths.

“I have never understood why it’s not flagged everywhere in the chart and EHR, just like an allergy or other alert for a patient would be,” Morrow said. “I know very few women who have had a positive postpartum visit experience after their baby’s death and it is so preventable.” 

Heather Florescue, M.D.

Dr. Heather Florescue agrees. An OB/GYN at Women’s Gynecology and Childbirth Associates (WGCA) in Rochester, New York, Florescue said it should never be the patient’s responsibility to inform or remind the practice of their loss.

“The onus is really on the provider,” she said. “A lot of times this is the providers dropping the ball and not taking the time to communicate with staff.”

That said, Florescue does believe programming enhancements to EHR systems could help.

“Anything that forces [the user] to view information is really important,” she said. “It doesn’t mean the person will read it, but it can be very helpful.” 

Florescue has used MEDENT’s EHR system at WGCA for nearly 10 years. She also uses Epic Systems at the local hospital and has used Greenway Health in the past. 

“One of the nice things about MEDENT is that the screens are very big and encompassing, so anything that is an alert is really very clear to see,” she said. “A lot of other EHR systems like Epic have these little icons and if you don’t hover over the icon or a small sticky sheet, you’re not going to see it.”

While Florescue and Morrow agreed that the responsibility ultimately falls on the practice and the provider to properly communicate these situations, both believe EHR systems could play a vital role in helping practices identify patients who have experienced a stillbirth or neonatal loss.

“In busier practices, prompts, alert icons, things that change color…those kinds of things can make a difference,” Florescue said. “I think the biggest place this [miscommunication] happens is in the scheduling of the appointments; it looks just like any other postpartum appointment. So anything that would separate that out might be a win.”

“There needs to be some kind of prompting of health of mother and health of baby,” Morrow added, noting that any alerts and prompts should extend to patients with babies in the neonatal intensive care unit (NICU) as well. “A required field similar to alerts of allergies. Some kind of identifier of the baby’s status within the mother’s chart that can change things from a viewing perspective so it is not so easily overlooked.”

Morrow suggested the ability for the provider to create an alert at the time of documenting delivery so the scheduling team and follow-up care team members are aware while talking to the patient in all future instances. Florescue went a step further to encourage the EHR system to prompt and remind all staff members, from scheduling and check-in personnel to medical assistants and providers. 

“I think the biggest thing electronic medical records can do is just prompt the person who is scheduling the appointment, prompt the person who is checking people in, prompt the medical assistant, prompt the provider,” she said. “People are burnt out…[As an OBGYN], you see too many people and you don’t take or have the time to make sure every patient is getting what they need and it just snowballs from there. So any additional prompts and reminders could be helpful.”

*Stillbirth refers to the loss of a baby before birth, typically after the 20th week of pregnancy.

**This number includes both early neonatal deaths (within the first week of life) and late neonatal deaths (between 7 and 28 days).

How an EHR system can help

 

Stories like Morrow’s highlight the importance of accurate and comprehensive information within EHR systems and effective communication practices in healthcare. Here are some ways EHR systems can reduce the risk of communication errors, misunderstandings or inappropriate interactions with patients who have had a stillbirth or neonatal death:

Documentation and History

EHR systems can include specific sections or templates to document emotional and psychological aspects of care. This allows healthcare providers to capture and track the patient's emotional state, grief reactions, and any counseling or support services provided. These records can help ensure that the patient's emotional well-being is addressed during subsequent healthcare visits.

Decision Support and Education

EHRs can provide decision support tools and educational resources to healthcare providers. They can offer evidence-based recommendations, guidelines, and educational materials related to stillbirth prevention, management, and counseling. This assists providers in making informed decisions and ensures that patients receive appropriate information and support.

Alerts and Reminders

EHR systems can be configured to generate alerts and reminders for healthcare providers. These alerts can help flag patients who have a history of stillbirths, ensuring that appropriate care and monitoring are provided during subsequent pregnancies. Reminders can prompt providers to check in on the patient's emotional well-being, offer additional support, and ensure appropriate follow-up care.

Care Plans

EHRs can facilitate the creation of personalized care plans for patients who have experienced a loss. These care plans can include information on recommended follow-up visits, tests, and interventions tailored to the patient's specific needs.

It is important for healthcare providers and organizations to leverage the capabilities of EHR systems and customize them to meet the specific needs of patients who have experienced stillbirth or loss of a baby. 

MEDENT Features

MEDENT is a comprehensive EHR system used in healthcare facilities. It offers the following features that can assist in providing support for patients who have experienced stillbirth or the loss of a baby:

MEDENT’s Alert Sheet warns all users about issues regarding the patient. Alert Sheets can be added anywhere documents are added. If the patient has an Alert Sheet, it will display immediately when entering the patient’s chart, depending on the user’s chart options settings. 

Throughout MEDENT,  will display next to the patient’s name. Click the icon to view the Alert Sheet.

If a patient chart has an active alert, when a user clicks into that chart the alert pops up. 

Answer Yes to Only show patient alert once per day? to only get the popup once per day, per patient that has an alert. 

Answer No to get the alert popup every time the user clicks into a chart that has an alert. 

If an alert is changed or if a new alert sheet is created on an account that a user has already clicked into that day, the alert will pop up the message as if it was the first time that a user clicked into the chart that day. 

Assign patient characteristic(s) to the patient. When characteristics have been assigned, a tab will display at the top; each characteristic will have its own tab. 

Patient Characteristics are customizable per office and can be used to track patients through DM and/or the Patient Information Report.

 

Users can turn on MEDENT’s Sidebar to display important information and links along the right side of the screen.

Many of the MEDENT screens can have information and links formatted in the sidebar for the particular screen. Each screen is set up individually by clicking the gear icon and Configure sidebar gadgets. 

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