PRENATAL CARE - A SYSTEMS APPROACH â

The Prenatal Care System developed by Advanced Medical Systems, Inc. is a new concept that integrates various components in the management of pregnancy. These include the patient’s history and physical examination, detection and management of risk factors, a flow sheet for monitoring visits and important information, patient education, physician education, periodic updates, and a means of training physicians and their office staff in the use of all parts of the system. This system differs from the traditional approaches that deal with the major crisis in obstetrical care as it provides a means for assuring the quality of the medical data that is collected, the medical decisions that are made and the events, including patient education, that occur during the pregnancy. It makes it possible for you to make your office staff more effective in helping you with patient care. It also provides time for more meaningful contact with patients, time that can effectively be used to teach, listen and more effectively relate with the patient. Improving Practice Efficiency and Documentation of Care are the hallmarks of the system. An innovative reminder system designed into each visit virtually abolishes errors of omission. A computerized version of the system is currently in its final stages of development.

These features have helped it achieve national acclaim for its remarkable track record of reducing malpractice premiums and providing quality assurance for Obstetricians and Family Physicians. It has been most recently been the focus of an article in FORBES Magazine as well as Medical Economics, OB & GYN Survey, AMA NEWS, the Harvard Risk Management Audio Tape Series, OB-GYN News, OBG MANAGEMENT, Family Practice News, Medical Tribune and Medscape.

The Obstetrics Department of the University of Colorado edit, revise and update the system. They, as well as other prominent Obstetricians and Perinatologists in the country, develop future updates and modifications.

The Colorado, Texas, Kansas, Wisconsin, Illinois and North Carolina Academy of Family Physicians have formally endorsed this system and now encourage their physicians to use it. The Ohio State Medical Association Committee on Maternal-Neonatal Health endorsed the system.

The system offers physicians doing Obstetrics reliability in how each user gathers, records data, and responds to problems, especially for physicians covering each other. It is well suited for use in group and solo practices. It was specially designed to maximize the effective use of nurses, office staff, midwifes and nurse practitioners in caring for the patient. In fact in many of the health departments in Colorado the nursing staff provide the prenatal care with very little physician supervision. The system assures patient education at each visit and for most problems that may occur in a pregnancy. It includes a special section on appropriately coding patient encounters to correctly improve reimbursement for the services that have been provided.

This system is used by two Managed Care organizations, Family Health Plan in Milwaukee, Wisconsin (a Family Practice based HMO) and Advantage Healthcare in Grand Rapids Michigan. It is also used by other physicians who are providers in managed care organizations. It is highly effective at detecting risk factors and equally important, assuring that the problems are appropriately managed or referred. It is ideally suited to assure quality in clinics and managed care organizations where physicians often cross cover for each other. The system has also been very effective in providing, community health centers, health departments, and managed care organizations, the quality of care information needed to easily meet state and federal audit criteria, as well as documenting what is needed to document HEDIS criteria for managed care plans.

The Spanish Language version of the Patient Questionnaire, Genetic Questionnaire and Patient Education Handouts have been welcomed and widely utilized.

The systems major components are :

· Flow Sheet and Self Administered Patient Questionnaire and Genetic Questionnaire

· Prenatal Care Guidelines Manual (Physician and staff education).

· Patient Education Master Set of Routine and High Risk Handouts. (Routine topics at each visit as well as handouts for special problems ). Preprinted sets of Routine Patient Education are available

· DVD or Videotape Training Unit - provides important staff training on the use of the system.

· Update Subscription - periodic updates of the manual content and patient education handouts.

Training the physicians office staff to consistently use the system is easily accomplished by means of the self instructional training DVD or videotape that involves the office staff in the care of a simulated patient.

In 1987, COPIC, the physician owned malpractice carrier in the State of Colorado offered this system to physicians providing prenatal care in Colorado. The Colorado Academy of Family Physicians, which initially requested that COPIC adopt the system, has approved the use of the system and has strongly encouraged its use by Family Physicians. COPIC continues to provide the entire system, as well as its forms and quarterly updates, to its physicians. Many of the Colorado County Health Departments and Community Health Clinics now use the system.

The system has been successfully used in Colorado for 16 years. It has been exceedingly well accepted by both Family Physicians and Obstetricians who, for the most part, see it as an opportunity to do something positive about the malpractice crisis. Four hundred physicians attended introductory workshops held throughout Colorado. Many of them now use the complete system, or parts of it, in their practices. In the 16 years of use in Colorado, there have been only four claims filed against physicians who use the system (well over 300,000 deliveries). Two of these claims have been settled for less than $ 50,000. That experience has not been true for physicians in Colorado who have not used the system and have significant numbers of claims filed (over 125 claims in a 4 1/2 year matched time period). The Colorado results mirror our national experience over the past 24 years with over one million (1,000,000) deliveries and only four other claims filed. The expected rate of malpractice claims is 1 per 2-3,000 deliveries when this system is not used. COPIC (Colorado's physician owned liability carrier) has virtually insisted that Family Physicians they insure use the system to remain insured.

During the 16 years of use in Colorado, the system has helped COPIC maintain low premiums for Family Physicians and significantly reduce them for Obstetricians, from $62,000 in 1988 to approximately $30,000 in 2004, a remarkable 55% reduction. This has made it possible for Family Physicians in Colorado, who at one time were being forced out of Obstetrical care, to now have stable and affordable premiums for the past 16 years, to provide this service. For many rural hospitals and communities, this is a vital economic issue. There were quite a few physicians who had ceased doing Obstetrics return to providing it and citing this system as the security they needed.

Besides its use in Colorado, the system is presently utilized by 2000 Obstetricians and Family Physicians in almost every state. These include private practice settings, residency training programs, group practices, HMO’s, as well as County Health Department clinics where nurses, nurse practitioners and midwifes care for a very high risk population.

Many hospitals now purchase and provide the system, its forms and patient education for their physicians. The hospitals, in turn, are using this as evidence of risk management when requesting favorable premium treatment from their insurers.

In Texas, American Physicians Insurance (API/FPIC), a physician malpractice insurer, began a statewide implementation program of providing its insured physicians in Texas with the system in May of 2000. This is an ongoing program.

TMLT (Texas Medical Liability Trust) began providing their physicians with our system in April of 2000.

State Volunteer Mutual Insurance Co. in Tennessee began a statewide implementation program for its physicians in May of 2000.

Associated Physicians Insurance Co. (APIC), previously the Illinois physician owned insurance carrier, provided the system and update service to their physicians along with a 10% premium reduction for its use. ProNational previously PICOM (Michigan), now ProAssurance purchased this company and continues to provide the system, updates and forms to its Illinois physicians as well as to their physicians in Michigan.

Physicians Insurance Co. of Wisconsin (PIC-W) provides the system to their physicians.

Doctors Insurance Reciprocal in Virginia also offered a 10% risk management credit on premium for physicians using this system.

LAMMICO in Louisiana provided the system to selected physicians and practices.

In Texas, API ( American Physicians Insurance Exchange ) offered this system to all of its 500 insured Obstetricians with the prospect of a premium rebate after a year of documented successful use. TMLT ( Texas Medical Liability Trust ), the physician malpractice insurer recently completed a similar program for Family Physicians. The System has been endorsed by the Texas Academy of Family Practice.

MDAdvantage in New Jersey now offers the system to its physicians along with a significant premium rebate for documented use.

The ability of this system to improve the quality of prenatal care is an obvious one. At the present time, a major opportunity exists to significantly improve perinatal morbidity and mortality by more careful attention to the prenatal period. Virtually all of the authorities in the field of perinatal medicine are in agreement that a much more concentrated effort in the prenatal care area will produce important results in the early detection of problems and the opportunity to alter unfavorable outcomes. Some authorities feel that up to 70% of the present liability claims against physicians in the Obstetrical area could have been avoided or successfully defended by use of this "Systems Approach".

The final report of the Newborn Neurological Deficit Study conducted by The Risk Management Foundation of the Harvard Medical Institutions in cooperation with the Physician Insurers Association of America (April 1987) concluded with the following statement:

"Because of inadequate attention to clinical record-keeping, however, these high-risk cases are especially vulnerable in litigation. The principal shortcoming in obstetric care as evidenced in this study is a lack of proper documentation. Even when tests were done, their results are not known. If, as the evidence suggests, high-risk births are prone to complications, care should be especially well documented to ensure optimal outcome. When the bad outcome leads to litigation, as here, the lack of clinical record-keeping becomes acutely visible."

This makes it rather apparent that record keeping is indeed the critical feature in the defense of most Obstetric claims. The use of this system helps in eliminating many of the malpractice situations in which physicians find themselves. In those instances where a suit is unavoidable, the system will at least provide documentation of the level of care and thought processes involved in caring for the patient. Many experts feel this is of major importance to juries.

Prenatal Care - A Systems Approach was developed nineteen years ago as a means of assuring quality of prenatal care. Its basic principal is the integration of the key elements of prenatal care in a single package, designed to accomplish several major tasks. The addition of formal training in its use for those who provide prenatal care (physicians and office staff) is a very important aspect of its success.

"PRENATAL CARE-A SYSTEMS APPROACH Ô " includes the following components:

A PRENATAL CARE MANUAL composed of a loose-leaf textbook (500 pages). Samples of this manual are the Gray Sheets and Table of Contents that are enclosed. The Manual is updated quarterly and provides the practitioner with current information needed to deal with most of the common problems encountered in pregnancy. The descriptions are brief, to the point, and offer the physician options as to how problems can be identified and managed. This represents a state-of-the-art textbook of Prenatal Care, essentially a Users Manual that remains current with advancing knowledge in this field. The manual recommends appropriate consultation when indicated. It assists urban and rural physicians in remaining abreast of current recommendations in Obstetrical care and in making effective use of consultants.

Another important component is the AUDIO-VISUAL TRAINING UNIT. This unit is designed to provide simple and consistent training to all users. Thus, physicians, nurse practitioners, nurses, and the office staff all receive the same training in a simple manner using a DVD or 1/2" VHS Videotape program and a DVD or VCR player. Training takes a little over an hour and uses simulated patients and worksheets that are filled out during the training session.

Most current attempts at achieving success in having people effectively use any system or forms are plagued by the fact that the users often do not understand what they are recording, where they are supposed to record it, and often forget to record what may be essential. In many prenatal charts it is often necessary for physicians to flip through several pages to find the data they need. This leads to omitting essential items of information that may be of major importance in the outcome of a pregnancy.

The FLOW SHEET, which is the large yellow sheet in your packet, monitors the entire pregnancy and permits the rapid evaluation of the pregnancy on one sheet of paper. It can be viewed and audited at a single glance. It provides a very important reminder system so that significant questions, procedures and tests are not overlooked.

All of the essential data in a pregnancy, especially risk data and problems, are included and readily visible on this sheet. The physician’s entire office staff can be effectively involved in the acquisition and recording of this data if that is desired. Our users claim that the flow sheet makes it impossible to forget the essential steps in care.

A Flow Sheet Extension Form make it easy to track additional visits in the rare instances where extremely frequent visits occur.

The DATA BASE QUESTIONNAIRE FORM represents a modern method of acquiring the information necessary to fully evaluate the risk status of any pregnancy. It is a comprehensive health history questionnaire for women. It includes such information as significant genetic factors and occupational exposure to chemicals and radiation. This is supplemented with a specially designed Genetic Questionnaire for practices desiring more information than that contained in the standard questionnaire. The patients usually fill out the forms themselves, or the office staff can assist them. A Spanish version of these questionnaires is also available.

THE PATIENT EDUCATION COMPONENT includes Yellow Handout Sheets and Pink (High Risk) Handout Sheets provided as a set of masters with the purchase of a complete unit. This provides a means of assuring that patient education is no longer a haphazard event. Instead, it becomes a task performed at each and every visit with predetermined patient education as well as education that is tailored to fit unanticipated special problems or procedures that may occur during the pregnancy. They are written at an easily understood national reading level.

These patient education materials are a major component of the system and are provided for the physician to use in his/her patient care. They may be photocopied by the physician and distributed to his/her patients at each visit, or the yellow (routine) patient education may be ordered through the publisher (saving your office staff valuable time). This makes patient education an integral part of each visit. This assures that the patient becomes an active partner in the health care process. Patient education is recorded as having been provided and thus aids in preventing litigation caused by failure to educate or failure to record what was said or given to the patient. The patient education handouts are provided as a set of masters with the purchase of a complete unit. A Spanish language version of the patient education is available as a master set and the yellow (routine) Spanish handouts may also be ordered through the publisher..

An important component of the system is a subscription to the PERIODIC UPDATE that is published three times a year and sent to physicians in loose-leaf format, to be added to or substituted for pages in their Manual. This acts to keep them and the system current as changes in Obstetrical recommendations (ACOG Guidelines) and practice occur. Changes in office management and the coding of office visits are included. The update also includes revisions of existing patient education as well as additions of new patient education topics.

Satisfaction studies on the system have shown an overwhelmingly positive response by the patients, physicians and staff.

This system is quite different from others that claim to be systems and are in reality just forms. Forms alone, do not constitute a system, and are usually ineffective. It is indeed the complete and integrated nature of the components in providing comprehensive patient care that make this system so successful. Our special reminder system that is built into each visit is very effective in eliminating the occurrence of "things just slipping through the cracks".

A prominent physician educator recently equated the current state of quality assurance and risk management in Obstetrics as comparable to going to combat in a camouflage suit. He further elaborated by stating that our Prenatal System is in contrast, analogous to using a bullet proof vest in the same situation.

Advanced Medical Systems, Inc.

440 E. Cheyenne Mtn., Blvd. Suite #26

Colorado Springs, CO 80906

Phone: 1-800-876-7145

Fax: 1-719-538-0735

Website: www.amsintl.com