The healthcare marketplace is in the midst of a remarkably active period of consolidations, mergers, and acquisitions. The healthcare systems that are joining forces must plan for and manage the process of consolidating different clinical documentation systems. Electronic conversion of EHR data from a legacy system to a target system and legacy data archiving are usually high priority considerations during the planned merging of systems. While the electronic conversion of clinical data is helpful, it has limitations including the technical inability to convert certain kinds of data from a legacy system to a new EHR. Also conversion efforts are often costly and many healthcare organizations have to balance clinical needs with budgetary constraints. These limitations lead many clinicians to argue that they need additional information in the new EHR system in order to preserve patient care and safety, expedite medical decision making, and facilitate clinicians’ use of the new system.
The Case for Manual Data Abstraction
Chart abstraction is the process of collecting important information from a patient’s medical record and transcribing that information into discrete fields or locations within the new EHR. Chart abstraction is a manual data entry effort where organizationally-defined, clinically relevant data elements that are not being electronically converted are collected from the legacy system and manually entered into the new target system. Generally, manual chart abstraction begins prior to the go-live event for a new EHR system. However, many organizations will find that manual chart abstraction becomes a routine part of patient care well after the go-live event (e.g., practices use manual chart abstraction to “prep” the charts for new patients to a clinical area, or to add outside records into an established patient’s record).
Benefits of Abstracting Data into an EHR
There are many benefits to manually abstracting clinical information, including:
- Makes discrete patient data readily available in the electronic chart, which allows providers and staff to care for the patient without needing to reference a paper chart or a legacy EHR.
- Makes data available to clinicians for review and reporting on first day of go-live, which can improve provider adoption of the new EHR.
- Allows triggering of decision support alerts related to the information entered during abstraction.
- Allows for faster decommissioning of the legacy EHR since there is less need to reference the legacy system.
- Mitigates risks to patient safety
- Provides continuity of care
- Patients are not burdened with having to relay or restate health-related information that was in the legacy system.
Which Data are Abstracted?
Commonly abstracted data includes scheduled appointments, active or standing orders, allergies, medications, immunizations, problem lists, and patient histories (Medical, Surgical, Social and Family). The chart abstraction planning process may also include the identification of key paper clinical documents that need to be included in the new EHR by scanning those records into the electronic chart prior to bringing the new EHR live.
The amount and type of information that is abstracted depends on the scope and extent of the organization’s electronic data conversion efforts. Generally, there is an inverse relationship between data conversion and abstraction – data that are electronically converted do not need to be abstracted. However, as noted above, even when an organization undertakes a robust and comprehensive conversion it is frequently the case that clinicians will want to have data in the new EHR that are not part of the electronic conversion plan.
Keys to a Successful Abstraction Process
The keys to a successful implementation are planning, preparation, and oversight. As health care executives begin planning for a new implementation or a merger of EHR systems, abstraction should be included in the planning (and budgeting) efforts at the project’s inception. Abstraction planning efforts should always take into consideration and address the following areas:
- Start the planning efforts early in the process. This will help determine scope and budgeting requirements early in the project’s lifecycle.
- Budget for abstraction costs! Ensure that the budget is realistic relative to the abstraction scope (and vice versa). Budgeting for abstraction resources prior to defining an abstraction scope can be challenging. Consider seeking the advice of consulting companies that have expertise in abstraction or contact other health care organizations that have experience with abstraction that they can share.
- Identify and empower key stakeholders to participate in the decision-making related to abstraction efforts. This should include both practice managers and clinicians.
- Determine the scope of abstraction. What data will be abstracted, by whom and when? Are there any special abstraction needs for sub specialties? Which patients will have their charts abstracted?
- Ask questions such as “how does the abstraction scope affect users’ access to the new EHR system, legacy systems, and paper charts?” Or, “When do project-related abstraction efforts (and costs) end?”
- Define oversight/management – who will manage the abstractors? How will they be trained? Will there be a quality review to ensure abstraction is accurate?
The process of consolidating different clinical documentation systems is complicated, resource intensive and time consuming. To maximize the benefits of a consolidation effort it is imperative to devote adequate time, planning, and resources to the conversion and abstraction efforts that support a successful consolidation process. Use the suggestions and recommendations discussed above to help guide you through the abstraction portion of this complex process.
Chart abstraction is one part of Impact Advisors’ comprehensive service for Legacy Data Management that also includes EHR data conversions and legacy data archiving. We offer strategic planning and implementation services that help our clients successfully prepare for and implement a legacy data management project including:
- Creating well-designed, thorough, and appropriately-funded project plans that address all aspects of legacy data management.
- Vendor selection – for archived data solutions, contracted resources for abstraction services, etc.
- Implementation services that support and guide the client through all phases of a legacy data management plan.
If you have any questions about Impact Advisors’ Legacy Data Management Services offering, please contact us.
A shorter version of this blog originally appeared in Healthcare Informatics. You can view that article here.