Considerations for Successful Clinical Data Abstraction

The healthcare marketplace is in the midst of a remarkably active period of consolidations, acquisitions and mergers.  The healthcare systems that are joining forces must plan for and manage the process of consolidating different clinical documentation systems.  Electronic conversion of electronic health record (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. 

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.

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.
• 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 risk to patient safety.

Which Data are Abstracted?

Commonly abstracted data includes scheduled appointments, active or standing orders, allergies, medications, immunizations, problem lists and patient history (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.

Keys to a Successful Abstraction Process

The keys to a successful implementation are planning, preparation and effective governance.  As healthcare 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).   
• 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.

Anna Hundt is a senior advisor with Impact Advisors and has 15 years of health information technology and healthcare operational experience, including managing a variety of projects focused on planning, implementation, and integration of information technology for healthcare clients.