Keys to a Successful Chart Abstraction Project

Most of us have years of saved digital telephone knowledge, like contacts, apps, texts, and perhaps just a few selfies, that we’re fairly depending on.

So, once we improve or swap telephones, we’ve come to anticipate that our knowledge will simply switch and be accessible on our new machine.

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The identical is true with medical data.

When hospitals swap EHRs (the equal of shifting from Android to iPhone), clinicians, employees, and sufferers, anticipate that the majority, if not all, of the historic chart knowledge captured within the outdated system can be transferred into the brand new system.

As a result of this can be a widespread requirement for EHR changeovers, implementation groups have a whole lot of technical instruments at their disposal to streamline the method and be sure that affected person data within the new system are populated with some legacy knowledge at Go-Reside.

However not like the convenience with which you’ll be able to transfer your trip photographs from one telephone to the subsequent, a complete switch of affected person info additionally normally entails a level of handbook knowledge entry and human choice making by means of a course of referred to as chart abstraction.

What’s Chart Abstraction?

Chart abstraction collects info from a affected person’s legacy medical file and populates that info into the correlating knowledge fields or places throughout the new EHR utility. Virtually talking, it typically requires transcribing or retyping notes from an outdated chart into the brand new one.

Shifting crucial affected person chart knowledge as quickly as doable right into a single supply of reality makes suppliers extra environment friendly and improves choice making on the level of care. It additionally improves person adoption of the brand new system and permits organizations to extra rapidly retire the legacy EHR.

We lately managed a big chart abstraction challenge for a well being system that had made a collection of acquisitions. The brand new websites had been introduced dwell on the group’s most well-liked EHR, however its suppliers and employees had been nonetheless managing between data of their legacy system and the brand new system.

To wean suppliers off of their legacy system, we wanted to speed up the switch of knowledge from the outdated charts into the brand new charts. Utilizing skilled abstractors and a talented challenge supervisor, we up to date near 48,000 affected person charts over a interval of 12 weeks with a excessive diploma of high quality and accuracy.

Preparation and a spotlight to element are crucial for any large-scale chart abstraction course of. As I mirror on our latest challenge, I can spotlight a number of areas of focus that helped us attain our targets and obtain the success metrics outlined by our shopper.

Outline Scope and Precedence

Earlier than the abstractors begin their work, a discovery course of is required to doc the targets of the shopper. The healthcare group ought to outline the info set to be abstracted. It’s not at all times possible to maneuver the complete sufferers file, so key stakeholders ought to determine what knowledge have to be readily accessible to employees and suppliers utilizing the brand new system.

The shopper must also outline the prioritization and timing for his or her charts to be abstracted. For instance, the data of sufferers with upcoming appointments are normally a excessive precedence to make sure that their charts are prepped for impending visits. Organizations may additionally select to prioritize the affected person data of sure clinics or specialty teams, so these preferences have to be captured up entrance.

One other key in pre-planning is to make sure abstractors are able to hit the bottom operating on day one. They are going to want:

  • Logins and passwords for every of the legacy and new EHRs previous to the beginning of engagement
  • A walkthrough of every legacy EHR system and the particular knowledge to be abstracted
  • Detailed directions on the best way to login and entry every of the legacy and new EHRs
  • Entry to a centralized communication / collaboration instrument to escalate points and get solutions to abstraction questions all through the engagement

Guarantee Rigorous and Common QA

A profitable chart abstraction challenge strikes a steadiness between quantity targets and high quality targets. Every abstractor ought to pay attention to their day by day quantity targets and topic to a rigorous high quality assurance course of.

In our latest challenge, we audited a minimal of 10 charts per individual per week with an anticipated high quality rating of 95% or increased. Typical areas of the EHR chart to audit embrace:

  • Issues Lists
  • Immunizations (particularly COVID-19)
  • Drugs
  • Allergy symptoms
  • Affected person Histories (Medical, Surgical procedure, Household, Social)
  • Final Progress Notes per Self-discipline

QA outcomes needs to be intently monitored by group leads with particular consideration to any points which may be widespread to the complete group, or that require particular person consideration and counseling. Extra on that beneath.

Handle and Encourage the Chart Abstraction Staff

Chart abstractors sometimes work remotely and in isolation. Frequent and clear communication may also help them really feel like a part of a group, whereas additionally addressing their particular person challenges and targets.

I prefer to set brief (not more than quarter-hour) video huddles with my complete group at the start of every workday to:

  • Evaluation chart abstraction totals from the day prior to this
  • Share any shopper updates
  • Verify assignments for the day

Outdoors of the group, my leads will set particular person conferences, as wanted, with any group members which are having issue assembly quantity or high quality targets. These conferences permit for direct suggestions and counseling that always achieves the specified impact of bettering efficiency.

Often, people have to be changed. As a greatest apply for useful resource planning, we anticipate some attrition and preserve a bench of certified replacements to maintain the challenge on monitor.

Thankfully, most abstractors are obsessive about high quality and are motivated by optimistic reinforcement. I like to make use of contests and prizes to incentivize efficiency and hold the challenge enjoyable. Saying the winners and awarding prime performers in a gaggle assembly lets everybody cheer on their teammates and creates a bit pleasant competitors that improves outcomes.

In case your well being system is contemplating a brand new EHR implementation and would profit from a managed chart abstraction course of, contact our consultants.


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