Clinical data abstraction is often one of the last steps in the patient care information workflow. Typically it's performed for the sole purpose of submitting data to compliance or quality improvement measurement programs.
What if you were able to perform data abstraction immediately upon receiving medical records from outside providers (labs, diagnostic test centers, pathologists, etc...) and capture the data in the designated, structured EMR data fields before patient care begins?
Would having that information in discrete fields in the EMR from the very beginning of the patient's journey be helpful and might it have a positive effect upon the overall quality of care?
Recently we conducted an informal survey with oncology clinicians to understand what records they routinely access in the media tab / documents tab in the EMR. Below is a list of the documents that respondents reported having to routinely access in the media tab.
Furthermore, the survey asked them to rate their like or dislike for searching through documents in the media tab. Perhaps not very surprising, 60% of respondents reported disliking this part of their job and 80% agreed or strongly agreed that the desired data from these unstructured records should be captured in discrete fields in their EMR.
While the survey sample size was too small to draw any scientific conclusions about the impact that unstructured medical records may have on clinicians and thus adversely affect the care they provide, the feedback in the survey is consistent with what we hear from our customers as we help them streamline clinical data abstraction workflows. That is, that the time and effort to wade through dense unstructured text documents in search of key pieces of data wears down busy clinicians who are already stretched thin trying to keep up with their workload. It's logical to conclude that the stress this places on clinicians can lead to 'media tab fatigue' and in turn have an adverse effect upon patient care.
Can the clinical data abstractors on your staff be a solution to this problem and be agents of care quality improvement and not simply data collectors for compliance and quality measurement programs? We believe they can. But in order to do so they need a technological boost to avoid being a bottleneck that delays care with labor and time-intensive manual data abstraction.
If you're going to the ASCO Quality Care Symposium later this month and would like to discuss this topic further with one of our clinical data abstraction experts, you can reserve a meeting time convenient to you. If you do, and you visit us at our booth, you'll also be entered to win an iPad Mini!
About the Author: Greg Gies
For 20 years in the software industry, Greg Gies has been helping businesses, government agencies and healthcare organizations achieve their goals and carry out their missions by making better use of information and automating business processes. Greg has held positions in sales, product management and marketing and holds an MBA from Babson College. He works and lives with his wife and three boys in the Boston area.