Despite massive adoption of electronic medical records over the past several years, the promise of easy and nearly effortless chart abstraction from electronic medical records enabled by an interconnected web of interoperable EMRs sharing standardized data has yet to be fully realized. You need to look no further than the media tab to see the evidence that we have yet to arrive at this Utopian future.
In addition to diagnostic images, which are supposed to reside in the media tab, there are other documents in there, like lab results, diagnostic test results, pathology reports, discharge summaries, medication lists and problem lists – all containing data that should instead reside in discrete EMR data fields. Having this information in the proper data fields would greatly ease chart abstraction by simply running a report that pulls the data you need into a spreadsheet or data table that can be manipulated easily.
Unfortunately, all too often documents containing the data you need wind up in the media tab because your hospital or practice is still receiving medical records from non-interoperable sources. And because of the high cost of manually abstracting these records, quality and compliance professionals are forced to settle for scanned documents in the media tab – a step in the right direction but one that doesn’t go far enough to ease the pain of abstracting paper medical records.
Rather than wait for this Utopian future to arrive, you can do something about it now. Intelligent clinical data extraction software coupled with a systematic quality control workflow dramatically lowers the cost of chart abstraction with a computer-assisted process that not only reduces abstraction time but also improves the accuracy of abstracted data.
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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.