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Can Medical Record Abstraction Be Automated?

Can Medical Record Abstraction Be Automated?

Ahhh, the age old question.  Can (or should) tasks that humans can do very well, but perhaps not very efficiently, be automated with technology?  While the views on this topic would vary greatly from an abstraction service provider to a low-budget medical research project manager, there are perhaps a few things that could be defined to help one decide what is best for their particular medical record abstraction situation.  Consider these ideas:

Population health without complete clinical data is like...

Population health without complete clinical data is like...

Your incomplete data set doesn’t tell you the full story.

A population health management program without the ability to analyze a complete set of clinical data is like reading a book with missing pages.  You’re left with only your imagination to fill in important details.

Is quality reporting in the EMR age not what you thought it would be?

Is quality reporting in the EMR age not what you thought it would be?

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.

Is EHR Interoperability Dead on Arrival?

Is EHR Interoperability Dead on Arrival?

Recently, Andy Slavitt, the CMS acting administrator, announced that CMS will likely end the Meaningful Use program this year.

Does that mean that the hopes of an internet-worked healthcare system that’s able to seamlessly share health information are completely dashed before interoperability truly got off the ground?

Is Your EMR Inbox Managing You?

Is Your EMR Inbox Managing You?

There’s no question that users rely on the EMR In Basket for day-to-day workflow management. The “In Basket” or “Inbox,” depending on what EMR you’re using, provides a centralized location to receive notifications and important patient information, such as admission and discharge notifications, new lab results, refill requests, patient calls, appointment reminders, patient portal communication and much more.

Specialty clinics still using paper? Get that data into your EMR!

What I know for Sure:

Discrete, trending data is the bread and butter of a specialty clinic.

Hunting and pecking through the media tab to track down information on a patient is infuriating! And not only for the doctors. For nurses. For abstractors. For the patient! Trending a post-transplant patient's drug levels alongside their medication doses, rejections, infections, transplant history, UNOS data, procedures, and relevant transplant-related scores is of paramount importance to a clinician and is very time sensitive. Getting all patient data into the EMR is the holy grail when it comes to specialty medicine.

Specialty clinics, especially transplant clinics, are mini-ACOs. 

When you are treating an acute, chronic disease it is critical that everything about the patient is known regardless of where they are being treated on a daily basis. Luckily, we now live in a world of Care Everywhere, CCD documents, and reference labs…BUT, despite what everyone wants to believe, these things are not a panacea.

Paper is very much alive and well in the healthcare world. 

Sometimes clinicians are "closet paper users," other times they just lay it out there. But don't make any mistake about it…they are using. In the transplant world, you may be familiar with the "wall chart." Also known as "the flowsheet" or "the flowchart." You know the one. The monstrous grid that is the holy grail for the transplant clinic, but is the disdain of the HIM team and the project team trying to migrate clinicians to the EMR. But there are good reasons for this chart and the other paper being used. Many hospitals have not implemented effective document management strategies that classify documents in useful ways. And many hospitals don't have the resources to support entering (and QAing) important data discretely as it comes in from external sources (or even internal sources such as the pathology lab).
 

Specialty clinics are crazy busy. 

There were times during my tenure at Epic that I felt stressed. That I felt my days were busy. That I felt it was hard to create work/life balance. And then I'd go onsite and spend a week in a transplant department. Wow. My workday was like a walk in the park! The chaos that is the life of a person in a specialty clinic is very hard to explain or quantify. It seems there is not a moment to breathe. And this isn't just for the doctors and nurses. Even the folks doing data entry are getting calls, being pulled into other things, being tapped on the shoulder constantly. It is nearly impossible to give something 100% of your attention.
 

Extract's products can help. 

I'm a passionate person. I don't back something I don't believe in and I don't work for companies whose product doesn't excite me. When I first encountered the Extract product I was very skeptical. Optical Character Recognition (OCR) with clinical data? Fuggettabout it! However, I've been able to peel back the curtain. The magic isn't in the OCR, it's in the rules, logic, and processing that Extract has fine-tuned while working with numerous healthcare organizations. I've seen it in action. I've seen the product improve with features that allow more reliable mapping to patients and existing orders. I've seen it process large documents and auto-classify subsections of that document and route them accordingly (think referral packets, transplant folks!). I've seen it work. I believe in the product and think it can improve data quality, care quality, data entry efficiency, EMR user happiness, and much more.
 

Extract's products aren't restricted to specialty clinics. 

Yes, it is very easy to see the benefit of using the product to discretely enter lab results or split/file referral packets in a specialty clinic. But once you've seen it in action, it's very hard not to let your imagination run wild. Have an HIM department that is backlogged and needs some help classifying and discretely filing data? Have a natural speech recognition engine that needs some intelligent processing and filing after the output is generated? Have Care Everywhere but wish that you could get some more discrete data from it, such as labs? Still have paper DNR, release forms, or patient surveys coming in and want them to be discrete?

Have any other ideas?

We want to hear them! You can email me directly to discuss your ideas further.


About the Author: Rob Fea

He has spent 12 years partnering with IT teams and clinicians at major hospitals and clinics worldwide during his tenure on the technical services team at Epic. For the vast majority of his time at Epic, Rob supported Epic's Phoenix product, playing a major role in project kickoffs, installation, data conversions, ongoing support, and optimization. During his tenure at Epic, he watched the Phoenix customer base expand from 0 to 55 live and installing transplant organizations. It was a terrific experience and he loved every minute of it. It gave him expansive insight into the healthcare world, especially the solid organ transplant industry. Rob has spent countless hours on the floor in transplant departments observing multidisciplinary visits, committee review meetings, data entry, data trending, reporting, medication dosing, and more.

Better Healthcare Data: Three things I learned from customers in 2015

Better Healthcare Data: Three things I learned from customers in 2015

With the final days of 2015 upon us, I would like to thank Extract’s customers and colleagues for your support and engagement this year. It’s been a significant year for our company which I’ll boil down by sharing two exciting milestones.

Mergers & Abstractions: Merging EMRs Feels Like A Forced March

Mergers & Abstractions: Merging EMRs Feels Like A Forced March

For those involved in the manual abstraction effort, the tedious nature of this work can feel like a forced march. As a result, EHR implementation costs rise, data quality deteriorates and morale suffers. It doesn’t have to be that way.

No lab interfaces? No problem.

No lab interfaces? No problem.

If you’re responsible for managing the process or technology for relaying test results from reference labs to ordering physicians, you’re probably familiar with the difficulty of handling non-interfaced clinical lab results even if you’re not familiar with the term “non-interfaced.” 

Transplant Outreach Part 5: How do I manage growth and ensure long term success?

Transplant Outreach Part 5: How do I manage growth and ensure long term success?

You have successfully set up your outreach program and established a strong local presence (please check out my 4 previous posts on this topic). What now? In order to achieve sustainability, you will have pressures to improve efficiency, reduce costs and demonstrate value. It is important to have in place a methodology by which you track your activity from both a quantitative perspective as well as to be sure that the quality delivered matches the quality of your main program.

The Needles in the Haystack – Case Finding Tools

The Needles in the Haystack – Case Finding Tools

Case finding is a never-ending cycle of review and follow up. It’s an enormous manual effort to abstract data from patient files to populate hospital, central, state or the National cancer database to complete the case entry; as well as checking on the status of cases in suspense and quality control that binds it all together. Though I’m not a certified registrar myself, I definitely get the impression from those that I have spoken with that they continue to be fiercely devoted to the important work they do; and are steadfast in getting it right.