5 Factors in a Successful Medical Record Abstraction

Medical record abstraction can be a laborious and exhaustive part of an EHR go-live for a hospital. But it is a necessary process in which quality is key because it directly impacts patient care.

Given that clinicians depend on the information in a medical record to treat patients, timely and accurate chart abstraction is essential to providing quality care in patients’ first appointments after go-live. When abstraction is done well, health systems avoid problems like incomplete medical records or duplicated patient notes.

In this post, HCI’s experienced EHR go-live team identify 5 key factors to a successful medical record abstraction.

1. Speed

Timing is essential in abstraction. A successful chart abstraction typically starts a month or two before go-live.

The speed with which the abstraction project is completed depends largely on the resources committed. Though a health system may be able to use internal staff to extract records from the legacy EHR and enter them into the new system, external abstractors can usually complete the project faster.

Also, in leveraging external abstractors, a health system’s internal team can better focus on learning the new EHR. The extra time and experience are vital for clinicians.

2. Accuracy

While abstracting records quickly is important, speed should not come at the expense of accuracy. Thus, an efficient process that is also accurate is paramount.

Efficient abstractors are trained in how to identify the most important information in a chart and enter it into the new system properly. Experience with different types of EHRs helps in this process because sometimes an abstractor may not be able to copy and paste information from one system to another.

Abstractors may have to choose from a drop-down menu of choices in the new EHR, for example. Having the necessary knowledge and experience allows efficient abstractors to maintain accuracy by confirming that the right choices are made and that accurate information is entered into the new EHR.

3. Flexibility

Some health systems like to pay external abstractors by the hour while others prefer flat fees, like per chart abstracted. The right chart abstraction provider can help a system determine the best pricing model for the project and work with them accordingly. For example, charging on a per chart abstracted basis as opposed to a more common per hour of work per resource model transfers the risk of slower-paced abstractions away from a health system.

An abstraction service should also be able to coordinate with a health system to complete the project within a system’s preferred timeline. Leading abstraction providers can confirm that they will have the resources needed well in advance because they have a robust pipeline of abstractors that stay busy, steadily rotating from one project to another.

Leading abstraction providers do not have to train abstractors for one go live at a time either, moving them up the learning curve in each instance. Abstractors can focus on accurately completing as many charts as possible ahead of the go-live instead, thus allowing clinicians to be prepared to meet with patients when go live starts.

4. Scalability

Some abstraction services may be fine for smaller projects, like 5,000 charts, while others may be well suited for big go-lives involving tens of thousands of medical records, or even hundreds of thousands. Ideally, an abstraction services provider could scale up or down to meet a health system’s needs.

Such scalability comes from having enough abstractors to staff multiple projects of varying sizes. This allows an abstraction service to help a health system with staggering go lives, perhaps including locations of different sizes.

Also, if an abstraction provider does not have to hire new agents, it can deploy the same resources across multiple waves of abstractions. Doing so provides incremental efficiencies for a health system as resources become familiar with the organization and its workflows.

5. Visibility

Watching an abstraction service’s progress in real-time can give a health system assurance. If a system can see how many charts have been abstracted and how many are left, it can tell whether it is on track to be ready for go live. And, if it is behind, the system can work with the provider to get back on pace.

Dashboards are the optimal visibility solution. Some abstraction service providers track progress like how many abstractions are completed in a day as well as how many are done by wave and how many are left before a given appointment date. Displaying such measurements in a mix of graphs, bar charts, and other forms of data can create confidence that abstractions will be done before patients arrive at the office.

Record abstractions must be finished before a patient’s first visit after go-live because clinicians need the proper information to provide quality care. Therefore, speed, accuracy, flexibility, scalability, and visibility are crucial to a successful chart abstraction project. 

With HCI Abstraction Services, you can rest assured that you are receiving efficiency, visibility, and above all, the utmost quality on your medical data abstractions.

Contact The HCI Group to learn more about how we can provide quality results with measured efficiency.