US healthcare organizations have to spend billions of dollars annually on reporting quality measures. For example, Johns Hopkins Hospital alone spent nearly five million dollars and more than one hundred thousand man-hours on gathering and reporting quality metrics data.
Clinical Data Abstraction Software is widely used by large healthcare systems that provide care to millions of patients, operate dozens of acute-care hospitals, same-day / urgent care centers, primary care clinics, home care and behavioral health services. They report nearly half relative improvement in clinical record extraction efficiency, high accuracy in the Centers for Medicare and Medicaid Services (CMS) and Joint Commission validation, significant decrease in the labor costs for clinical chart abstraction processes, and maximizing reimbursement. What exactly do they do to achieve such successful outcomes?
Healthtech vendors that provide data analytics solutions for healthcare organizations could help. Belitsoft offers software development services for medical SaaS startups — building of SaaS Data Collection and Reporting platform, MVP and PoC development, cloud migration, consulting, etc. They also can customize advanced analytics solutions, such as Clinical Quality Analytics Software for efficiency and accuracy of medical data abstraction.
What are the Challenges for Healthcare Data Abstraction?
Large healthcare systems receive many patients each year and collaborate with thousands of doctors and nurses. So, the volume of clinical data constantly grows. The number of government registries that require data extraction also increases and their requirements for data collection are strict. The lion’s share of the clinical data needed for compliance with regulators and reporting registries is unstructured data that specialists process manually and for a long time.
However, health systems may lack data analytics tools to create evidence-based standard methods for clinical reporting and automate the abstraction of clinical data. Organizations may face non-compliance with government regulators and reporting registries, such as National Surgical Quality Improvement Program (NSQIP), increased costs, decreased efficiency, data quality, and team satisfaction.
One of the goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act is to encourage organizations to implement electronic healthcare records (EHR) to improve the safety, efficacy, and quality of care. The widespread use of electronic healthcare records was intended to replace manual chart review and data extraction and make the clinical reporting process timely and accurate.
EHRs can be poorly designed for clinical purposes. Clinical data abstractors can review maps and assess the abstraction accuracy quarterly. This control system has its weak links — with quarterly checks abstractors can’t find and correct errors quickly. The gaps accumulate.
Clinical data abstractors still manually extract narrative notes and other unstructured clinical data from electronic medical records (EMRs), even though EMRs are constantly customized. It takes millions of dollars annually for healthcare firms. They receive lower reimbursement if the specialists don’t meet CMS’s clinical abstraction accuracy standards in ≥75 percent accuracy.
Healthcare organizations may extract clinical data at different rates and speeds for example, months after patients are discharged. Because of it multiple cases wait to be reviewed. Also, data from various registries may arrive with delays. Abstractors cannot use it as a strategic resource.
Regulators and reporting registries also set core standards that determine what data to collect and how to evaluate the quality of care. They also set requirements for how to fill out documents correctly. If a hospital doesn’t comply with core standards or the documentation is incomplete / inaccurate, CMS may reduce payments.
Standards do change, and it can be hard for organizations to make EHR modifications quickly and then transfer them to staff. Operations can be disrupted if physicians and nurses do not quickly learn new rules and complete the necessary documentation correctly.
What Are the Features of Clinical Data Abstraction Software with Analytics Capabilities?
Healthcare organizations can automate parts of clinical record abstraction about a patient's condition via specialized tools to improve data quality and save money. They identify trends and changes in employee costs, productivity and quality of work. The info obtained helps organizations to gain new ideas and clinical improvement opportunities. Clinical Data Abstraction Software also allows customers for:
What Organizational Measures Are Needed for Accurate and Fast Medical Chart Abstraction Process?
Stakeholders need to take certain actions to achieve a seamless transformation of the standardized process for abstracting clinical data.
It’s necessary to establish management committees that would monitor the consistency of the process, develop and carry out an evaluation system for ongoing value determination. Communication and training are recommended for all key stakeholders in the process, i.e., reporting and pharmacy staff, quality improvement specialists, and EHR support.
Physicians, nurses and clinical data abstractors should be kept informed as new compliance requirements are created or existing ones are changed. This allows organization leaders to maintain high team engagement and enthusiasm.
Abstractors need to work with the reporting group to change the workflow from manual abstraction to automatic, to save resources. Teams should meet monthly. At the meetings, teams identify opportunities to improve the abstraction process. Abstractors review each other's work (case validation and failures) to improve the reliability and accuracy of the process.
Responsible abstractors should verify that all charts selected are accurate and that all required documentation for the request is included before submitting them for CMS review. Quality improvement specialists should train clinical staff to accurately and correctly document regulatory requirements. In addition, specialists should review documentation and workflow to ensure that compliance requirements are met.
Clinical Data Abstraction teams also should work with the teams that ensure clinical decision support to improve the most common processes. They help refine flowsheets, order forms, documentation for discharge, and training of patients to make it easier for providers and clinicians to collect the necessary info.
What Benefits Can Practices Receive While Implementing Clinical Data Abstraction Software?
Automation of medical chart abstraction allows healthcare organizations to improve the quality of collected information. Healthcare institutions that have been unable to pass CMS inspection for a long time demonstrate compliance rates even higher than the CMS norm. This contributes to the increase of the level of experience of the working team and saves financial resources. Among the reported achievements are:
Addressing a Custom Medical Software Development Company
Healthtech companies like Belitsoft offer their services to medical data analytics firms. They develop and tailor data analytics platforms and applications. With integrated analytics systems and operating platforms for data, medical organizations can evaluate their current results in performance, find the weak links and coordinate workflows.
Custom medical software development companies design integrated data platforms with those it's possible to gather, store, process and analyze huge sets of data from laboratory systems, EMRs, billing systems, clinic management systems, etc. Those platforms provide the following functionality:
For those who would like to get high level expertise and comprehensive advice in cloud development (Google Cloud, AWS, Azure), data infrastructure, on-premises or hybrid environments, data analytics, workflow engineering, HL7 interfaces, and data platforms, a medical software development company like Belitsoft can provide these services.
