Chart Abstraction: C A L I FOR N I A H EALTH C ARE F OU NDATION EHR Deployment Techniques Introduction 3. Multi-site expansion. Support multi-site This investigation and analysis of chart abstraction clinics to expand adoption of their existing techniques is the first in a series of tactically EHR product and implementation services to at oriented issue briefs based on lessons learned least three additional clinic sites. Grantees: Issue Brief through the California Networks for EHR ◾◾ Golden Valley Health Centers (GVHC) Adoption (CNEA) initiative. The CNEA program ◾◾ Shasta Community Health Center (SCHC) was initiated in 2006 to speed adoption and lower the overall cost of electronic health records 4. Hospital-based regional extension. Work (EHR) in California community clinics and health with local hospital to extend their existing centers (CCHCs).1 In August, 2008, eight grantees EHR product and implementation services to representing four models of EHR deployment were CCHCs in a region or service area. Grantees: funded to advance the adoption of EHRs in the ◾◾ San Mateo Medical Center (SMMC) safety net and to share their experiences. Following ◾◾ The Children’s Clinic, Serving Children are brief descriptions of the CNEA models, along and Their Families (TCC), Long Beach, with the grantees that are using them.2 California 1. National network. Build or leverage existing EHR networks, often national in scope, to Through this CNEA collaboration, an array of provide for individual or groups of clinics in services is provided to support the adoption of California. Grantees: EHR and other applications. ◾◾ Open Door Community Health Center (ODCHC) in partnership with Our Chart Abstraction Overview Community Health Information Network Electronic health records promise substantial (OCHIN) efficiency and quality benefits to community clinics, but the implementation phase entails ◾◾ Next Generation Health Network an inevitable decrease in productivity due to (NGHN) disruption in workflow, user training, and the 2. Clinic consortia. Work with a California clinic need to maintain both paper and electronic consortia to expand their existing EHR product records during the transition period. Productivity and implementation services to at least three of loss is of particular concern to organizations that their members. Grantees: are compensated on a per-visit basis. Reducing ◾◾ Redwood Community Health Coalition provider schedules to accommodate training and/ (RCHC) or lengthening the duration of each visit reduces provider and clinic revenue and also decreases ◾◾ California Rural Indian Health Board access to care. (CRIHB) F ebruary 2010 A well-thought-out chart abstraction strategy — the ◾◾ Do we have consensus from all providers about the process of entering or “populating” the electronic chart type, quantity, and timing of data entry? Is there a with clinical data from the traditional paper record or decisionmaking body that has authority over these other sources — is one technique that mitigates the loss decisions? How much individual variation will be in productivity and increases provider acceptance. This allowed among the providers? tactical brief offers lessons learned from the CNEA ◾◾ Have we considered all perspectives, including the grantees and provides a framework from which to plan medical records and billing personnel — who will be and assess the chart abstraction process. heavily burdened during the transition period. Start with a Strategy ◾◾ How do we want this information displayed? Should Through clinical committees or other consensus- we allow free text or alter the EHR in some areas so building forums, CNEA grantees developed strategies that only pre-set drop-down menus of responses are that defined what information would be entered, when, available? Will the data entry method evolve over and by whom — weighing the value of the information time (voice dictation first, then moving to templates versus the cost of entering it. Here are some important with structured text)? considerations and questions to ask when developing a ◾◾ How do we incorporate all of our reporting chart abstraction strategy: requirements (UDS, GPRA, OSHPD, etc.) into our ◾◾ Which data are important to have entered prior to a abstraction process? patient coming in, and which are not? Which data ◾◾ How far in advance can we start the process? What are needed at the point of care? will be entered in advance and what will be entered at ◾◾ Is there a sub-segment of our patient population that the visit? should be prioritized, such as diabetic patients or those who seek care frequently? Among the CNEA grantees, most decided to enter some or all of the following data: ◾◾ Do we have a way of identifying our active patients so that we can focus our efforts on their charts? ◾◾ Past medical and or surgical history ◾◾ Should we enter the same data elements for all ◾◾ Allergies patients or does it vary? What are the patient ◾◾ Diagnostic history / recent consultations characteristics that would cause a variation in required data (e.g., pediatric vs. adult)? ◾◾ Last progress note ◾◾ What is the quality of the source data that we want ◾◾ Medications to replicate in the electronic chart? Is it up to date ◾◾ Immunizations and complete? If not, what needs to be done to clean up the data? ◾◾ Health maintenance and disease management indicators ◾◾ For each data element or chart document we wish to convert, what is the best method of entering the data, ◾◾ Alcohol and/or tobacco use how long will it take, and who will do it? 2  |  California HealthCare Foundation Table 1. Chart Abstraction Data Entry Methods Methods for Chart Abstraction Scanning Three primary methods are employed, often in Advantages Scanning has an appeal in its relative simplicity combination, to accomplish chart abstraction: and it remains a necessary method for ensuring that non-electronic clinical information from ◾◾ Scanning documents from the paper chart; external sources gets entered into the electronic record. Extensive scanning of a large quantity ◾◾ Electronic migration of data from legacy of clinical documents can also minimize the number of chart pulls for viewing historical data, systems; and/or enabling the chart to be retired sooner. ◾◾ Manual data entry (free text, structured entry Disadvantages Scanned documents produce an image that from pick lists, or voice dictation). is available for viewing only; the data are not structured or “actionable” and are, therefore, of limited value in the EHR. In addition, some Each of the three methods of building the initial CNEA grantees reported difficulty in organizing and categorizing the scanned documents in the electronic record has advantages and can be used electronic chart, and providers can have difficulty effectively in certain circumstances and with specific types locating the document. Excessive scanning can of clinical information. Conversely, each method presents potentially degrade system performance if the EMR is not architected to support the volume. its own challenges and has associated costs in dollars and staff time. Most of the CNEA grantees worked diligently Best suited for Most recent progress notes (handwritten), diagnostic reports, consult notes from external to build the electronic chart as quickly as possible and sources, patient correspondence. retire the paper chart to minimize the transition period Costs and Generally inexpensive technology. Medical of working in a hybrid paper/electronic environment. staffing records staff is typically responsible for scanning This period is characterized by confusion regarding and can become over­ urdened during initial b implementation. policies and workflow for remnant paper — working with information that is still being captured on paper, Electronic Data Conversion such as forms that are not reproducible in the EHR and Advantages Data that can be transferred from one database to another through an electronic conversion information that comes in from organizations that do not offers an efficient way to “bulk load” the EMR. send data electronically. Demographic data can be converted from the practice management system that creates the shell of an EHR chart. Nearly all of the CNEA grantees continued to provide Disadvantages Most health centers do not have a significant access to the paper chart through the initial go-live amount of clinical information captured period. Some organizations had a formal policy for electronically other than data from registries and chronic disease management systems. Each retiring the paper chart. For example, the protocol might data element needs to be evaluated to be sure call for the paper chart pulls for the first three patient that the definition and format is the same in both the sending and receiving system, and that visits post go-live. Others let each provider determine the data are of high quality. when they were ready to let go of the paper chart at the Best suited for Demographic data, registry data, lab results. point of care. Most clinics were able to place an indicator on the patient’s electronic record indicating that the Costs and Data conversions, like interfaces, often require paper chart was no longer needed at the time of the next staffing programming interventions on the part of both the legacy system and the new PM/EHR vendor, visit. Eventually, paper records can be migrated to off-site which can be expensive. Estimates range storage. Data entry methods are outlined in Table 1. from $5,000 to $20,000 for various types of conversions. Clinic staff needs to be available for testing a statistically significant sample of the data to verify the conversion program worked properly. Chart Abstraction: EHR Deployment Techniques  |  3 Manual Data Entry that further helped providers to rapidly access and Advantages Data entered manually can be input into the organize clinical date in the electronic chart. EHR in a structured format that allows providers to act upon it and that can drive alerts and care ◾◾ At Golden Valley Health Centers, the clinical protocols. Accuracy checking and clean-up naturally accompanies manual data entry, and committee that was convened to guide system the process provides valuable pre-live training configuration and implementation defined what for providers and staff. needed to be converted into the electronic chart and Disadvantages Manual entry of clinical data is time-consuming gave these standards and guidelines to the medical and often overwhelming for staff. records staff for scanning. Providers were given the Best suited for Medications, allergies, problem lists, population opportunity to flag additional documents to be health management indicators, and recall dates. scanned in at the time of the patient visit. GVHC Costs and Although some data can be entered by medical soon discovered that they did not have the resources staffing assistants, medical students, or temporary staff, most entry needs to be done by to convert charts via scanning and manage their daily someone who knows the patient. Providers are operational demands. Their solution was to hold off ultimately responsible for data accuracy. The time-consuming process is costly in terms of on extensive scanning of the paper chart and instead extra administrative time for providers and the continue to keep it readily available as providers potential hiring of temporary staff. need it. At the same time, GVHC was able to make innovative use of scanning as an implementation/ clinical documentation approach. As providers begin their use of EMR “light” — ePrescribing and lab Fine-Tuning the Process ordering — their handwritten progress note for the The CNEA grantees’ experiences with the above methods visit is immediately scanned at any one of several provide fine-tuning techniques as well as insights to learn locations throughout the clinic, thus initiating the from. The examples below illustrate the impact of chart transition to full digital charts. abstraction on staff and productivity, and demonstrate the value of flexibility and constant adjustment of the process ◾◾ At San Mateo Medical Center, scanning existing to obtain the best outcomes. documents for pre-load was left to the discretion of each of the 11 ambulatory clinics. Although Scanning each chart was allowed a limit of five pre-loaded ◾◾Shasta Community Health Center struggled documents (per the decision of the clinical steering with scanning initially. Their challenges were in committee), all clinics elected not to do any scanning organizing and retrieving the data. For example, if prior to go-live, citing inadequate time or resources four radiology reports were scanned into a patient’s available beyond those dedicated to patient care. chart, all four reports would carry the date of the scan rather than the date of the test or consult. To find Electronic Data Conversion these dates, providers had to open each document, ◾◾The Children’s Clinic, Serving Children and their which was frustrating and time-consuming. Shasta Families (TCC) of Long Beach agreed on a standard worked with their vendor to upgrade a software set of data that needed to be entered into the chart module that provides more descriptive headers for and gave providers early access to their EMR so scanned documents. In addition, Director of Health they could preload chart data. Providers filled out Information Services Alexis Parsons devised a detailed a form to abstract patient charts as part of their hierarchical categorization for scanned documents training, and the abstraction process itself forced 4  |  California HealthCare Foundation users to build skills on the system. First, however, ◾◾ SMMC’s pre-EHR documentation environment a “shell” of the chart needed to be created through consisted of dictated notes that were edited and the practice management module. The electronic electronically signed through a vendor’s Web site and conversion of patient demographics was used as a then transferred to the center’s health information way to both build and clean up the database. Social system (HIS). These dictations could then easily be security number, name, and birth date were the only accessed digitally by all providers within the system, fields converted electronically. Each time patients along with laboratory and radiology results. come in they are treated as new patients with all A pre-loading strategy was initiated several months remaining demographic data, consents, etc., updated before go-live. All primary care providers were at that time. Duplicate patients were identified and instructed to do at least one dictation with a new merged as part of the conversion. TCC reported that document type labeled “AEMR Data Extraction,” the entire process has enabled staff to feel confident which included, at a minimum, the problem list, the about the data. patient’s current medications, and allergies. These key data elements had been decided upon by the Clinical Manual Data Entry Standards Committee, a group of providers convened At Golden Valley Health Centers, the overriding ◾◾ to make decisions about EMR implementation, implementation goal was to keep visit activity and content, and display. productivity stable while increasing the use of EHR over time. Allergies and medication lists were entered Interns at the high school or beginning college level by support staff initially. However, it became apparent were hired as temporary help and trained in the task that medication lists are dynamic and changing as of pre-populating the electronic charts with the data. patients navigate the medical system, diminishing the The advantages of this approach were less expensive value of this data-entry effort. Therefore the process labor and protecting clinical personnel so that they was adjusted to have medication lists entered at the could continue to care for patients. A significant time of the patient visit and reconciled at every visit number of charts were pre-populated, and the entered thereafter. data were validated or modified by the clinician when he or she saw the patient. However, it turned out ◾◾ At Clinic Ole, a member of the RCHC network, to be an unsustainable model for chart pre-loading. Medical Director Robert Moore acknowledged that Extra time was needed to train people inexperienced chart abstraction takes time. “It is a productivity hit, in medical data entry and to catch and correct their but it’s an investment in patient safety, quality data, inevitable mistakes. Go-live later revealed charts of and an effective system going forward. If you want extremely complex patients with long problem lists chart abstraction you need to give providers the time and medications numbering in the teens that had not to do it.” Dr. Moore initially gave providers an hour been touched by the interns. When clinicians became a day to abstract the charts of complex patients in the frustrated, SMMC’s provider champion suggested that weeks preceding go-live in an attempt to minimize providers enter only 30 to 50 percent of the crucial dramatic productivity losses as the system went live. data (which would include items relevant to their One hour per day proved to be insufficient due to current visit and immediate future care), and leave the competing administrative activities, and Clinic Ole rest for the patient’s next clinic visit. moved to offering blocks of four to eight hours, in addition to asking providers if they were willing to work some extra shifts to do chart abstraction. Chart Abstraction: EHR Deployment Techniques  |  5 ◾◾ Shasta Community Health Center discussed the Author tactic of using nurses to populate the EMR with SA Kushinka, M.B.A., Full Circle Projects, Inc. medications and other clinical elements, but stressed to the medical staff that it was their responsibility About the F o u n d at i o n The California HealthCare Foundation is an independent to ensure that the entries were accurate. They also philanthropy committed to improving the way health care used clinical and clerical support from the quality is delivered and financed in California. By promoting improvement department to help input certain data innovations in care and broader access to information, our elements, such as the last dates of services for PAPs, goal is to ensure that all Californians can get the care they mammograms, etc. Shasta explored using a private need, when they need it, at a price they can afford. For more company that hires RNs to preload data, but found information, visit www.chcf.org. it too costly for most CHCs. As they started the EMR implementation, the practitioners and their nursing teams started to enter data. Schedules were reduced and the clinicians typically worked several Endnotes hours beyond their normal daily hours to do this. 1.The Blue Shield of California Foundation (BSCF), the They were compensated for these hours and, while California HealthCare Foundation (CHCF), and the expensive, the alternative was to cut access further Community Clinics Initiative (CCI), a joint project of during the day. “It was a tough six to eight months,” the Tides Foundation and The California Endowment, said CEO Dean Germano, “realizing that your most are funding this project. complex patients are typically the first ones you will 2.For additional information about the CNEA initiative see first, and that made it even more difficult.” and the collaborative models of adoption, please see “Making a Connection: Clinics Collaborate on EHR Conclusion Deployment” from the California HealthCare Foundation There is a natural reluctance among providers to at www.chcf.org/topics/view.cfm?itemid=134138. relinquish the paper chart, with all the historical data it contains, and a desire to then replicate as much information as possible in the electronic chart. However, most of the CNEA grantees found that only a few key data elements are necessary to have in the electronic chart at the time of the visit, and there is a diminishing return on the investment of time and energy for entering the rest. Establishing a solid strategy that identifies the key elements of what, when, who, and how the data will enter the chart is essential to getting the job done in a way that minimizes productivity loss and paves the way for a smooth transition. Balancing cost with utility is fundamental to developing the approach that works best for each health center. 6  |  California HealthCare Foundation