The 2018 AHIMA convention session “Improving Quality Measures Through Data Abstraction” will take place Wednesday, September 26 from 10-10:45 a.m. in Lincoln Ballroom A-D of the Miami Convention Center. The Journal of AHIMA recently spoke with presenter Cheryl Rowe for a preview of her session.
Journal of AHIMA: What are you hoping members will take away from your session?
Rowe: I hope AHIMA members take away the message that HIM professionals’ roles and responsibilities must continue to evolve to meet the changing needs of both our external and internal customers. The demand for “big data” within healthcare is constantly growing, due to efforts to improve the quality and safety of patient care and changes in the healthcare delivery system. Meaningful use requirements, new payment approaches that reward good patient care coordination, and other payer incentives are driving the interest in and demand for health information. The ability to capture this data is limited when information is not in defined structured data fields. Additionally, abstraction tasks often fell to clinical staff, such as nurses. who would comb though countless pages in paper records to locate the data. With the transition to an electronic health record (EHR), there became more opportunities to capture data, but only through claims or defined structured data fields. Once again, nurses and other clinical staff were called upon to abstract this data into those defined structured data fields. At the Dartmouth-Hitchcock (D-H) Health System we began to look at how HIM could expand their roles and responsibilities to better serve the needs of our health system and return the nurses back to the job they do best—caring for our patients. I hope that when attendees leave my session, they begin to consider ways that they can transform their HIM departments to play a more active role in capturing and reporting data.
Journal of AHIMA: What should HIM professionals be focusing on now in regards to data quality measures?
Rowe: I believe that HIM professionals should be focusing on how to best capture this data accurately and ensure the information is available to those that need access. Frankly, who else would you want to be collecting and recording your health information (data that must be reliable, complete, consistent, and—most importantly—accurate) than health information professionals? The need for health data is not going to go away any time soon, so HIM has an opportunity to play a key role in capturing this data. This will not only drive future HIM career paths, but demonstrate just how important HIM’s role is within our evolving healthcare organizations. Dartmouth-Hitchcok’s (D-H’s) data abstraction program is especially important because we are members of a number of [accountable care ] organizations, where data-driven, value-based payment models are so important. Information that is not directly interfaced or resulted into the EHR often fails to be captured; data abstraction may be the only means to get this important information in the right place in real time. If a healthcare facility were interested in beginning an abstracting program, it is important to focus on those measures with the highest impact. For D-H we began with flu vaccines, colonoscopies, mammograms, diabetic, eye, and foot exams, to name a few.
Journal of AHIMA: Are there any specific policies and procedures on the horizon attendees should be prepared for?
Rowe: HIM professionals should develop new job descriptions to position ourselves for these roles as they present themselves at our organizations, such as HIM clinical data abstractor. An additional challenge will be to break the stereotype that HIM professionals should never document in the medical record; we had to seek guidance and approval from Senior Leadership to receive security access to enter clinical data. With any new process, there are many procedures to outline the steps for capturing this data. My team not only captures the date of an exam, but also the result, releasing the diagnostic testing order, which triggers notification to the provider of the completed exam. This information is added to the laboratory flowsheet or within the health maintenance module for easy viewing and extracting. Part of the procedure that caused the most concern for providers was that this information would first be handled by HIM, as we are now the centralized repository for the information, who abstracts the data and then disseminates the information to the appropriate provider/department. This is a significant change in workflow that is completely reversed from what is happening in most healthcare settings (that is, information is sent to the provider, who reviews, and then is sent to HIM for scanning into the chart).
Journal of AHIMA: How can attendees start incorporating the lessons from your session in their organization right away?
Rowe: Attendees can start incorporating the lessons from the session in their organization right away by simply thinking outside the box and working to reimagine what the role of HIM professionals should be now and in the future. As technology continues to evolve, HIM must be at the table. We must play a key role in ensuring that information remains reliable, complete, consistent, and, most importantly, accurate. We are the “Keepers of the Record,” and so it is our job to protect the integrity of the information contained within the record. I see this role as one way to not only ensure the information is accurate, but that it is available to meet the quality and new payment initiatives that are the driving force in healthcare today.
I am looking forward to sharing our data abstraction program with other HIM professionals, and while the program is only one year old, we have already seen an increase in mammography, pneumovax, and A1c results. We have heard from auditors that finding key quality measures is faster and easier because we have captured the data in a standardized way. Our staff feel empowered and take the role very seriously—they are always looking for ways to improve the process and gain efficiencies. Additionally, we have heard from our nurses that they have more time to care for patients, who, really, are the reason we are all involved in healthcare.
Cheryl L. Rowe is operations manager, health information services at Dartmouth-Hitchcock in Manchester, NH.