This is part 3 of a 3-part series: EMR 101.
Along with Step 4, Step 5 starts to open the door into EMR 201: Getting Really Good.
If EMR 101 is about surviving the day, EMR 201 is about getting efficient, which enables you to think widely and deeply about patient care, as well as proactively.
Step 5a: Abstract
Abstracting refers to distilling old chart or patient record info directly into your EMR. It differs from scanning those other records, in the same way that data is different from information – one is raw potential, the other is immediately useful.
- A scanned chart, or hospital discharge summary, is just a snapshot, an image in your medical record reference files. It can be accessed and read, and key info extracted, but until someone actively accesses, reads, and extracts that information, it stays “hidden” in that stored picture.
- An abstracted record, on the other hand, has those key elements already extracted and transferred into your EMR where it can be quickly accessed.
More important than speed, that abstracted information can spring into action in your electronic medical record.
“Will no one rid me of this meddlesome transcription?”
So the date of a colonoscopy report can trigger an alert when the patient’s next one is due. The date of a flu shot can trigger a reminder to give them another one this winter.
Abstracting jump starts a patient’s chart; without it, you’re missing critical information you need to treat patients on the spot. The key is to streamline that initial process.
Preferably, without you being the one doing it all, especially during the first patient visit when you should be focusing on other matters.
Step 5b: Delegate
Ideally, the electronic chart should be ready for you from the very moment you “open” it during your first patient contact.
A physician often ends up being the one inputing the “critical info set”:
- dates of certain past tests
- diagnostic codes corresponding to diagnoses for the chronic conditions list
This results in the most accurate carryover, but at a high cost. Abstraction at this point is little more than transcribing — words from paper column A, entered into data field B. If you’re doing this regularly, congratulations on being one of the most highly paid and frustrated typists on earth.
Get good at entering the diagnosis codes, especially, and remember: this is temporary.
Delegation rears its screaming head, here — “Will no one rid me of this meddlesome transcription?” — but it actually starts long before. If your data source is legible, like from a typed hospital discharge note or a clear-clear chart summary sheet, you’re in luck. It’s possible to assign office staff (or hire personnel) to do the transfer, as closely as the day before the patient visit.
If your data is illegible, like your own handwritten notes (or where the critical data is scattered throughout), you’ve got to suck it up, plain and simple.
Get good at entering the diagnosis codes, especially, and remember: this is temporary. As the patient visits increase, the visits themselves build the necessary context for future judgments.
As long as you’re accepting new patients, the abstracting and delegating will never entirely disappear. To keep it manageable — and guard against imported data that you haven’t approved — consider the following physician/staff workflow:
- Never allow records to be scanned without you signing off on them. The last thing you want is a damning piece of buried data that you will be responsible for, that you never saw, except at deposition.
- Keep an inbox for documents from elsewhere, and using the previously mentioned batch processing method, work through it steadily at set times of the day.
- Have a highlighter, or better yet, sticky pad labels (the kind that mark forms where you have to sign?), and mark the info bits you want your staff to enter into the chart, such as
- entire EKG’s
- dates of colonoscopies, mammograms, Pap smears, vaccines
- any other “stick pin” items you must track or update over time
- Pass the documents to staff in an outbox, to enter just the choice highlighted bits, then off to the general scan pile.
This way, you are not being bogged down with abstracting, your staff isn’t having to wade through and interpret an entire note for the few bits of interest, and nothing gets scanned without being cleared, first.