NGHN has a Clinical Quality Committee (CQC) comprised of medical directors and other clinical administrative staff at the member Planned Parenthood affiliates which oversees the development of the templates and meets on a monthly basis. The CQC agreed upon a recommend abstraction policy, although the member affiliates can modify it according to their needs or requirements of their specific medical director. The committee looked at the range of options for abstraction and recommended that limited information be abstracted from existing paper charts with minimal scanning. Data to be abstracted and/or scanned include:
· Chronic problems
· Immunizations
· Past medical procedures or any abnormal past history (this data are both abstracted and scanned)
· Previous abnormal lab results (some limited to the previous year; all abnormal pap and biopsy reports both abstracted and scanned)
NGHN has developed a specific abstraction EMR template so that this information can be easily entered into the EMR and relevant information flows to other templates, including the Home Page which includes a summary of the EMR chart.
Two member Planned Parenthood affiliates have gone live with full EMR and each has chosen slightly different strategies in their workflow around abstracting, although neither affiliate has hired any additional staff for these tasks, and both have reported that it has been challenging to keep up with the abstraction work particularly at the busier clinic sites.
One affiliate decided to abstract information from paper charts at the time of the patient visit. This decision was made due to the high no show rate of clients. The mid-level provider reviews the chart and abstracts the relevant information during or after the visit. This affiliate has chosen to let the clinical provider review the paper chart once and make the abstraction and scanning decisions, and then the paper chart is sent off site and is not readily available (although it can always be retrieved).
The other affiliate is having staff abstract information ahead of time. A medical assistant is responsible for abstracting data from the chart into EMR the day before, and the mid-level provider approves the abstracted data as well as notes what documents should be scanned. This affiliate has chosen to keep the chart on site for the time being in case it needs to be reviewed again.
At both affiliates, each patient (regardless of whether they are new or established) who visits the clinic is asked to complete a new comprehensive medical history that mirrors the EMR templates and this is entered into the EMR. This reduces the amount of abstraction that needs to occur because data like previous medical history, chronic problems and allergies are already being entered.
· Chronic problems
· Immunizations
· Past medical procedures or any abnormal past history (this data are both abstracted and scanned)
· Previous abnormal lab results (some limited to the previous year; all abnormal pap and biopsy reports both abstracted and scanned)
NGHN has developed a specific abstraction EMR template so that this information can be easily entered into the EMR and relevant information flows to other templates, including the Home Page which includes a summary of the EMR chart.
Two member Planned Parenthood affiliates have gone live with full EMR and each has chosen slightly different strategies in their workflow around abstracting, although neither affiliate has hired any additional staff for these tasks, and both have reported that it has been challenging to keep up with the abstraction work particularly at the busier clinic sites.
One affiliate decided to abstract information from paper charts at the time of the patient visit. This decision was made due to the high no show rate of clients. The mid-level provider reviews the chart and abstracts the relevant information during or after the visit. This affiliate has chosen to let the clinical provider review the paper chart once and make the abstraction and scanning decisions, and then the paper chart is sent off site and is not readily available (although it can always be retrieved).
The other affiliate is having staff abstract information ahead of time. A medical assistant is responsible for abstracting data from the chart into EMR the day before, and the mid-level provider approves the abstracted data as well as notes what documents should be scanned. This affiliate has chosen to keep the chart on site for the time being in case it needs to be reviewed again.
At both affiliates, each patient (regardless of whether they are new or established) who visits the clinic is asked to complete a new comprehensive medical history that mirrors the EMR templates and this is entered into the EMR. This reduces the amount of abstraction that needs to occur because data like previous medical history, chronic problems and allergies are already being entered.
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