Clinical Data Abstraction: A Research Study.

Abstract

This is the second part in a two-part research study on clinical data abstraction.¹ Clinical data abstraction is the process of capturing key administrative and clinical data elements from a medical record. Very little is known about how the abstraction function is organized and managed today. A research study to gather data on how the clinical data abstraction function is managed in healthcare organizations across the country was performed. Results show that the majority of the healthcare organizations surveyed have a decentralized system, still perform the abstraction in-house as part of the coding workflow, and use manual abstraction followed by natural language processing (NLP) and simple query. The qualifications and training of abstractors varied across abstraction functions, however coders followed by nurses and health information management (HIM) professionals were the three top performers in abstraction. While, in general, abstraction is decentralized in most enterprises, two enterprise-wide abstraction models emerged from our study. In Model 1, the HIM department is responsible for coding, as well as all of the abstraction functions except the cancer registry and trauma registry abstraction. In Model 2, the quality department is responsible for all of the abstraction functions except the cancer registry, trauma registry, and coding function.