Tips for a successful outsourced clinical abstracting process

What is clinical abstracting in healthcare?

Clinical abstracting is the manual work of pulling key patient details from medical records and entering them into a digital system so care teams can find and use them fast.

• It moves patient data from paper charts and old systems into one shared electronic record.
• Skilled abstractors, often nurses, review and summarize each chart for accuracy.
• Many providers now outsource clinical abstracting to trained BPO teams to save time.

Digital tools are now part of almost every industry. Healthcare is no different. More clinics and hospitals use digital systems to run their day-to-day work.

Many aim for a paperless practice. To do this, they use a central electronic health record (EHR) system. As a result, staff can store patient records with less effort and focus more on care.

Clean and complete records also help providers give better service. For example, they can answer patient needs faster and lift patient satisfaction. So the quality of the data matters a great deal.

Clinical abstracting is what makes this possible. In short, it gathers each patient’s past and current records and merges them into the EHR.

What is clinical data abstraction?

Clinical abstraction is the manual entry of key patient details that are not yet stored in a digital form. Staff type this data into set fields. After that, everyone who needs it can access it.

In medical terms, abstraction means summarizing the most important parts of a patient’s record. In short, it turns scattered notes into clear, usable data.

Most providers run several systems at once. So they must manage the merge of many record sources with care. This is even more true when they convert and move EHR data from an old legacy system.

Good medical records management keeps this process on track. Still, teams should know that digital conversion has limits.

Still, some data cannot move from one legacy system to a new record. Because of this, teams must plan what to convert and what to abstract by hand.

In addition, cost is another factor. Conversions are not cheap. So providers often weigh their clinical needs against a tight budget. Because of this, careful planning pays off.

Clinical abstracting: What information can be abstracted?

For example, here are the kinds of information that clinical abstractors usually handle:

• Family medical history
• Scheduled appointments
• Medications
• Immunizations
• Active or standing orders
• Allergies
• Growth charts
• Demographics
• Patient history (previous surgeries, medical procedures, etc.)
• Social history (drug use, smoking and drinking habits, etc.)

Clinical abstracting: Duties and responsibilities of a clinical data abstractor

In practice, the main job of a clinical abstractor is simple to state. They analyze, summarize, and organize medical data into charts or databases. For this work, speed and accuracy both matter a lot.

Most clinical abstractors are registered nurses (RNs) or health information management (HIM) professionals. In other words, they are skilled and know how to build thorough patient records.

In addition, providers can outsource the whole process. Many hand it to a healthcare BPO team that already knows the work. This is one form of clinical support outsourcing that frees up in-house staff.

Clinical abstracting: 7 key points to consider for a successful outsourcing process

You may want to set up an EHR system or merge two systems. Either way, clinical abstracting should sit in your plan and budget from the start.

Here are seven key areas to weigh for a smooth outsourced result:

• Set a clear scope and budget need.
• Keep the budget realistic for that scope.
• Involve stakeholders such as practice managers or clinicians in the choice.
• Decide which data sets to abstract, and whether sub-specialties need special rules.
• Identify which patients will have their charts abstracted.
• Check how the scope affects team access to the EHR, paper charts, or legacy system.
• Decide who will manage the outsourced abstractors, and whether they need training.

After these steps, one task remains. Always double-check the abstracted data for accuracy before you rely on it.

Outsourcing clinical abstractor and other healthcare services

Outsourced Global is a trusted outsourcing company that provides the right solutions to medical establishments’ clinical data management needs.

In addition, a good partner can match the clinical data needs of any provider. As a result, staff can hit the outcome they need without losing quality.

Healthcare outsourcing also goes well beyond abstracting alone.

Providers have many services they can hand off. For example, Medical transcription, revenue cycle management, and medical billing are common picks. Insurance claims support is another one.

In addition, they can choose where the work sits. Some keep it local. Others nearshore to a close country, or offshore to a hub in Asia. Offshoring stays the most common choice.

If you plan to outsource your clinical abstracting, feel free to browse our Directory. It lists hundreds of BPO firms that are ready to help.

Are you a provider that offers clinical abstracting services? We would like to hear from you too. Just email us at [email protected] to get featured.

Frequently asked questions about clinical abstracting

What does a clinical abstractor do?

First, a clinical abstractor reads patient records and pulls out the key facts. They then enter that data into set fields in a digital system. In short, they turn raw notes into clean, usable records.

Why do healthcare providers outsource clinical abstracting?

Outsourcing saves time and cuts cost. It also gives providers access to trained abstractors on demand. As a result, in-house staff can focus more on patient care.

Is clinical abstracting the same as medical coding?

No, the two jobs differ. Abstracting gathers and summarizes patient data into records. Coding assigns standard codes to diagnoses and procedures for billing. Still, both support clean and accurate charts.

What data can be abstracted from a medical record?

Abstractors handle many data types. For example, they capture family history, medications, allergies, immunizations, and past procedures. They also record demographics and social history.

How do I choose a clinical abstracting partner?

First, set a clear scope and budget. Next, check the partner’s clinical skill and data security. Finally, confirm who will manage the team and how they will train staff.