Everyone Loves a Good Story - Except CMS

[Health IT Social]

The Meaningful Use Move to Structured Data Recording and Automated Abstraction

Do you enjoy the freedom and flexibility of chronicling a case in your own words in the patient record?  Do you feel you can reflect patient details at a high level in your own narrative reporting?  With Meaningful Use’s move to structured data, all that is about to change—or maybe it already has in your facility. It seems everyone likes a good story, except CMS.

With Meaningful Use, you’ll be doing a lot less SOAP (Subjective, Objective, Assessment and Planning) reporting familiar to any nurse, to narrative charting and even to fill-in-the-blanks forms--all with their personalized verbiage and more creative style. Replacing a lot of free text documentation will be a far more structured form of record keeping that can be easily abstracted, reported and analyzed.

For the unfamiliar below are samples of both data types:

For the unfamiliar below are samples of both data types:

Unstructured

Have you used tobacco in the last year?

How much? ____ (number/frequency/etc.)

Structured (MU Stage 1 Required Responses)

Are you a smoker?

A. Current every day smoker

B. Current some day smoker

C. Former smoker

D. Never smoked

E. Smoker, current status unknown

F. Unknown if ever smoked

Codified (MU Stage 2 Required Responses with codes that must be in the system and attached to each answer)

Are you a smoker?

A. Current every day smoker (449868002)

B. Current some day smoker (428041000124106)

C. Former smoker (8517006)

D. Never smoked (266919005)

E. Smoker, current status unknown (77176002)

F. Unknown if ever smoked (266927001)

G.  Heavy tobacco smoker (428071000124103)

H. Light tobacco smoker (428061000124105)　

While clinicians will no longer be able to solely tell the story of a case their way, actually there’s a lot of wisdom behind this change. Unstructured, narrative reporting is extremely subjective, often difficult to decipher and rarely compels caretakers to chronicle the same data across a similar patient population to provide any genuine basis for care comparison. In an effort to enhance the stagnant performance of prior CMS reporting formats, Meaningful Use will now require all records as structured data--familiar to everyone from their school days as the close cousin of a multiple choice test. Pick your answer A,B or C—nothing in between is offered.

Structured and codified data removes the problems associated with manual data extraction, which involves extensive human judgment about the caregiver’s reporting style and any real objectivity and scientific rigor. Unstructured data lacks the standardization that ultimately stands up to analysis, that will support credible feedback to hospitals on their results and that will provide the basis for fine-tuning of best-practice guidelines on a national basis. In addition, it has no consistency across individual abstractors and is extremely time-consuming and costly to perform. Just finding the data required by CMS can be difficult in a folder filled with notes or long paragraphs in charts that do not conform to a common organizational structure.

Yes, setting up an EHR to support structured data reporting will be an arduous task. But once in place, many hospitals report that the change is largely positive. We’ll discuss more about structured data and CMS reporting in our upcoming blogs.

Meanwhile, let us know, what will be missed by moving away from free text? Will you miss the ability to put your own thumbprint on your record of how you care for patients?

Join us for our next post, "Launching Your Screen Career: When It Comes to the EHR,...where we will discuss the next major step on the road to ensuring Meaningful Use attestation – creating the EHR screens and prompts to ensure all the necessary data elements are captured.

Author: Heather Hitchcock, VP of Marketing at IHM Services