Hospitals Use Six Basic Steps to Collect and Submit Quality Data, Two of Which Involve Complex Abstraction by Hospital Staff

The case study hospitals we visited used six steps to collect and submit  quality data, two of which involved complex abstraction—the process of  reviewing and assessing all relevant pieces of information in a patient’s  medical record to determine the appropriate value for each data element. Factors accounting for the complexity of the abstraction process included  the content and organization of the medical record, the scope of  information required for the data elements, and frequent changes by CMS  in its data specifications. Due in part to these complexities, most of our  case study hospitals relied on clinical staff to abstract the quality data. Increases in the number of required quality measures led to increased  demands on clinical staff resources. However, all case study hospitals  reported finding benefits in the quality data that helped to offset the  demands placed on clinical staff. 1). Step 2: Locate information in the medical record—Steps 2 and 3 were  in practice closely linked in our case study hospitals. Step 6: Supply copies of selected medical records—CMS has put in  place a data validation process to ensure the accuracy of hospital quality  data submissions. Based on those results, they provided feedback to  individual clinicians and reports to hospital administrators and trustees. Existing IT Systems Can Help Hospitals Gather Some Quality Data but Are Far from Enabling Automated Abstraction

In the case studies, existing IT systems helped hospital abstractors to  complete their work more quickly, but the limitations of those IT systems  meant that trained staff still had to examine the entire patient medical  record and manually abstract the quality data submitted to CMS. The challenges reported by hospital officials included  having a mix of paper and electronic records, which required abstractors  to check multiple places to get the needed information; the prevalence of  unstructured data, which made locating the information time-consuming  because it was not in a prescribed place in the record; and the presence of  multiple IT systems that did not share data, which required abstractors to  separately access each IT system for related pieces of information that  were in different parts of the medical record. While hospital officials  expected the scope and functionality of their IT systems to increase over  time, they projected that this would occur incrementally over a period of  years. The limitations that hospital officials reported in using existing IT systems  to collect quality data stemmed from having a mix of paper and electronic  systems; the prevalence of data recorded in IT systems as unstructured  paragraphs of narrative or text, as opposed to discrete data fields reserved  for specific pieces of information; and the inability of some IT systems to  access related data stored on another IT system in the same hospital. CMS Sponsored Studies and Joined Broader HHS Initiatives to Promote Use of IT for Quality Data Collection and Submission, but HHS Lacks Detailed Plans, Milestones, and Time Frame

CMS has sponsored studies and joined HHS initiatives to examine and  promote the current and potential use of hospital IT systems to facilitate  the collection and submission of quality data, but HHS lacks detailed  plans, including milestones and a time frame against which to track its  progress. CMS has  joined this broader effort by HHS, as well as the Quality Workgroup that  AHIC created in August 2006 to specify how IT could capture, aggregate,  and report inpatient and outpatient quality data. However, HHS has identified no detailed plans, milestones, or time frames  for either its broad effort to encourage IT in health care nationwide or its  specific objective to promote the use of health IT for quality data  collection. CMS Has Joined HHS’s Efforts to Promote Greater Use of Health IT for Quality Data Collection and Submission, but HHS Lacks Detailed Plans, Milestones, and a Time Frame to Track Progress

CMS has joined efforts by HHS to promote greater use of health IT in  general and, more recently, in facilitating the use of health IT for quality  data collection and submission. 1. Appendix IV: Scope and Methodology

To examine how hospitals collect and submit quality data, and to  determine the extent to which information technology (IT) facilitates  those processes, we conducted case studies of eight individual acute care  hospitals that collect and submit quality data to the Centers for Medicare  & Medicaid Services (CMS).
Why GAO Did This Study

Hospitals submit data in electronic form on a series of quality measures to the Centers for Medicare & Medicaid Services (CMS) and receive scores on their performance. Increasingly, the clinical information from which hospitals derive the quality data for CMS is stored in information technology (IT) systems. GAO was asked to examine (1) hospital processes to collect and submit quality data, (2) the extent to which IT facilitates hospitals' collection and submission of quality data, and (3) whether CMS has taken steps to promote the use of IT systems to facilitate the collection and submission of hospital quality data. GAO addressed these issues by conducting case studies of eight hospitals with varying levels of IT development and interviewing relevant officials at CMS and the Department of Health and Human Services (HHS).

What GAO Found

The eight case study hospitals used six steps to collect and submit quality data: (1) identify the patients, (2) locate information in their medical records, (3) determine appropriate values for the data elements, (4) transmit the quality data to CMS, (5) ensure that the quality data have been accepted by CMS, and (6) supply copies of selected medical records to CMS to validate the data. Several factors account for the complexity of abstracting all relevant information in a patient's medical record, including the content and organization of the medical record, the scope of information and the clinical judgment required for the data elements, and frequent changes by CMS in its data specifications. Due in part to these complexities, most of the case study hospitals relied on clinical staff to abstract the quality data. Increases in the number of quality measures required by CMS led to increased demands on clinical staff resources. Offsetting the demands placed on clinical staff were the benefits that case study hospitals reported finding in the quality data, such as providing feedback to clinicians and reports to hospital administrators. GAO's case studies showed that existing IT systems can help hospitals gather some quality data but are far from enabling hospitals to automate the abstraction process. IT systems helped hospital staff to abstract information from patients' medical records, in particular by improving accessibility to and legibility of the medical record. The limitations reported by officials in the case study hospitals included having a mix of paper and electronic records, which required staff to check multiple places to get the needed information; the prevalence of data recorded as unstructured narrative or text, which made locating the information time-consuming because it was not in a prescribed place in the record; and the inability of some IT systems to access related data stored in another IT system in the same hospital, which required staff to access each IT system separately to obtain related pieces of information. Hospital officials expected the scope and functionality of their IT systems to increase over time, but this process will occur over a period of years. CMS has sponsored studies and joined HHS initiatives to examine and promote the current and potential use of hospital IT systems to facilitate the collection and submission of quality data, but HHS lacks detailed plans, including milestones and a time frame against which to track its progress. CMS has joined efforts by HHS to promote the use of IT in health care, including a Quality Workgroup charged with specifying how IT could capture, aggregate, and report inpatient and outpatient quality data. HHS plans to expand the use of health IT for quality data collection and submission through contracts with nongovernmental entities that currently address the use of health IT for a range of other purposes. However, HHS has identified no detailed plans, milestones, or time frames for either its broad effort to encourage IT in health care nationwide or its specific objective to promote the use of health IT for quality data collection.