Clinical Data Reporting

Clinical Data Reporting And Its Complexity

The Government Accountability Office or GAO conducted hospital case studies that depict the complication of extracting quality data. This complexity in abstracting data is evident even with the presence of information technology systems in the hospitals which is used to collect quality data. Hospital case studies were accomplished by the Government Accountability Office in compliance to the recent endorsement of electronic health records. In addition, GAO conducted the study based on the rising volume of quality data reported on CMS which is stored on the information technology systems in hospitals.

Eight hospitals were used in the case study. These hospitals have six steps in gathering and submitting quality data. The first step is to identify the patients. Looking for information in the patient's medical records is the second step. Third, correct values were ascertained for the data elements. The fourth step is to transfer the quality data to the CMS. Making sure that the quality data have been received by the CMS is the fifth step. Sixth, provide copies of chosen medical records to the CMS for data validation.

Several issues can be accounted for the complication of extracting all the pertinent information on the medical record of a certain patient. One of the issues is the organization and content of the medical record. The next factor is the extent of information and the clinical judgment that is needed for the data elements. Lastly, the changes in the data specifications of the CMS that is quite recurrent.

Almost all of the hospitals in the case study have to rely on clinical staffs to extract the quality data since the process is so complicated. This resulted to an increase in the demand of clinical staff resources. Although the demand on clinical staff resources was evident, the benefits received by the hospitals used in the case study were evident. The benefits associated with locating the quality data include reports to administrators of the hospital and giving feedback to clinicians.

Officials in the case study also stated several limitations. These limitations are the following.

Mixture of Paper and Electronic Records The officials noticed the presence of both paper and electronic records which burdened the staff because there is a need to check several locations to get the required information.

Occurrence of Unstructured Text Popularity of data which has been recorded in the form of an unstructured text or narrative proved to be a hindrance in locating information because of the time needed to look into the narrative. Also, the information cannot be found immediately on a specific place in the record.

Lack of Interconnection of the IT Systems There are some hospitals which use several IT systems. The inability of these IT systems to access data that is located on a different IT system proved to be a drawback for the hospital staff. This is due to the fact that the staff has to access the needed IT systems independently to be able to acquire the related parts of information. In response, hospital officials predicted that the extent and functionalities of their IT systems would improve with time but this endeavor will take years to complete.

As a recommendation, GAO stated the need to identify the actual steps needed to encourage the use of health IT in collecting and submitting data for the quality measures in CMS' hospitals and letting interested groups know about these steps, the time frame projected and the related milestones.