Report: Chart abstraction eases transition from paper to EHR

Chart abstraction can help lessen the inevitable productivity slow-down associated with an EHR project and shorten the transition period between paper and electronic records, according to an assessment of EHR implementation at community health clinics in California.

"A well-thought-out chart abstraction strategy--the process of entering or 'populating' the electronic chart with clinical data from the traditional paper record or other sources--is one technique that mitigates the loss in productivity and increases provider acceptance," says a newly released issue brief from the California HealthCare Foundation. The paper is the first of a planned series of issue briefs on lessons learned from the California Networks for Electronic Health Record Adoption (CNEA) initiative, a program that dates to 2006.

The CNEA participants were successful, the brief says, because they, for the most part, had cohesive strategies to define the data that had to be entered into the EHR, including when the data should be entered and by whom. "Balancing cost with utility is fundamental to developing the approach that works best for each health center," the paper says.

Most chose to include information on: patient medical and surgical history; diagnostic history; recent consultations; allergies; the most recent progress note; medications; immunizations; alcohol and tobacco use; and indicators for health maintenance and disease management. Some migrated data by scanning, others by importing files from legacy systems and some via manual data entry, and participants found advantages and disadvantages with each method.

For further details:
- view the CHCF issue brief (.pdf)