THE PROBLEM
Current Vendor Disruption
While Loma Linda University Health has outsourced data abstraction for many years, organizational changes within its previous vendor partner prompted them to evaluate alternatives.
“Our previous vendor had a pretty significant shift in leadership and their ability to complete abstraction because they lost several of their own resources,” said the Assistant Vice President of Quality & Patient Safety Brenda Bruneau, MBA, RN. “And because they couldn’t meet the contract requirements, we made a decision to change vendors.”
Fortunately for the six-hospital system in California, one of their hospitals already had a vetted backup plan. “We selected ADN because one of our hospitals, our Murrieta campus, when they made the choice to go through outsourced vendors for abstraction, elected to utilize ADN because at the time the Quality Director in that location had worked with ADN in a previous position. And so she knew ADN’s abilities and had relationships with some of the team.”
“When we made the transition to ADN, it was probably one of the smoothest transitions from any vendor standpoint. And I’m not just talking about abstraction,” she said. “We use vendors for lots of things in hospitals. It was a very, very smooth transition to onboard all of the work that we’d previously been doing with another vendor.”
THE PATH
Why Not Return to In-House?
Bruneau shared that there are two major reasons why Loma Linda prefers outsourcing data abstraction vs maintaining an in-house team of abstractors.
Seamless Performance Despite Turnover or Absences
“Each of the areas of outsourced abstraction is very specialized. We don’t outsource only our Core Measures abstraction. We also outsource many of our registry abstractions – our cardiac registries and our Get With The Guidelines Registry for Stroke for both Primary and Comprehensive Stroke. In order to have adequate resources to backfill in the event of voluntary or involuntary termination or for someone who unexpectedly gets sick and needs to go out on some sort of a leave of absence, we don’t have the capacity to have a Plan A, Plan B, and Plan C when you have that many areas in which you’re doing abstraction. So the flexibility and the nimbleness for coverage provided by outsourcing I think are really important.”
More Strategic Use of Clinic Personnel for Performance Improvement
“My former abstractors are now stronger partners with our operations teams, like our physicians or our nurse clinicians, in really understanding and dissecting the data, and being able to participate in quality improvement. Their clinical brain is now transitioned from abstraction to partnering in making our performance better. And that’s been a big win for many of our teams.”
“But I think it’s important to understand that when you outsource, it doesn’t mean you let go of the accuracy or the completion of that data. You don’t ever let go of that. However, when I outsource it, I have another partner. And I am not solely responsible for the obtaining of that data. It actually makes it easier because an outsourced organization has a little broader ability. They’ve got a few more people than you likely have.”
Brenda Bruneau, MBA, RN
Assistant Vice President of Quality & Patient Safety
Loma Linda University Health
THE OUTCOME
Benefits of Reallocating Valuable Clinical Resources
Quality and Quantity of PI Projects
Bruneau detailed several specific examples that illustrate how refocusing their valuable clinical resources results in more impactful performance improvement work.
PI Project #1: Proactive Visibility into Stroke Treatment Documentation
With both Primary and Comprehensive Stroke Centers as part of their system, Bruneau and her team identified opportunities for improvement in their stroke treatment documentation process.
“In many of our Comprehensive Stroke measures, we were struggling.” So Bruneau tasked her former abstractor to team up with the operations and Epic EHR teams to create a summary view. As various individuals are feeding the EHR, it creates a real-time picture of each episode of care for stroke patients. “It displays a coalition of information for all of our providers to see the summary of the trajectory of that stroke patient to make sure that all of those elements that are required in our performance are actually met. And if they’re not, it identifies it.” For example, Bruneau said, if the NIH score was not documented on admission, the electronic summary presents it to the clinician as a missing element so that it can be addressed in a timely manner.
“That came out of the work that our data coordinator is collaborating with our clinical teams on. She is a nurse who was previously doing abstraction. The work that she’s now focused on with the team is understanding our performance and our data as opposed to just collecting that data.”
Given the significant improvements resulting from such a forward-thinking PI project, Bruneau added that her team actually presented on this project at an Epic conference. “We now routinely achieve high compliance with Comprehensive Stroke without there being ‘fire drills’ and relying on human factor interventions, like a charge nurse remembering to go do something or the data coordinator chasing after somebody to make sure all those elements are in the medical record so that we can maintain certification as a Comprehensive or Primary Stroke Organization. That work was able to be done because the individuals who know that data best were able to partner with our operations and Epic teams to say, ‘How do we do this better?'”
PI Project #2: WATCHMAN™ Documentation Specificity
As Loma Linda performs WATCHMAN procedures, those cases can have significant reimbursement consequences. “If you don’t have very specific documentation of the only types of Afib that CMS will cover, the case is denied. And it’s not a cheap case,” Bruneau said. “And so that used to be a complete fire drill if we were able to get it and not have it proceed before we got denied.”
“We now have worked with our team on making sure we have correct documentation in that record at the time of procedure so that I don’t have denials of those procedures,” she added.
PI Project #3: Procedure Type Indicators Documentation
“We were struggling in one of our cardiac registries in some of our documentation of indicators for procedure type, which affects us on multiple levels. It affects us on a reimbursement level as well as on some of our risk adjustment work that we do in our registries. And so they have been working with the operations teams on altering some of our templates so that we are appropriately documenting our procedures and the indications for those procedures.” Bruneau noted that this improvement project has directly resulted in a reduction of the need for urgent follow-up with providers after a case is closed and they’re in the middle of abstraction. “That was when it became a fire drill. It’s reduced the fire drills. But it’s also improved the consistency of that documentation. So in that vein, their ability to not be focused on abstraction but to be really focused on partnering with the team on making improvements has been important.”
ROI
As the PI projects above demonstrate, Bruneau has strategically deployed her clinical personnel who are freed from the burden of data collection to obtain a return on investment, from both a care-quality and reimbursement perspective.
“I think some of the angst people have around outsourcing is the financial component. And I think you’ve got to weigh not just the cost of your current abstractors. Because you may not let go of all of your abstractors. We did not. We chose to deploy those abstractors to obtain an ROI on the data,” she said.
While some of the PI work has a much clearer return on investment like their documentation work related to reimbursements, some of the gains may be less tangible but nonetheless impactful. “Some of the ROI I don’t think is accounted for when you just look at the dollars and cents of the cost of abstraction,” Bruneau said. “Because for one, I’m making patient care better by doing more performance improvement. And two, I have the opportunity to engage in projects around that data that help me more consistently achieve 100% in many of my measures where previously I was sitting in the 80s and 90s. So you need to look at the ROI as greater than just the cost of those abstractors.”
Team Fulfillment
Another benefit of outsourcing not lost on Bruneau is the positive emotional impact it has had on her team.
When asked if she thought her former abstractors found their new work on performance improvement more fulfilling, she replied: “100%.” Twice.
“All of my individuals who did abstraction previously are nurses. So for them to see that their knowledge of the data, workflows, and processes and their contribution with the team in making care better for patients, that’s invaluable,” she said. “Because they then get to look at what’s happened with our data outcomes, celebrate those things, and move on to the next area of opportunity. It’s very fulfilling to those individuals. It is important to folks to know that the work that they’re doing is positively impacting patient outcomes.”
Relationship and Vendor Transition
To Bruneau, relationship fit is critical. “It’s why I left the other organization. They weren’t able to meet the obligations that they had committed to for us. And it was beginning to negatively impact our ability to meet the requirements that we have for things like CMS and Joint Commission.”
“When we made the transition to ADN, it was probably one of the smoothest transitions from any vendor standpoint. And I’m not just talking about abstraction. We use vendors for lots of things in hospitals. It was a very, very smooth transition to onboard all of the work that we’d previously been doing with another vendor. And again, we don’t just do Core Measures. We do our Joint Commission measures for our Primary and Comprehensive Stroke, and all of our registries for our cardiac care were transitioned for both adults and pediatrics,” she said.
“And that relationship was quickly established through the customer service, the attention to the account, and the communication that occurred during that transition and ever since.”
While the commitment to high-quality customer service has contributed to Bruneau’s experience, the organizational structure of how ADN handles its client accounts also differs from some vendors, in that ADN places emphasis on a key point of contact to ensure timely and transparent communications regarding abstraction status and progress.
“The Account Lead that ADN has is a critical role and not a role we had with our previous vendor. When the partnership with our previous vendor started to deteriorate, because of some of the things that were happening in that organization, it quickly became quite painful. We didn’t know where they were in their current work structure. We didn’t know the plans for filling the gaps. It became very quickly an untenable situation for us,” she said.
“And so in the transition, I had some of the same angst that if there wasn’t good communication, I wasn’t going to be able to share with our senior leaders where we were in being able to meet our requirements. But we didn’t experience any of that with ADN, any of it.”
Think of Outsourcing as Extension, Not Expulsion
While a proponent of outsourcing abstraction, Bruneau said she certainly understands the reservations some leaders feel about it. “I think one of the things likely driving that angst is reliance on someone outside of yourself for data that you are accountable for,” she said. “But I think it’s important to understand that when you outsource, it doesn’t mean you let go of the accuracy or the completion of that data. You don’t ever let go of that. However, when I outsource it, I have another partner. And I am not solely responsible for the obtaining of that data. It actually makes it easier because an outsourced organization has a little broader ability. They’ve got a few more people than you likely have.”
CONCLUSION
What This Means for You…
Outsourcing data abstraction to ADN is a change you need as the department leader. You have no idea what kind of stress and headspace you can free up when you’re not worried about staffing and managing data abstraction. Holding on to the management of routine data collection processes is taking up too much of your valuable time and expertise during an unprecedented time for healthcare. Instead, focus the time you save by outsourcing on putting the abstracted data to use on bigger, more impactful work that will elevate your department and organization. Waiting 6 months or a year will just further delay your ability to accomplish the significant quality improvements that are more critical now than any time in recent memory. If it’s uncertainty about the process that’s giving you pause, many of our clients have tested the outsourcing waters by offloading just a few measures or registries. Most quickly go on to fully outsource once they feel the effects of lifting the burden of data abstraction management. Whatever is holding you back, ADN can help you let that go so you and your team can experience relief, hard and soft ROIs, greater professional fulfillment, and more.
Loma Linda University Health is an academic medical center operating six hospitals, a physician practice corporation, remote clinics in the western United States, and affiliate organizations around the world. The system’s facilities have received multiple awards and distinctions including being named among the Best Regional Hospitals in 2021-2022 by U.S. News and World Report, scoring consecutive A’s in Leapfrog Hospital Safety Grades 4 years running, and receiving Magnet Recognition.