Abstraction Partner Clinical

Clinical Data Abstractor/Registrar

Professional clinical data abstractors/registrars support the on-going work of performance improvement through the enterprise by performing high-quality data abstraction, compilation, validation, for clinical registries using clinical expertise to support abstraction activities and support/educate team members related to registry domain topics. The abstractors/registrar/clinical reviewer partner with registry owners in the identification of opportunities and performance improvement activities. The registries may include federal/accreditation program, third-party gold standard registries, and internal regulatory required abstraction/registries.

These registries are critical in support of CMS/TJC regulatory requirements, Clinical Excellence, Clinical Services and Programs for quality improvement and identification of improved outcomes. Different professional accreditation organizations, registries or Centers of Excellence designation utilize different names for staff who function as an abstractor, specialist, or registrar. This job description covers partnerships, dotted or otherwise direct lines of connection to clinical registries stakeholders as defined by these organizations.

This job description is an Intermountain job description to meet these requirements independent of the registry specific title recommendations. When a registry requires specific reference to roles or relationships they are defined below:

• American College of Surgeons (ACS), Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). References to Clinical Reviewer are covered in this document by the term "Abstractor". References to the MBSAQIP Coordinator, MBSAQIP Surgeon and office staff are covered by terms such as "Coordinator, Medical Staff, Surgeon and office staff, stakeholder, as well as hospital or enterprise positions such as Leader, Clinical Leader, Clinical Programs or Services, and hospital administrative leaders".
• American College of Surgeons (ACS), Trauma Registry (TQIP). References to Abstractor or Registrar are covered in this document by the term "Abstractor". Trauma Program Manager/Coordinator, Trauma Surgeon, Performance Improvement Coordinators, Outreach and Injury Prevention Coordinator are covered in this document by terms such as "Coordinator, Medical Staff, Surgeon and office staff, stakeholder, as well as hospital or enterprise positions such as Leader, Clinical Leader, Clinical Programs or Services, and hospital administrative leaders".

Essential Functions

• Execute professionally and expertly the technical work of abstraction in accordance with the specifications of the registry. This includes abstraction and input of clinical element from the Electronic Health Record (EHR), surgeons/physicians' offices and associated medical records with unrestricted access as required by specific registry. Duties include patient identification, validation, timely abstraction and submission of data consistent with registry-defined requirements, capture of index and follow-up components, and strict adherence to Intermountain and registry HIPAA/privacy standards.
  
  The clinical reviewer must also complete initial certification and maintain ongoing education/certification requirements specific to the registry, while supporting performance improvement activities.
• Supports non-clinical abstractors with training / education related to clinical expertise in abstraction.
• When allowed by a registry, they use clinical professional skills to understand healthcare workflows and interpret documentation as it relates to abstraction.
• Assists in identification of clinical, financial, and risk issues and escalates them to the supervisor and/or clinical leaders as appropriate.
• Establishes and maintains relations with key registry stakeholders as a trusted partner in the performance improvement related to registry work. Supports registry owner meetings, site visits, and processes with expertise to clarify, inform, identify opportunities, outcomes review, and support performance improvement work. These partnerships, depending on the registry, may include a coordinator or program lead, members of the medical staff, affiliated office staff, clinical programs or services leaders, and hospital administrative leaders.
  
  Keep leader informed of applicable program volumes and follow-up requirements, to partner with immediate leader in evaluation to ensure adequate resources.
• Where accreditation standards or registries require, meet minimum annual requirements for attendance at selective meetings and actively participate in the site visit (for example, attend at least two of three committee meetings with mandatory attendance at the MBSAQIP annual comprehensive meeting or large committee meetings).
• This role does not work as a clinician by entering registry specific variables into the electronic health record for the purposes of improving registry outcomes unless this is required state or federal…