Handling data: Concurrent vs. retrospective approach

Concurrent data collection has some advantages

Are you collecting data elements concurrently, while patients still are receiving care, or retrospectively after discharge? Each approach has distinct advantages and disadvantages, and which is best depends on the individual situation, says Patrice L. Spath, a health care quality specialist with Forest Grove, OR-based Brown-Spath & Associates.

"The biggest mistake that people make is to view data collection as an all or nothing activity, by gathering all data either concurrently or retrospectively," Spath explains.

At Freeport, IL-based FHN, quality managers do both concurrent and retrospective data collection, depending on the scenario, says Glenda Koeller, assistant vice president of performance excellence.

Concurrent data collection is used to determine appropriateness of utilization, while retrospective data collection is used for clinical indicators for clinical pathways and guidelines and data collection for the Joint Commission on Accreditation of Healthcare Organizations, the Centers for Medicare & Medicaid Services, VHA, and the FHN’s own internal balanced scorecard.

The cost of quality falls into three broad categories: prevention, appraisal, and failure; and data collection is an appraisal cost, Spath notes.

As a quality manager, you must find creative approaches to data collection so appraisal costs don’t outweigh the benefits, she explains. "Well thought-out investments in cost-efficient appraisal mechanisms can be repaid many times over by significant decreases in the costs of failure."

Here are advantages and disadvantages for each approach:

There is lack of data quality control with concurrent data collection.

If several different people will be gathering data, make sure your data collection form is easy to use, Spath advises. "This means that data entry maps in sequence with how things occur, it is placed as close as possible to the point of action, and it doesn’t require so much entry time that the data collectors throw their hands up in frustration. The more disruption, the lower the accuracy."

She recommends meeting with data collectors often during the first few days of data collection. The goal is to be sure they understand what data they are to collect, how important they are, and to gain their feedback as to what may need changing to make it easier or more meaningful. Then review data at the end of day one to validate they are accurate and complete, and follow up with individuals who are not following instructions, Spath adds.

Concurrent data collection may require additional retrospective review to correct errors or gather missing data.

When doing concurrent data collection, some cases may be missed and require retrospective data collection. For example, data collectors have to go back to determine if any patients with a short length of stay slipped through the cracks, Koeller explains.

In addition, retrospective data collection gives you the benefit of having all the necessary data elements, including criteria and justification for patient care interventions that were not done, she says.

For instance, if you are doing concurrent data collection for a pneumonia patient, there may be a justification for why the antibiotic wasn’t given in a four-hour time frame that isn’t apparent until after the patient is discharged, Koeller notes. "It isn’t always there until we pull it all together with the discharge summary, so you can see the whole picture."

With retrospective data collection, medical record documentation may be inadequate.

The patient record can be incomplete at any point in time, but once the patient is discharged, it is difficult to get the doctor to add additional information in the progress notes, Spath says.

To address that issue, consider implementing a concurrent documentation improvement program, with a nurse or health information management professional reviewing patient records concurrently and working with physicians and other caregivers to ensure documentation in the record accurately reflects what actually is happening with the patient, she suggests.

She gives an example of a quality measure for patients admitted for treatment of an acute myocardial infarction (AMI): Percent of patients without beta-blocker contraindications who received a beta-blocker within 24 hours after hospital admission.

If a patient does not receive a beta-blocker, the documentation improvement specialist would check to be sure the record includes information about why the patient did not receive this medication, and if documentation is lacking, the physician is asked to record why a beta-blocker was not prescribed, Spath says.

Concurrent data collection allows for real-time improvements.

"Concurrent data collection gives us the opportunity to do proactive improvements, so we can actually improve on the spot," Koeller adds. For example, physicians can correct incomplete documentation in real time, she says.

Patient care can be impacted, such as administering aspirin to an AMI patient if it was not given prior to arrival; or if the patient should have received a beta-blocker, the physician can be reminded to order the medication, Spath adds. "If data collection is more than merely gathering data elements — if it is interventional — potential quality of care problems can be addressed immediately."

If you are including intervention to resolve potential quality problems, then data elements should be gathered concurrently, she advises. "But if people are merely placing a check in a box indicating that a beta-blocker was not given so that aggregate results can be compiled later on, then it may be more efficient to collect the data retrospectively," Spath says.

As organizations switch to paperless medical records, concurrent data collection should increase because all the information will be readily accessible, Koeller predicts.

"We have a partial electronic medical record but not total. Right now, it’s still pretty much a paper system," she says. "We are going in that direction, but we aren’t there yet."

Retrospective data collection can be incorporated into routine post-discharge record review activities, and all data elements can be collected at one time, Spath notes.

At first glance, this method is less expensive, since the patient record only is reviewed once to gather all data elements at one time, she adds. "However, retrospective data collection can be more expensive if you are missing opportunities to improve quality at the point of care."

[For more information on data collection, contact:

Glenda Koeller, Assistant Vice President, Performance Excellence, FHN, 1045 W. Stephenson St., Freeport, IL 61032. Phone: (815) 599-6125. E-mail: gkoeller@fhn.org.]