Welcome! The Health Story Project Dictation to Clinical Data: Automating the Production of Structured and Encoded Docum

1. Welcome!The Health Story ProjectDictation to Clinical Data: Automating the Production of Structured and Encoded Documents Kim Stavrinaki s AHDI Conference, July 2009 Nick van Terheyden, MD, Chief Medical Officer, M*Modal

2. Presentation Overview • Background: The Current Situation • Enabling the EMR with the Missing Link • A User Experience (GE/RISL) • The Health Story Project • Conclusion

3. Background The Current Situation

4. Critical to the success of EHRs is to reconcile two opposing needs Enterprise need for structured and coded information capture Physician’s practical need for a fast and easy method for creating clinical notes. Electronic Health Record Universe

5. Tedious manual process Time-consuming Documentation lacks expressiveness of natural language Lack of Flexibility Poor user interface Cost Fails to Meet Individual Physician Time vs. Benefit Test Cultural resistance Oblivious to HIM Requirements Incomplete and Inadequate Semantic Standards The Current Situation – Structured Direct Data Entry: Structured and encoded information.

6. Transcription can be expensive Subject to longer turn-around times Clinical data lost, because documents are neither structured nor encoded Majority of attested information is only in the document Contains the detail and comprehensive scope of patient information Support human decision making Reimbursement is based on narrative documentation Retains current workflow, favored by physicians Interoperable Under utilized source of data for EMR The Current Situation Dictation: Fast and easy, expressive.

7. High cost of documentation Cost of ownership and physician time vs. transcription cost 60% of the data lost to the EHR Care process inefficiencies and impact on quality The Current Situation

8. Enabling the EMR The Missing Link in Information Capture in Healthcare

9. Data Entry Time • The average physician spends 33 seconds dictating an establish office visit • 92% of all office visits are established • If the average physician sees 40 patients a day, total dictation time of 30 minutes plus time to search for the data. • Using a traditional EHR application, the same number of patients would require 140 minutes of data entry time. • Physicians are not willing to spend an additional 90 minutes per day for data entry. (40 X 92% x 33 seconds) + (40 x 8% x 125) = < 30 minutes per day Data and Chart courtesy Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group

10. What if you could continue to use narrative and dictation and at the same time increase usage of the EMR and make more records available for the health information exchange? Crossing the Chasm…

11. Health Story Project Vision • Comprehensive electronic clinical records that tell a patient’s complete health story • All of the clinical information required for • good patient care • administration • reporting and • research • will be readily available electronically, including information from narrative documents

12. Based on HL7 CDA Clinical Document Architecture Requirements • Human readable document • Must be presentable as a document • Rendered version covers clinical information intended by the author • Can contain machine-processable data • Cross platform and application independent • Can be transformed with style sheets

13. Adoption • Incremental adoption overcomes the “not me first” dilemma • Not dependent on recipient’s ability to receive or process • Reverse adoption (can encode headers of existing documents) • Non-proprietary • Readable with any browser

14. Accessible Clinical Data

15. User ExperienceGE/RISL Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare The Missing Link in Information Capture in Healthcare

16. Key Workflows • Self Editing • real time – read, proof, sign each exam • batch mode - read multiple exams then sign via signature queue • VR edits • Option to send to Medical Editor during reporting process • Batch Option – dynamic combinations of workflow based on confidence models • user based thresholds that determines how report is returned/reviewed to signature queue • preliminary/draft to signature queue • transcriptionist then preliminary to signature queue • Transcriptionist – Medical Editor workflow

17. Results Reporting Workflow Data Center Dictation Report in conversational speaking Edit Mode using local capture tool – can either type to correct or voice commands When dictation is complete and EOL is pushed Report is returned ready for edits Dictating the Procedure

18. Results Reporting Workflow 2 Data Center After final sign the report is processed in the NLP engine for learning Edit Mode using local capture tool – voice in selection between brackets Voice in options for brackets, sign report, add via voice more dictation in the sections, then sign

19. Results Reporting Batch Mode Report goes to Medical Editor or signature queue, Radiologist moves on to next exam Dictating the Procedure When dictation is complete

20. Radiology Imaging of Lakeland Florida Radiology & Imaging Specialists (RIS) • physician-owned • twenty board-certified radiologists • many sub-specialized • live since November 12, 2008

21. “You didn’t change the radiologists’ work, and that is what made it easy on me.” David Marichal, CIO, Radiology and Imaging Spec. of Lakeland, FL

22. EHR Conversational Documentation … transformation of dictation directly into structured clinical documents while encoding data depending on the care givers and organizations needs

23. Results VOC: • flexibility is key • full-time rads: 70% Medical Editor workflow/30% self-edit • part-time radiologists can use it in batch digital dictation mode • radiologist love not having to dictate accession #, name, signs/symptoms, etc… • quality of the engine is very good • self-edit for stat exams has reduced # of calls from the hospital

24. The Health Story Project and Meaningful Clinical Documents Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare The Missing Link in Information Capture in Healthcare

25. Meaningful Clinical Documents vs. Text • Structured and encoded clinical content enables… • pre-signature alerts, • decision support, • best documentation practices, • multiple output formats, • multi-media reporting, • data mining • Implements HL7 CDA4CDT standard compliant document types • Increases quality of documentation

26. Health Story Document Types Implementation Guides Completed • History & Physical • Consultation • Operative Report • DICOM Imaging Reports Upcoming • Discharge Summary in progress through HL7 • Billing and Reimbursement Requirements • Progress Notes • .PDF work with Adobe

27. Project Members Founders Promoters Participants

28. Our Advocacy To Date Participation in public comment periods NCVHS Hearing on Meaningful Use HHS Request for Input on Meaningful Use HITSP Request for Input on ARRA Comments are posted on our site www.healthstory.com

29. Our Advocacy Messages Dictation is the documentation method of choice for 85% of physician providers Standardization of dictated notes is an achievable step for providers; Standards are available today The current EHR systems certification process does not include requirements for integration with dictated notes per available standards The current draft definition of meaningful use focuses on recording clinical documentation in the EHR through data entry

30. Our Advocacy Requests Actions Requested: Require certified EHR systems to accept interfaced data from dictation/transcription process per available Healthstory standards Modify the definition of meaningful use to recognize use of certified EHR systems with the above capabilities Assist in spreading the word about this avenue for getting important information into the EHR that allows physicians to continue dictating and that provides patients with comprehensive electronic records

31. Conclusion

32. Crossing the Chasm…Babel Must Go • Medical text “typed” from dictation has “no meaning” • black marks on a page… • info must be tagged as discrete data elements in order to assign meaning • Clinical documentation uses wide variety of terms with same meaning…. • and terms that sound the same that have different meanings….. • authors have a wide variety of styles, accents, methods of dictation…

33. Health Story… • Captures meaningful clinical documents • Is the bridge between • free form narrative and expressive notes, and • fully structured clinical data • Improves the quality of clinical documentation • Generates semantically interoperable clinical data that will • solve the fundamental challenges with EMRs - allowingclinical decision support, alerts, decision support, data mining • enable interoperability, reporting, patient safety initiatives, PQRI (pay for performance), PSI (patient safety indicators) and improve billing data capture

34. Impact • Allows providers to maintain preferred workflow and documentation methods • Increases the value and usability of narrative documents • Accelerates the implementation of interoperable electronic health records • Allows reuse of information

35. Getting Involved Become an “Ambassador” We need a grass roots effort to help spread the word; Support our advocacy messages You can help educate your employers, clients, etc. about Health Story Joint the Effort Varying membership levels, including individuals Volunteer for a Project Currently developing data standards for discharge summary Participate in HL7 ballots on project draft standards Encourage Implementation E.g. Include requirements for standards in transcription RFPs

36. Membership Options and Benefits

37. Q&A Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare

38. Where You Can Find Me Nick van Terheyden, MD, CMO, M*Modal Twitter http://twitter.com/drnic1 Technorati http://technorati.com/people/technorati/nvt1 RSSSpeech Understanding http://speechunderstanding.blogspot.com/feeds/posts/default MyBlogLog http://www.mybloglog.com/buzz/members/nvt LinkedIn http://www.linkedin.com/in/nickvt Plaxo http://nvt.myplaxo.com FaceBook http://profile.to/drnick Digg http://digg.com/users/nvt1 Delicious http://delicious.com/nvt1 E-Mail nvt@mmodal.com GrandCentral (301) 355-0877