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Get Ready EMRs and HIEs: Here Comes One Billion Clinical Documents. Bob Dolin, MD, FACP, FACMI Principal, Semantically Yours, LLC Chair, Health Level Seven Thursday, March 4, 2010 10:00-11:00 a.m. HIMSS10 Annual Conference & Exhibition Georgia World Conference Center Atlanta, GA.

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Get ready emrs and hies here comes one billion clinical documents

Get Ready EMRs and HIEs:Here Comes One Billion Clinical Documents

Bob Dolin, MD, FACP, FACMI

Principal, Semantically Yours, LLC

Chair, Health Level Seven

Thursday, March 4, 2010

10:00-11:00 a.m.

HIMSS10 Annual Conference & Exhibition

Georgia World Conference Center

Atlanta, GA

Kim Stavrinaki

s


Conflict of interest disclosure
Conflict of Interest Disclosure

Bob Dolin, MD

Has no real or apparent

conflicts of interest to report.




Session overview
Session Overview

  • Health Story interoperability strategy

  • How Health Story leads to meaningful use

  • What this means for you



What is meaningful use
What is Meaningful Use?

“Meaningful use, in the long-term, is when EHRs are used by health care providers to improve patient care, safety and quality.”

David Blumenthal, MD

National Coordinator for HIT


Meaningful use data reuse
Meaningful Use ≈ Data Reuse

patient care

quality reporting

clinical

decision support

outcomes analysis

research

billing/claims adjudication


Meaningful use data reuse1
Meaningful Use ≈ Data Reuse

“If you can not measure it, you can not improve it.”

Lord Kelvin (1824-1907)


The health story project
The Health Story Project

  • Non profit, industry alliance

  • Founded 2007

  • Associate Charter Agreement: HL7

  • Sponsor HL7 standards for flow of information between narrative and EMR systems

  • Member organizations provide direction


Health story members
Health Story Members

Founding Members

Promoters

Contributors

Aprima Software | Scribe Healthcare Technologies

Participants

All Type | Dictation Services Group | Healthline, Inc.

MD-IT | Sten-Tel, Inc. | Broward Sheridan Technical Center


Health story guiding principles
Health Story: Guiding Principles

1. Inclusive and open process

2. Leverage current technology investments

3. Enable broad stakeholder engagement

4. Provide a glide path for incremental interoperability

5. Minimize disruption to clinician workflow

6. Base strategy on existing standards

7. Use proven technology


Health story incremental interoperability
Health Story: Incremental Interoperability

EHR Repository

Disease, DF-00000

Metabolic Disease, D6-00000

Clinical Applications

Disorder of carbohydrate metabolism, D6-50000

Disorder of glucose metabolism, D6-50100

HIMApplications

Diabetes Mellitus, DB-61000

SNOMED CT

Type 1, DB-61010

Neonatal, DB75110

Carpenter Syndrome, DB-02324

Insulin dependant type IA, DB-61020


Hl7 clinical document architecture
HL7 Clinical Document Architecture

  • Health Story specifications are based on HL7 CDA

  • CDA is “just right”

    • Single standard for entire EHR is too broad

    • Multiple standards and/or messages for each EHR function may be too difficult to implement


Hl7 clinical document architecture1
HL7 Clinical Document Architecture

  • Other benefits of CDA:

  • Normative HL7 standard since 2000

  • Widely implemented

  • Provides a gentle on-ramp to information exchange

  • Providesmechanism for inserting evidence-based medicine directly into the process of care

  • Top down strategy lets you implement once and reuse many times for new scenarios


Cda is the basis for
CDA is the basis for ...

  • HITSP/C28 Emergency Care Summary

  • HITSP/C32 - Summary Documents Using HL7 CCD

  • HITSP/C38 - Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS)

  • HITSP/C48 Encounter Document constructs

  • HITSP/C84 Consult and History & Physical Note Document

  • HITSP/C78 Immunization Document

  • HITSP/C74 PHRM

  • HITSP/C62 Scanned document

  • Consult Note

  • Continuity of Care Document

  • Diagnostic Imaging Report

  • Discharge Summary

  • Healthcare-associated Infections, Public Health Case Reports

  • History and Physical

  • Operative Note

  • Personal Health Monitoring

  • Plan-2-Plan Personal Health Record

  • Procedure Note

  • Quality Reporting Document

  • Minimum Data Set

  • Unstructured Documents

  • … and more …





Path to meaningful use
Path to Meaningful Use

“A journey of a thousand miles begins with a single step.”

Lao-tzu, The Way of Lao-tzu

Chinese philosopher (604 BX – 531 BC)


Health story meaningful use
Health Story  Meaningful Use

  • Health Story’s path to Meaningful Use

  • Hit the ground running with basic CDA, to meet the needs of front line clinicians

  • Incrementally layer discrete data elements into CDA documents



Why health story
Why Health Story?

HL7 Implementation Guide for CDA R2: Procedure Note

Sample: Endoscopy Report

Judy Logan

Associate Professor

Oregon Health & Science University



Actionable next steps
Actionable Next Steps

Is your system capable of producing an HL7 CDA document?

Requirements:


In summary
In Summary

  • A physician’s practical

  • need for fast and easy

  • methods for creating

  • clinical documentation

The enterprise need for

structured and coded

information capture to support meaningful use

Computer image courtesy of M*Modal



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