The Health Story Project Clinical Narrative and Structured Data in the EHR: Venus and Mars live in Harmony with CDA4CDT

1. The Health Story ProjectClinical Narrative and Structured Data in the EHR: Venus and Mars live in Harmony with CDA4CDT Kim Stavrinaki s AHIMA Conference, October 2009 Nick van Terheyden, MD Board of Directors, MTIA Chief Medical Officer, M*Modal

2. Presentation Primary Purpose Raise awareness and encourage participation and adoption of available data standards that support continuity of care and enrich the EMR

3. Presentation Overview • Background: The Current Situation • Enabling the EMR with the Missing Link • User Experiences • The Health Story Project • Conclusion

4. Background The Current Situation

5. 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 Slide courtesy of M*Modal

6. EMRs AREFROM MARS,HIM SystemsAre from Venus A Practical Guide forImproving CollaborationBetween Documents and Databases and Getting Physician Adoption of EMRs Jim Klein, M.S. With apologies to Jim Klein, MS of Quadramed and John Gray, Ph.D. … Slide courtesy of Jim Klein, Quadramed

7. 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. Slide courtesy of M*Modal

8. Cost Comparisons 1 MGMA Dashboard, $340,000 collections for IM professional charges 2 Outsourced transcription at 16 cents per 65-character line Source: Healthcare Ledger – March 2009: Medical Transcription Relevance in the EHR Age – What is DRThttp://www.healthcareledger.com/march2009.htmlhttp://www.healthcareledger.com/march2009/Medical%20Transcription%20Relevance%20in%20the%20EHR%20Age%20_%20What%20is%20DRT%20HCL%20Mar%202009.pdf

9. 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. Slide courtesy of M*Modal

10. 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 Slide courtesy of M*Modal

11. Home Planet of the EMR Home to: Association of Computing Machinery, IEEE, EHR Vendors Assoc., Slide courtesy of Jim Klein, Quadramed

12. Lack of Flexibility Inadequate standards Incomplete or lack of adoption of available standards Poor facilities for clinical documentation Weak clinical decision support system Cost Vendor viability and strategy changes Cultural resistance Fails to MeetIndividual PhysiciansTime vs. BenefitTest Lack of Flexibility Obliviousto HIMRequirements Incomplete and Inadequate SemanticStandards Poor Clinical Documentation Implementation Significant Impediments to EMRs EMR Weak Decision Support Slide courtesy of Jim Klein, Quadramed

13. Home Planet of HIM Organizations Headquartered on Venus: AHIMA, AHDI, MTIA … Slide courtesy of Jim Klein, Quadramed

14. Welcome to the HIM Department ICD-9/10 H&P Consent Lawyers CMS HIPAA Payers JCAHO Slide courtesy of Jim Klein, Quadramed

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

16. 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…

17. What or who can federate these planets? And unite theirinhabitants? Slide courtesy of Jim Klein, Quadramed

18. 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

19. 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

20. 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

21. Accessible Clinical Data Slide courtesy of M*Modal

22. User Experience Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare The Missing Link in Information Capture in Healthcare

23. Meaningful Clinical Documents Meaningful Clinical Documents are a blend between free form text and fully structured documentation that • represent the thought process, and • capture the clinical facts Slide courtesy of M*Modal

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 EHR Repository Disease, DF-00000 Metabolic Disease, D6-00000 Clinical Applications Disorder of carbohydrate metabolism, D6-50000 Disorder of glucose metabolism, D6-50100 HIM Applications Diabetes Mellitus, DB-61000 SNOMED CT Type 1, DB-61010 Neonatal, DB75110 Carpenter Syndrome, DB-02324 Insulin dependant type IA, DB-61020 Slide courtesy of V. "Juggy" Jagannathan PhD, Medquist

26. 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

27. Adoption • Medical transcription companies must support creation and delivery of standards-based meaningful documents • EHR vendors systems must have ability to receive, display, transform and parse these standards-based meaningful documents • Health Providers need to require support for import and export of standards-based meaningful clinical documents • Health Story helps by developing and publishing the technical implementation guides to support adoption

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

29. Adoption • Health Story vendor members are generating (GE Medical, MedQuist, M*Modal) and others are planning to generate the standards in the next year • Radiology Imaging of Lakeland is live today • Included in HITSP1 requirements • On CCHIT2 roadmap 1 Healthcare Information Technology Standards Panel 2 Certification Commission for Healthcare Information Technology

30. Project Members Promoters Participants All Type | Dictation Services Group | Healthline, Inc. | MD-IT

31. 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

32. 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

33. Our Advocacy Requests Actions Requested: Require certified EHR systems to accept interfaced data from dictation/transcription process per available 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

34. Conclusion

35. 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…

36. 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

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

38. Getting Involved Share the Good News: Be an “Ambassador” We need a grass roots effort to help spread the word Educate your employers, clients, etc. about this pathway Join the Effort Varying membership levels, including individuals Volunteer for a Project See “data standards” section of www.healthstory.com Encourage Implementation See “data standards” section of www.healthstory.com for suggested requirements language for transcription and EMR vendors

39. www.healthstory.com Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare For More Information

40. Examples on the Show Floor A-Life (#2029) Medquist (#1600) M*Modal (#2201)

41. The Health Story ProjectClinical Narrative and Structured Data in the EHR: Venus and Mars live in Harmony with CDA4CDT Kim Stavrinaki s AHIMA Conference, October 2009 Nick van Terheyden, MD Board of Directors, MTIA Chief Medical Officer, M*Modal