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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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