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The Health Story Project Clinical 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. Presentation Primary Purpose.

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slide1

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

presentation primary purpose
Presentation Primary Purpose

Raise awareness and encourage participation and adoption of available data standards that support continuity of care and enrich the EMR

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

Background

The Current Situation

electronic health record universe
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

with apologies to jim klein ms of quadramed and john gray ph d

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

the current situation structured
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

cost comparisons
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

the current situation
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

the current situation1
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

home planet of the emr
Home Planet of the EMR

Home to: Association of Computing Machinery, IEEE, EHR Vendors Assoc.,

Slide courtesy of Jim Klein, Quadramed

significant impediments to emrs
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

home planet of him
Home Planet of HIM

Organizations Headquartered on Venus: AHIMA, AHDI, MTIA …

Slide courtesy of Jim Klein, Quadramed

welcome to the him department
Welcome to the HIM Department

ICD-9/10

H&P

Consent

Lawyers

CMS

HIPAA

Payers

JCAHO

Slide courtesy of Jim Klein, Quadramed

enabling the emr

Enabling the EMR

The Missing Link in

Information Capture in Healthcare

crossing the chasm
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…
slide17

What or who can federate these planets?

And unite theirinhabitants?

Slide courtesy of Jim Klein, Quadramed

health story project vision
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
based on hl7 cda
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
adoption
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
accessible clinical data
Accessible Clinical Data

Slide courtesy of M*Modal

user experience

User Experience

Kim Stavrinakis

Sr. Manager, Product Definition, GE Healthcare

The Missing Link in

Information Capture in Healthcare

meaningful clinical documents
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

the health story project and meaningful clinical documents

The Health Story Project and Meaningful Clinical Documents

Kim Stavrinakis

Sr. Manager, Product Definition, GE Healthcare

The Missing Link in

Information Capture in Healthcare

meaningful clinical documents1
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

meaningful clinical documents vs text
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
adoption1
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
health story document types
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
adoption2
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

project members
Project Members

Promoters

Participants

All Type | Dictation Services Group | Healthline, Inc. | MD-IT

our advocacy to date
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

our advocacy messages
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

our advocacy requests
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

crossing the chasm babel must go
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…
health story
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
impact
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
getting involved
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

www healthstory com

www.healthstory.com

Kim Stavrinakis

Sr. Manager, Product Definition, GE Healthcare

For More Information

examples on the show floor
Examples on the Show Floor

A-Life (#2029)

Medquist (#1600)

M*Modal (#2201)

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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