Healthstory Project Overview - Dictation To Clinical Data For AHDI

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

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

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.

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
Direct Data Entry: Structured and encoded information.

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
Dictation: Fast and easy, expressive.

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

Enabling the EMR
The Missing Link in
Information Capture in Healthcare

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

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…

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
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
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

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

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

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

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

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

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

“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

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

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

The Health Story Project and Meaningful Clinical Documents
Kim Stavrinakis
The Missing Link in

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

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

Project Members
Founders
Promoters
Participants

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
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
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

Conclusion

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…
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
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

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

Membership Options and Benefits

Q&A
Kim Stavrinakis

Nick van Terheyden, MD, CMO, M*Modal
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Where You Can Find Me

Healthstory Project Overview - Dictation To Clinical Data For AHDI

by Nick van Terheyden

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Healthstory Project Overview - Dictation To Clinical Data For AHDI Presentation Transcript