www.healthstory.com
The Health Story Project
Clinical Narrative and Structured Data in the EHR: Venus and Mars
live in Har...
www.healthstory.com
Presentation Primary Purpose
Raise awareness and encourage
participation and adoption of
available dat...
www.healthstory.com
Presentation Overview
 Background: The Current Situation
 Enabling the EMR with the Missing Link
 U...
www.healthstory.com
Background
The Current Situation
www.healthstory.com
Electronic Health Record Universe
Critical to the success
of EHRs is to reconcile
two opposing needs
...
www.healthstory.com
With apologies to Jim Klein, MS of
Quadramed and John Gray, Ph.D. …
EMRs ARE
FROM MARS,
HIM Systems
Ar...
www.healthstory.com
The Current Situation – Structured
 Tedious manual process
 Time-consuming
 Documentation lacks exp...
www.healthstory.com
Cost Comparisons
Transcribed
Note
Time Physician
Cost 1
/min
Transcription
Cost 2
/min
Total Cost
Dict...
www.healthstory.com
The Current Situation
 Transcription can be expensive
 Subject to longer turn-around times
 Clinica...
www.healthstory.com
The Current Situation
 High cost of documentation
 Cost of ownership and physician time vs. transcri...
www.healthstory.com
Home to: Association of Computing Machinery, IEEE, EHR Vendors Assoc.,
Home Planet of the EMR
Slide co...
www.healthstory.com
Lack of Flexibility
Inadequate standards
Incomplete or lack of adoption of available standards
Poor fa...
www.healthstory.com
Home Planet of HIM
Organizations Headquartered on Venus: AHIMA, AHDI, MTIA …
Slide courtesy of Jim Kle...
www.healthstory.com
Welcome to the HIM
Department
HIPAA JCAHOPayers
CMS
Lawyers
ICD-
9/10
Slide courtesy of Jim Klein, Qua...
www.healthstory.com
Enabling the EMR
The Missing Link in
Information Capture in Healthcare
www.healthstory.com
What if you could continue to use
narrative and dictation and at the same
time increase usage of the E...
www.healthstory.com
And unite their
inhabitants?
What or who can federate these planets?
Slide courtesy of Jim Klein, Quad...
www.healthstory.com
Health Story Project Vision
 Comprehensive electronic clinical records that
tell a patient’s complete...
www.healthstory.com
Based on HL7 CDA
Clinical Document Architecture Requirements
 Human readable document
 Must be prese...
www.healthstory.com
Adoption
 Incremental adoption overcomes the “not me
first” dilemma
 Not dependent on recipient’s ab...
www.healthstory.com
Accessible Clinical Data
Slide courtesy of M*Modal
www.healthstory.com
User Experience
Kim Stavrinakis
Sr. Manager, Product Definition, GE Healthcare
The Missing Link in
Inf...
www.healthstory.com
Meaningful Clinical Documents
Meaningful Clinical Documents are a blend between
free form text and ful...
www.healthstory.com
The Health Story Project and
Meaningful Clinical Documents
Kim Stavrinakis
Sr. Manager, Product Defini...
www.healthstory.com
Narrative
Text
Structured
Documents
Extracted, Coded
Discrete Data
Elements
EHR
Repository
HIM
Applica...
www.healthstory.com
Meaningful Clinical Documents vs. Text
 Structured and encoded clinical content enables…
 pre-signat...
www.healthstory.com
Adoption
 Medical transcription companies must support creation
and delivery of standards-based meani...
www.healthstory.com
Health Story Document Types
Implementation Guides
Completed
 History & Physical
 Consultation
 Oper...
www.healthstory.com
Adoption
 Health Story vendor members are generating
(GE Medical, MedQuist, M*Modal) and others
are p...
www.healthstory.com
Project Members
Promoters
Participants
All Type | Dictation Services Group | Healthline, Inc. | MD-IT
www.healthstory.com
Our Advocacy To Date
 Participation in public comment periods
 NCVHS Hearing on Meaningful Use
 HHS...
www.healthstory.com
Our Advocacy Messages
 Dictation is the documentation method of choice
for 85% of physician providers...
www.healthstory.com
Our Advocacy Requests
 Actions Requested:
 Require certified EHR systems to accept interfaced
data f...
www.healthstory.com
Conclusion
www.healthstory.com
Crossing the Chasm…Babel Must Go
 Medical text “typed” from dictation
has “no meaning”
 black marks ...
www.healthstory.com
Health Story…
 Captures meaningful clinical documents
 Is the bridge between
 free form narrative a...
www.healthstory.com
Impact
 Allows providers to choose preferred workflow
and documentation methods
 Increases the value...
www.healthstory.com
Getting Involved
 Share the Good News: Be an “Ambassador”
 We need a grass roots effort to help spre...
www.healthstory.com
www.healthstory.com
Kim Stavrinakis
Sr. Manager, Product Definition, GE Healthcare
For More Information
www.healthstory.com
Examples on the Show Floor
 A-Life (#2029)
 Medquist (#1600)
 M*Modal (#2201)
www.healthstory.com
The Health Story Project
Clinical Narrative and Structured Data in the EHR: Venus and Mars
live in Har...
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Clinical Narrative And Structured Data In The Ehr Venus And Mars Live In Harmony With Healthstory - AHIMA

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For nearly two decades healthcare technology has attempted to impose new documentation methods that are more suited to database management but do not meet the needs of the busy practicing physician. Conventional wisdom is that documents are bad and discrete data is good but historically clinicians have resisted efforts to establish structured data entry methodologies trying to replace the clinician preferred method of data capture – dictation. Clinical Document Architecture for Common Document Types (CDA4CDT) offers a bridge between the two opposing worlds of clinical documentation creating semantically interoperable data while retaining the precise clinical content contained in free flowing narrative

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Clinical Narrative And Structured Data In The Ehr Venus And Mars Live In Harmony With Healthstory - AHIMA

  1. 1. www.healthstory.com 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
  2. 2. www.healthstory.com Presentation Primary Purpose Raise awareness and encourage participation and adoption of available data standards that support continuity of care and enrich the EMR
  3. 3. www.healthstory.com Presentation Overview  Background: The Current Situation  Enabling the EMR with the Missing Link  User Experiences  The Health Story Project  Conclusion
  4. 4. www.healthstory.com Background The Current Situation
  5. 5. www.healthstory.com 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. Slide courtesy of M*Modal
  6. 6. www.healthstory.com With apologies to Jim Klein, MS of Quadramed and John Gray, Ph.D. … EMRs ARE FROM MARS, HIM Systems Are from Venus A Practical Guide for Improving Collaboration Between Documents and Databases and Getting Physician Adoption of EMRs Jim Klein, M.S. Slide courtesy of Jim Klein, Quadramed
  7. 7. www.healthstory.com 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. Slide courtesy of M*Modal
  8. 8. www.healthstory.com Cost Comparisons Transcribed Note Time Physician Cost 1 /min Transcription Cost 2 /min Total Cost Dictate Note 1 min $2.70 $2.70 Transcribe and edit note 4 min $0.40 $1.60 Total 5 min $4.30 Structured Data Entry Time Physician Cost 1 /min Transcription Cost 2 /min Total Cost Data Entry 5 min $2.70 $13.50 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 DRT http://www.healthcareledger.com/march2009.html http://www.healthcareledger.com/march2009/Medical%20Transcription%20Relevance%20in%20the%20EHR%20Age%20_%20What%20is%20DRT%20HCL%20Mar%202009.pdf
  9. 9. www.healthstory.com 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 Dictation: Fast and easy, expressive. Slide courtesy of M*Modal
  10. 10. www.healthstory.com The Current Situation  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 Slide courtesy of M*Modal
  11. 11. www.healthstory.com Home to: Association of Computing Machinery, IEEE, EHR Vendors Assoc., Home Planet of the EMR Slide courtesy of Jim Klein, Quadramed
  12. 12. www.healthstory.com 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 EMR Lack of Flexibility Fails to Meet Individual Physicians Time vs. Benefit Test Oblivious to HIM Requirements Incomplete and Inadequate Semantic Standards Weak Decision Support Poor Clinical Documentation Implementation Significant Impediments to EMRs Slide courtesy of Jim Klein, Quadramed
  13. 13. www.healthstory.com Home Planet of HIM Organizations Headquartered on Venus: AHIMA, AHDI, MTIA … Slide courtesy of Jim Klein, Quadramed
  14. 14. www.healthstory.com Welcome to the HIM Department HIPAA JCAHOPayers CMS Lawyers ICD- 9/10 Slide courtesy of Jim Klein, Quadramed
  15. 15. www.healthstory.com Enabling the EMR The Missing Link in Information Capture in Healthcare
  16. 16. www.healthstory.com 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. 17. www.healthstory.com And unite their inhabitants? What or who can federate these planets? Slide courtesy of Jim Klein, Quadramed
  18. 18. www.healthstory.com 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. 19. www.healthstory.com 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. 20. www.healthstory.com 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. 21. www.healthstory.com Accessible Clinical Data Slide courtesy of M*Modal
  22. 22. www.healthstory.com User Experience Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare The Missing Link in Information Capture in Healthcare
  23. 23. www.healthstory.com 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. 24. www.healthstory.com 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. 25. www.healthstory.com Narrative Text Structured Documents Extracted, Coded Discrete Data Elements EHR Repository HIM Applications Clinical Applications SNOMED CT Disease, DF- 00000 Metabolic Disease, D6- 00000 Disorder of glucose metabolism, D6-50100 Diabetes Mellitus, DB- 61000 Type 1, DB- 61010 Insulin dependant type IA, DB-61020 Neonatal, DB75110 Carpenter Syndrome, DB-02324 Disorder of carbohydrate metabolism, D6-50000 Meaningful Clinical Documents Slide courtesy of V. "Juggy" Jagannathan PhD, Medquist
  26. 26. www.healthstory.com 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. 27. www.healthstory.com 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. 28. www.healthstory.com 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. 29. www.healthstory.com 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. 30. www.healthstory.com Project Members Promoters Participants All Type | Dictation Services Group | Healthline, Inc. | MD-IT
  31. 31. www.healthstory.com 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. 32. 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
  33. 33. www.healthstory.com 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. 34. www.healthstory.com Conclusion
  35. 35. www.healthstory.com 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. 36. www.healthstory.com 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 - allowing clinical 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. 37. www.healthstory.com 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. 38. www.healthstory.com 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. 39. www.healthstory.com www.healthstory.com Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare For More Information
  40. 40. www.healthstory.com Examples on the Show Floor  A-Life (#2029)  Medquist (#1600)  M*Modal (#2201)
  41. 41. www.healthstory.com 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
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