Clinical Narrative And Structured Data In The Radiology Report Harmony With Healthstory Rsna 2009 Presentation


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Harmony with Healthstory for radiology clinical narrative documentation to generate structured encoded clinical data

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  • Why Health Story?1.2 billion clinical documents produced in U.S./yearDictated and transcribed documents around 60% of clinical dataGetting valuable info from narrative documents into the EHRWhat 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?Dictation is the documentation method of choice for 85% of physician providersStandardization of dictated notes is an achievable step for providers; Standards are available today
  • Health Story members share the vision that all of the clinical information required for good patient care, administration, reporting and research will be readily available electronically, including information from narrative documents.Other key points:Active for three years (founded 2007 by AHIMA, AHDI, Alschuler, MTIA, M*Modal) Associate Charter Agreement: HL7Elected executive committee from member organizations provide direction- Members support project with active participation and annual membership dues
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  • Clinical Narrative And Structured Data In The Radiology Report Harmony With Healthstory Rsna 2009 Presentation

    1. 1. Clinical Narrative and Structured Data in the Radiology ReportHarmony with Healthstory <br />Nick van Terheyden, MD<br />Board of Directors MTIA<br />Chief Medical Officer, M*Modal<br />December 1, 2009<br />
    2. 2. A radiologist’s practical <br />need for fast and easy <br />method for creating <br />clinical documentation<br />The enterprise need for<br />structured and coded<br />information capture<br />Balancing Two Opposing Needs<br />
    3. 3. Health Story Project<br />Vision: Comprehensive electronic clinical records that tell a patient’s complete health story.<br />Who We Are: A non profit alliance of healthcare vendors, providers and associations <br />Mission: Pool resources to develop data standards through HL7 for flow of information between common types of healthcare documents and EHR systems<br />Goals: Bridge the gap between the narrative documents and structured data<br />
    4. 4. Adoption Strategy<br />HL7 collaborates with Health Story on development and ballot of technical implementation guides<br />Medical transcription companies support creation, delivery and enrichment<br />HIT vendors systems send, receive, display and integrate<br />Health providers select the approach and receive vendor support for standards-based document creation, management and enrichment<br />
    5. 5. Why CDA? <br />Radiology results are a key tool in providing diagnosis<br />Results need to be:<br />concise<br />consistent<br />precipitate alerts before the report is distributed<br />Radiology Information System<br />rich in data<br />eliminates redundancy<br />streamlines workflow<br />CDA benefits<br />standard for clinical communication<br />foundation for structuring data<br />
    6. 6. EHR Repository<br />Disease, DF-00000<br />Metabolic Disease, D6-00000<br />Clinical Applications<br />Disorder of carbohydrate metabolism, D6-50000<br />Disorder of glucose metabolism, D6-50100<br />HIM Applications<br />Diabetes Mellitus, DB-61000<br />SNOMED CT<br />Type 1, DB-61010<br />Neonatal, DB75110<br />Carpenter Syndrome, DB-02324<br />Insulin dependant type IA, DB-61020<br />Meaningful Clinical Documents<br />Slide courtesy of V. &quot;Juggy&quot; Jagannathan PhD, Medquist<br />
    7. 7. Meaningful Clinical Documents vs. Text<br />Structured and encoded clinical content enables…<br />pre-signature alerts, <br />decision support, <br />best documentation practices,<br />multiple output formats, <br />multi-media reporting, <br />data mining<br />Implements HL7 CDA4CDT standard compliant document types<br />Increases quality of documentation<br />
    8. 8. Current and Future Standards<br />HL7 Implementation Guides<br />Completed<br />History & Physical <br />Consultation<br />Operative Report<br />DICOM Imaging Reports<br />Discharge Summary (in publication)<br />Upcoming<br />Procedure Note (focus on Endoscopy Report)<br />CDA with unstructured body<br />Billing and Reimbursement Requirements <br />Progress Notes<br /><br />
    9. 9. Adoption<br />Healthstory vendor members are generating Healthstory Documents (GE Medical, MedQuist, M*Modal) and others are planning to generate the standards in the next year<br />Included in HITSP1 requirements<br />On CCHIT2 roadmap<br />1 Healthcare Information Technology Standards Panel<br />2 Certification Commission for Healthcare Information Technology<br />
    10. 10. Project Members<br />Promoter Members<br />Participant Members<br />All Type | Dictation Services Group | Healthline, Inc.<br />MD-IT | Broward Sheridan Technical Center<br />
    11. 11. Our Advocacy To Date<br />Participation in public comment periods<br />NCVHS Hearing on Meaningful Use<br />HHS Request for Input on Meaningful Use<br />HITSP Request for Input on ARRA<br />Comments are posted on our site<br /><br />
    12. 12. Our Advocacy Requests<br />Actions Requested:<br />Require certified systems to accept interfaced data from dictation/transcription process per available standards<br />Modify the definition of meaningful use to recognize use of certified systems with the above capabilities<br />Assist in spreading the word about this avenue for getting the full story into the EHR that allows physicians to continue dictating and provides patients with comprehensive electronic records<br />
    13. 13. Getting Involved<br />Share the Good News: Be an “Ambassador” <br />Grass roots effort to help spread the word<br />Educate your employers, clients, vendors etc. about this pathway<br />Join the Effort<br />Varying membership levels, including individuals<br />Volunteer for a Project<br />See “data standards” section of<br />Encourage Implementation<br />See “data standards” section of for suggested requirements language for transcription and EMR vendors<br />Ensure your selection team are aware of the available data standards that support the Health Story approach<br />
    14. 14. What Healthstory Offers You<br />Allows providers to choose preferred workflow and documentation methods<br />Increases the value and usability of narrative documents<br />Accelerates the implementation of interoperable electronic health records<br />Allows intelligent and meaningful reuse of information<br />Provides on-ramp to EMR system adoption<br />pre-populate EMR with structured documents<br />integrate legacy documents<br />
    15. 15. The Health Story ProjectClinical Narrative and Structured Data in the Radiology ReportHarmony with Healthstory <br />Kim Stavrinaki<br />s<br />RSNA Conference, December 2009<br />Nick van Terheyden, MD<br />Board of Directors, MTIA<br />Chief Medical Officer, M*Modal<br />
    16. 16. Nick van Terheyden, MD Chief Medical Officer, M*Modal<br />Twitter<br />Technorati<br />RSSSpeech Understanding<br />MyBlogLog<br />LinkedIn<br />Plaxo<br />FaceBook<br />Digg<br />Delicious<br />E-Mail<br />GrandCentral (301) 355-0877<br />Where You Can Find Me<br />