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. 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. 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. Presentation Overview  Background: The Current Situation  Enabling the EMR with the Missing Link  User Experiences  The Health Story Project  Conclusion
  4. 4. Background The Current Situation
  5. 5. 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. 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. 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. 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
  9. 9. 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. 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. Home to: Association of Computing Machinery, IEEE, EHR Vendors Assoc., Home Planet of the EMR Slide courtesy of Jim Klein, Quadramed
  12. 12. 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. Home Planet of HIM Organizations Headquartered on Venus: AHIMA, AHDI, MTIA … Slide courtesy of Jim Klein, Quadramed
  14. 14. Welcome to the HIM Department HIPAA JCAHOPayers CMS Lawyers ICD- 9/10 Slide courtesy of Jim Klein, Quadramed
  15. 15. Enabling the EMR The Missing Link in Information Capture in Healthcare
  16. 16. 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. And unite their inhabitants? What or who can federate these planets? Slide courtesy of Jim Klein, Quadramed
  18. 18. 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. 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. 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. Accessible Clinical Data Slide courtesy of M*Modal
  22. 22. User Experience Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare The Missing Link in Information Capture in Healthcare
  23. 23. 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. 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. 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. 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. 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. 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. 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. Project Members Promoters Participants All Type | Dictation Services Group | Healthline, Inc. | MD-IT
  31. 31. 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 
  32. 32. 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. 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. Conclusion
  35. 35. 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. 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. 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. 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  Encourage Implementation  See “data standards” section of for suggested requirements language for transcription and EMR vendors
  39. 39. Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare For More Information
  40. 40. Examples on the Show Floor  A-Life (#2029)  Medquist (#1600)  M*Modal (#2201)
  41. 41. 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