Health Story RSNA 2011 Update

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  • Structured data and physician narrative is necessary for the best careSo while everyone works hard to adapt to the new structureThey still need to make the existing system more and more efficientReduce costsAnd continue to improve the quality of care
  • HIE = Health Information ExchangeMRM = Medical Record ManagementEMR = Electronic Medical RecordCDA = Clinical Document ArchitectureOCR = Optical Character RecognitionPDR = Physician’s Desk ReferenceNLP = Natural Language ProcessingDRT = Discrete Reportable TranscriptionCAC = Computer Assisted CodingICD = International Classification of DiseasesCPT = Current Procedural TerminologyHL7 V2 = Health Level Seven, Version 2 Standard
  • ONC Standards & Interoperability FrameworkHealth Level Seven InternationalIntegrating the Healthcare Enterprise
  • Relevance to national requirements
  • Interoperability Showcase, January, Las Vegas
  • Approach builds on your existing workflow Productive, not disruptiveEHR Vendors: rapidly increase the information in your EMRprepares you for future meaningful use requirements
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  • Health Story RSNA 2011 Update

    1. 1. The Radiologist’s Speech –Realizing the Full Potential of the Diagnostic Report Nick van Terheyden, MD Board of Directors CDIA Chief Medical Information Officer, Nuance December 1, 2011 w w w . h e a l t h s t o r y. c o m
    2. 2. Health Story Project Non profit, industry alliance Founded 2007 Associate Charter Agreement: HL7 Sponsor HL7 standards for flow of information between narrative and EMR systems (8!) Member organizations provide direction www.healthstory.com w w w . h e a l t h s t o r y. c o m
    3. 3. HEALTHCARE SOLUTIONSSlide CONFIDENTIAL | © 2002-20113 courtesy of Nuance Nuance Communications, Inc. All rights reserved.
    4. 4. Health Story Project MembersOrganization AffiliatesPromotersContributors Canon U.S.A. - Scribe Healthcare Technologies All Type - Apixio - Arrendale Associates - BayScribe - Chase Transcriptions ChartLogic - DictateIT, Ltd - Dispersive Medical - Documentation Services GroupParticipants eMTS - Healthline, Inc. - InfraWare - InterFix - MedEDocs - MD-IT New England Medical Transcription - Phoenix Medcom Physicians Medical Group of Santa Cruz County - Sten-Tel, Inc. - Webmedx w w w . h e a l t h s t o r y. c o m
    5. 5. Health Story Telling Clinical Document Ecosystem Meaningful UsePeople H HIE Dictating Transcript- Clerk MD ionist Abstractor e MRM aPlatforms EMR l Integration Platform t BillingApplications h Analytics Voice Enrich Standard S Quality Imaging Voice capture to text Format t o Desktop Telephone Transcription NLP CDA appliances PDR Speech DRT ICD, CPT… r recognition Scan-to- Smart CAC HL7 V2 y CDA phone OCR w w w . h e a l t h s t o r y. c o m
    6. 6. Guide Consolidation: US Dept Of Health and Human Services Office of the National1. HL7 Consult Note Coordinator2. HL7 Diagnostic Imaging Report3. HL7 Discharge Summary4. HL7 History and Physical5. HL7 Operative Note6. HL7 Procedure Note7. HL7 Unstructured Documents One master8. HL7 Progress Notes implementation9. HL7 Continuity of Care Document10. HITSP/C84 Consult and History & Physical guide Note Document11. HITSP/C32 - Summary Documents Using HL7 CCD12. HITSP/C38 - Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS)13. HITSP/C48 Encounter Document constructs14. HITSP/C62 Scanned document Health Story supported guides in blue w w w . h e a l t h s t o r y. c o m
    7. 7. HL7 Clinical Document ArchitectureHealth Story Specs are Based on HL7 CDA Normative HL7 standard since 2000 Widely implemented Provides a gentle on-ramp to information exchange Provides mechanism for inserting evidence- based medicine directly into the process of care Top down strategy lets you implement once and reuse many times for new scenarios w w w . h e a l t h s t o r y. c o m
    8. 8. Why CDA? Radiology results are a key tool in providing diagnosis Results need to be:  concise  consistent  precipitate alerts before the report is distributed Radiology Information System  rich in data  eliminates redundancy  streamlines workflow CDA benefits  standard for clinical communication  foundation for structuring data w w w . h e a l t h s t o r y. c o m
    9. 9. Meaningful Use Stage 2 ONC Standards and Interoperability Framework has indicated intent to recommend CDA and Health Storyspecifications in meaningful use Stage 2requirements for clinical documentation w w w . h e a l t h s t o r y. c o m
    10. 10. Meaningful Use ≈ Data Reuse patient care quality reportingclinicaldecision outcomessupport analysis billing/claims research adjudication w w w . h e a l t h s t o r y. c o m
    11. 11. Health Story ApproachBenefit ValueRetains patient story Maintains primary role of radiology reports to clearly describe and communicate what is going on with patient.Preserves physician Makes efficient use of physician time by enablingtime for clinical care choice of documentation methods and fosters EMR acceptanceSupports meaningful Interoperability: implements HL7 CDA documentuse standards for electronic exchange of clinical informationEnables data reuse Structured narrative enables better outcomes reporting, data mining, and decision supportCollaborative approach Developed by broad array of providers, vendors and IT organizations; Balloted process through HL7 supports harmonizationBetter documentation Supports better coding, DRG optimization = better reimbursement Slide, with edits, courtesy of MD-IT w w w . h e a l t h s t o r y. c o m
    12. 12. Health Story Use CasesHealth Story Use Case, Transitions of Care Demonstration project at HIMSS 12 Using Standard published from HL7/IHE Health Story Consolidation Project in conjunction with the ONC Standards & Interoperability Framework. ~85% of information needed crosses enterprise boundaries Demonstration of complete information flow from  Unstructured documents Scanned documents Consult & discharge summaries Enriched with NLP and CAC w w w . h e a l t h s t o r y. c o m
    13. 13. What Healthstory Offers You 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 Provides on-ramp to EMR system adoption  pre-populate EMR with structured documents  integrate legacy documents w w w . h e a l t h s t o r y. c o m
    14. 14. Our Advocacy Requests Actions Requested:  Require certified systems to accept interfaced data from dictation/transcription process per available standards  Modify the definition of meaningful use to recognize use of certified systems with the above capabilities  Assist in spreading the word about this avenue for getting the full story into the EHR that allows radiologists to continue dictating and provides patients with comprehensive electronic records w w w . h e a l t h s t o r y. c o m
    15. 15. Actionable Next Steps1. Providers: 1. Is your documentation vendor set up to deliver CDA documents? If no, when? 2. Is your EHR vendor set up to receive CDA documents? If no, when?2. Vendors: Check out the requirements here: www.healthstory.com w w w . h e a l t h s t o r y. c o m
    16. 16. The Radiologist’s Speech –Realizing the Full Potential of the Diagnostic Report Nick van Terheyden, MD Board of Directors CDIA Chief Medical Information Officer, Nuance December 1, 2011 w w w . h e a l t h s t o r y. c o m

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