Healthstory Enabling The Emr Dictation To Clinical Data


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EHRs are database centric while medical records are document centric. The conventional wisdom is that documents are bad and discrete data is good. Historically, clinicians have resisted efforts to establish structured data standards for dictated reports. This lack of an industry-wide standard for report content and format confounds interoperability efforts. For nearly two decades, information system specialists have attempted to impose new documentation methods that are more suited to database management but do not meet the needs of the practicing physician. Achieving physician buy-in for electronic record systems that do not accommodate narrative documentation methods such as dictation and transcription has proven to be quite difficult for many EHR vendors

The Health Story Project (formerly the CDA4CDT initiative Clinical Document Architecture for Common Data Types) is an alliance of organizations that have been working together with HL7 for nearly two years to develop and publish data standards for electronic clinical documents. The initiative is based on Clinical Document Architecture (CDA) - a balloted HL7 document markup standard that specifies the structure and semantics of a clinical document for the purpose of exchange. Document templates for the most commonly dictated report types (H&P, Consult, Operative Note, etc) specify required and optional headings. Templates are developed based on prevailing practice and establish consensus on content and format

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  • Healthstory Enabling The Emr Dictation To Clinical Data

    1. 1. The Healthstory Project Dictation to Clinical Data: Automating the Production of Structured and Encoded Documents Nick van Terheyden, MD Chief Medical Officer M*Modal
    2. 2. The Healthstory Project Dictation to Clinical Data: Automating the Production of Structured and Encoded Documents Transcend Advisory Board Friday March 13, 2009 Nick van Terheyden, MD Chief Medical Officer, M*Modal
    3. 3. Current Problems Facing Clinicians in Healthcare <ul><li>According to an American College of Physician Executives survey, 6 in 10 physicians have considered leaving the profession due to: </li></ul><ul><ul><li>burnout </li></ul></ul><ul><ul><li>low morale/depression </li></ul></ul><ul><ul><li>loss of autonomy </li></ul></ul><ul><ul><li>low reimbursement rates </li></ul></ul><ul><ul><li>patient overload </li></ul></ul><ul><ul><li>bureaucratic red tape </li></ul></ul><ul><ul><li>loss of respect, and </li></ul></ul><ul><ul><li>medical liability environment </li></ul></ul>Complexity and workload is crippling Physicians and hindering their ability to deliver High Quality Care
    4. 4. Electronic Health Record Universe <ul><li>Critical to the success of electronic health records is to reconcile two opposing needs </li></ul><ul><ul><li>Enterprise need for structured and coded information capture </li></ul></ul><ul><ul><li>Physician’s practical need for a fast and easy method for creating clinical notes. </li></ul></ul>
    5. 5. EHR Data Requirements <ul><li>Structured </li></ul><ul><li>Searchable </li></ul><ul><li>Computer-interpretable </li></ul><ul><li>Transportable </li></ul><ul><li>Exchangeable </li></ul>
    6. 6. Structured Data <ul><li>Uses standardized terminology (controlled medical vocabulary) </li></ul><ul><ul><li>LOINC </li></ul></ul><ul><ul><li>SNOMED </li></ul></ul><ul><li>Uses standardized encoding </li></ul><ul><ul><li>CDA (Clinical Document Architecture) </li></ul></ul><ul><ul><li>XML (Extensible Markup Language) </li></ul></ul>
    7. 7. Semantic Interoperability <ul><li>Ability to pass information between two computers that can then be processed, analyzed, and reused by both computer systems </li></ul>
    8. 8. EMRs Need Structured Encoded Clinical Data
    9. 9. EMRs Need Structured Encoded Clinical Data How does this fit in
    10. 10. The Current Situation – Structured <ul><li>Tedious manual process </li></ul><ul><li>Time-consuming </li></ul><ul><li>Documentation lacks expressiveness of natural language </li></ul><ul><li>Lack of Flexibility </li></ul><ul><li>Poor user interface </li></ul><ul><li>Cost </li></ul><ul><ul><li>Fails to Meet Individual Physicians Time vs. Benefit Test </li></ul></ul><ul><ul><li>Cultural resistance </li></ul></ul><ul><li>Oblivious to HIM Requirements </li></ul><ul><li>Incomplete and Inadequate Semantic Standards </li></ul>Direct Data Entry : Structured and encoded information.
    11. 11. <ul><li>“ Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue.” </li></ul><ul><li>Pamela Hartzband, M.D., and Jerome Groopman, M.D. </li></ul><ul><li>n engl j med 358;16 april 17, 2008 </li></ul>
    12. 12. The Current Situation - Dictation <ul><li>Transcription can be expensive </li></ul><ul><li>Subject to longer turn-around times </li></ul><ul><li>Clinical data lost, because documents are neither structured nor encoded </li></ul><ul><li>Majority of attested information is only in the document </li></ul><ul><li>Contains the detail and comprehensive scope of patient information </li></ul><ul><li>Support human decision making </li></ul><ul><li>Reimbursement is based on narrative documentation </li></ul><ul><li>Retains current workflow, favored by physicians </li></ul><ul><li>Interoperable </li></ul><ul><li>Under utilized source of data for EMR </li></ul>Dictation : Fast and easy, expressive.
    13. 13. The Current Situation <ul><li>High cost of documentation </li></ul><ul><ul><li>Cost of ownership and physician time vs. transcription cost </li></ul></ul><ul><li>60% of the data lost to the EHR </li></ul><ul><li>Care process inefficiencies and impact on quality </li></ul>
    14. 14. Data Capture—Current Methods Unstructured Data Structured Data Dictation and Transcription System generated or interfaced data Direct data entry, not physician Direct data entry, physician Handwritten
    15. 15. <ul><li>“ We have uncovered powerful evidence that sophisticated EMR technologies positively correlate to improved measures of patient outcomes.” </li></ul><ul><li>HIMSS analytics </li></ul>1. White Paper: EMR Sophistication Correlates To Hospital Quality Data, (HIMSSanalytics 2006) *1
    16. 16. Enabling the EMR The Missing Link in Information Capture in Healthcare
    17. 17. Value of EHRs over Dictation <ul><li>EHRs save you time </li></ul><ul><ul><li>but it takes much longer to enter the information </li></ul></ul><ul><li>You have more discrete data </li></ul><ul><ul><li>over 700 data elements </li></ul></ul><ul><ul><li>but you only use about 3% of these data elements </li></ul></ul><ul><li>E & M coding improves </li></ul><ul><ul><li>In theory, but EHR vendors have no 3 rd party validation studies. </li></ul></ul><ul><li>EHRs provide orders and alerts </li></ul><ul><ul><li>but you can have the same with Healthstory enabled EHRs </li></ul></ul>
    18. 18. Time To Collect Data Number of seconds for data entry of discrete clinical data Source: 573 Patient charts Data and Chart courtesy Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group
    19. 19. Data Entry Time <ul><li>The average physician spends 33 seconds dictating an establish office visit </li></ul><ul><li>92% of all office visits are established </li></ul><ul><li>If the average physician sees 40 patients a day, total dictation time of 30 minutes plus time to search for the data. </li></ul><ul><li>Using a traditional EHR application, the same number of patients would require 140 minutes of data entry time. </li></ul><ul><li>Physicians are not willing to spend an additional 90 minutes per day for data entry. </li></ul>(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
    20. 20. Why are Practices not using what they Purchased Source: AC Group Annual Survey of buying patterns New England Journal of Medicine Data and Chart courtesy Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group
    21. 21. <ul><li>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? </li></ul>Crossing the Chasm…
    22. 22. Health Story Project Vision <ul><li>all of the clinical information required for </li></ul><ul><ul><li>Good patient care </li></ul></ul><ul><ul><li>Administration </li></ul></ul><ul><ul><li>Reporting and </li></ul></ul><ul><ul><li>Research </li></ul></ul><ul><li>will be readily available electronically, including information from narrative documents </li></ul>
    23. 23. Goals <ul><li>Bridge the gap between narrative documents and structured data </li></ul><ul><li>Encourage proliferation of information for the EHR </li></ul>
    24. 24. CDA Documents <ul><li>Requirements </li></ul><ul><ul><li>Human readable document— </li></ul></ul><ul><ul><ul><li>Must be presentable as a document </li></ul></ul></ul><ul><ul><ul><li>Rendered version covers clinical information intended by the author </li></ul></ul></ul><ul><ul><li>Can contain machine-processable data </li></ul></ul><ul><ul><li>Cross platform and application independent </li></ul></ul><ul><ul><li>Can be transformed with style sheets </li></ul></ul>
    25. 25. Adoption <ul><li>Incremental adoption overcomes the “not me first” dilemma </li></ul><ul><li>Not dependent on recipient’s ability to receive or process </li></ul><ul><li>Reverse adoption (can encode headers of existing documents) </li></ul><ul><li>Non-proprietary </li></ul><ul><li>Readable with any browser </li></ul>
    26. 26. Levels of Encoding <ul><li>Level I—Header metadata (required) </li></ul><ul><ul><li>Identify patient, provider, and document type </li></ul></ul><ul><ul><li>Provide info for DMS, storage, query and retrieval </li></ul></ul><ul><li>Level II—section level </li></ul><ul><ul><li>Identifies content of sections within document </li></ul></ul><ul><ul><li>Allows for section reuse </li></ul></ul><ul><ul><li>Uses LOINC to identify document sections </li></ul></ul><ul><li>Level III—discrete data </li></ul><ul><ul><li>High level of encoding </li></ul></ul><ul><ul><li>Decision support automation </li></ul></ul>
    27. 27. Encoding <ul><ul><li>Does not preclude “once and done” concept </li></ul></ul><ul><ul><li>Compatible with Speech Understanding/Recognition </li></ul></ul><ul><ul><li>Can be facilitated by Natural Language Processing </li></ul></ul><ul><ul><li>Leverage existing relationships with transcriptionists/editors/knowledge based workers </li></ul></ul><ul><ul><li>Potential for automated coding (billing) </li></ul></ul><ul><ul><li>Supports data abstraction/research </li></ul></ul>
    28. 28. CDA Templates
    29. 29. Conversational Documentation The Missing Link in Information Capture in Healthcare
    30. 30. Speech Recognition Challenges <ul><li>Challenges faced in understanding regular dictation </li></ul><ul><li>Good dictators </li></ul><ul><li>Challenging Dictators </li></ul>
    31. 31. Nothing but Speech to Text
    32. 32. Speech-to-Clinical Document
    33. 33. “ Best of Both Worlds” Approach <ul><li>Creation and validation of meaningful clinical documents that are accurate, complete, accessible and shareable… </li></ul><ul><ul><li>… by leveraging existing workflow </li></ul></ul><ul><ul><li>… to populate the electronic health record, </li></ul></ul><ul><ul><li>… without requiring change for the physician. </li></ul></ul><ul><li>Significant productivity gains in generating high quality medical documentation from dictation - across all work types and medical specialties. </li></ul>
    34. 34. Conversational Documentation <ul><li>… transformation of dictation directly into structured clinical documents while encoding data depending on the care givers and organizations needs </li></ul>EHR
    35. 35. Meaningful Clinical Documents <ul><li>Meaningful Clinical Documents are a blend between free form text and fully structured documentation that </li></ul><ul><ul><li>represent the thought process, and </li></ul></ul><ul><ul><li>capture the clinical facts </li></ul></ul>
    36. 36. How it works
    37. 37. Meaningful Clinical Documents The Missing Link in Information Capture in Healthcare
    38. 38. Accessible Clinical Data
    39. 39. One Voice – Many Outputs™
    40. 40. Clinical Documentation Architecture <ul><li>Meaningful Clinical Documents vs. Text </li></ul><ul><ul><li>Structured and encoded clinical content enables… </li></ul></ul><ul><ul><ul><li>pre-signature alerts, </li></ul></ul></ul><ul><ul><ul><li>decision support, </li></ul></ul></ul><ul><ul><ul><li>best documentation practices, </li></ul></ul></ul><ul><ul><ul><li>multiple output formats, </li></ul></ul></ul><ul><ul><ul><li>multi-media reporting, </li></ul></ul></ul><ul><ul><ul><li>data mining </li></ul></ul></ul><ul><ul><li>Implements HL7 C DA 4C DT compliant document types </li></ul></ul><ul><ul><li>Increases quality of documentation </li></ul></ul>
    41. 41. Document Types <ul><li>History & Physical (completed) </li></ul><ul><li>Consultation (completed) </li></ul><ul><li>Operative Report (completed) </li></ul><ul><li>DICOM Imaging Reports (completed) </li></ul><ul><li>Progress Notes </li></ul><ul><li>Specialty reports (eg, Pediatric H&P) </li></ul>
    42. 42. Get the Full Healthstory CDA4CDT: bridging the gap between EMRs and eDocuments <ul><li>CDA implementation guides are being embraced by the EMR community </li></ul><ul><ul><li>Clinical societies: </li></ul></ul><ul><ul><ul><li>ASTM/HL7 Continuity of Care Document </li></ul></ul></ul><ul><ul><ul><li>CDA for anatomic pathology, imaging, anesthesiology, pediatrics, periodontal, long term care, others </li></ul></ul></ul><ul><ul><li>Reimbursement: HIPAA Attachments </li></ul></ul><ul><ul><li>HITSP: included in all use cases </li></ul></ul><ul><ul><li>IHE </li></ul></ul><ul><ul><ul><li>2006: 14 vendors, 1 content type </li></ul></ul></ul><ul><ul><ul><li>2007: 22 vendors, 7 content types </li></ul></ul></ul><ul><ul><li>Reporting: </li></ul></ul><ul><ul><ul><li>Public health: Cancer abstracts & Infectious Disease </li></ul></ul></ul><ul><ul><ul><li>Quality: Pediatric </li></ul></ul></ul><ul><ul><li>Providers: in production at Mayo, UPMC, NY Presbyterian, VA, MHS, others </li></ul></ul>
    43. 43. Conclusion
    44. 44. Conclusion… <ul><li>Crossing the Chasm… Babel Must Go </li></ul><ul><li>Medical text “typed” from dictation has “no meaning” – </li></ul><ul><li>Black marks on a page… </li></ul><ul><li>Information must be tagged as discrete data elements in order to assign meaning </li></ul><ul><li>Clinical documentation uses a wide variety of terms that have the same meaning…. </li></ul><ul><li>And terms that sound the same that have different meanings….. </li></ul><ul><li>Authors have a wide variety of styles, accents, methods of dictation… </li></ul>
    45. 45. Conclusion <ul><li>The Healthstory Captures Meaningful Clinical Documents </li></ul><ul><ul><li>Bridge between </li></ul></ul><ul><ul><ul><li>Free form narrative and expressive notes, and </li></ul></ul></ul><ul><ul><ul><li>Fully structured clinical data </li></ul></ul></ul><ul><ul><li>Improve the overall quality of clinical documentation </li></ul></ul><ul><ul><li>Generates Semantically Interoperable Clinical Data that will </li></ul></ul><ul><ul><ul><li>Solve the fundamental challenges with EMR’s allowing clinical decision support, alerts, decision support, data mining </li></ul></ul></ul><ul><ul><ul><li>Enables interoperability, reporting, patient safety initiatives, PQRI (pay for performance), PSI (Patient safety indicators) and improves billing data capture </li></ul></ul></ul>
    46. 46. Impact <ul><li>Allows providers to maintain preferred workflow and documentation methods </li></ul><ul><li>Increases the value and usability of narrative documents (dictation/trans, SRT) </li></ul><ul><li>Accelerates the implementation of interoperable electronic health records </li></ul><ul><li>Allows reuse of information </li></ul>
    47. 47. Getting Involved <ul><li>Join Healthstory </li></ul><ul><ul><li> </li></ul></ul><ul><li>Participate in HL7 SDTC </li></ul><ul><li>Participate in HL7 ballots </li></ul><ul><li>Encourage implementation </li></ul><ul><ul><li>EHR vendor adoption </li></ul></ul><ul><ul><li>Provider preference </li></ul></ul><ul><ul><li>Transcription RFPs </li></ul></ul>
    48. 48. Health Story <ul><li>Membership </li></ul><ul><ul><li>Promoter, Contributor, Participant </li></ul></ul><ul><li>Member responsibilities </li></ul><ul><ul><li>designate a minimum of one primary representative to the project </li></ul></ul><ul><ul><li>provide input into developing standards </li></ul></ul><ul><ul><li>act as ambassadors for the project in the industry through informal and formal networking and educational opportunities </li></ul></ul><ul><ul><li>become early adopters of standards published by the project </li></ul></ul>
    49. 49. The Healthstory Project Dictation to Clinical Data: Automating the Production of Structured and Encoded Documents Nick van Terheyden, MD Chief Medical Officer M*Modal
    50. 50. Where you can Find Me Twitter Technorati RSSSpeech Understanding MyBlogLog LinkedIn Plaxo FaceBook Digg Delicious E-Mail [email_address] GrandCentral (301) 355-0877