Amdis documentation panel nick van terheyden


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Amdis documentation panel nick van terheyden

  1. 1. AMDIS Documentation Panel Nick van Terheyden, MD CMIO – CLU Nuance Communications Inc
  2. 2. Paper is no longer fit for purpose Slide Courtesy of Dr Michael Bainbridge
  3. 3. Current Methods for Data Capture Unstructured Data Structured Data Dictation and Transcription System generated or interfaced data Direct data entry, not physician Direct data entry, physician Handwritten
  4. 4. Future Concepts from 1992 Imagine…..!
  5. 5. ∗Tel the patient story ∗Fill in the data Gaps ∗Unambiguous Sharing of information The Purpose of the EMR
  6. 6. ∗ Conventional Wisdom: ∗ The EMR is the solution ∗ Documents are the problem ∗ Questions: ∗ Are EMRs and documents mutually exclusive or complementary? ∗ Can eDocuments bridge the gap between physicians and EMRs? … and enable Computer-Assisted Coding too? More EMR planetary wisdom … and some questions
  7. 7. ∗ Why do documents have such a bad rap? ∗ Can’t compute ∗ Can’t automate decision support ∗ Can’t validate conformance to content requirements ∗ And why are documents still prevalent? ∗ Nuanced & precise ∗ Support human decision making ∗ Can be supplemented by multiple coded entries (optimized for reimbursement, decision support, quality metrics, research) ∗ Retains current workflow, favored by physicians ∗ Interoperable Documents and narrative text
  8. 8. 8 CONFIDENTIAL | © 2002-2011 Nuance Communications, Inc. All rights reserved. HEALTHCARE SOLUTIONS
  9. 9. Supporting the Clinician in the Avalanche of Increasing Demands POA/HAC Medical Necessity Core Measures MU Patient Safety Outcome Measures CMI Severity of Illness
  10. 10. For really tough problems … Try a different perspective!
  12. 12. • Meaningful Use • Quality Reporting • Decision Support • Value-Based Purchasing • Coding/CMI • POA/HAC • Medical Necessity • Coding • Documentation Integrity Financial Integrity Compliance Patient Care Narrative In EHR MT-editing Feedback With a RIS/PACS In EHR Self-editing On the Go On a PC At a Dictation Station On an MFP EHR
  13. 13. Key Challenges with Current Process DISRUPTIVE CDI QUERIES CDI SPECIALIST“The patient has respiratory failure” What is the acuity?
  14. 14. Fits Your Workflow • Interactive clarifications while physician is documenting “Patient has altered mental status, abnormal liver function and treatment with lactulose” Evidence suggests that this patient has hepatic encephalopathy. Do you agree? “Yes” Hepatic Encephalopathy Hepatic Encephalopathy
  15. 15. Fuel for intelligent clinical applications DETAILED, ACTIONABLE PATIENT RECORDS Fine Grained problem lists Up to date allergies Current medications Diabetes, Tumor, CHF Registry Automated Extraction From dictated notes to patient care
  16. 16. Fuel for intelligent clinical applications GRANULAR PATIENT DATA FOR CLINICAL DECISIONS Sepsis Screening Cardiac Monitoring Venous Thromboembolism Stroke Indicators From dictated notes to patient care
  17. 17. ∗ As Greg Shorr Said ∗ Patients want the doctor to focus on me not on the technology ∗ Showing Empathy improves Outcomes Focus on the Patient
  18. 18. ∗ Study done by the Mayo Clinic in 2006 identified the most important characteristics patients feel a good doctor must possess ∗ The Ideal clinician is ∗ confident, ∗ empathetic, ∗ humane, ∗ personal, ∗ forthright, ∗ respectful, and ∗ thorough ∗ You won’t get these by focusing on the Technology Focusing on the Patient Mayo Clin Proc. 2006;81(3):338-344
  19. 19. Nick van Terheyden, MD CMIO, Nuance Communications AboutMe Twitter LinkedIn Voice of the Doctor Plaxo FaceBook E-Mail, GrandCentral (301) 355-0877 Where You Can Find Me
  20. 20. AMDIS Documentation Panel Nick van Terheyden, MD CMIO – CLU Nuance Communications Inc