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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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www.healthstory.com
The Health Story ProjectClinical Narrative and Structured Data in the EHR: Venus and Mars
live in Harmony with CDA4CDT
Kim Stavrinaki
s
AHIMA Conference, October 2009Nick van Terheyden, MDBoard of Directors, MTIA
Chief Medical Officer, M*Modal
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Presentation Primary Purpose
Raise awareness and encourage participation and adoption of
available data standards that support continuity of care and enrich the EMR
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Presentation Overview
Background: The Current Situation Enabling the EMR with the Missing Link User Experiences The Health Story Project Conclusion
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Background
The Current Situation
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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
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With apologies to Jim Klein, MS of Quadramed and John Gray, Ph.D. …
EMRs AREFROM MARS,
HIM SystemsAre from Venus
A Practical Guide forImproving Collaboration
Between Documents and
Databases and Getting Physician Adoption of
EMRs
Jim Klein, M.S.
EMRs AREFROM MARS,
HIM SystemsAre from Venus
A Practical Guide forImproving Collaboration
Between Documents and
Databases and Getting Physician Adoption of
EMRs
Jim Klein, M.S.
Slide courtesy of Jim Klein, Quadramed
www.healthstory.com
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
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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 charges2 Outsourced transcription at 16 cents per 65-character line
Source: Healthcare Ledger – March 2009: Medical Transcription Relevance in the EHR Age – What is DRThttp://www.healthcareledger.com/march2009.htmlhttp://www.healthcareledger.com/march2009/Medical%20Transcription%20Relevance%20in%20the%20EHR%20Age%20_%20What%20is%20DRT%20HCL%20Mar%202009.pdf
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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
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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
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Home to: Association of Computing Machinery, IEEE, EHR Vendors Assoc.,
Home Planet of the EMR
Slide courtesy of Jim Klein, Quadramed
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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 MeetIndividual PhysiciansTime vs. BenefitTest
Obliviousto HIMRequirements
Incomplete and
Inadequate SemanticStandards
Weak Decision
SupportPoor Clinical
Documentation
Implementation
Significant Impediments to EMRs
Slide courtesy of Jim Klein, Quadramed
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Home Planet of HIM
Organizations Headquartered on Venus: AHIMA, AHDI, MTIA …
Slide courtesy of Jim Klein, Quadramed
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Welcome to the HIM Department
HIPAA JCAHOPayersCMS
Lawyers
Consent
H&P
ICD-9/10
Slide courtesy of Jim Klein, Quadramed
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Enabling the EMR
The Missing Link in Information Capture in Healthcare
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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…
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And unite theirinhabitants?And unite theirinhabitants?
What or who can federate these planets?
Slide courtesy of Jim Klein, Quadramed
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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
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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
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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
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Accessible Clinical Data
Slide courtesy of M*Modal
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User Experience
Kim Stavrinakis
Sr. Manager, Product Definition, GE Healthcare
The Missing Link in Information Capture in Healthcare
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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
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The Health Story Project and Meaningful Clinical Documents
Kim Stavrinakis
Sr. Manager, Product Definition, GE Healthcare
The Missing Link in Information Capture in Healthcare
www.healthstory.com
Narrative
Text
Structured Documents
Extracted, Coded Discrete Data Elements
EHR Repository
HIM Applications
Clinical Applications
SNOMED CTDisease, 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
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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
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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
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Health Story Document Types
Implementation GuidesCompleted History & Physical Consultation Operative Report DICOM Imaging Reports Discharge Summary
Upcoming Billing and Reimbursement Requirements Progress Notes .PDF work with Adobe
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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 Panel2 Certification Commission for Healthcare Information Technology
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Project Members
Promoters
Participants
All Type | Dictation Services Group | Healthline, Inc. | MD-IT
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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 www.healthstory.com
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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
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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
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Conclusion
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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…
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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
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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
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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 www.healthstory.com
Encourage Implementation See “data standards” section of www.healthstory.com for
suggested requirements language for transcription and EMR vendors
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Kim Stavrinakis
Sr. Manager, Product Definition, GE Healthcare
For More Information
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Examples on the Show Floor
A-Life (#2029)
Medquist (#1600)
M*Modal (#2201)
www.healthstory.com
The Health Story ProjectClinical Narrative and Structured Data in the EHR: Venus and Mars
live in Harmony with CDA4CDT
Kim Stavrinaki
s
AHIMA Conference, October 2009Nick van Terheyden, MDBoard of Directors, MTIA
Chief Medical Officer, M*Modal
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