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
Pipeline session speech and medical intelligence – revolutionizing the doctor...
Clinical Narrative And Structured Data In The Ehr Venus And Mars Live In Harmony With Healthstory - AHIMA
1. www.healthstory.com
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
5. www.healthstory.com
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. www.healthstory.com
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. 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
8. www.healthstory.com
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
http://www.healthcareledger.com/march2009.html
http://www.healthcareledger.com/march2009/Medical%20Transcription%20Relevance%20in%20the%20EHR%20Age%20_%20What%20is%20DRT%20HCL%20Mar%202009.pdf
9. www.healthstory.com
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. www.healthstory.com
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
12. www.healthstory.com
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
16. www.healthstory.com
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…
18. www.healthstory.com
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. www.healthstory.com
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. www.healthstory.com
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
23. www.healthstory.com
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. www.healthstory.com
The Health Story Project and
Meaningful Clinical Documents
Kim Stavrinakis
Sr. Manager, Product Definition, GE Healthcare
The Missing Link in
Information Capture in Healthcare
26. www.healthstory.com
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. www.healthstory.com
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. www.healthstory.com
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. www.healthstory.com
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
31. www.healthstory.com
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
32. www.healthstory.com
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. www.healthstory.com
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
35. www.healthstory.com
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. www.healthstory.com
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. www.healthstory.com
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. www.healthstory.com
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
41. www.healthstory.com
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