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

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. 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

8. EMRs Need Structured Encoded Clinical Data

9. EMRs Need Structured Encoded Clinical Data How does this fit in

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

16. Enabling the EMR The Missing Link in Information Capture in Healthcare

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

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

28. CDA Templates

29. Conversational Documentation The Missing Link in Information Capture in Healthcare

31. Nothing but Speech to Text

32. Speech-to-Clinical Document

36. How it works

37. Meaningful Clinical Documents The Missing Link in Information Capture in Healthcare

38. Accessible Clinical Data

39. One Voice – Many Outputs™

43. Conclusion

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

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