Presentation - Health Story

Report
The Radiologist’s Speech –
Realizing the Full Potential of the
Diagnostic Report
Nick van Terheyden, MD
Board of Directors CDIA
Chief Medical Information Officer, Nuance
December 1, 2011
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Health Story Project
 Non profit, industry alliance
 Founded 2007
 Associate Charter
Agreement: HL7
 Sponsor HL7 standards for flow
of information between
narrative and EMR systems (8!)
 Member organizations provide
direction
 www.healthstory.com
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3
CONFIDENTIAL | © 2002-2011
Slide
courtesy of Nuance
Nuance Communications, Inc. All rights reserved.
HEALTHCARE SOLUTIONS
Health Story Project Members
Organization Affiliates
Promoters
Contributors
Participants
Canon U.S.A. - Scribe Healthcare Technologies
All Type - Apixio - Arrendale Associates - BayScribe - Chase Transcriptions
ChartLogic - DictateIT, Ltd - Dispersive Medical - Documentation Services Group
eMTS - Healthline, Inc. - InfraWare - InterFix - MedEDocs - MD-IT
New England Medical Transcription - Phoenix Medcom
Physicians Medical Group of Santa Cruz County - Sten-Tel, Inc. - Webmedx
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Health Story Telling
Clinical Document Ecosystem
People
Clerk
Dictating
MD
Transcriptionist
Abstractor
Platforms
Integration Platform
Applications
Imaging Voice
capture
Desktop
appliances
Scan-toCDA
OCR
Voice
to text
Enrich
Telephone Transcription NLP
Speech
PDR
DRT
recognition
Smart
CAC
phone
Standard
Format
CDA
ICD, CPT…
HL7 V2
Meaningful Use
H
e
a
l
t
h
S
t
o
r
y
HIE
MRM
EMR
Billing
Analytics
Quality
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1.
Guide Consolidation: US Dept Of Health and
Human Services Office of the National
Coordinator
HL7 Consult Note
2.
HL7 Diagnostic Imaging Report
3.
HL7 Discharge Summary
4.
HL7 History and Physical
5.
HL7 Operative Note
6.
HL7 Procedure Note
7.
HL7 Unstructured Documents
8.
HL7 Progress Notes
9.
HL7 Continuity of Care Document
10. HITSP/C84 Consult and History & Physical
Note Document
One master
implementation
guide
11. HITSP/C32 - Summary Documents Using
HL7 CCD
12. HITSP/C38 - Patient Level Quality Data
Document Using IHE
Medical Summary (XDS-MS)
13. HITSP/C48 Encounter Document constructs
14. HITSP/C62 Scanned document
Health Story supported guides in blue
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HL7 Clinical Document Architecture
Health Story Specs are Based on HL7 CDA
 Normative HL7 standard since 2000
 Widely implemented
 Provides a gentle on-ramp to information
exchange
 Provides mechanism for inserting evidencebased medicine directly into the process of
care
 Top down strategy lets you implement once
and reuse many times for new scenarios
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Why CDA?
 Radiology results are a key tool in providing
diagnosis
 Results need to be:



concise
consistent
precipitate alerts before the report is distributed
 Radiology Information System



rich in data
eliminates redundancy
streamlines workflow
 CDA benefits


standard for clinical communication
foundation for structuring data
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Meaningful Use Stage 2
ONC Standards and Interoperability
Framework has indicated intent to
recommend CDA and Health Story
specifications in meaningful use Stage 2
requirements for clinical documentation
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Meaningful Use ≈ Data Reuse
patient care
clinical
decision
support
billing/claims
adjudication
quality reporting
outcomes
analysis
research
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Health Story Approach
Benefit
Value
Retains patient story
Maintains primary role of radiology reports to clearly
describe and communicate what is going on with
patient.
Preserves physician
time for clinical care
Makes efficient use of physician time by enabling
choice of documentation methods and fosters EMR
acceptance
Supports meaningful
use
Interoperability: implements HL7 CDA document
standards for electronic exchange of clinical
information
Enables data reuse
Structured narrative enables better outcomes
reporting, data mining, and decision support
Collaborative approach Developed by broad array of providers, vendors and IT
organizations; Balloted process through HL7 supports
harmonization
Better documentation
Supports better coding, DRG optimization
= better reimbursement
Slide, with edits, courtesy of MD-IT
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Health Story Use Cases
Health Story Use Case, Transitions of Care
 Demonstration project at HIMSS 12
 Using Standard published from HL7/IHE Health Story
Consolidation Project in conjunction with the ONC
Standards & Interoperability Framework.
 ~85% of information needed crosses enterprise
boundaries
 Demonstration of complete information flow from

Unstructured documents
Scanned documents
Consult & discharge summaries
Enriched with NLP and CAC
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What Healthstory Offers You
 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
 Provides on-ramp to EMR system adoption


pre-populate EMR with structured documents
integrate legacy documents
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Our Advocacy Requests
 Actions Requested:



Require certified systems to accept interfaced data
from dictation/transcription process per available
standards
Modify the definition of meaningful use to recognize
use of certified systems with the above capabilities
Assist in spreading the word about this avenue for
getting the full story into the EHR that allows
radiologists to continue dictating and provides patients
with comprehensive electronic records
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Actionable Next Steps
1. Providers:
1.
2.
Is your documentation vendor set
up to deliver CDA documents? If
no, when?
Is your EHR vendor set up to
receive CDA documents? If no,
when?
2. Vendors: Check out the
requirements here:
www.healthstory.com
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The Radiologist’s Speech –
Realizing the Full Potential of the
Diagnostic Report
Nick van Terheyden, MD
Board of Directors CDIA
Chief Medical Information Officer, Nuance
December 1, 2011
w w w . h e a l t h s t o r y. c o m

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