w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

Clinical Narrative and Structured Data in the Radiology Report

Harmony with Healthstory Nick van Terheyden, MDBoard of Directors MTIA

Chief Medical Officer, M*ModalDecember 1, 2009

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

A radiologist’s practical

need for fast and easy method for creating

clinical documentation

The enterprise need forstructured and codedinformation capture

Balancing Two Opposing Needs

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

Health Story Project

Vision: Comprehensive electronic clinical records that tell a patient’s complete health story.

Who We Are: A non profit alliance of healthcare vendors, providers and associations

Mission: Pool resources to develop data standards through HL7 for flow of information between common types of healthcare documents and EHR systems

Goals: Bridge the gap between the narrative documents and structured data

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

Adoption Strategy

HL7 collaborates with Health Story on development and ballot of technical implementation guides

Medical transcription companies support creation, delivery and enrichment

HIT vendors systems send, receive, display and integrate

Health providers select the approach and receive vendor support for standards-based document creation, management and enrichment

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

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

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

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

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

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

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

Current and Future Standards

HL7 Implementation GuidesCompleted History & Physical Consultation Operative Report DICOM Imaging Reports Discharge Summary (in publication)

Upcoming Procedure Note (focus on Endoscopy Report) CDA with unstructured body Billing and Reimbursement Requirements Progress Notes

w w w. h e a l t h s t o r y. c o m

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

Adoption

Healthstory vendor members are generating Healthstory Documents (GE Medical, MedQuist, M*Modal) and others are planning to generate the standards in the next year

Included in HITSP1 requirements

On CCHIT2 roadmap

1 Healthcare Information Technology Standards Panel2 Certification Commission for Healthcare Information Technology

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

Project Members

Promoter Members

Participant Members

All Type | Dictation Services Group | Healthline, Inc.MD-IT | Broward Sheridan Technical Center

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

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

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

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 physicians to continue dictating and provides patients with comprehensive electronic records

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

Getting Involved

Share the Good News: Be an “Ambassador” Grass roots effort to help spread the word Educate your employers, clients, vendors 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

Ensure your selection team are aware of the available data standards that support the Health Story approach

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

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

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

The Health Story ProjectClinical Narrative and Structured Data in the Radiology Report

Harmony with Healthstory

Kim Stavrinaki

s RSNA Conference, December 2009Nick van Terheyden, MDBoard of Directors, MTIA

Chief Medical Officer, M*Modal

w w w . h e a l t h s t o r y . c o mNick van Terheyden, MD

Nick van Terheyden, MD Chief Medical Officer, M*ModalTwitter http://twitter.com/drnic1Technorati http://technorati.com/people/technorati/nvt1RSSSpeech Understanding http://speechunderstanding.blogspot.com/feeds/posts/defaultMyBlogLog http://www.mybloglog.com/buzz/members/nvtLinkedIn http://www.linkedin.com/in/nickvtPlaxo http://nvt.myplaxo.comFaceBook http://profile.to/drnickDigg http://digg.com/users/nvt1Delicious http://delicious.com/nvt1E-Mail nvt@mmodal.comGrandCentral (301) 355-0877

Where You Can Find Me