Download - Health Story RSNA 2011 Update
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The Radiologist’s Speech – Realizing the Full Potential of the
Diagnostic ReportNick van Terheyden, MDBoard of Directors CDIA
Chief Medical Information Officer, NuanceDecember 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
CONFIDENTIAL | © 2002-2011 Nuance Communications, Inc. All rights reserved. HEALTHCARE SOLUTIONS3Slide courtesy of Nuance
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Health Story Project Members
Organization Affiliates
ParticipantsAll Type - Apixio - Arrendale Associates - BayScribe - Chase TranscriptionsChartLogic - DictateIT, Ltd - Dispersive Medical - Documentation Services GroupeMTS - Healthline, Inc. - InfraWare - InterFix - MedEDocs - MD-ITNew England Medical Transcription - Phoenix MedcomPhysicians Medical Group of Santa Cruz County - Sten-Tel, Inc. - Webmedx
ContributorsCanon U.S.A. - Scribe Healthcare Technologies
Promoters
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Health Story Telling
Integration Platform
Dictating MD
Transcript-ionist Abstracto
r
Voice capture
Voice to text
Enrich
Standard Format
TelephonePDRSmart phone
TranscriptionSpeech recognition
NLPDRTCAC
CDAICD, CPT…HL7 V2
HIE
MRMEMR
BillingAnalyticsQuality
People
Platforms
Applications
HealthStory
Meaningful UseClinical Document Ecosystem
Clerk
Imaging
Desktop appliancesScan-to-CDAOCR
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Guide Consolidation: US Dept Of Health and Human Services Office of the National
Coordinator 1. 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
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
One master implementation guide
Health Story supported guides in blue
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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 evidence-
based medicine directly into the process of care
Top down strategy lets you implement once and reuse many times for new scenarios
HL7 Clinical Document Architecture
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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
billing/claims adjudication
research
quality reporting
clinical decision support
outcomes analysis
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Health Story ApproachBenefit 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 documentsConsult & discharge summariesEnriched 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. Is your documentation vendor set
up to deliver CDA documents? If no, when?
2. 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 ReportNick van Terheyden, MDBoard of Directors CDIA
Chief Medical Information Officer, NuanceDecember 1, 2011