health story rsna 2011 update

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  • 1. The Radiologists Speech Realizing the Full Potential of theDiagnostic Report Nick van Terheyden, MD Board of Directors CDIA Chief Medical Information Officer, NuanceDecember 1, 2011 w w w . h e a l t h s t o r y. c o m

2. Health Story Project Non profit, industry alliance Founded 2007 Associate CharterAgreement: HL7 Sponsor HL7 standards for flowof information betweennarrative and EMR systems (8!) Member organizations providedirection www.healthstory.com w w w . h e a l t h s t o r y. c o m 3. HEALTHCARE SOLUTIONSSlide CONFIDENTIAL | 2002-20113courtesy of Nuance Nuance Communications, Inc. All rights reserved. 4. Health Story Project MembersOrganization AffiliatesPromotersContributors Canon U.S.A.- Scribe Healthcare Technologies All Type - Apixio - Arrendale Associates - BayScribe - Chase Transcriptions ChartLogic - DictateIT, Ltd - Dispersive Medical - Documentation Services GroupParticipants eMTS - Healthline, Inc. - InfraWare - InterFix - MedEDocs - MD-IT New England Medical Transcription - Phoenix Medcom Physicians Medical Group of Santa Cruz County - Sten-Tel, Inc. - Webmedxw w w . h e a l t h s t o r y. c o m 5. Health Story Telling Clinical Document Ecosystem Meaningful UsePeople H HIEDictating Transcript-Clerk MDionistAbstractor e MRM aPlatformsEMR l Integration Platformt BillingApplications h AnalyticsVoiceEnrich Standard S Quality Imaging Voice captureto text Format t oDesktopTelephone Transcription NLP CDAappliances PDR SpeechDRT ICD, CPT r recognitionScan-to- Smart CAC HL7 V2yCDAphoneOCRw w w . h e a l t h s t o r y. c o m 6. Guide Consolidation: US Dept Of Health andHuman Services Office of the National1. HL7 Consult Note Coordinator2. HL7 Diagnostic Imaging Report3. HL7 Discharge Summary4. HL7 History and Physical5. HL7 Operative Note6. HL7 Procedure Note7. HL7 Unstructured Documents One master8. HL7 Progress Notesimplementation9. HL7 Continuity of Care Document10. HITSP/C84 Consult and History & PhysicalguideNote Document11. HITSP/C32 - Summary Documents UsingHL7 CCD12. HITSP/C38 - Patient Level Quality DataDocument Using IHEMedical Summary (XDS-MS)13. HITSP/C48 Encounter Document constructs14. HITSP/C62 Scanned document Health Story supported guides in bluew w w . h e a l t h s t o r y. c o m 7. HL7 Clinical Document ArchitectureHealth Story Specs are Based on HL7 CDA Normative HL7 standard since 2000 Widely implemented Provides a gentle on-ramp to informationexchange Provides mechanism for inserting evidence-based medicine directly into the process ofcare Top down strategy lets you implement onceand reuse many times for new scenariosw w w . h e a l t h s t o r y. c o m 8. Why CDA? Radiology results are a key tool in providingdiagnosis 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 m 9. Meaningful Use Stage 2ONC Standards and Interoperability Framework has indicated intent torecommend CDA and Health Storyspecifications in meaningful use Stage 2requirements for clinical documentationw w w . h e a l t h s t o r y. c o m 10. Meaningful Use Data Reusepatient care quality reportingclinicaldecision outcomessupportanalysisbilling/claims researchadjudicationw w w . h e a l t h s t o r y. c o m 11. Health Story ApproachBenefitValueRetains patient storyMaintains primary role of radiology reports to clearly describe and communicate what is going on with patient.Preserves physicianMakes efficient use of physician time by enablingtime for clinical care choice of documentation methods and fosters EMR acceptanceSupports meaningfulInteroperability: implements HL7 CDA documentusestandards for electronic exchange of clinical informationEnables data reuse Structured narrative enables better outcomes reporting, data mining, and decision supportCollaborative approach Developed by broad array of providers, vendors and IT organizations; Balloted process through HL7 supports harmonizationBetter documentation Supports better coding, DRG optimization = better reimbursement Slide, with edits, courtesy of MD-IT w w w . h e a l t h s t o r y. c o m 12. Health Story Use CasesHealth Story Use Case, Transitions of Care Demonstration project at HIMSS 12 Using Standard published from HL7/IHE Health StoryConsolidation Project in conjunction with the ONCStandards & Interoperability Framework. ~85% of information needed crosses enterpriseboundaries Demonstration of complete information flow from Unstructured documents Scanned documents Consult & discharge summaries Enriched with NLP and CACw w w . h e a l t h s t o r y. c o m 13. What Healthstory Offers You Allows providers to choose preferred workflowand documentation methods Increases the value and usability of narrativedocuments Accelerates the implementation of interoperableelectronic health records Allows intelligent and meaningful reuse ofinformation 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 m 14. Our Advocacy Requests Actions Requested: Require certified systems to accept interfaced datafrom dictation/transcription process per availablestandards Modify the definition of meaningful use to recognizeuse of certified systems with the above capabilities Assist in spreading the word about this avenue forgetting the full story into the EHR that allowsradiologists to continue dictating and provides patientswith comprehensive electronic records w w w . h e a l t h s t o r y. c o m 15. Actionable Next Steps1. 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.comw w w . h e a l t h s t o r y. c o m 16. The Radiologists Speech Realizing the Full Potential of theDiagnostic Report Nick van Terheyden, MD Board of Directors CDIA Chief Medical Information Officer, NuanceDecember 1, 2011 w w w . h e a l t h s t o r y. c o m