healthstory enabling the emr - dictation to clinical data
DESCRIPTION
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 formatTRANSCRIPT
The Healthstory ProjectDictation to Clinical Data: Automating the Production of Structured and Encoded Documents
Nick van Terheyden, MDChief Medical OfficerM*Modal
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
Current Problems Facing Clinicians in Healthcare
According to an American College of Physician Executives survey, 6 in 10 physicians have considered leaving the profession due to: burnout low morale/depression loss of autonomy low reimbursement rates patient overload bureaucratic red tape loss of respect, and medical liability environment
Complexity and workload is crippling Physicians and hindering their ability to deliver High Quality Care
Electronic Health Record Universe
Critical to the success of electronic health records is to reconcile two opposing needs
Enterprise need for structured and coded information capture
Physician’s practical need for a fast and easy method for creating clinical notes.
EHR Data Requirements
Structured Searchable Computer-interpretable Transportable Exchangeable
Semantic Interoperability
Ability to pass information between two computers that can then be processed, analyzed, and reused by both computer systems
EMRs Need Structured Encoded Clinical Data
EMRs Need Structured Encoded Clinical Data How does this fit in
The Current Situation – Structured
Tedious manual process Time-consuming Documentation lacks
expressiveness of natural language
Lack of Flexibility Poor user interface Cost
Fails to Meet Individual Physicians Time vs. Benefit Test
Cultural resistance
Oblivious to HIM Requirements Incomplete and Inadequate
Semantic Standards
Direct Data Entry: Structured and encoded information.
“Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue.”
Pamela Hartzband, M.D., and Jerome Groopman, M.D.
n engl j med 358;16 april 17, 2008
The Current Situation - Dictation
Transcription can be expensive Subject to longer turn-around
times Clinical data lost, because
documents are neither structured nor encoded
Majority of attested information is only in the document
Contains the detail and comprehensive scope of patient information
Support human decision making Reimbursement is based on
narrative documentation Retains current workflow, favored
by physicians Interoperable Under utilized source of data for
EMR
Dictation: Fast and easy, expressive.
The Current Situation
High cost of documentation Cost of ownership and physician time vs. transcription cost
60% of the data lost to the EHR Care process inefficiencies and impact on quality
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
“We have uncovered powerful evidence that sophisticated EMR technologies positively correlate to improved measures of patient outcomes.”
HIMSS analytics
1. White Paper: EMR Sophistication Correlates To Hospital Quality Data, (HIMSSanalytics 2006)
*1
Enabling the EMR
The Missing Link in Information Capture in Healthcare
Value of EHRs over Dictation
EHRs save you time but it takes much longer to enter the information
You have more discrete data over 700 data elements but you only use about 3% of these data elements
E & M coding improves In theory, but EHR vendors have no 3rd party
validation studies.
EHRs provide orders and alerts but you can have the same with Healthstory enabled
EHRs
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
Data Entry Time The average physician spends 33 seconds
dictating an establish office visit 92% of all office visits are established If the average physician sees 40 patients a day,
total dictation time of 30 minutes plus time to search for the data.
Using a traditional EHR application, the same number of patients would require 140 minutes of data entry time.
Physicians are not willing to spend an additional 90 minutes per day for data entry.
(40 X 92% x 33 seconds) + (40 x 8% x 125) = < 30 minutes per day
Data and Chart courtesy Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group
Why are Practices not using what they Purchased
Source: AC Group Annual Survey of buying patterns
New England Journal of MedicineData and Chart courtesy Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group
What if you could continue to use narrative and dictation and at the same time increase usage of the
EMR and make more records available for the health information exchange?
Crossing the Chasm…
Health Story Project Vision
all of the clinical information required for Good patient care Administration Reporting and Research
will be readily available electronically, including information from narrative documents
Goals
Bridge the gap between narrative documents and structured data
Encourage proliferation of information for the EHR
CDA Documents Requirements
Human readable document— Must be presentable as a document Rendered version covers clinical information
intended by the author Can contain machine-processable data Cross platform and application
independent Can be transformed with style sheets
Adoption Incremental adoption overcomes the “not
me first” dilemma Not dependent on recipient’s ability to
receive or process Reverse adoption (can encode headers of
existing documents) Non-proprietary Readable with any browser
Levels of Encoding Level I—Header metadata (required)
Identify patient, provider, and document type Provide info for DMS, storage, query and retrieval
Level II—section level Identifies content of sections within document Allows for section reuse Uses LOINC to identify document sections
Level III—discrete data High level of encoding Decision support automation
Encoding Does not preclude “once and done”
concept Compatible with Speech
Understanding/Recognition Can be facilitated by Natural Language
Processing Leverage existing relationships with
transcriptionists/editors/knowledge based workers
Potential for automated coding (billing) Supports data abstraction/research
CDA Templates
Conversational DocumentationThe Missing Link in Information Capture in Healthcare
Speech Recognition Challenges Challenges faced in understanding
regular dictation
Good dictators
Challenging Dictators
Nothing but Speech to Text
Speech-to-Clinical Document
“Best of Both Worlds” Approach
Creation and validation of meaningful clinical documents that are accurate, complete, accessible and shareable… …by leveraging existing workflow …to populate the electronic health record, …without requiring change for the
physician.
Significant productivity gains in generating high quality medical documentation from dictation - across all work types and medical specialties.
Conversational Documentation … transformation of dictation directly
into structured clinical documents while encoding data depending on the care givers and organizations needs
EHR
Meaningful Clinical Documents Meaningful Clinical Documents are a
blend between free form text and fully structured documentation that represent the thought process, and capture the clinical facts
How it works
Meaningful Clinical DocumentsThe Missing Link in Information Capture in Healthcare
Accessible Clinical Data
One Voice – Many Outputs™
Clinical Documentation Architecture 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 compliant document types
Increases quality of documentation
Document Types
History & Physical (completed) Consultation (completed) Operative Report (completed) DICOM Imaging Reports (completed) Progress Notes Specialty reports (eg, Pediatric H&P)
Get the Full HealthstoryCDA4CDT: bridging the gap between EMRs and eDocuments
CDA implementation guides are being embraced by the EMR community Clinical societies:
ASTM/HL7 Continuity of Care Document CDA for anatomic pathology, imaging,
anesthesiology, pediatrics, periodontal, long term care, others
Reimbursement: HIPAA Attachments HITSP: included in all use cases IHE
2006: 14 vendors, 1 content type 2007: 22 vendors, 7 content types
Reporting: Public health: Cancer abstracts & Infectious
Disease Quality: Pediatric
Providers: in production at Mayo, UPMC, NY Presbyterian, VA, MHS, others
Conclusion
Conclusion…Crossing the Chasm…
Babel Must Go
Medical text “typed” from dictation has “no meaning” – Black marks on a page… Information must be tagged as discrete data elements
in order to assign meaning
Clinical documentation uses a wide variety of terms that have the same meaning….
And terms that sound the same that have different meanings…..
Authors have a wide variety of styles, accents, methods of dictation…
Conclusion The Healthstory Captures Meaningful
Clinical Documents Bridge between
Free form narrative and expressive notes, and Fully structured clinical data
Improve the overall quality of clinical documentation
Generates Semantically Interoperable Clinical Data that will Solve the fundamental challenges with EMR’s allowing
clinical decision support, alerts, decision support, data mining
Enables interoperability, reporting, patient safety initiatives, PQRI (pay for performance), PSI (Patient safety indicators) and improves billing data capture
Impact Allows providers to maintain preferred
workflow and documentation methods Increases the value and usability of
narrative documents (dictation/trans, SRT) Accelerates the implementation of
interoperable electronic health records Allows reuse of information
Getting Involved Join Healthstory
www.healthstory.com
Participate in HL7 SDTC Participate in HL7 ballots Encourage implementation
EHR vendor adoption Provider preference Transcription RFPs
Health Story Membership
Promoter, Contributor, Participant Member responsibilities
designate a minimum of one primary representative to the project
provide input into developing standards act as ambassadors for the project in the
industry through informal and formal networking and educational opportunities
become early adopters of standards published by the project
The Healthstory ProjectDictation to Clinical Data: Automating the Production of Structured and Encoded Documents
Nick van Terheyden, MDChief Medical OfficerM*Modal
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