www.healthstory.com health story project: using standards to get to meaningful use: exchange basic...
TRANSCRIPT
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Health Story Project:Using Standards to Get to Meaningful Use: Exchange Basic Records and Meet Early Requirements
Kim Stavrinaki
sHIMSS11 Interoperability ShowcaseWednesday, February 23, 11:45 am-12:05 pm
Bob Dolin, MDPresident & CMO, Lantana Consulting GroupChair, HL7 International
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Meaningful Use?
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Meaningful Use!
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Session Overview
1. Challenge
2. Health Story Project Solution
3. Where to Start
4. Q&A
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CHALLENGE
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A physician’s practical need for fast and easy
(30 sec) methods of creating
clinical documentation
The enterprise need forstructured and codedinformation capture to support meaningful use
Challenge
Computer image courtesy of M*Modal
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We Can Get Here TodayMRN: 00000
DOS: 11/11/2001
CHIEF COMPLAINT:
Fatigue
SUBJECTIVE:
Patient is a 25 year old woman complaining of feeling frequently fatigues. She reported also occasional dizziness, sleeping difficulties and morning headaches.
OBJECTIVE:
Recent bout with the flu
PHYSICAL EXAMINATION:
Vital signs are normal with a blood pressure of 120/80, pulse 62, temperature 98.6 degrees, weight 108 pounds.
ASSESSMENT:
Although flu symptoms were in remission, patient has not fully recovered yet.
PLAN:
Place patient on Biaxin for the next two weeks. The patient will call us if there is no improvement, any worsened or new symptoms.
MRN: 00000
DOS: 11/11/2001
CHIEF COMPLAINT:
Fatigue
SUBJECTIVE:
Patient is a 25 year old woman complaining of feeling frequently fatigues. She reported also occasional dizziness, sleeping difficulties and morning headaches.
OBJECTIVE:
Recent bout with the flu
PHYSICAL EXAMINATION:
Vital signs are normal with a blood pressure of 120/80, pulse 62, temperature 98.6 degrees, weight 108 pounds.
ASSESSMENT:
Although flu symptoms were in remission, patient has not fully recovered yet.
PLAN:
Place patient on Biaxin for the next two weeks. The patient will call us if there is no improvement, any worsened or new symptoms.
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Meaningful Use
“If you can not measure it, you can not improve it.”
Lord Kelvin (1824-1907)
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EHR Repository
HIM Applications
Clinical Applications
SNOMED CT
Disease, DF-00000Metabolic 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
Health Story Approach
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THE SOLUTION
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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
Member organizations provide direction
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Health Story Project Members
Founding Members
ParticipantsAll Type - Arrendale Associates - BayScribe - Chase TranscriptionsDictateIT, Ltd - Dispersive Medical - Documentation Services Group
eMTS - Healthline, Inc. - MedEDocs - MD-ITNew England Medical Transcription - Phoenix Medcom
Sten-Tel, Inc. - Webmedx
Contributors Aprima Software - Scribe Healthcare Technologies
Promoters
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Based on HL7 CDA
Single standard for entire EHR is too
broad Multiple standards and/or messages for
each EHR function may be too difficult to
implement
CDA is “just right”HL7 Clinical Document Architecture
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CDA is the basis for ...
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. HL7 Healthcare-associated Infections, Public Health Case Reports
11. HL7 Personal Health Monitoring
12. HL7 Plan-2-Plan Personal Health Record
13. HL7 Quality Reporting Document
14. HL7 Minimum Data Set
and more …
1. HITSP/C84 Consult and History & Physical Note Document
2. HITSP/C32 - Summary Documents Using HL7 CCD
3. HITSP/C38 - Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS)
4. HITSP/C48 Encounter Document constructs
5. HITSP/C62 Scanned document
6. HITSP/C28 Emergency Care Summary
7. HITSP/C78 Immunization Document
8. HITSP/C74 PHRM
Health Story supported guides in blue
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Consolidation Project Underway!
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 implementati
on guide
Health Story supported guides in blue
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Health Story Meaningful Use
Meaningful Use
Health Story Interoperability Strategy
Delivers common clinical documents to the point of care
Standardizing document types and sections today makes it easier to agree on data elements tomorrow
Incrementally adding key data elements into narrative is attractive to clinicians
Partial structuring facilitates natural language processing
Health Story’s path to Meaningful Use
Hit the ground running with basic CDA, to meet the needs of front line clinicians
Incrementally layer discrete data elements into CDA documents
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WHERE TO START
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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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Actionable Next Steps
Join the Health Story Project
Project is interested in tracking and highlighting implementations’
More information: visit the Health Story kiosk in the Interoperability Showcase
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A physician’s practical need for fast and easy methods for creating clinical documentation
The enterprise need forstructured and codedinformation capture to support meaningful use
In Summary
Computer image courtesy of M*Modal
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Q&A
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