Welcome! The Health Story Project Dictation to Clinical Data: Automating the Production of Structured and Encoded Documents Kim Stavrinaki s AHDI Conference, July 2009 Nick van Terheyden, MD, Chief Medical Officer, M*Modal

Presentation Overview  Background: The Current Situation  Enabling the EMR with the Missing Link  A User Experience (GE/RISL)  The Health Story Project  Conclusion

Background The Current Situation

Electronic Health Record Universe Critical to the success of EHRs 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.

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 Physician Time vs. Benefit Test  Cultural resistance  Oblivious to HIM Requirements  Incomplete and Inadequate Semantic Standards Direct Data Entry: Structured and encoded information.

The Current Situation  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

Enabling the EMR The Missing Link in Information Capture in Healthcare

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

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  Comprehensive electronic clinical records that tell a patient’s complete health story  All of the clinical information required for  good patient care  administration  reporting and  research  will be readily available electronically, including information from narrative documents

Based on HL7 CDA Clinical Document Architecture 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

Accessible Clinical Data

User Experience GE/RISL Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare The Missing Link in Information Capture in Healthcare

Key Workflows  Self Editing  real time – read, proof, sign each exam  batch mode - read multiple exams then sign via signature queue  VR edits  Option to send to Medical Editor during reporting process  Batch Option – dynamic combinations of workflow based on confidence models  user based thresholds that determines how report is returned/reviewed to signature queue  preliminary/draft to signature queue  transcriptionist then preliminary to signature queue  Transcriptionist – Medical Editor workflow

Results Reporting Workflow Dictation Report in conversational speaking Edit Mode using local capture tool – can either type to correct or voice commands Dictating the Procedure When dictation is complete and EOL is pushed Report is returned ready for edits Data Center

Results Reporting Workflow 2 Edit Mode using local capture tool – voice in selection between brackets Voice in options for brackets, sign report, add via voice more dictation in the sections, then sign After final sign the report is processed in the NLP engine for learning Data Center

Results Reporting Batch Mode Dictating the Procedure When dictation is complete Report goes to Medical Editor or signature queue, Radiologist moves on to next exam

Radiology & Imaging Specialists (RIS)  physician-owned  twenty board-certified radiologists  many sub-specialized  live since November 12, 2008 Radiology Imaging of Lakeland Florida

“You didn’t change the radiologists’ work, and that is what made it easy on me.” David Marichal, CIO, Radiology and Imaging Spec. of Lakeland, FL

Conversational Documentation … transformation of dictation directly into structured clinical documents while encoding data depending on the care givers and organizations needs EHR

Results VOC:  flexibility is key full-time rads: 70% Medical Editor workflow/30% self-edit part-time radiologists can use it in batch digital dictation mode  radiologist love not having to dictate accession #, name, signs/symptoms, etc…  quality of the engine is very good  self-edit for stat exams has reduced # of calls from the hospital

The Health Story Project and Meaningful Clinical Documents Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare The Missing Link in Information Capture in Healthcare

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

Health Story Document Types Implementation Guides Completed  History & Physical  Consultation  Operative Report  DICOM Imaging Reports Upcoming  Discharge Summary in progress through HL7  Billing and Reimbursement Requirements  Progress Notes .PDF work with Adobe

Project Members Founders Promoters Participants

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 

Our Advocacy Messages  Dictation is the documentation method of choice for 85% of physician providers  Standardization of dictated notes is an achievable step for providers; Standards are available today  The current EHR systems certification process does not include requirements for integration with dictated notes per available standards  The current draft definition of meaningful use focuses on recording clinical documentation in the EHR through data entry

Our Advocacy Requests  Actions Requested:  Require certified EHR systems to accept interfaced data from dictation/transcription process per available Healthstory standards  Modify the definition of meaningful use to recognize use of certified EHR systems with the above capabilities  Assist in spreading the word about this avenue for getting important information into the EHR that allows physicians to continue dictating and that provides patients with comprehensive electronic records

Conclusion

Crossing the Chasm…Babel Must Go  Medical text “typed” from dictation has “no meaning”  black marks on a page…  info must be tagged as discrete data elements in order to assign meaning  Clinical documentation uses wide variety of terms with same meaning….  and terms that sound the same that have different meanings…..  authors have a wide variety of styles, accents, methods of dictation…

Health Story…  Captures meaningful clinical documents  Is the bridge between  free form narrative and expressive notes, and  fully structured clinical data  Improves the quality of clinical documentation  Generates semantically interoperable clinical data that will  solve the fundamental challenges with EMRs - allowing clinical decision support, alerts, decision support, data mining  enable interoperability, reporting, patient safety initiatives, PQRI (pay for performance), PSI (patient safety indicators) and improve billing data capture

Impact  Allows providers to maintain preferred workflow and documentation methods  Increases the value and usability of narrative documents  Accelerates the implementation of interoperable electronic health records  Allows reuse of information

Getting Involved  Become an “Ambassador”  We need a grass roots effort to help spread the word; Support our advocacy messages  You can help educate your employers, clients, etc. about Health Story  Joint the Effort  Varying membership levels, including individuals  Volunteer for a Project  Currently developing data standards for discharge summary  Participate in HL7 ballots on project draft standards  Encourage Implementation  E.g. Include requirements for standards in transcription RFPs

Membership Options and Benefits

Q&A Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare

Nick van Terheyden, MD, CMO, M*Modal Twitterhttp://twitter.com/drnic1 Technoratihttp://technorati.com/people/technorati/nvt1 RSSSpeech Understandinghttp://speechunderstanding.blogspot.com/feeds/posts/default MyBlogLoghttp:// LinkedInhttp:// Plaxohttp://nvt.myplaxo.com FaceBookhttp://profile.to/drnick Digghttp://digg.com/users/nvt1 Delicioushttp://delicious.com/nvt1 GrandCentral(301) Where You Can Find Me