1. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 1 Creating A Functional Bridge With The EMR Presentation to Kentucky HFMA Reid W Coleman MD FACP CMIO, Nuance Communications Inc.

2. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 2 Disclosures – Bias – I work for a company that sells solutions to some of the issues I’ll discuss  I will not be discussing, or even mentioning, these products  I will be delighted to talk to anyone later about my company's solutions – Conflicts – I have, unfortunately, no conflicts to disclose – I am always open to offers

3. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 3 Why AM I Speaking? – Clinician – Internist, FACP, still see patients in the ambulatory clinic – Teacher – Associate Professor of Medicine, Warren Alpert School of Medicine, Brown University – CMIO – 11 Years at Lifespan (Brown Teaching System), 2+ years at Nuance

4. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 4 Why Am I Not Wearing a Tie?

5. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 5 Notice About the Presentation – The core points are on slides marked with: – There are only five of them – If you only pay attention to these you will get most of my message – I’ll let you know when these slides come up Important Slide

6. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 6 Brief Statement of the Problem Coding Institutional billing Institutional reimbursement Compliance Meaningful use requirements What is important to a clinician is not what is important to other stakeholders Important Slide

7. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 7 What is wanted from the physician? Diagnostic specificity SOI/ROM MU Medical Necessity Core/ Outcome Measures Patient satisfaction POA/HAC Patient safety

8. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 8 What is wanted by the physician? Tell the patient story Justify E&M Code Malpractice Issues Performance measures Aid in The Reasoning process Communicate With Patients Communicate With Other Clinicians Quality Of Care

9. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 9 EMR’s Are Supposed to Solve These Issues Dropdowns Click boxes Pick lists The first generations of EMR’s used “defined data” fields to collect the needed information Often expected to enter data separate from writing note Clinicians entered data as part of charting Some EMR’s create parts of a note from entered data An example: orders become the plan As more and more data was required, clinicians entered data as the means of charting

10. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 10 What Made EMR’s Use This Approach? Meaningful use Stage One – Collect and transmit data Anticipated move to ICD-10 Requires much more granularity Payment “reform” P4P, VBP, ACO’s

11. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 11 7-year old girl’s drawing published in JAMA, June 20, 2012, Vol 307, No. 23, Thomas G. Murphy, MD http://jama.jamanetwork.com/article.aspx?articleid=1187932 http://jama.jamanetwork.com/article.aspx?articleid=1187932 A Patient’s View of the Data Centered EMR

12. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 12 Who will rid me of this meddlesome priest? A Physician Perspective on the Data Centered EMR

13. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 13 How do Physicians Want to Document? Important Slide

14. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 14 The Holy Grail for Physicians – Enter narrative to: – Tell the patient story – To add new information via notes – Assist in diagnosis and treatment  CDS – Communicate – Get paid – Have the note generate data, and orders Important Slide

15. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 15 A Brief Divergence – Payment Models Fee For Service Still the physician model Fee For Disease The DRG model Fee For Patient ACO’s and Capitation

16. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 16 The Documentation Conundrum Physician reimbursement is still predominantly based on E&M coding Volume of information not quality Institution reimbursement is no longer driven by volume of care Three questions: How sick is the patient Was the right thing done Was it done in the right place the right way Documentation needs to satisfy both mechanisms And support physician quality measures

17. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 17 What’s Wrong With Narrative? It often doesn’t contain the needed information Even if it does, it isn’t in normalized, coded format Extraction becomes time consuming, difficult, and expensive

18. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 18 Fixing the Narrative Process Has Issues Retrospective Time and resource intense Interrupts the clinician when away from the patient Clinical Documentation Improvement Nascent technology Requires information to be present in the narrative Natural Language Processing

19. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 19 Narrative EHR NLP Re-imagine the clinical documentation process Get it right from the start Patient care Meaningful use Quality reporting Decision support Financial integrity Value-based purchasing Coding/CMI POA/HAC Compliance Medical necessity Coding Documentation integrity Speech Rec NLP How sick is the patient? Was the right thing done? In the right way and place? Important Slide

20. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 20 This Could Connect the Clinical Documentation chain

21. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 21 Building Toward This Solution Can Lead To A True Bridge – The tools: – Create narrative with voice recognition – typing and dictation work – Copy and paste is a big problem – Improve documents with computerized as well as human CDI – computerized CDI will never replace human functions totally – Extract needed information using NLP Important Slide

22. © 2002-2013 Nuance Communications, Inc. All rights reserved. Page 22 Thank You – Questions? You can also ask at: Reid.Coleman@Nuance.com