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The Radiologist’s Speech – Realizing the Full Potential of the

Diagnostic ReportNick van Terheyden, MDBoard of Directors CDIA

Chief Medical Information Officer, NuanceDecember 1, 2011

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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 (8!)

Member organizations provide direction

www.healthstory.com

CONFIDENTIAL | © 2002-2011 Nuance Communications, Inc. All rights reserved. HEALTHCARE SOLUTIONS3Slide courtesy of Nuance

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Health Story Project Members

Organization Affiliates

ParticipantsAll Type - Apixio - Arrendale Associates - BayScribe - Chase TranscriptionsChartLogic - DictateIT, Ltd - Dispersive Medical - Documentation Services GroupeMTS - Healthline, Inc. - InfraWare - InterFix - MedEDocs - MD-ITNew England Medical Transcription - Phoenix MedcomPhysicians Medical Group of Santa Cruz County - Sten-Tel, Inc. - Webmedx

ContributorsCanon U.S.A. - Scribe Healthcare Technologies

Promoters

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Health Story Telling

Integration Platform

Dictating MD

Transcript-ionist Abstracto

r

Voice capture

Voice to text

Enrich

Standard Format

TelephonePDRSmart phone

TranscriptionSpeech recognition

NLPDRTCAC

CDAICD, CPT…HL7 V2

HIE

MRMEMR

BillingAnalyticsQuality

People

Platforms

Applications

HealthStory

Meaningful UseClinical Document Ecosystem

Clerk

Imaging

Desktop appliancesScan-to-CDAOCR

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Guide Consolidation: US Dept Of Health and Human Services Office of the National

Coordinator 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 implementation guide

Health Story supported guides in blue

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Health Story Specs are Based on HL7 CDA Normative HL7 standard since 2000 Widely implemented Provides a gentle on-ramp to information

exchange Provides mechanism for inserting evidence-

based medicine directly into the process of care

Top down strategy lets you implement once and reuse many times for new scenarios

HL7 Clinical Document Architecture

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Why CDA?

Radiology results are a key tool in providing diagnosis

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

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Meaningful Use Stage 2

ONC Standards and Interoperability Framework has indicated intent to recommend CDA and Health Story

specifications in meaningful use Stage 2 requirements for clinical documentation

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Meaningful Use ≈ Data Reuse

patient care

billing/claims adjudication

research

quality reporting

clinical decision support

outcomes analysis

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Health Story ApproachBenefit Value

Retains patient story Maintains primary role of radiology reports to clearly describe and communicate what is going on with patient.

Preserves physician time for clinical care

Makes efficient use of physician time by enabling choice of documentation methods and fosters EMR acceptance

Supports meaningful use

Interoperability: implements HL7 CDA document standards for electronic exchange of clinical information

Enables data reuse Structured narrative enables better outcomes reporting, data mining, and decision support

Collaborative approach Developed by broad array of providers, vendors and IT organizations; Balloted process through HL7 supports harmonization

Better documentation Supports better coding, DRG optimization= better reimbursement

Slide, with edits, courtesy of MD-IT

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Health Story Use Cases

Health Story Use Case, Transitions of Care

Demonstration project at HIMSS 12

Using Standard published from HL7/IHE Health Story Consolidation Project in conjunction with the ONC Standards & Interoperability Framework.

~85% of information needed crosses enterprise boundaries

Demonstration of complete information flow from Unstructured documents

Scanned documentsConsult & discharge summariesEnriched with NLP and CAC

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What Healthstory Offers You

Allows providers to choose preferred workflow and documentation methods

Increases the value and usability of narrative documents

Accelerates the implementation of interoperable electronic health records

Allows intelligent and meaningful reuse of information

Provides on-ramp to EMR system adoption pre-populate EMR with structured documents integrate legacy documents

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Our Advocacy Requests

Actions Requested: Require certified systems to accept interfaced data

from dictation/transcription process per available standards

Modify the definition of meaningful use to recognize use of certified systems with the above capabilities

Assist in spreading the word about this avenue for getting the full story into the EHR that allows radiologists to continue dictating and provides patients with comprehensive electronic records

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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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The Radiologist’s Speech – Realizing the Full Potential of the

Diagnostic ReportNick van Terheyden, MDBoard of Directors CDIA

Chief Medical Information Officer, NuanceDecember 1, 2011