Clinical Narrative and Structured Data in the Radiology Report Harmony with Healthstory

1. Clinical Narrative and Structured Data in the Radiology ReportHarmony with Healthstory Nick van Terheyden, MD Board of Directors MTIA Chief Medical Officer, M*Modal December 1, 2009

2. Balancing Two Opposing Needs • A radiologist’s practical • need for fast and easy • method for creating • clinical documentation The enterprise need for structured and coded information capture

3. Health Story Project • Vision: Comprehensive electronic clinical records that tell a patient’s complete health story. • Who We Are: A non profit alliance of healthcare vendors, providers and associations • Mission: Pool resources to develop data standards through HL7 for flow of information between common types of healthcare documents and EHR systems • Goals: Bridge the gap between the narrative documents and structured data

4. Adoption Strategy • HL7 collaborates with Health Story on development and ballot of technical implementation guides • Medical transcription companies support creation, delivery and enrichment • HIT vendors systems send, receive, display and integrate • Health providers select the approach and receive vendor support for standards-based document creation, management and enrichment

5. Why CDA? • Radiology results are key tool to provide 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

6. Meaningful Clinical Documents EHR Repository Disease, DF-00000 Metabolic Disease, D6-00000 Clinical Applications Disorder of carbohydrate metabolism, D6-50000 Disorder of glucose metabolism, D6-50100 HIM Applications Diabetes Mellitus, DB-61000 SNOMED CT Type 1, DB-61010 Neonatal, DB75110 Carpenter Syndrome, DB-02324 Insulin dependant type IA, DB-61020 Slide courtesy of V. "Juggy" Jagannathan PhD, Medquist

7. 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

8. Current and Future Standards HL7 Implementation Guides Completed • History & Physical • Consultation • Operative Report • DICOM Imaging Reports • Discharge Summary (in publication) Upcoming • Procedure Note (focus on Endoscopy Report) • CDA with unstructured body • Billing and Reimbursement Requirements • Progress Notes www.healthstory.com

9. Adoption • Health Story vendor members are generating Health Story Documents (GE Medical, MedQuist, M*Modal) and others are planning to generate the standards in the next year • Included in HITSP1 requirements • On CCHIT2 roadmap 1 Healthcare Information Technology Standards Panel 2 Certification Commission for Healthcare Information Technology

10. Project Members Promoter Members Participant Members All Type | Dictation Services Group | Healthline, Inc. MD-IT | Broward Sheridan Technical Center

11. 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 www.healthstory.com

12. 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 physicians to continue dictating and provides patients with comprehensive electronic records

13. Getting Involved Share the Good News: Be an “Ambassador” Grass roots effort to help spread the word Educate your employers, clients, vendors etc. about this pathway Join the Effort Varying membership levels, including individuals Volunteer for a Project See “data standards” section of www.healthstory.com Encourage Implementation See “data standards” section of www.healthstory.com for suggested requirements language for transcription and EMR vendors Ensure your selection team are aware of the available data standards that support the Health Story approach

14. What Health Story 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

15. The Health Story ProjectClinical Narrative and Structured Data in the Radiology ReportHarmony with Health Story Kim Stavrinaki s RSNA Conference, December 2009 Nick van Terheyden, MD Board of Directors, MTIA Chief Medical Officer, M*Modal

16. Where You Can Find Me Nick van Terheyden, MD Chief Medical Officer, M*Modal Twitter http://twitter.com/drnic1 Technorati http://technorati.com/people/technorati/nvt1 RSSSpeech Understanding http://speechunderstanding.blogspot.com/feeds/posts/default MyBlogLog http://www.mybloglog.com/buzz/members/nvt LinkedIn http://www.linkedin.com/in/nickvt Plaxo http://nvt.myplaxo.com FaceBook http://profile.to/drnick Digg http://digg.com/users/nvt1 Delicious http://delicious.com/nvt1 E-Mail nvt@mmodal.com GrandCentral (301) 355-0877