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

The Radiologist’s Speech – Realizing the Full Potential of the Diagnostic Report. Nick van Terheyden, MD Board of Directors CDIA Chief Medical Information Officer, Nuance December 1, 2011. Health Story Project. Non profit, industry alliance Founded 2007

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

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  1. The Radiologist’s Speech – Realizing the Full Potential of the Diagnostic Report Nick van Terheyden, MD Board of Directors CDIA Chief Medical Information Officer, Nuance December 1, 2011

  2. 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

  3. Slide courtesy of Nuance

  4. Health Story Project Members Organization Affiliates Promoters Contributors Canon U.S.A. - Scribe Healthcare Technologies All Type - Apixio - ArrendaleAssociates - BayScribe - Chase Transcriptions ChartLogic - DictateIT, Ltd - Dispersive Medical - Documentation Services Group eMTS - Healthline, Inc. - InfraWare - InterFix- MedEDocs - MD-IT New England Medical Transcription - Phoenix Medcom Physicians Medical Group of Santa Cruz County - Sten-Tel, Inc. - Webmedx Participants

  5. Health Story Telling Clinical Document Ecosystem Meaningful Use HealthStory HIE People Transcript-ionist Dictating MD Clerk Abstractor MRM EMR Platforms Integration Platform Billing Analytics Applications Quality Voice to text Enrich Standard Format Imaging Voice capture Telephone PDR Smart phone Desktop appliances Scan-to-CDA OCR Transcription Speech recognition NLP DRT CAC CDA ICD, CPT… HL7 V2

  6. Guide Consolidation: US Dept Of Health and Human Services Office of the National Coordinator • HL7 Consult Note • HL7 Diagnostic Imaging Report • HL7 Discharge Summary • HL7 History and Physical • HL7 Operative Note • HL7 Procedure Note • HL7 Unstructured Documents • HL7 Progress Notes • HL7Continuity of Care Document • HITSP/C84 Consult and History & Physical Note Document • HITSP/C32 - Summary Documents Using HL7 CCD • HITSP/C38 - Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS) • HITSP/C48 Encounter Document constructs • HITSP/C62 Scanned document One master implementation guide Health Story supported guides in blue

  7. HL7 Clinical Document Architecture • Health Story Specs are Based on HL7 CDA • Normative HL7 standard since 2000 • Widely implemented • Provides a gentle on-ramp to information exchange • Providesmechanism 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

  8. 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

  9. 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

  10. Meaningful Use ≈ Data Reuse patient care quality reporting clinical decision support outcomes analysis research billing/claims adjudication

  11. Health Story Approach Slide, with edits, courtesy of MD-IT

  12. 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 documentsScanned documentsConsult & discharge summariesEnriched with NLP and CAC

  13. 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

  14. 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

  15. Actionable Next Steps • Providers: • Is your documentation vendor set up to deliver CDA documents? If no, when? • Is your EHR vendor set up to receive CDA documents? If no, when? • Vendors: Check out the requirements here: www.healthstory.com

  16. The Radiologist’s Speech – Realizing the Full Potential of the Diagnostic Report Nick van Terheyden, MD Board of Directors CDIA Chief Medical Information Officer, Nuance December 1, 2011

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