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Get Ready EMRs and HIEs: Here Comes One Billion Clinical Documents

Get Ready EMRs and HIEs: Here Comes One Billion Clinical Documents. Bob Dolin, MD, FACP, FACMI Principal, Semantically Yours, LLC Chair, Health Level Seven Thursday, March 4, 2010 10:00-11:00 a.m. HIMSS10 Annual Conference & Exhibition Georgia World Conference Center Atlanta, GA.

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Get Ready EMRs and HIEs: Here Comes One Billion Clinical Documents

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  1. Get Ready EMRs and HIEs:Here Comes One Billion Clinical Documents Bob Dolin, MD, FACP, FACMI Principal, Semantically Yours, LLC Chair, Health Level Seven Thursday, March 4, 2010 10:00-11:00 a.m. HIMSS10 Annual Conference & Exhibition Georgia World Conference Center Atlanta, GA Kim Stavrinaki s

  2. Conflict of Interest Disclosure Bob Dolin, MD Has no real or apparent conflicts of interest to report.

  3. Meaningful Use?

  4. Meaningful Use!

  5. Session Overview • Health Story interoperability strategy • How Health Story leads to meaningful use • What this means for you

  6. Health Story Interoperability Strategy

  7. What is Meaningful Use? “Meaningful use, in the long-term, is when EHRs are used by health care providers to improve patient care, safety and quality.” David Blumenthal, MD National Coordinator for HIT

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

  9. Meaningful Use ≈ Data Reuse “If you can not measure it, you can not improve it.” Lord Kelvin (1824-1907)

  10. The 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 • Member organizations provide direction

  11. Health Story Members Founding Members Promoters Contributors Aprima Software | Scribe Healthcare Technologies Participants All Type | Dictation Services Group | Healthline, Inc. MD-IT | Sten-Tel, Inc. | Broward Sheridan Technical Center

  12. Health Story: Guiding Principles 1. Inclusive and open process 2. Leverage current technology investments 3. Enable broad stakeholder engagement 4. Provide a glide path for incremental interoperability 5. Minimize disruption to clinician workflow 6. Base strategy on existing standards 7. Use proven technology

  13. Health Story: Incremental Interoperability EHR Repository Disease, DF-00000 Metabolic Disease, D6-00000 Clinical Applications Disorder of carbohydrate metabolism, D6-50000 Disorder of glucose metabolism, D6-50100 HIMApplications Diabetes Mellitus, DB-61000 SNOMED CT Type 1, DB-61010 Neonatal, DB75110 Carpenter Syndrome, DB-02324 Insulin dependant type IA, DB-61020

  14. HL7 Clinical Document Architecture • Health Story specifications are based on HL7 CDA • CDA is “just right” • Single standard for entire EHR is too broad • Multiple standards and/or messages for each EHR function may be too difficult to implement

  15. HL7 Clinical Document Architecture • Other benefits of 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

  16. CDA is the basis for ... • HITSP/C28 Emergency Care Summary • 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/C84 Consult and History & Physical Note Document • HITSP/C78 Immunization Document • HITSP/C74 PHRM • HITSP/C62 Scanned document • Consult Note • Continuity of Care Document • Diagnostic Imaging Report • Discharge Summary • Healthcare-associated Infections, Public Health Case Reports • History and Physical • Operative Note • Personal Health Monitoring • Plan-2-Plan Personal Health Record • Procedure Note • Quality Reporting Document • Minimum Data Set • Unstructured Documents • … and more …

  17. Today’s Workflow

  18. Growing Use of Clinician EMR Interaction

  19. Evolving Dictation/Transcription

  20. Path to Meaningful Use “A journey of a thousand miles begins with a single step.” Lao-tzu, The Way of Lao-tzu Chinese philosopher (604 BX – 531 BC)

  21. Health Story  Meaningful Use • Health Story’s path to Meaningful Use • Hit the ground running with basic CDA, to meet the needs of front line clinicians • Incrementally layer discrete data elements into CDA documents

  22. Incrementalism Works for the Internet

  23. Why Health Story? HL7 Implementation Guide for CDA R2: Procedure Note Sample: Endoscopy Report Judy Logan Associate Professor Oregon Health & Science University

  24. What this means for you

  25. Actionable Next Steps Is your system capable of producing an HL7 CDA document? Requirements:

  26. In Summary • A physician’s practical • need for fast and easy • methods for creating • clinical documentation The enterprise need for structured and coded information capture to support meaningful use Computer image courtesy of M*Modal

  27. Bob Dolin, MD bobdolin@gmail.com Q&A

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