Health Story Project: Using Standards to Get to Meaningful Use: Exchange Basic Records and Meet Early Requirements

1. Health Story Project:Using Standards to Get to Meaningful Use: Exchange Basic Records and Meet Early Requirements HIMSS11 Interoperability Showcase Wednesday, February 23, 11:45 am-12:05 pm Bob Dolin, MD President & CMO, Lantana Consulting Group Chair, HL7 International Kim Stavrinaki s

2. Meaningful Use?

3. Meaningful Use!

4. Session Overview • Challenge • Health Story Project Solution • Where to Start • Q&A

5. Challenge

6. Challenge • A physician’s practical • need for fast and easy • (30 sec) methods of creating • clinical documentation The enterprise need for structured and coded information capture to support meaningful use Computer image courtesy of M*Modal

7. MRN: 00000 DOS: 11/11/2001 CHIEF COMPLAINT: Fatigue SUBJECTIVE: Patient is a 25 year old woman complaining of feeling frequently fatigues. She reported also occasional dizziness, sleeping difficulties and morning headaches. OBJECTIVE: Recent bout with the flu PHYSICAL EXAMINATION: Vital signs are normal with a blood pressure of 120/80, pulse 62, temperature 98.6 degrees, weight 108 pounds. ASSESSMENT: Although flu symptoms were in remission, patient has not fully recovered yet. PLAN: Place patient on Biaxin for the next two weeks. The patient will call us if there is no improvement, any worsened or new symptoms. We Can Get Here Today

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

9. Health Story Approach 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

10. The Solution

11. 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

12. Health Story Project Members Founding Members Promoters Contributors Aprima Software - Scribe Healthcare Technologies All Type - Arrendale Associates - BayScribe - Chase Transcriptions DictateIT, Ltd - Dispersive Medical - Documentation Services Group eMTS - Healthline, Inc. - MedEDocs - MD-IT New England Medical Transcription - Phoenix Medcom Sten-Tel, Inc. - Webmedx Participants

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

14. CDA is the basis for ... • 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 • HITSP/C28 Emergency Care Summary • HITSP/C78 Immunization Document • HITSP/C74 PHRM • 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 • HL7 Continuity of Care Document • HL7 Healthcare-associated Infections, Public Health Case Reports • HL7 Personal Health Monitoring • HL7 Plan-2-Plan Personal Health Record • HL7 Quality Reporting Document • HL7 Minimum Data Set • and more … Health Story supported guides in blue

15. Consolidation Project Underway! • 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

16. 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

17. Where to Start

18. 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

19. Actionable Next Steps • Join the Health Story Project • Project is interested in tracking and highlighting implementations’ • More information: visit the Health Story kiosk in the Interoperability Showcase

20. 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

21. Q&A