Our Vision: comprehensive electronic clinical records that tell a patient’s complete health story

1. Our Vision: comprehensive electronic clinical records that tell a patient’s complete health story HIMSS Conference Tuesday, April 7, 2009 8:30-9:30 AM central Room N128

2. Agenda Welcome and agenda review Introductions Background Current status HL7 perspective Q&A

3. Meeting Objectives Raise awareness as an option for integrating narrative notes and the EHR Generate interest in participation and membership Gather feedback

4. Introductions Presenters Peter Preziosi, PhD Chief Executive Officer Association for Healthcare Documentation Integrity  Medical Transcription Industry Association ppreziosi@ahdionline.org Nick van Terheyden, MD Chief Medical Officer, M*Modal nvt@mmodal.com V. “Juggy” Jagannathan Vice President of Research, Medquist juggy@medquist.com Bob Dolin, MD HL7 Chair-elect bobdolin@gmail.com Attendees • Name • Organization

5. Background

6. Background: Why Health Story? Challenge … • 600 million clinical documents produced in U.S./year • Dictated and transcribed documents around 60% of clinical data • Getting valuable info from narrative documents into the EHR What if you could … • Continue to use narrative and dictation and • at the same time increase usage of the EMR and • make more records available for the health information exchange?

7. CDA Templates

8. Accessible Clinical Data

9. CDA: A Document Exchange Specification This is a CDA and this and this and this and this and this and this 9

10. CDA: Investing in Information CDA at the Mayo Clinic • Initiated in 1999 • Thousands of documents each week • Clinical documents: Most important capital asset CDA at New York Presbyterian (was Col-Pres) • “CDA Philosophy” • Clinical notes contain critical information in narrative • Best format for information mining and aggregation across applications • 1/3 of all discharges summaries

11. Background: Why Health Story? CDA4CDT: rapid development initiative • “Clinical Document Architecture for Common Document Types” • Founders: AHDI/MTIA, AHIMA, M*Modal and Alschuler • Benefactors: 3M, A-Life Medical, Imagetek, Interfix, MedQuist, MDinTouch, Misys, Precyse, Quadramed, Spheris, Webmedx • Published HL7 draft standards: 1) consultation note, 2) history and physical, 3) operative note and 4) diagnostic imaging reports • Earned positive recognition in national press • Strong volunteer participation in standards development • Cited by AHIC as source for national standards

12. Background: Why Health Story? Health Story: industry alliance • In 2008, participants agreed to: • Build on momentum and success of CDA4CDT • Continue development work and further adoption • Develop 5-year business plan to guide activities • SWOT analysis led to new brand • Speaks to common vision for comprehensive electronic clinical records • Planning led to refined mission • To develop and promote information standards that support the flow of information between narrative documents and EHRs

13. Current Status

14. The Project is Operational Non profit, informal industry alliance Members contribute through participation and annual dues based on membership model Advisory groups, committees, work groups guide decision making and activities Contracted directors of communications and technology manage day-to-day activities Interim executive committee in place; elections in May

15. Project Members Founders Promoters Participants Original Benefactors: 3M, A-Life Medical, Imagetek, Interfix, Mdintouch, Medquist, Misys, Precyse Solutions, Quadramed, Spheris and Webmedx

16. Product Development Technical implementation guides • Consultation note • History and physical • Operative note • Diagnostic imaging report • Discharge summary (w/IHE) • Encounter note Training program designed and available 2009

17. Adoption Status Members generating Health Story CDA GE Medical, Medquist, M*Modal Provider adoption Radiology Imaging of Lakeland HITSP requirement C84 Consult and History & Physical Note Component Add Diagnostic Imaging, Op Note On CCHIT roadmap

18. Getting Started Providers: You want to include information from narrative notes into your EHR.... Transcription and EHR Vendors: You want to offer your customers a way to get information from narrative notes into their EHR...

19. Getting Started Identify requirements and partners • Tap into the Health Story project to learn from others Review available specifications • Four are available online Plan a pilot

20. Get Involved Join the project Participate in HL7 Structured Documents Work Group Participate in HL7 ballot comment periods Participate in other public comment periods (CCHIT, HITSP, etc.) Work standards into your development plans Encourage implementation

21. HL7 Perspective

22. Q&A and Feedback

23. Parking Lot