Using Electronic Health Records to Enhance Operating Efficiency

1. Using Electronic Health Records to Enhance Operating Efficiency V. “Juggy” Jagannathan V.P. Research MedQuist, Inc. March 12, 2010 Presentation to: HFMA North Carolina Chapter NLP STRUCTURED DATA EHR SUPPORT MEANINGFUL USE CODING EDITING SPEECH RECOGNITION

2. Acknowledgements Support of HealthStory (for slides on HealthStory and some on meaningful use) Liora Alschuler, Joy Kuhl, Bob Dolin Support of the MedQuist Team Steven Russell, Sr. VP Marketing Chris Spring, VP Product Management Don Fallati, Marketing Discussion on Meaningful Use From Dr. Halamka blog post: http://mycourses.med.harvard.edu/ec_res/nt/48A3E7A8-23FA-43C8-A526-F743D05C91EA/ifr.ppt

3. Agenda Meaningful Use ARRA Stimulus Legislation and HITECH Act HealthStory How to structure clinical documents ACT to Practice Policy & Standards bodies, Certification and Industry Groups Adoption Make the most of your EHR & keep physicians productive

4. Meaningful Use ARRA Stimulus Legislation and HITECH Act Meaningful Use

5. 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 Slide Courtesy of HealthStory

6. Stage 1: Meaningful Use Stage 1: The Stage 1 meaningful use criteria focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured, but in structured format whenever feasible); consistent with other provisions of Medicare and Medicaid law, implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information. Actual text from the Notice of Proposed Rule Making

7. Meaningful Use Objectives for Hospitals • Use CPOE for at least 10% of orders. • Implement drug-drug, drug-allergy, drug-formulary checks • Maintain an up to date problem listof current and active diagnoses (at least one coded entry or "No Problems exist") in ICD9-CM or SNOMED-CT for at least 80% of all patients • Maintain active medication list. • Maintain active medication allergy list.

8. Meaningful Use • Record vital signs including height, weight, blood pressure, Body Mass Index (calculated) and growth charts for children 2-20 years for 80% of patients. • Record smoking status for 80% of patients 13 years or older • Incorporate 50% of clinical lab test results as structured data using LOINC codes • Generate lists of patients by specific conditionsto use for quality improvement, reduction of disparities, and outreach Slide Courtesy of Dr. Halamka

9. Meaningful Use • Report quality measures to CMS • Send reminders to at least 50% of all patients who are 50 years and over for preventative care/followup. The intent is to allow the patient to choose between post card, email, phone reminder, or PHR reminder. • Implement 5 clinical decision support rules relevant to the clinical quality metrics. • Check insurance eligibility and submit claims electronically for at least 80% of patients. Slide Courtesy of Dr. Halamka

10. Meaningful Use • Provide 80% of patients who request an electronic copy of their health information in the CCD or CCR format within 48 hoursof their request • Provide 10% of patients with online access to their problem list, medication lists, allergies, lab results within 96 hours of the information being available to the clinician. Slide Courtesy of Dr. Halamka

11. Meaningful Use • At least one test of health information exchangeamong providers of care and patient authorized entities. • Perform Medication reconciliation for at least 80% of relevant encounters and transitions of care.

12. Meaningful Use • Provide a summary of care record for at least 80% of transitions of care and referrals. This also implies the ability to receive a record and display it in human readable format • Perform at least one test of the EHR capacity to submit electronic data to immunization registries. • Perform at least one test of the EHR's capacity to submit electronic lab results to public health agencies. Slide Courtesy of Dr. Halamka

13. Meaningful Use • Perform at least one test of the EHR's capacity to submit syndromic surveillance data to public health agencies. • Conduct or review a security risk analysis and implement updates as necessary Slide Courtesy of Dr. Halamka

14. Meaningful Use ≈ Data Reuse patient care quality reporting clinical decision support outcomes analysis research billing/claims adjudication Slide Courtesy of HealthStory

15. HealthStory How to Structure Clinical Documents HealthStory

16. The Health Story Project • Non profit, industry alliance • Founded 2007 • Associate Charter Agreement: HL7 • Produce data standards for flow of information between narrative and EMR systems • Member organizations provide direction Slide Courtesy of HealthStory

17. The Current Situation – Structured • Tedious manual process • Time-consuming • Documentation lacks expressiveness of natural language • Lack of Flexibility & Poor user interface • Studies show that it introduces errors1 • Cost • Fails to Meet Individual Physician Time vs. Benefit Test • Cultural resistance • Not supportive to HIM Requirements • Incomplete and Inadequate Semantic Standards Direct Data Entry: Structured and encoded information 1: Weir et. al. “Direct Text Entry in Electronic Progress Notes”, Methods Inf Med, 1/2003 Slide Adapted from HealthStory

18. The Current Situation • Transcription can be expensive • Subject to longer turn-around times • Clinical data lost, because documents are neither structured nor encoded • Majority of attested information is only in the document • Contains the detail and comprehensive scope of patient information • Studies show that transcriptionists fix lot of errors in dictated reports • Support human decision making • Reimbursement is based on narrative documentation • Retains current workflow – favored by physicians • Interoperable • Under utilized source of data for EMR Dictation: Fast and easy, expressive Slide Adapted from HealthStory

19. The Current Situation • High cost of documentation • Cost of ownership and physician time vs. transcription cost • 60% of the data lost to the EHR • Care process inefficiencies and impact on quality Slide Courtesy of HealthStory

20. Data Entry Time • The average physician spends 33 seconds dictating an established office visit • 92% of all office visits are established • If the average physician sees 40 patients a day, total dictation time of 30 minutes plus time to search for the data. • Using a traditional EHR application, the same number of patients would require 140 minutes of data entry time. • Physicians are not willing to spend an additional 90 minutes per day for data entry. (40 X 92% x 33 seconds) + (40 x 8% x 125) = < 30 minutes per day Slide Courtesy of HealthStory Data and Chart courtesy Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group

21. The Current Situation • Forcing busy physicians to type into templated sections will inevitably lead them to adopting IM/Twitter style/telegraphic content recording • Real world example: • “d/c'd CCB 2/2 HOTN” • Translation: Discontinued Calcium Channel Blocker secondary to hypotension. • Problem with this is many fold: • It can be misinterpreted – is it discontinued or discharged? • It is local to the care setting and harder to manage outside the care setting • And, over time this documentation becomes harder to interpret

22. Crossing the Chasm… What if you could make your physicians very efficient and the clinical documentation they create effective for care and revenue cycle management?

23. Health Story Project Vision • Comprehensive electronic clinical records that tell a patient’s complete health story • All of the clinical information required for • good patient care • administration • reporting and • research • Will be readily available electronically, including information from narrative documents Slide Courtesy of HealthStory

24. Based on HL7 CDA • Clinical Document Architecture Requirements • Human readable document • Must be presentable as a document • Rendered version covers clinical information intended by the author • Can contain machine-processable data • Cross platform and application independent • Can be transformed with style sheets Slide Courtesy of HealthStory

25. 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 Slide Courtesy of HealthStory

26. Health Story Document Types Implementation Guides Completed • History & Physical • Consultation • Operative Report • DICOM Imaging Reports Upcoming • Discharge Summary in progress through HL7 • Billing and Reimbursement Requirements • Progress Notes • PDF work with Adobe Slide Courtesy of HealthStory

27. 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

28. ACT to Practice Policy & Standards bodies, Certification and Industry Groups Act to Practice

29. How does an act translate to practice? • Office of National Coordinator (ONC) • Federal Advisory Committees • Health IT Policy Committee New • Health IT Standards CommitteeNew • Health Information Technology Standards Panel (HITSP) • Other Government Stakeholders • CMS, VA, CDC, AHRQ, FDA

30. Industry & Standards Groups • Standards • HL7 • ASTM • Industry groups • Certificate Commission for Health Information Technology (CCHIT) • Interoperability in Healthcare Enterprise (IHE) • HealthStory • HIMSS, AHIMA, AHDI

31. How this all fits together… ONC Charter to accelerate Adoption of EHR HIT Policy & Standards Guidelines/Scenarios Where to focus HITSP Recommends a variety of standards Healthcare Information Technology Standards Panel (HITSP) CCHIT Certification Commission for Health Information Technology 31

32. What this means to you… • Need to upgrade your EMR systems to ones that are certified. • Review your processes and assess physician adoption and documentation strategies. • Realize that clinical documentation solutions, speech recognition (both front and back-end) are part of the solution space – not the problem space – to increase physician adoption.

33. Adoption Make the most of your EHR & keep physicians productive Adoption

34. Adoption and Physician Choice • Variety of options for Physicians • Templated solutions – direct entry into EHR • Partial templates – dictating within templates • Front-end speech recognition solution • Mobile and smart phone solutions Physician Choice  Increased Adoption of EHR  Increased Benefits of using EHR

35. Structuring Transcribed Documents Draft Report EHR Voice Capture Transcription Physician eSign / Review Unstructured Report Available for Care Editing Speech Recognition NLP Structure Review Structured Reports

36. The “NLP Gap” NLP is the Transformative Technology Text Generation Text Entry Transcribed Dictation Clinical Database Text OCR Unprocessed Text Speech Recognition Coded Items Extract Precoded Items Pick List Coded Items Source: Gartner

37. Supporting Physicians by ProvidingStructuring Solutions 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

38. Progressive uses of Structure Realizes EHR use and Promise Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions Requirement Keys to Achieve Enabling Advanced Technology

39. What it provides… Physician CHOICE Allows physicians to be effective in clinical documentation Drives adoption rate of EHR All of the EHR benefits are realized much faster Concluding Thoughts What it is • Use of Speech Recognition and NLP to extract clinical concepts • Use of Editors to validate extracted concepts • Feeding EHR systems with structured documentation using interoperable standards promoted by HITSP, CCHIT, IHE , HL7 and HealthStory Dictation/Transcription is Your On Ramp To EHR

40. Any questions: juggy@medquist.com