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1 | Using Standards to Get to Meaningful Use: Exchange Basic Records and Meet Early Requirements Kim Stavrinaki s Presenters: Liora Alschuler, Alschuler Associates, LLC Bob Dolin, MD, Semantically Yours, LLC Facilitator: Joy Kuhl, Health Story Project Wednesday, July 21, 2010 Welcome! Please note that your line is on mute due to the large number of participants

2 | Agenda  Agenda review  Housekeeping  Purpose  Introductions ------------  Presentation  Dialogue with the speakers

3 | Housekeeping  Please enter your “audio pin”  Please use “Questions” tool for questions and comments  Please submit questions and comments at any time

4 | Audio and Slide Presentation  Posted online by end of week at

5 | Purpose


7 | Liora Alschuler Principal, Alschuler Associates, LLC Health Story Executive Committee  Led project that produced design of first XML-based exchange specification for healthcare  Co-editor of HL7 CDA, CCD and many HL7 implementation guides that leverage the CCD templates  Founding member of Health Story and leads technical strategy and development

8 | Bob Dolin, MD Principal, Semantically Yours, LLC Chair, HL7  15 years experience with interoperability standards  Co-editor of HL7 CDA, CCD and Using SNOMED CT in HL7 V3  Member of ONC HIT Standards Committee, Vocabulary Task Force  Co-chaired HITSP Foundations Committee  Prior member of SNOMED International Editorial Board

9 | Agenda  Agenda review  Housekeeping  Purpose  Introductions ------------  Presentation  Dialogue with the speakers

10 | Meaningful Use?

11 | Meaningful Use! Image courtesy of M*Modal

12 | Session Overview  Health Story interoperability strategy  How Health Story leads to meaningful use  What this means for you


14 | 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

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

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

17 | 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

18 | Health Story Members Founding Members Participants All Type | Arrendale Associates | BayScribe Documentation Services Group | Healthline, Inc. Broward Sheridan Technical Center | MD-IT New England Medical Transcription | Sten-Tel, Inc. Contributors Aprima Software | Scribe Healthcare Technologies Promoters

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

20 | Narrative Text HL7 CDA Structured Documents Coded Discrete Data Elements EHR Repository HIM Applications Clinical Applications SNOMED CT Disease, DF- 00000 Metabolic Disease, D6- 00000 Disorder of glucose metabolism, D6-50100 Diabetes Mellitus, DB- 61000 Type 1, DB- 61010 Insulin dependant type IA, DB-61020 Neonatal, DB75110 Carpenter Syndrome, DB-02324 Disorder of carbohydrate metabolism, D6-50000 Health Story: Incremental Interoperability

21 | 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

22 | Other benefits of CDA:  Normative HL7 standard since 2000  Widely implemented  Provides a gentle on-ramp to information exchange  Provides mechanism 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 HL7 Clinical Document Architecture

23 | Based on HL7 CDA Clinical Document Architecture supports:  Human readable document  Machine-processable data (e.g. discrete reportable transcription)  Cross platform and application independent Health Story Approach  Standardize through ANSI SDO (HL7 ballot)  Support Meaningful Use MinimumOptimum CDA header Standard section codes Broad industry agreement on clinical content Reuse of entry-level templates “Templated CDA”

24 | Health Story Documents Blend between free form text and fully structured documentation that  represent the thought process, and  capture the clinical facts  Health Story makes “discrete reportable transcription” work

25 | Minimal Document for Exchange... Adam Everyman

26 | Achievable: Today REASON FOR VISIT/CHIEF COMPLAINT Stomach ache.

27 | Achievable: Meaningful Use 1 pack per day

28 | Health Story and Meaningful Use  Required data is in clinical notes  Physicians do not write summaries (CCR & CCD)  Summary data is drawn from many sources, including clinical notes  Some data may, increasingly, be direct-physician entered  Data required for Meaningful Use can be captured in clinical notes and integrated into the EHR  Natural language processing: it’s real, it works, it’s available and it works very well in the context of structured CDA templates  Abstractors, computer assisted coding, transcription knowledge workers:  same workflow, altered coding focus  CDA templates ensure consistency, conformance  Template-driven dictation  Standard templates give real-time feedback to dictation physicians  Ensure conformance, provide structured data

29 | Templated CDA is the basis for...  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 …  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

30 | “The key to intelligent tinkering is to keep all the parts.” Aldo Leopold

31 | Today’s Workflow

32 | Growing Use of Clinician EMR Interaction

33 | Evolving Dictation/Transcription iPhone images courtesy of M*Modal

34 | 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)

35 | Health Story  Meaningful Use Meaningful Use Health Story Interoperability Strategy Delivers common clinical documents to the point of care Standardizing document types and sections today makes it easier to agree on data elements tomorrow Incrementally adding key data elements into narrative is attractive to clinicians Partial structuring facilitates natural language processing 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

36 | Incrementalism Works for the Internet

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


39 | Actionable Next Steps Is your transcription supplier capable of producing an HL7 CDA document? Is your EHR/document management system capable of receiving an HL7 CDA document? Requirements:

40 | Actionable Next Steps  Get involved in Health Story  Lead the industry  Weigh in on development priorities  Project is interested in tracking and highlighting implementations

41 | 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 In Summary Computer image courtesy of M*Modal

42 | Agenda  Agenda review  Housekeeping  Purpose  Introductions ------------  Presentation  Dialogue with the speakers

43 | Q&A

44 | Contact Information Bob Dolin, MD Semantically Yours, LLC Liora Alschuler Alschuler Associates, LLC Joy Kuhl Health Story Project

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