The Radiologist’s Speech – Realizing the Full Potential of the Diagnostic Report Nick van Terheyden, MD Board of Directors CDIA Chief Medical Information Officer, Nuance December 1, 2011

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 (8!)  Member organizations provide direction 

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Health Story Project Members Organization Affiliates Participants All Type - Apixio - Arrendale Associates - BayScribe - Chase Transcriptions ChartLogic - DictateIT, Ltd - Dispersive Medical - Documentation Services Group eMTS - Healthline, Inc. - InfraWare - InterFix - MedEDocs - MD-IT New England Medical Transcription - Phoenix Medcom Physicians Medical Group of Santa Cruz County - Sten-Tel, Inc. - Webmedx Contributors Canon U.S.A. - Scribe Healthcare Technologies Promoters

Health Story Telling Integration Platform Dictating MD Transcript- ionist Abstractor Voice capture Voice to text Enrich Standard Format Telephone PDR Smart phone Transcription Speech recognition NLP DRT CAC CDA ICD, CPT… HL7 V2 HIE MRM EMR Billing Analytics Quality People Platforms Applications Meaningful UseClinical Document Ecosystem Clerk Imaging Desktop appliances Scan-to- CDA OCR

Guide Consolidation: US Dept Of Health and Human Services Office of the National Coordinator 1.HL7 Consult Note 2.HL7 Diagnostic Imaging Report 3.HL7 Discharge Summary 4.HL7 History and Physical 5.HL7 Operative Note 6.HL7 Procedure Note 7.HL7 Unstructured Documents 8.HL7 Progress Notes 9.HL7 Continuity of Care Document 10.HITSP/C84 Consult and History & Physical Note Document 11.HITSP/C32 - Summary Documents Using HL7 CCD 12.HITSP/C38 - Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS) 13.HITSP/C48 Encounter Document constructs 14.HITSP/C62 Scanned document One master implementation guide Health Story supported guides in blue

Health Story Specs are Based on HL7 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

Why CDA?  Radiology results are a key tool in providing diagnosis  Results need to be:  concise  consistent  precipitate alerts before the report is distributed  Radiology Information System  rich in data  eliminates redundancy  streamlines workflow  CDA benefits  standard for clinical communication  foundation for structuring data

Meaningful Use Stage 2 ONC Standards and Interoperability Framework has indicated intent to recommend CDA and Health Story specifications in meaningful use Stage 2 requirements for clinical documentation

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

Health Story Approach BenefitValue Retains patient storyMaintains primary role of radiology reports to clearly describe and communicate what is going on with patient. Preserves physician time for clinical care Makes efficient use of physician time by enabling choice of documentation methods and fosters EMR acceptance Supports meaningful use Interoperability: implements HL7 CDA document standards for electronic exchange of clinical information Enables data reuseStructured narrative enables better outcomes reporting, data mining, and decision support Collaborative approachDeveloped by broad array of providers, vendors and IT organizations; Balloted process through HL7 supports harmonization Better documentationSupports better coding, DRG optimization = better reimbursement Slide, with edits, courtesy of MD-IT

Health Story Use Cases Health Story Use Case, Transitions of Care  Demonstration project at HIMSS 12  Using Standard published from HL7/IHE Health Story Consolidation Project in conjunction with the ONC Standards & Interoperability Framework.  ~85% of information needed crosses enterprise boundaries  Demonstration of complete information flow from  Unstructured documents Scanned documents Consult & discharge summaries Enriched with NLP and CAC

What Healthstory Offers You  Allows providers to choose preferred workflow and documentation methods  Increases the value and usability of narrative documents  Accelerates the implementation of interoperable electronic health records  Allows intelligent and meaningful reuse of information  Provides on-ramp to EMR system adoption  pre-populate EMR with structured documents  integrate legacy documents

Our Advocacy Requests  Actions Requested:  Require certified systems to accept interfaced data from dictation/transcription process per available standards  Modify the definition of meaningful use to recognize use of certified systems with the above capabilities  Assist in spreading the word about this avenue for getting the full story into the EHR that allows radiologists to continue dictating and provides patients with comprehensive electronic records

Actionable Next Steps 1.Providers: 1. Is your documentation vendor set up to deliver CDA documents? If no, when? 2. Is your EHR vendor set up to receive CDA documents? If no, when? 2.Vendors: Check out the requirements here:

The Radiologist’s Speech – Realizing the Full Potential of the Diagnostic Report Nick van Terheyden, MD Board of Directors CDIA Chief Medical Information Officer, Nuance December 1, 2011