1. Illinois PDF Healthcare Pilot September 13, 2008
Rick Benoit
Chair PDF/Healthcare Workgroup
Stasia Kahn, MD
Co-Founder, Fox Prairie Medical Group
Vice President, Northern Illinois Physicians For Connectivity

2. What is PDF Healthcare?
A “Best Practices Guide” describing attributes of the Portable Document Format (PDF) to facilitate the capture, exchange, preservation and protection of healthcare information
Share data easily between healthcare institutions
Ease the transition into digital health records for information exchange and sharing
Bridge the gap between healthcare providers and consumers

3. What it is NOT… NOT Another PDF format… Another PDF creation tool…
PDF Healthcare
NOT
Another PDF format…
Another PDF creation tool…
Another PDF product…
Another PHR offering…
Another proprietary solution…
Another PDF standard…

4. PDF Healthcare’s Mission
provides a trusted and universal means by which healthcare data is captured, exchanged, preserved and protected
facilitates the use of digital healthcare content of various platforms and devices
encourages and supports healthcare patients / consumers to control and account for their own and family health records
Therefore, through the development, deployment and evolution of the PDF Healthcare Guides, the following will be realized:
PDF supports the migration of multiple record types to a universal PDF-based container
PDF promotes and accelerates the adoption of an electronic healthcare record
PDF provides efficiencies potentially resulting in:
Error reductions
Elimination of redundancies
Improvements in workflow processes
Improvements in patient care delivery and communication

5. PDF Healthcare’s Objective
To develop a secure, electronic container that can store and transmit relevant healthcare information, including but not limited to personal documents, clinical notes, lab reports, electronic forms, scanned images, photographs, digital X-rays, and ECGs, important for maintaining and improving one’s health.

6. Why PDF Healthcare? PDF is powerful and flexible
PDF focuses on the specific needs of the healthcare market
Interoperability and portability
PDF is based on open, published specifications
The PDF Healthcare Best Practices Guide has been developed and will be maintained by an external committee with healthcare industry knowledge
PDF Readers are ubiquitous, easy to access and use as well as being a trusted document container

7. Objectives
Identify, document, distribute, and publish multiple use cases to physicians and consumers
Explore and develop a strategy for including the HL7 CDA / CCD document format
Gather feedback from users and identify needs for version 2 of the BPG and IG

8. Dak Systems Consulting

9. Additional Information
For more information please
To join the working group please contact:
Betsy Fanning -
To purchase and download the Best Practice Guide:
To download the Implementation Guide and Toolkits:

10. Initial PDF Healthcare Offering
Best Practices Guide
Describes the attributes of the Portable Document Format (PDF) that are relevant to facilitate the capture, exchange, preservation and protection of healthcare information
Implementation Guide / Use Cases
Supplemental information that provides examples of interoperability with existing healthcare standards such as ASTM’s Continuity of Care Record (CCR)
Future use cases could include Health Level 7’s Clinical Document Architecture (CDA) as well as other, new, emerging standards

11. Why did we Implement PDF/H?
An ambulatory EMR is a data repository which is a subset of a longitudinal health record
Except in a completely closed healthcare system, a longitudinal EMR includes imported documents and images
Imported data cannot be captured by the discrete data fields delineated by the CCR
Consulting providers are used to dealing with narrative documents rather than summary data displayed by the CCR

12. Overview of Data Flow Patterns in Ambulatory Healthcare Settings
Raw data is transformed into clinical output during an in-person medical encounter

13. Exporting Summary Care information From an EMR
Healthcare Delivery Organization creates and exports summary care information from an EMR

14. Continuity of Care Record Pilot in Illinois
June ASTM CCR successfully balloted
September June CCRs exchanged
February 2008 PDF/H successfully balloted ASTM and AIIM
December September PDF/Healthcares exchanged and 1 CCR
Receiving physicians were representatives of small, medium and large academic and private groups.

15. Summary PDF/H Pilot Feedback
11 PDF/Hs and 1 CCR uploaded to the portal
1 failure- PDF/Healthcare not accessed 2 more failures
1 imported directly into EMR
10 Viewed online by the provider
5 Providers printed the document themselves
2 had someone else print
Those that were working in a digital office were interested in being able to download the PDF/H into their system
One that was paper based was interested in saving the file to an office computer

22. Lessons Learned
If at all possible call the receiving physician ahead of time (a week or more ideally)
Confirm the address of either the administrator or physician who will be accessing the portal
Confirm the provider who is seeing the patient
Spam filters may block the notification s
Solution: Implement a return receipt for notification s or a decision support feature that notifies the sender that the PDF/H or CCR has not been viewed by the recipient within a specified period of time

23. Lessons Learned
When referring to an institution that screens patients prior to making appointments, it may be difficult to find a physician willing to view the PDF/H
The receiving providers may not have a complete view of the rendered CCR due to margin issues
Solution: Change the margins of the style sheet
If the image is saved in nonstandard image format such as PCX the recipient will have to save the attachment and find an application to view it
Solution: Scan all documents into EMR using a widely available format such as TIF,BMP

24. Lessons Learned
Standard style sheet proved to be confusing to the recipients with delivery of multiple discrete lab results
Solution: Modify CCR style sheet to better group the results
EMR PDF viewers have varying ability to view attachments to the PDF
Providers saving the PDF in their EMR need to save attachments separately if viewer will not allow access

25. Provider Feedback
Incorporate a Narrative Note explaining the purpose of the referral
Attach the most recent Office Encounter
Be more concise to avoid excessive scrolling
Simplify the procedure to access the PDF/H
Attach MRI Image
Limit Administrative Burden on Provider

26. Limiting Administrative Burden
For practice groups where a physician prefers not to view PDF/H directly, use a generic log in
Consulting provider field would be generic for the entire practice
Health Information Management Specialist would be responsible for delivering the content of the PDF/H to the appropriate physician
Disadvantage to this approach is that the physician no longer chooses what to import from the PDF package
Beware of using generic log in office with multiple sites

27. Technology Next Steps
Render images and text documents into the PDF document so they can be viewed without concerns for file type
Implement XFA form technology to allow for creation of different views of CCR data
Allow transmission of PDF to patients via portal for importing into PHR

28. Expansion of the Technology
Import CCR/CCD data as structured data into recipient EMR
Allow for the exchange of PHR data into EMRs
Implement PDF/H at hospital discharge

29. Expansion of the Technology
Import CCR/CCD data as structured data
This is dependent on EMR vendors addressing the data integrity issues of
Identifying the creator and sources of data
Tracking the creator and sources of data

30. Obstacles for Discrete Data Import
It is important to identify and differentiate whether a diagnosis or medication entry originated from a healthcare provider, which healthcare provider, or patient
Fraud and errors in medications and diagnosis could be perpetuated
Patients have not been educated to code data in a structured format. Personal Health Record past medical history and medication entries allows for unstructured data
Entries from patients should not be used for billing purposes or take the place of a dialogue between a healthcare provider and patient
A patient could be labeled or treated inappropriately because of their own misunderstanding of the nuiances of coding structured data
Providers vary in their familiarity with structured data pertaining to other medical specialties

31. Tracking the Creator and Sources of Data
Currently EMR systems will tag all data entered through the EMR as to the data by user ID
EMR vendors would need to be required to identify the creator and the source of all structured data as coming in from an external source
EMR vendors would need to be required to tag the originator of all structured data fields
EMR vendors would need to be required to have tracking mechanisms in place to allow data sources to flow across disparate electronic health records systems

32. Expansion of the Technology
Allow for the exchange of PHR data into EMRs
This is dependent on the following:
Engaging Consumers in using Personal Health Records
Limiting the IT burden on providers who agree to accept asynchronous PDF/Hs from patients
Defining Informed Consent
Compensating Physicians who exchange data with their patients electronically

33. Next steps
Additional Use Cases of PDF/Healthcare being explored in Illinois

34. Next steps NIPFC regional data sharing pilot at Hospital Discharge
PDF/Healthcare implemented in Legacy Hospital Information Systems
Limited data set CCR to be implemented allowing for Medication and Problem list reconciliation
Patient will receive a paper version with the goal of exporting the electronic file to primary care providers

35. Next steps Fox Prairie Medical Group/Healthstring Pilot
Prepopulate PHR for patients with one or more chronic diseases
Export PDF/Healthcare files to patient portal
Import files into Healthstring PHR
Healthstring nurse coaches will facilitate transfer of the technology to the patient’s home environment
Initial exchange EMR to PHR but the long term goal is to allow for PHR to EMR exchange

36. Stay Tuned www.niphysiciansforconnectivity.org

37. Questions? Dr. Stasia Kahn
Contact Information:
Dr. Stasia Kahn
Vice President,Northern Illinois Physicians For Connectivity
Vik Sheshadri PhD,Vice President eMedapps