Transcript Document

Health Story Project:
Using Standards to Get to
Meaningful Use: Exchange Basic
Records and Meet Early
Requirements
Kim Stavrinaki
HIMSS11 Interoperability Showcase
s
Wednesday,
February 23, 11:45 am-12:05 pm
Bob Dolin, MD
President & CMO, Lantana Consulting Group
Chair, HL7 International
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Meaningful Use?
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Meaningful Use!
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Session Overview
1. Challenge
2. Health Story Project Solution
3. Where to Start
4. Q&A
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CHALLENGE
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Challenge
A physician’s practical
need for fast and easy
(30 sec) methods of
creating
clinical documentation
Computer image courtesy of M*Modal
The enterprise need for
structured and coded
information capture to
support meaningful use
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MRN:
00000
DOS:
11/11/2001
CHIEF COMPLAINT:
We Can Get Here Today
Fatigue
SUBJECTIVE:
Patient is a 25 year old woman
complaining of feeling frequently
fatigues. She reported also occasional
dizziness, sleeping difficulties and
morning headaches.
OBJECTIVE:
Recent bout with the flu
PHYSICAL EXAMINATION:
Vital signs are normal with a blood
pressure of 120/80, pulse 62,
temperature 98.6 degrees, weight 108
pounds.
ASSESSMENT:
Although flu symptoms were in
remission, patient has not fully
recovered yet.
PLAN:
Place patient on Biaxin for the next two
weeks. The patient will call us if there
is no improvement, any worsened or
new symptoms.
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Meaningful Use
“If you can not
measure it,
you can not
improve it.”
Lord Kelvin (1824-1907)
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Health Story Approach
EHR
Repository
Clinical
Applications
HIM
Applications
Coded Discrete
Data Elements
HL7 CDA Structured
Documents
Narrative
Text
SNOMED CT
Disease, DF00000
Metabolic Disease, D600000
Disorder of carbohydrate
metabolism, D6-50000
Disorder of glucose metabolism,
D6-50100
Diabetes Mellitus, DB61000
Neonatal,
DB75110
Type 1, DB61010
Carpenter Syndrome,
DB-02324
Insulin dependant type IA,
DB-61020
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THE SOLUTION
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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
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Health Story Project Members
Founding Members
Promoters
Contributors
Participants
Aprima Software - Scribe Healthcare Technologies
All Type - Arrendale Associates - BayScribe - Chase Transcriptions
DictateIT, Ltd - Dispersive Medical - Documentation Services Group
eMTS - Healthline, Inc. - MedEDocs - MD-IT
New England Medical Transcription - Phoenix Medcom
Sten-Tel, Inc. - Webmedx
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Based on HL7 CDA
 Single standard for
entire EHR is too
broad
 Multiple standards
and/or messages for
each EHR function
may be too difficult to
implement
CDA is “just right”
HL7 Clinical Document Architecture
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CDA is the basis for ...
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
1. HITSP/C84 Consult and History &
Physical Note Document
2. HITSP/C32 - Summary Documents Using
HL7 CCD
3. HITSP/C38 - Patient Level Quality Data
Document Using IHE
Medical Summary (XDS-MS)
8. HL7 Progress Notes
4. HITSP/C48 Encounter Document
constructs
9. HL7 Continuity of Care Document
5. HITSP/C62 Scanned document
10. HL7 Healthcare-associated Infections,
Public Health Case Reports
6. HITSP/C28 Emergency Care Summary
11. HL7 Personal Health Monitoring
8. HITSP/C74 PHRM
7. HITSP/C78 Immunization Document
12. HL7 Plan-2-Plan Personal Health
Record
13. HL7 Quality Reporting Document
14. HL7 Minimum Data Set

Health Story supported guides in blue
and more …
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Consolidation Project Underway!
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
One master
implementation
guide
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
Health Story supported guides in blue
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Health Story  Meaningful Use
Meaningful Health Story Interoperability Strategy
Use

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
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WHERE TO START
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Actionable Next Steps
1. Providers:
1.
2.
Is your documentation vendor set
up to deliver CDA documents? If
no, when?
Is your EHR vendor set up to
receive CDA documents? If no,
when?
2. Vendors: Check out the
requirements here:
www.healthstory.com
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Actionable Next Steps
 Join the Health Story
Project
 Project is interested in
tracking and highlighting
implementations’
 More information: visit the
Health Story kiosk in the
Interoperability Showcase
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In Summary
A physician’s practical
need for fast and easy
methods for creating
clinical documentation
Computer image courtesy of M*Modal
The enterprise need for
structured and coded
information capture to
support meaningful use
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Q&A
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