Maximizing Electronic Record Adoption & Physician Productivity Through Technology

1. Maximizing Electronic Record Adoption & Physician Productivity Through Technology V. “Juggy” Jagannathan V.P. Research MedQuist, Inc. August 20, 2009 Presentation to: HFMA Virginia Chapter

2. Acknowledgements Support of HealthStory (and its executive members) Dr. Nick van Terheyden, Liora Alschuler, Joy Kuhl, Mark Ivie Support of the MedQuist Team Emmy Weber Chris Spring Don Fallati

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

5. Meaningful Use Timeline

6. Meaningful Use Timeline July 16 Final Version Changes 1. For inpatient CPOE, only 10% of orders must be entered electronically2. For problem lists, ICD9 or SNOMED must be used3. Advanced directives must be recorded4. Smoking status must be recorded5. Quality measures must be reported to CMS6. Clinicians and Hospitals must implement at least one clinical decision rule relevant to a high clinical priority7. Administrative transactions, including eligibility and claims, must be completed electronically

7. HealthStory How to Structure Clinical Documents

8. Electronic Health Record Universe Slide Courtesy of HealthStory Critical to the success of EHRs is to reconcile two opposing needs • Enterprise need for structured and coded information capture • Physician’s practical need for a fast and easy method for creating clinical notes.

9. The Current Situation – Structured Direct Data Entry: Structured and encoded information 1: Weir et. al. “Direct Text Entry in Electronic Progress Notes”, Methods Inf Med, 1/2003 • 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 Slide Adapted from HealthStory

10. The Current Situation Dictation: Fast and easy, expressive 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 Slide Adapted from HealthStory

11. 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

12. 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

13. Data Entry Time (40 X 92% x 33 seconds) + (40 x 8% x 125) = < 30 minutes per day The average physician spends 33 seconds dictating an establish 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. Slide Courtesy of HealthStory Data and Chart courtesy Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group

14. 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?

15. 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

16. 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

17. 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

18. 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

19. Project Members Promoters Participants All Type | Dictation Services Group | Healthline, Inc. | MD-IT

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

21. 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

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

23. 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 23

24. 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 transcription solutions, speech recognition (both front and back-end) are part of the solution space – not the problem space – to increase physician adoption.

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

26. Adoption and Physician Choice Physician Choice  Increased Adoption of EHR  Increased Benefits of using EHR • 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

27. 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

28. 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

29. 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

30. 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

31. 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 Dictation/Transcription is Your On Ramp To EHR 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