Welcome! The Health Story Project Dictation to Clinical Data: Automating the Production of Structured and Encoded Docum

1. Welcome!The Health Story ProjectDictation to Clinical Data: Automating the Production of Structured and Encoded Documents Kim Stavrinaki s MTIA Conference, April 2009 Kim Stavrinakis MHA,RT, Sr. Manager, GE Healthcare Nick van Terheyden, MD, Chief Medical Officer, M*Modal

2. Presentation Overview • Background: The Current Situation • Enabling the EMR with the Missing Link • A User Experience (GE/RISL) • The Health Story Project • Conclusion

3. Background The Current Situation

4. Problems Facing Clinicians According to an American College of Physician Executives survey, 6 in 10 physicians have considered leaving the profession due to: • burnout • low morale/depression • loss of autonomy • low reimbursement rates • patient overload • bureaucratic red tape • loss of respect, and • medical liability environment Complexity and workload is crippling physicians and hindering their ability to deliver high quality care

5. 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. Electronic Health Record Universe

6. Tedious manual process Time-consuming Documentation lacks expressiveness of natural language Lack of Flexibility Poor user interface Cost Fails to Meet Individual Physician Time vs. Benefit Test Cultural resistance Oblivious to HIM Requirements Incomplete and Inadequate Semantic Standards The Current Situation – Structured Direct Data Entry: Structured and encoded information.

7. “Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue.” Pamela Hartzband, M.D., and Jerome Groopman, M.D. n engl j med 358;16 april 17, 2008

8. 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 Support human decision making Reimbursement is based on narrative documentation Retains current workflow, favored by physicians Interoperable Under utilized source of data for EMR The Current Situation Dictation: Fast and easy, expressive.

9. 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 The Current Situation

10. Enabling the EMR The Missing Link in Information Capture in Healthcare

11. Data Entry Time • 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. (40 X 92% x 33 seconds) + (40 x 8% x 125) = < 30 minutes per day Data and Chart courtesy Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group

12. What if you could continue to use narrative and dictation and at the same time increase usage of the EMR and make more records available for the health information exchange? Crossing the Chasm…

13. 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

14. Goals • Bridge the gap between narrative documents and structured data • Encourage proliferation of information for the EHR

15. 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

16. Adoption • Incremental adoption overcomes the “not me first” dilemma • Not dependent on recipient’s ability to receive or process • Reverse adoption (can encode headers of existing documents) • Non-proprietary • Readable with any browser

17. Encoding • Does not preclude “once and done” concept • Compatible with Speech Understanding/Recognition • Can be facilitated by Natural Language Processing • Leverage existing relationships with transcriptionists/editors/knowledge based workers • Potential for automated coding (billing) • Supports data abstraction/research

18. Accessible Clinical Data

19. User ExperienceGE/RISL Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare The Missing Link in Information Capture in Healthcare

20. Clinical Document Architecture

21. Why CDA? • Radiology results is key tool in providing diagnosis • Results need to be: • concise • consistent representing the highest quality • 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

22. Precision Reporting • Building a reporting tool that • leverages standards for • structuring data that • drives patient care • drives outcomes for best practices • drives research for better patient care and outcomes Screen shot of report with halo Utilizing data at each point of care that culminates in rich information for the radiologist

23. Key Workflows • Self Editing • real time – read, proof, sign each exam • batch mode - read multiple exams then sign via signature queue • VR edits • Option to send to Medical Editor during reporting process • Batch Option – dynamic combinations of workflow based on confidence models • user based thresholds that determines how report is returned/reviewed to signature queue • preliminary/draft to signature queue • transcriptionist then preliminary to signature queue • Transcriptionist – Medical Editor workflow

24. Results Reporting Workflow Data Center Dictation Report in conversational speaking Edit Mode using local capture tool – can either type to correct or voice commands When dictation is complete and EOL is pushed Report is returned ready for edits Dictating the Procedure

25. Results Reporting Workflow 2 Data Center After final sign the report is processed in the NLP engine for learning Edit Mode using local capture tool – voice in selection between brackets Voice in options for brackets, sign report, add via voice more dictation in the sections, then sign

26. Results Reporting Batch Mode Report goes to Medical Editor or signature queue, Radiologist moves on to next exam Dictating the Procedure When dictation is complete

27. Understanding Diagnostic Reporting Source: GE analysis

28. Radiology Imaging of Lakeland Florida • Radiology & Imaging Specialists (RIS) • physician-owned • twenty board-certified radiologists • many sub-specialized • live since November 12, 2008

29. “You didn’t change the radiologists’ work, and that is what made it easy on me.” David Marichal, CIO, Radiology and Imaging Spec. of Lakeland, FL

30. Results VOC: • flexibility is key • full-time rads: 70% Medical Editor workflow/30% self-edit • part-time rads can use it in batch digital dictation mode • rads love not having to dictate accession #, name, signs/symptoms, etc… • quality of the engine is very good • self-edit for stat exams has reduced # of calls from the hospital

31. EHR Conversational Documentation … transformation of dictation directly into structured clinical documents while encoding data depending on the care givers and organizations needs

32. Meaningful Clinical Documents Meaningful Clinical Documents are a blend between free form text and fully structured documentation that • represent the thought process, and • capture the clinical facts

33. How it Works

34. The Health Story Project and Meaningful Clinical Documents Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare The Missing Link in Information Capture in Healthcare

35. 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

36. Health Story Document Types Implementation Guides Completed • History & Physical • Consultation • Operative Report • DICOM Imaging Reports Upcoming • Discharge Summary w/IHE • Billing and Reimbursement Requirements • Progress Notes • .PDF work with Adobe

37. Project Members Founders Promoters Original Benefactors: Participants

38. Conclusion

39. Crossing the Chasm…Babel Must Go • Medical text “typed” from dictation has “no meaning” • black marks on a page… • info must be tagged as discrete data elements in order to assign meaning • Clinical documentation uses wide variety of terms with same meaning…. • and terms that sound the same that have different meanings….. • authors have a wide variety of styles, accents, methods of dictation…

40. Health Story… • Captures meaningful clinical documents • Is the bridge between • free form narrative and expressive notes, and • fully structured clinical data • Improves the quality of clinical documentation • Generates semantically interoperable clinical data that will • solve the fundamental challenges with EMRs - allowingclinical decision support, alerts, decision support, data mining • enable interoperability, reporting, patient safety initiatives, PQRI (pay for performance), PSI (patient safety indicators) and improve billing data capture

41. Impact • Allows providers to maintain preferred workflow and documentation methods • Increases the value and usability of narrative documents (dictation/trans, SRT) • Accelerates the implementation of interoperable electronic health records • Allows reuse of information

42. Getting Involved • Join the Health Story Project • www.healthstory.com • Participate in HL7 Structured Document work group • Participate in HL7 ballots • Encourage implementation • EHR vendor adoption • provider preference • transcription RFPs

43. Membership Options and Benefits

44. Q&A Kim Stavrinakis Sr. Manager, Product Definition, GE Healthcare

45. Where You Can Find Me Nick van Terheyden, MD, CMO, M*Modal Twitter http://twitter.com/drnic1 Technorati http://technorati.com/people/technorati/nvt1 RSSSpeech Understanding http://speechunderstanding.blogspot.com/feeds/posts/default MyBlogLog http://www.mybloglog.com/buzz/members/nvt LinkedIn http://www.linkedin.com/in/nickvt Plaxo http://nvt.myplaxo.com FaceBook http://profile.to/drnick Digg http://digg.com/users/nvt1 Delicious http://delicious.com/nvt1 E-Mail nvt@mmodal.com GrandCentral (301) 355-0877