Title: Clinical Narrative and Structured Data in the Radiology Report Harmony with Healthstory
1Clinical Narrative and Structured Data in the
Radiology ReportHarmony with Healthstory
- Nick van Terheyden, MD
- Board of Directors MTIA
- Chief Medical Officer, MModal
- December 1, 2009
2Balancing Two Opposing Needs
A radiologists practical need for fast and easy
method for creating clinical documentation
The enterprise need for structured and
coded information capture
3Health Story Project
- Vision Comprehensive electronic clinical records
that tell a patients complete health story. - Who We Are A non profit alliance of healthcare
vendors, providers and associations - Mission Pool resources to develop data standards
through HL7 for flow of information between
common types of healthcare documents and EHR
systems - Goals Bridge the gap between the narrative
documents and structured data
4Adoption Strategy
- HL7 collaborates with Health Story on development
and ballot of technical implementation guides - Medical transcription companies support creation,
delivery and enrichment - HIT vendors systems send, receive, display and
integrate - Health providers select the approach and receive
vendor support for standards-based document
creation, management and enrichment
5Why CDA?
- Radiology results are key tool to provide
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
6Meaningful Clinical Documents
SNOMED CT
Slide courtesy of V. "Juggy" Jagannathan PhD,
Medquist
7Meaningful 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
8Current and Future Standards
- HL7 Implementation Guides
- Completed
- History Physical
- Consultation
- Operative Report
- DICOM Imaging Reports
- Discharge Summary (in publication)
- Upcoming
- Procedure Note (focus on Endoscopy Report)
- CDA with unstructured body
- Billing and Reimbursement Requirements
- Progress Notes
www.healthstory.com
9Adoption
- Health Story vendor members are generating Health
Story Documents (GE Medical, MedQuist, MModal)
and others are planning to generate the standards
in the next year - Included in HITSP1 requirements
- On CCHIT2 roadmap
1 Healthcare Information Technology Standards
Panel 2 Certification Commission for Healthcare
Information Technology
10Project Members
Promoter Members
Participant Members
All Type Dictation Services Group Healthline,
Inc. MD-IT Broward Sheridan Technical Center
11Our Advocacy To Date
- Participation in public comment periods
- NCVHS Hearing on Meaningful Use
- HHS Request for Input on Meaningful Use
- HITSP Request for Input on ARRA
- Comments are posted on our site
- www.healthstory.com
12Our 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 physicians to continue dictating and
provides patients with comprehensive electronic
records
13Getting Involved
- Share the Good News Be an Ambassador
- Grass roots effort to help spread the word
- Educate your employers, clients, vendors etc.
about this pathway - Join the Effort
- Varying membership levels, including individuals
- Volunteer for a Project
- See data standards section of
www.healthstory.com - Encourage Implementation
- See data standards section of
www.healthstory.com for suggested requirements
language for transcription and EMR vendors - Ensure your selection team are aware of the
available data standards that support the Health
Story approach
14What Health Story 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
15The Health Story ProjectClinical Narrative and
Structured Data in the Radiology ReportHarmony
with Health Story
Kim Stavrinaki s
- RSNA Conference, December 2009
- Nick van Terheyden, MD
- Board of Directors, MTIA
- Chief Medical Officer, MModal
16Where You Can Find Me
Nick van Terheyden, MD Chief Medical Officer,
MModal Twitter http//twitter.com/drnic1 Techno
rati http//technorati.com/people/technorati/nvt1
RSSSpeech Understanding http//speechunderstandin
g.blogspot.com/feeds/posts/default MyBlogLog http
//www.mybloglog.com/buzz/members/nvt LinkedIn h
ttp//www.linkedin.com/in/nickvt Plaxo http//nv
t.myplaxo.com FaceBook http//profile.to/drnick
Digg http//digg.com/users/nvt1 Delicious http
//delicious.com/nvt1 E-Mail nvt_at_mmodal.com Gran
dCentral (301) 355-0877