Health Story Project: Using Standards to Get to Meaningful Use: Exchange Basic Records and Meet Early Requirements

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Health Story ProjectUsing Standards to Get to
Meaningful Use Exchange Basic Records and Meet
Early Requirements
Kim Stavrinaki s

• HIMSS11 Interoperability Showcase
• Wednesday, February 23, 1145 am-1205 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

• Challenge
• Health Story Project Solution
• Where to Start
• QA

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Challenge
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Challenge
A physicians practical need for fast and easy
(30 sec) methods of creating clinical
documentation
The enterprise need for structured and
coded information capture to support meaningful
use
Computer image courtesy of MModal
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We Can Get Here Today
MRN 00000 DOS 11/11/2001 CHIEF
COMPLAINT 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
SNOMED CT

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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
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
Participants
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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 ...

• HL7 Consult Note
• HL7 Diagnostic Imaging Report
• HL7 Discharge Summary
• HL7 History and Physical
• HL7 Operative Note
• HL7 Procedure Note
• HL7 Unstructured Documents
• HL7 Progress Notes
• HL7 Continuity of Care Document
• HL7 Healthcare-associated Infections, Public
  Health Case Reports
• HL7 Personal Health Monitoring
• HL7 Plan-2-Plan Personal Health Record
• HL7 Quality Reporting Document
• HL7 Minimum Data Set
• and more

• HITSP/C84 Consult and History Physical Note
  Document
• HITSP/C32 - Summary Documents Using HL7 CCD
• HITSP/C38 - Patient Level Quality Data Document
  Using IHE Medical Summary (XDS-MS)
• HITSP/C48 Encounter Document constructs
• HITSP/C62 Scanned document
• HITSP/C28 Emergency Care Summary
• HITSP/C78 Immunization Document
• HITSP/C74 PHRM

Health Story supported guides in blue
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Consolidation Project Underway!

• HL7 Consult Note
• HL7 Diagnostic Imaging Report
• HL7 Discharge Summary
• HL7 History and Physical
• HL7 Operative Note
• HL7 Procedure Note
• HL7 Unstructured Documents
• HL7 Progress Notes
• HL7 Continuity of Care Document
• HITSP/C84 Consult and History Physical Note
  Document
• HITSP/C32 - Summary Documents Using HL7 CCD
• HITSP/C38 - Patient Level Quality Data Document
  Using IHE Medical Summary (XDS-MS)
• HITSP/C48 Encounter Document constructs
• HITSP/C62 Scanned document

One master implementation guide
Health Story supported guides in blue
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Health Story ? Meaningful Use
Meaningful Use Health Story Interoperability Strategy
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 Storys 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

• Providers
• 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?
• 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 physicians practical need for fast and easy
methods for creating clinical documentation
The enterprise need for structured and
coded information capture to support meaningful
use
Computer image courtesy of MModal
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QA
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(No Transcript)