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The Health Story ProjectDictation to Clinical Data: Automating the Production of

Structured and Encoded Documents

Kim Stavrinaki

s

WHIMA, May 8, 2009Nick van Terheyden, MD

aka – SnakeDoctorChief Medical Officer, M*Modal

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Presentation Overview

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

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Background

The Current Situation

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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

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Electronic Health Record Universe

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.

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The Current Situation – Structured

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

Direct Data Entry: Structured and encoded information.

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“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

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The Current Situation

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

Dictation: Fast and easy, expressive.

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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

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Enabling the EMR

The Missing Link in Information Capture in Healthcare

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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

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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…

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A word About Speech Recognition

What speech recognition often means for physicians… Disruption of their workflow

Change in their dictation style

More time spent on documentation

“Typing with your tongue”

The real world of dictation: Disorganized speakers

Mumbled/fast speech

Corrections

Instructions to transcriber

Different dictation habit

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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

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Goals

Bridge the gap between narrative documents and structured data

Encourage proliferation of information for the EHR

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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

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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

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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

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Accessible Clinical Data

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User ExperienceGE/RISL

Kim Stavrinakis

Sr. Manager, Product Definition, GE Healthcare

The Missing Link in Information Capture in Healthcare

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Clinical Document Architecture

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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

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Precision Reporting

Screen shot of report with halo

Building a reporting tool thatleverages standards for structuring data that

drives patient care drives outcomes for best

practices drives research for better

patient care and outcomes

Utilizing data at each point of care that culminates in rich information for the radiologist

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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

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Results Reporting Workflow

Dictation Report in conversational speaking

Edit Mode using local capture tool – can either type to correct or voice commands

Dictating the Procedure

When dictation is complete and EOL is

pushed

Report is returned ready

for edits

Data Center

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Results Reporting Workflow 2

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

After final sign the report is

processed in the NLP

engine for learning

Data Center

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Results Reporting Batch Mode

Dictating the Procedure When

dictation is

complete

Report goes to medical editor or signature

queue, Radiologist

moves on to next exam

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Understanding Diagnostic Reporting

ValuesMeans (Why?)

BenefitsDoes (How?)

AttributesIs (What?)

• Enables easy Radiologist adoption by adjusting to your workflow

• Easy to create reports using a variety of workflow models

• Multiple modes of workflow around dictation

• Focus time on findings and results

• Speedy process • Pre-configured document models

• Capture a competitive advantage over other RAD groups

• No re-dictate existing information

• Compliance alerts

• Increase revenue with more reports / day

• Easily identify items to be confirmed or corrected; Deliver reports to referring MDs faster

• Pre-populated patient information

Source: GE analysis

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Radiology & Imaging Specialists (RIS) physician-owned twenty board-certified radiologists many sub-specialized live since November 12, 2008

Radiology Imaging of Lakeland Florida

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“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

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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

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Conversational Documentation

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

EHR

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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

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How it Works

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The Health Story Project and Meaningful Clinical Documents

Kim Stavrinakis

Sr. Manager, Product Definition, GE Healthcare

The Missing Link in Information Capture in Healthcare

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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

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Health Story Document Types

Implementation GuidesCompleted History & Physical Consultation Operative Report DICOM Imaging Reports

Upcoming Discharge Summary w/IHE Billing and Reimbursement Requirements Progress Notes .PDF work with Adobe

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Project Members

Founders

Promoters

Original Benefactors:

Participants

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Conclusion

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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…

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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 - allowing clinical

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

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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

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Getting Involved

Join the Health Story Project www.healthstory.com

Participate in HL7 Structured Document work group

Participate in HL7 ballotsEncourage implementation

EHR vendor adoption provider preference transcription RFPs

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Membership Options and Benefits

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Q&A

Kim Stavrinakis

Sr. Manager, Product Definition, GE Healthcare

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Nick van Terheyden, MD, CMO, M*Modal

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