The Health Story Project

1. The Health Story Project Emmy Weber VP, Product Management MedQuist

2. Vision • Comprehensive electronic clinical records that tell a patient’s complete health story. • Health Story members share the vision that all of the clinical information required for good patient care, administration, reporting and research will be readily available electronically, including information from narrative documents.

3. Balancing Your Needs in the EHR • Your Physician’s Practical • Need for a Fast and Easy • Method for Creating • Clinical Documentation Your Enterprise Need for Structured and Coded Information Capture

4. 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 Slide courtesy of M*Modal

5. Data Standards Health Story Document Types Available Guides History & Physical Consultation Operative Report DICOM Imaging Reports Discharge Summary Upcoming Procedure Note (Endoscopy Report) Billing and Reimbursement Requirements Progress Notes .PDF work with Adobe

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

7. Adoption • Medical Transcription Companies support creation and delivery of standards-based meaningful documents • EHR Vendors Systems can receive, display, transform and parse these standards-based meaningful documents • Health Providers require support for import and export of standards-based meaningful clinical documents • Health Story helps by developing and publishing the technical implementation guides to support adoption

8. Advocacy for Support for Narrative Dictation is the documentation method of choice for 85% of physician providers Standardization of dictated notes is an achievable step for providers; Standards are available today The current EHR systems certification process does not include requirements for integration with dictated notes per available standards The current draft definition of meaningful use focuses on recording clinical documentation in the EHR through data entry

9. Our Advocacy Requests Actions Requested: Require certified EHR systems to accept interfaced data from dictation/transcription process per available standards Modify the definition of meaningful use to recognize use of certified EHR systems with the above capabilities Assist in spreading the word about this avenue for getting important information into the EHR that allows physicians to continue dictating and that provides patients with comprehensive electronic records

10. 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 interoperability between clinical data that will • solve the fundamental challenges with EMRs - allowingclinical decision support, alerts, data mining… • enable interoperability, reporting, patient safety initiatives, PQRI (pay for performance), PSI (patient safety indicators) and improve billing data capture

11. Impact • 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 re-use of information

12. Getting Involved Share the Good News: Be an “Ambassador” We need a grass roots effort to help spread the word Educate your employers, clients, 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

13. Wednesday Session Clinical Narrative & Structured Data in the EHR: Venus and Mars Live in Harmony with CDA4CDT Grapevine Ballroom D 11:15 – 12:15 p.m. Nick van Terheyden, MD Board of Directors, MTIA Chief Medical Officer, M*Modal

14. www.healthstory.com For More Information