The Health Story Project

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The Health Story Project
Emmy Weber VP, Product Management MedQuist
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Vision

• Comprehensive electronic clinical records that
  tell a patients 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.

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Balancing Your Needs in the EHR
Your Physicians Practical Need for a Fast and
Easy Method for Creating Clinical Documentation
Your Enterprise Need for Structured and
Coded Information Capture
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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

Slide courtesy of MModal
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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

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

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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

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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

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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 interoperability between clinical data
  that will
• solve the fundamental challenges with EMRs -
  allowing clinical decision support, alerts, 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 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

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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

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Wednesday Session

• Clinical Narrative Structured Data in the EHR
• Venus and Mars Live in Harmony with CDA4CDT
• Grapevine Ballroom D
• 1115 1215 p.m.
• Nick van Terheyden, MD
• Board of Directors, MTIA
• Chief Medical Officer, MModal

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www.healthstory.com

• For More Information