For Immediate Release
HIMSS10: CHAIR OF HL7, BOB DOLIN, MD, RECOMMENDS INCREMENTAL INTEROPERABILITY STRATEGY TO REACH MEANINGFUL USE
Suggests Adoption of Health Story Supported HL7 Specifications
March 10, 2010 -- In a presentation at HIMSS10, Bob Dolin, MD, chair of the Health Level Seven international healthcare data standards organization and principal of Semantically Yours, LLC, introduced a paradigm shift in thinking for many in the industry as he recommended an interoperability strategy that emphasizes use of clinical notes.
In a presentation at the Healthcare Information and Management Systems Society's 10th Annual Conference & Exhibition on March 4, 2010 entitled, "Get Ready EMRs and HIEs: Here Comes One Billion Clinical Documents," Dr. Dolin suggested that with standards, electronic clinical documents can easily integrate with Electronic Medical Record systems (EMRs) and Health Information Exchanges (HIEs) in a way that provides a glide path to interoperability.
"Over a billion clinical notes are created by physicians in the U.S. each year, comprising around 60 percent of clinical information - the majority of physician-attested information - and are used as the primary source of information for reimbursement and proof of service," he said. "Let's make sure that narrative reporting is included in the mix as we work toward discrete data capture to support national goals for meaningful use."
Recent proposed rulings from the Office of the National Coordinator for Health Information Technology in the U.S. require use of data standards, such as HL7 Continuity of Care Document (CCD) to support meaningful use of certified electronic health record technology. CCD specifies the encoding, structure and semantics of a patient summary clinical document for exchange in the U.S. A CCD is an amalgamation of specific data elements. According to Dr. Dolin, some of those data elements are captured discretely, such as medications via computerized order entry or lab results captured through a lab system interface, and some of the data elements are more readily captured in the context of a clinical document.
"There are many paths to get to the discrete data required in a CCD," he said. "The Health Story Project offers a path that builds upon a bedrock of well-established clinical documents in a way that allows clinicians to move toward EMR system adoption and meet early meaningful use targets while retaining their preferred methods of care."
The Health Story Project is an industry alliance of healthcare vendors, providers and associations that pooled resources over the previous two years in a rapid-development initiative to produce data standards for the flow of information between common types of healthcare documents and electronic medical records. Standards are based on HL7 Clinical Document Architecture (CDA), which is the base standard for the CCD. The intent of the project is to ensure that all of the clinical information required for good patient care, administration, reporting and research is readily available electronically, including information from narrative documents. To that end, the project has an associate charter agreement with HL7 and has produced five HL7 technical implementation guides for standard electronic documents, including the Consultation Note, History and Physical, Operative Note, Discharge Summary and Diagnostic Imaging Report. Work is currently underway within HL7 to produce standards for a Procedure Note specification using endoscopy report as an example and CDA for Unstructured Documents.
A number of Health Story members can produce electronic documents based on HL7 CDA. "We need to raise awareness of this option," said Dr. Dolin. "Many EMR system vendors do not know that companies in the transcription and clinical documentation industry can produce and offer electronic documents in the CDA format." He continued, "And, providers are not aware that they can ask for this approach to discrete data capture, which is minimally disruptive to clinician workflow."
Dr. Dolin's HIMSS10 presentation is available in the News section of the Health Story web site. He is a co-editor of HL7 CDA and co-author of the CCD standard.
About Health Story
The Health Story Project was founded a little over two years ago by Alschuler Associates, LLC, the Association for Healthcare Documentation Integrity (AHDI), the Medical Transcription Industry Association (MTIA), the American Health Information Management Association (AHIMA) and M*Modal. It is now a collaborative of twenty-five healthcare vendors, providers and associations. Health Story develops HL7 Clinical Document Architecture (CDA) Implementation Guides for common types of electronic healthcare documents, brings them through the HL7 ballot process and promotes their adoption within the industry. Over the previous two years, the initiative supported the development of five technical implementation guides for standard electronic documents, including the Consultation Note, History and Physical, Operative Note, Discharge Summary and Diagnostic Imaging Report. Work is currently underway within HL7 to produce standards for a Procedure Note using endoscopy report as an example and CDA for Unstructured Documents.
The Health Story Project’s five-year plan includes ramping up development of implementation guides for additional types of clinical documents and promoting their adoption within industry. Members are also working to influence policy decisions that would provide incentives for those who take the Health Story approach toward enhancing their EHR systems with information from narrated notes – providing patients with comprehensive electronic records that offer a complete health story.
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For more information contact:
Joy Kuhl
The Health Story Project
joy@optimalaccords.com
