Presentation to AHRA Annual conference in Las Vegas 2009

1. Speech UnderstandingUnlocking the Clinical Information in Health Documents Nick van Terheyden, MD Chief Medical Officer, M*Modal

2. Background The Current Situation

3. 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

4. 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.

5. 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.

6. “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

7. 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.

8. 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

9. The Current Situation Direct data entry, physician Direct data entry, not physician Structured Data System generated or interfaced data Unstructured Data Dictation and Transcription Dictation and Transcription Handwritten 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

10. Unlocking Clinical Knowledge

11. Value of EHRs over Dictation EHRs save you time but it takes much longer to enter the information You have more discrete data over 700 data elements but you only use about 3% of these data elements E&M coding improves in theory, but EHR vendors have no 3rd party validation studies EHRs provide orders and alerts but you can have the same with Health Story enabled EHRs Data and Chart courtesy Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group

12. 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

13. Cost Comparisons 1 MGMA Dashboard, $340,000 collections for IM professional charges 2 Outsourced transcription at 16 cents per 65-character line Source: Healthcare Ledger – March 2009: Medical Transcription Relevance in the EHR Age – What is DRThttp://www.healthcareledger.com/march2009.htmlhttp://www.healthcareledger.com/march2009/Medical%20Transcription%20Relevance%20in%20the%20EHR%20Age%20_%20What%20is%20DRT%20HCL%20Mar%202009.pdf

14. Speech Understanding

15. Dictation and Speech Recognition Speech Recognition Background to technology and history 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 habits

16. “Best of Both Worlds” Approach Creation and validation of meaningful clinical documents that are accurate, complete, accessible and shareable… …by leveraging existing workflow …to populate the electronic health record, …without requiring change for the physician. Significant productivity gains in generating high quality medical documentation from dictation - across all work types and medical specialties.

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

18. 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

19. Speech Understanding in Action Document Model incl.Concepts,Extractors Dictation Recording Editing &ImplicitValidation Publishing &Querying SpeechUnderstanding Clinical Context Feedback: corrected structured and encoded draft documents and medical facts

20. Technical View Document Model incl.Meds, Allergies… SpeechUnderstanding

21. One Voice – Many Outputs™

22. How it works

23. The Healthstory Project and CDA

24. 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

25. Health Story Document Types Implementation Guides Completed History & Physical Consultation Operative Report DICOM Imaging Reports Upcoming Discharge Summary w/IHE Billing and Reimbursement Requirements Progress Notes .PDF work with Adobe

26. Conclusions

27. 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…

28. 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 - allowingclinical 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

29. 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

30. Getting Involved Join the Health Story Project www.healthstory.com Participate in HL7 Structured Document work group Participate in HL7 ballots Encourage implementation EHR vendor adoption provider preference transcription RFPs

31. Q&A See the solution at work at: GE Booth 823 M*Modal: 216/7

32. Nick van Terheyden, MD, CMO, M*Modal Twitter http://twitter.com/drnic1 Technorati http://technorati.com/people/technorati/nvt1 RSSSpeech Understanding http://speechunderstanding.blogspot.com/feeds/posts/default MyBlogLog http://www.mybloglog.com/buzz/members/nvt LinkedIn http://www.linkedin.com/in/nickvt Plaxo http://nvt.myplaxo.com FaceBook http://profile.to/drnick Digg http://digg.com/users/nvt1 Delicious http://delicious.com/nvt1 E-Mail nvt@mmodal.com GrandCentral (301) 355-0877 Where You Can Find Me

33. M*Modal Speech Understanding: Nick van Terheyden, MDChief Medical OfficerM*Modal