1. The Radiologist’s Speech –
Realizing the Full Potential of the
Diagnostic Report
Nick van Terheyden, MD
Board of Directors CDIA
Chief Medical Information Officer, Nuance
December 1, 2011
w w w . h e a l t h s t o r y. c o m

2. Health Story Project
 Non profit, industry alliance
 Founded 2007
 Associate Charter
Agreement: HL7
 Sponsor HL7 standards for flow
of information between
narrative and EMR systems (8!)
 Member organizations provide
direction
 www.healthstory.com
w w w . h e a l t h s t o r y. c o m

3. HEALTHCARE SOLUTIONS
Slide CONFIDENTIAL | © 2002-2011
3
courtesy of Nuance Nuance Communications, Inc. All rights reserved.

4. Health Story Project Members
Organization Affiliates
Promoters
Contributors Canon U.S.A. - Scribe Healthcare Technologies
All Type - Apixio - Arrendale Associates - BayScribe - Chase Transcriptions
ChartLogic - DictateIT, Ltd - Dispersive Medical - Documentation Services Group
Participants eMTS - Healthline, Inc. - InfraWare - InterFix - MedEDocs - MD-IT
New England Medical Transcription - Phoenix Medcom
Physicians Medical Group of Santa Cruz County - Sten-Tel, Inc. - Webmedx
w w w . h e a l t h s t o r y. c o m

5. Health Story Telling
Clinical Document Ecosystem Meaningful Use
People H HIE
Dictating Transcript-
Clerk MD ionist Abstractor e MRM
a
Platforms EMR
l
Integration Platform t Billing
Applications h Analytics
Voice Enrich Standard
S Quality
Imaging Voice
capture
to text Format t
o
Desktop Telephone Transcription NLP CDA
appliances PDR Speech DRT ICD, CPT… r
recognition
Scan-to- Smart CAC HL7 V2 y
CDA phone
OCR
w w w . h e a l t h s t o r y. c o m

6. Guide Consolidation: US Dept Of Health and
Human Services Office of the National
1. HL7 Consult Note Coordinator
2. HL7 Diagnostic Imaging Report
3. HL7 Discharge Summary
4. HL7 History and Physical
5. HL7 Operative Note
6. HL7 Procedure Note
7. HL7 Unstructured Documents One master
8. HL7 Progress Notes
implementation
9. HL7 Continuity of Care Document
10. HITSP/C84 Consult and History & Physical guide
Note Document
11. HITSP/C32 - Summary Documents Using
HL7 CCD
12. HITSP/C38 - Patient Level Quality Data
Document Using IHE
Medical Summary (XDS-MS)
13. HITSP/C48 Encounter Document constructs
14. HITSP/C62 Scanned document
Health Story supported guides in blue
w w w . h e a l t h s t o r y. c o m

7. HL7 Clinical Document Architecture
Health Story Specs are Based on HL7 CDA
 Normative HL7 standard since 2000
 Widely implemented
 Provides a gentle on-ramp to information
exchange
 Provides mechanism for inserting evidence-
based medicine directly into the process of
care
 Top down strategy lets you implement once
and reuse many times for new scenarios
w w w . h e a l t h s t o r y. c o m

8. Why CDA?
 Radiology results are a key tool in providing
diagnosis
 Results need to be:
 concise
 consistent
 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
w w w . h e a l t h s t o r y. c o m

9. Meaningful Use Stage 2
ONC Standards and Interoperability
Framework has indicated intent to
recommend CDA and Health Story
specifications in meaningful use Stage 2
requirements for clinical documentation
w w w . h e a l t h s t o r y. c o m

10. Meaningful Use ≈ Data Reuse
patient care quality reporting
clinical
decision outcomes
support analysis
billing/claims research
adjudication
w w w . h e a l t h s t o r y. c o m

11. Health Story Approach
Benefit Value
Retains patient story Maintains primary role of radiology reports to clearly
describe and communicate what is going on with
patient.
Preserves physician Makes efficient use of physician time by enabling
time for clinical care choice of documentation methods and fosters EMR
acceptance
Supports meaningful Interoperability: implements HL7 CDA document
use standards for electronic exchange of clinical
information
Enables data reuse Structured narrative enables better outcomes
reporting, data mining, and decision support
Collaborative approach Developed by broad array of providers, vendors and IT
organizations; Balloted process through HL7 supports
harmonization
Better documentation Supports better coding, DRG optimization
= better reimbursement
Slide, with edits, courtesy of MD-IT
w w w . h e a l t h s t o r y. c o m

12. Health Story Use Cases
Health Story Use Case, Transitions of Care
 Demonstration project at HIMSS 12
 Using Standard published from HL7/IHE Health Story
Consolidation Project in conjunction with the ONC
Standards & Interoperability Framework.
 ~85% of information needed crosses enterprise
boundaries
 Demonstration of complete information flow from
 Unstructured documents
Scanned documents
Consult & discharge summaries
Enriched with NLP and CAC
w w w . h e a l t h s t o r y. c o m

13. What Healthstory Offers You
 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 reuse of
information
 Provides on-ramp to EMR system adoption
 pre-populate EMR with structured documents
 integrate legacy documents
w w w . h e a l t h s t o r y. c o m

14. Our Advocacy Requests
 Actions Requested:
 Require certified systems to accept interfaced data
from dictation/transcription process per available
standards
 Modify the definition of meaningful use to recognize
use of certified systems with the above capabilities
 Assist in spreading the word about this avenue for
getting the full story into the EHR that allows
radiologists to continue dictating and provides patients
with comprehensive electronic records
w w w . h e a l t h s t o r y. c o m

15. Actionable Next Steps
1. Providers:
1. Is your documentation vendor set
up to deliver CDA documents? If
no, when?
2. Is your EHR vendor set up to
receive CDA documents? If no,
when?
2. Vendors: Check out the
requirements here:
www.healthstory.com
w w w . h e a l t h s t o r y. c o m

16. The Radiologist’s Speech –
Realizing the Full Potential of the
Diagnostic Report
Nick van Terheyden, MD
Board of Directors CDIA
Chief Medical Information Officer, Nuance
December 1, 2011
w w w . h e a l t h s t o r y. c o m