Meaningful Use has entered the vernacular, and the political rhetoric is on the healthcare pathway. But, what does it mean to me? As Victor Frankl said, "One can choose one\'s attitude in any given set of circumstances," and while the picture of what Meaningful Use means to Clinical Documentation remains unclear you cannot just add water and go! To continue to be an integral part of the successful and safe delivery of healthcare the documentation industry must understand the impact of healthcare legislation and Meaningful Use criteria and incorporate this into the solutions and services they offer. This presentation will decode the requirements and translate these into individual and business actions to execute over the coming year to deliver on the vision of Meaningful Use for Clinical Documentation.

1. Health Story Project:Meaningful UseDay of Reckoning: Exchange Basic Records and Meet Early Requirements Kim Stavrinaki s CDIA Presentation Thursday, April 14, 11:00 am-12:00 pm Nick van Terheyden, MD Chief Medical Information Officer - CLU, Nuance Communications Executive Committee, Healthstory Project Board of Directors, CDIA

2. Session Overview Meaningful Use Current Legislation and Requirements The Current Healthcare Challenges Health Story Project Solution Where to Start Q&A

3. What is Meaningful Use? “Meaningful use, in the long-term, is when EHRs are used by health care providers to improve patient care, safety and quality.” “HIT is the means, but not the end. Getting an EHR up and running in health care is not the main objective behind the incentives provided by the federal government under ARRA. Improving Health is. Promoting health care reform is. David Blumenthal, MD National Coordinator for HIT

4. Meaningful Use EHR Goals Improve quality, safety, efficiency, and reduce health disparities Engage patients and families Improve care coordination Improve population and public health Ensure adequate privacy and security protections for personal health information Largely aimed at driving healthcare organizations to collect and report on quality and safety metrics

5. Meaningful Use: Core Set Vital signs – structured data (>50%) Problem List (1 entry for >80%) Active Medication List (1 entry for >80%) Smoking status (>50%) Drug/Drug and Drug/Allergy Checking e-Prescribing (>40%) CPOE for medication (1 medication >30%) Medication Allergy (1 entry >80%) Patient Demographics (>50%) Electronic Exchange (1 test exchange) One clinical decision support rule Implement privacy and security Report Clinical quality Measures through attestation in 2011 Generate Electronic Summary (>50% within 3 days) Provide e-copy to patients (>50% within 3 days)

6. Meaningful Use – Menu Set Medication Reconciliation (>50% of transitions of care) Drug Formulary Checks (one internal or external formulary check) Incorporate Labs as Structured Data (>40%) Patients specific education (>10%) Generate Lists of Patients by Condition Summary of Care record (>50%) Electronic Immunization Reporting (1 test submission) Electronic syndrome surveillance (1 test submission) Record Advance Directives (Hosp >50%) Electronic submission of lab data (Hosp 1 test submission) Patient Reminders for Preventative/f/u care (EP >20%) Provide Patients with electronic access to Health Record (EP >105 within 4 days) Summary of MU Measures available fromhttp://mycourses.med.harvard.edu/ec_res/nt/26F568D6-E6F3-418A-96B9-497666DEF5C0/MUQuick.pdf

7. Paper is no longer fit for purpose Slide Courtesy of Dr Michael Bainbridge

8. Meaningful Use! Slide Courtesy of Nuance Communications

9. Challenge

10. Challenge–“Major” Medical Advances 1600 to 2000 Source: Harvard Medical School, 2001 Slide Courtesy of Dr Michael Bainbridge

11. Reading to Keep up – Information Overload Today's experienced clinician needs close to 2 million pieces of information to practice medicine Doctors subscribe to an average of seven journals representing over 2,500 new articles each year, making it literally impossible to keep up-to-date with the latest information about diagnosis, prognosis and therapy Comparison of the time required for reading (for general medicine, enough to examine 19 articles per day, 365 days per year ) with the time available (well under an hour per week by British medical consultants, even on self-reports ). Furthermore, the interpretation of patient data is difficult and complicated, mainly because the required expert knowledge in each of the many different medical fields is enormous and the information available for the individual patient is multi-disciplinary, imprecise and very often incomplete.

12. Challenge–Clinical Knowledge-Processing Burden “Current medical practice relies heavily on the unaided mind to recall a great amount of detailed knowledge – a process which, to the detriment of all stakeholders, has repeatedly been shown unreliable” Crane and Raymond The Permanente Journal Winter 2003 Volume 7 No.1 Kaiser Permanente Institute for Health Policy Knowledge processing requirement This gap injures patients Knowledge processing capacity Today Years ago Slide Courtesy of Dr Michael Bainbridge

13. Current Methods for Data Capture Direct data entry, physician Direct data entry, not physician Unstructured Data Systemgenerated or interfaced data Structured Data Dictation and Transcription Handwritten

14. The occurrence was one hour prior to arrival The course of pain is constant Location of pain: Left foot Location of bleeding: None Assessment: Broken Left Foot donut dizzy ran upstairs The occurrence was one hour prior to arrival The course of pain is constant Location of pain: Left foot Location of bleeding: None Assessment: Broken Left Foot The Challenge of Narrative vs. Discrete dataBeyond convenience, quality of care at risk Narrative Dictation Structured Entry The patient is a 74-year-old female who presents with a complaint of fall, she woke up this morning and had a donut for breakfast instead of her usual cheese bagel, while eating breakfast she heard the phone ringing in the upstairs bedroom. She ran upstairs to get it. She felt dizzy and fell down the stairs and broke her left foot. Example 1 The patient is a 74-year-old female who presents with a complaint of fall, she was playing soccer with her grandkids in the backyard and slipped and broke her left foot Example 2 Source: Nuance Survey with nearly 1,000 responses from physicians, Dec 2009 Slide Courtesy of Nuance Communications

15. EHR Repository Disease, DF-00000 Metabolic Disease, D6-00000 Clinical Applications Disorder of carbohydrate metabolism, D6-50000 Disorder of glucose metabolism, D6-50100 HIM Applications Diabetes Mellitus, DB-61000 SNOMED CT Type 1, DB-61010 Neonatal, DB75110 Carpenter Syndrome, DB-02324 Insulin dependant type IA, DB-61020 Meaningful Clinical Documents

17. Want to focus on patient care

18. Value rich patient narrative

19. Want improved productivity

20. Comfortable with dictationBetter care with accessible, up-to-date and codified patient info Structured data for appropriate coding, billing and compliance Reduced cost Faster TAT

22. Want to focus on patient care

23. Value rich patient narrative

24. Want improved productivity

25. Comfortable with dictationBetter care with accessible, up-to-date and codified patient info Structured data for appropriate coding, billing and compliance Reduced cost Faster TAT We can get here today

26. We Can Get Here Today MRN: 00000 DOS: 11/11/2001 CHIEF COMPLAINT:Fatigue SUBJECTIVE:Patient is a 25 year old woman complaining of feeling fatigued. Occasional dizziness. Sleeping difficulties and morning headaches. OBJECTIVE:Recent bout with the flu PHYSICAL EXAMINATION:Vital signs are normal with a blood pressure of 120/80, pulse 62, temperature 98.6, weight 108 pounds. ASSESSMENT:Although flu symptoms were in remission, patient has not fully recovered. PROBLEM:Flu PLAN:Place patient on Biaxin for the next two weeks. The patient will call us if there is no improvement, any worsened or new symptoms.

27. Meaningful Use “If you can not measure it, you can not improve it.” Lord Kelvin (1824-1907)

29. Promote the adoption of these standardsNon profit, industry alliance Founded 2007 Associate Charter Agreement: HL7 Sponsor HL7 standards for flow of information between narrative and EMR systems Member organizations provide direction

30. Health Story Project Members Founding Members Promoters Contributors Aprima Software - Scribe Healthcare Technologies All Type - Arrendale Associates - BayScribe - Chase Transcriptions DictateIT, Ltd - Dispersive Medical - Documentation Services Group eMTS - Healthline, Inc. - MedEDocs - MD-IT New England Medical Transcription - Phoenix Medcom Sten-Tel, Inc. - Webmedx Participants

32. Multiple standards and/or messages for each EHR function may be too difficult to implementCDA is “just right” HL7 Clinical Document Architecture

33. CDA is the basis for ... HL7 Consult Note HL7 Diagnostic Imaging Report HL7 Discharge Summary HL7 History and Physical HL7 Operative Note HL7 Procedure Note HL7 Unstructured Documents HL7 Progress Notes HL7 Continuity of Care Document HL7 Healthcare-associated Infections, Public Health Case Reports HL7 Personal Health Monitoring HL7 Plan-2-Plan Personal Health Record HL7 Quality Reporting Document HL7 Minimum Data Set and more … HITSP/C84 Consult and History & Physical Note Document HITSP/C32 - Summary Documents Using HL7 CCD HITSP/C38 - Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS) HITSP/C48 Encounter Document constructs HITSP/C62 Scanned document HITSP/C28 Emergency Care Summary HITSP/C78 Immunization Document HITSP/C74 PHRM Health Story supported guides in blue

34. Consolidation Project Underway! HL7 Consult Note HL7 Diagnostic Imaging Report HL7 Discharge Summary HL7 History and Physical HL7 Operative Note HL7 Procedure Note HL7 Unstructured Documents HL7 Progress Notes HL7Continuity of Care Document HITSP/C84 Consult and History & Physical Note Document HITSP/C32 - Summary Documents Using HL7 CCD HITSP/C38 - Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS) HITSP/C48 Encounter Document constructs HITSP/C62 Scanned document One master implementation guide Health Story supported guides in blue

37. Actionable Next Steps Providers: Is your documentation vendor set up to deliver CDA documents? If no, when? Is your EHR vendor set up to receive CDA documents? If no, when? Vendors: Check out the requirements here: www.healthstory.com

38. Actionable Next Steps Join the Health Story Project Project is interested in tracking and highlighting implementations More information: visit the Health Story websitewww.healthstory.com

40. Narrative remains the Foundation of the Clinical Record and Incorporating this into the Future is Essential

41. Capturing Meaningful clinical documentation is the foundation

42. Bridging from Narrative to Structured Clinically Actionable Data is Possible today with Healthstory

43. Improving the Overall Quality and Efficiency of Documentation by Offering Clinicians a Range of Tools and Services to Capture and Generate Clinical Information

45. Health Story Project:Meaningful UseDay of Reckoning: Exchange Basic Records and Meet Early Requirements Kim Stavrinaki s CDIA Presentation Thursday, April 14, 11:00 am-12:00 pm Nick van Terheyden, MD Chief Medical Information Officer - CLU, Nuance Communications Executive Committee, Healthstory Project Board of Directors, CDIA