Transcript Slides - Health IT Safety Center Roadmap

RTI International
Health IT Safety Webinar Series
EHR Documentation and Health IT Safety
July 30, 2015
1:00-2:30 pm EDT
RTI International is a trade name of Research Triangle Institute.
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www.rti.org
RTI International
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RTI International
Health IT Safety Webinar Series
This series of 10 webinars focused on health IT and patient
safety issues will occur monthly through September 2015.
These webinars are funded by the Office of the National
Coordinator for Health Information Technology (ONC) and are
being conducted by RTI International, a non-profit research
organization, as part of a year-long project to develop a road
map for a Health IT Safety Center for ONC (contract
HHSP23320095651WC).
Additional information is available at:
www.healthitsafety.org
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The views of the speakers are their own and do not represent the views of RTI or the ONC.
RTI International
Jonathan S. Wald, MD, MPH, FACMI
Today’s Presentations
Gordon D. Schiff, MD, Associate Director, Center for Patient
Safety Research and Practice, Brigham and Women’s Hospital
Adam Wright, PhD, Senior Scientist in the Division of General
Medicine at Brigham and Women’s Hospital, Boston, MA
Anna Orlova, PhD, Senior Director for Standards at the
American Health Information Management Association
(Moderator) Mark Graber, MD, Senior Fellow at RTI
International
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RTI International
Today’s Moderator
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Mark Graber, MD, is a Senior Fellow at RTI International and an
internationally recognized authority on diagnostic error in medicine.
He founded the Diagnostic Error in Medicine conference series, the
Society to Improve Diagnosis in Medicine, and the journal Diagnosis
and has published widely.
RTI International
Today’s Presenter
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
Brief Biography:
Dr. Schiff is the Associate Director, Center for Patient Safety
Research and Practice, Brigham and Women’s Hospital, Associate
Professor Harvard Medical School and Safety Director of the
Harvard Center for Primary Care Academic Improvement
Collaborative. He has recently completed a series of studies
related to electronic prescribing errors and safety sponsored by the
FDA and National Patient Safety Foundation. He is a practicing
general internist and worked for more than three decade at
Chicago’s Cook County Hospital. His specific areas of expertise
include diagnostic errors and clinical documentation, medication
prescribing safety and appropriateness, and malpractice issues in
primary care.

Presentation:
“Clinical documentation and Patient Safety- The next frontier for
better diagnosis and treatment”
Clinical documentation and Patient Safety
The next frontier for better diagnosis & treatment
ONC Health IT Safety Webinar Series
7/30/2015
Gordon Schiff MD
Associate Director Center for Patient Safety Research and Practice
Brigham and Women's Hospital Div. General Medicine
Safety Director – Harvard Center for Primary Care
Academic Improvement Collaborative
Associate Professor of Medicine Harvard Medical School
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Outline:
Chief Complaints, Assessment, Plan
• Personal background, perspectives
– New Epic user; prior Brigham LMR, Cook County Cerner
– HIT Safety Perspective
• Recent CPOE safety studies: can we transfer lessons
– Personal clinical note conceptual thoughts
• Issues & Ideas: Beyond usual issues to new paradigm
– Beyond Copy/paste, note bloat, distracts encounter, ↑work
– Failure to realize potential for quality, efficiency, safety,
caring, communication, care redesign.
• Supporting diagnosis safety
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Clinical Documentation
•1991 Landmark IOM Report
•HITECH adoption tipping point
•Central role in care; occupies
much of MDs’, others’ time
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Widespread frustrations about notes
• “I just want to finish my note and move on to the next
patient.”
• “I want to come home at night and play with my kids and
go to sleep (or maybe read some medicine), but instead I
have to do my charting.”
• “I am embarrassed to have others read my notes they are
so bad, but I have to keep cutting more and more
corners just to get them done.”
• “ Meaningful use = meaningless notes
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• New, struggling EMR user
• Just matter of time to:
– Get trained and familiar
– Enter backlog of meds, prior problems
– Learn various tricks, shortcuts
– Establish new workflows
– Overcome “Trough of Disillusionment”
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Adapting to the Suboptimal
Frederick Douglass
Abolitionist, ex slave
When told in late 1850’s by a
recent visitor to the South that
the slaves appeared to be
happy and well adjusted,
he is reported to have replied:
“Then it’s even worse than
I thought.”
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Malpractice Risk in Ambulatory Care
Only Small % related to Documentation??
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Electronic Clinical DocumentationFailing in Myriad of Ways
• Failing in ways both apparent and less visible
• Most serious/sad is demoralization of primary care, other
front line clinicians
–
–
–
–
Added time for charting; subtracted time for caring
Degrading pride in workmanship; my notes are a mess
Clutter; Loss trust in quality and accuracy, ease to find info
Scribes: solution or workaround?
• Need to move away from paper record conceptualization,
toward integrated care process redesign/workflow tool
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• Our findings suggest that current CPD system
design and usage is not optimally meeting the
needs of users and appears to be based on an
outdated paradigm. While there are clear
benefits to CPD, the degree of angst and
dissatisfaction with it speaks to a fundamental
need for changes that probably reflect the
need for a new paradigm governing how such
systems should be built, implemented and
used.
Embi et al JAMIA 2013
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Clinical Documentation- New Paradigm
10 Functions Redesigned Documentation Needs to Fulfill
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Reflect, record, thinking
Documentation should be interactive
Info can input one way, display another
Should be produced jointly and shared w/ pt
Aid to synthesize, organize, history & course
Identify, understand changes over time
Support cognition, ↓memory burden
Prevents overlooking problems, premature closure of dx
Help overcome (rather than ↑) fragmentation
Redesign for reliable communication, follow-up
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Unmet Requirements/Wish List
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Prioritized/organized/integrated problem lists
Reliable, continuously updated family hx; genetics
Incorporation of patient sx questionnaires into history
Enriched, omnipresent social hx
Drive proactive, reliable plan and follow-up
Visual affordances for cognitive support
Rapid access to info while writing note
Support my decision-making
Real integration of voice recognition
Take ½ time currently does
– Done by end of patient if not clinic session
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Care Workflow NeedsMostly Poorly Supported
• “Interval history”
– Review, record (prior to visit; w/ pt)
• Open-ended invitation/solicitation of how doing
– Eye contact; fingers (mostly) off keyboard
• “Review of problems”
– Prior description (pt/yours), status, assessment
• Not lose track of problems, issues, results
• Social history at forefront
– Visually, patient-centered interaction, updating kids ages
• Assessment
– Bury on bottom? ; need for narrative “voiced” in
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COPY & PASTE – Disease or Symptom
I have outlawed cutting and pasting. It is illegal and
immoral and bad for both patient care and
student/resident education. If I find a medical
student in my ward team cutting and pasting
anything in a note, they flunk the rotation
• William Tierney President and CEO, Regenstrief
Institute, Chief, Internal Medicine Service, Eskenazi
Health. Indianapolis IN
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Is Copy-Paste Billing Fraud?
• In our view the federal government should not
penalize physicians and hospitals for
responsible use of tools in the electronic
helath record that faciliate efficiency and the
appropriate standardizationof the
documentation of care
-Sheehey et al JAMA Intern Med 2014
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COPY & PASTE – Disease vs. Symptom?
• Is Copy and Paste the cause of bloated, untrustworthy
(even at times dishonest) notes?
• Or is it a symptom of more fundamental
design flaws?
TWO CHEERS for COPY/PASTE
• Copying forward existing history is not unreasonable
starting point for today's note
– Leg still amputated (tho David Bates case of how DKA turned
into BKA), daughter still on drugs, still multiple warty lesions
• Efficient way to avoid manual typing big blocks of text
• How to minimize negatives, maximize +’s
• A creative workaround, but bypasses real redesign needs
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Scribes-Wonderful or Workaround?
• Assist in navigating EMR
• Enter data to allow more undivided attention
to patient
• Help create more complete and timely notes
• Track down needed/missing information
requested by provider
• Shown they can be cost effective and
beneficial for restoring joy to practicing
AHIMA . "Using Medical Scribes in a Physician Practice."
Journal of AHIMA 83, no.11 (November 2012): 64-69 [
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Scribes-Wonderful or Workaround?
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Navigating EMR
Easier data entry
Less distraction from pt
More complete timely
notes
• Track down missing info
• Restoring joy to work
• Easing burden or
working around
poor design of EMR?
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• Realizing the potential of electronic
clinical documentation to prevent,
minimize, and mitigate diagnostic errors
• Loss of safety for failure to fully leverage these
potentials in these 15 areas.
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Role for Electronic
Documentation
Goals and Features of Redesigned Systems
Providing access to
information
Ensure ease, speed, and selectivity of information searches; aid
cognition through aggregation, trending, contextual relevance,
and minimizing of superfluous data.
Recording and sharing
assessments
Provide a space for recording thoughtful, succinct assessments,
differential diagnoses, contingencies, and unanswered questions;
facilitate sharing and review of assessments by both patient and
other clinicians.
Maintaining dynamic patient
history
Carry forward information for recall, avoiding repetitive pt
querying and recording while minimizing erroneous copying and
pasting
Maintaining problem lists
Ensure that problem lists are integrated into workflow to allow
for continuous updating.
Tracking medications
Record medications patient is actually taking, patient responses
to medications, and adverse effects to avert misdiagnoses and
ensure timely recognition of medication problems.
Tracking tests
Integrate management of diagnostic test results into note
workflow to facilitate review, assessment, and responsive action
as well as documentation of these steps.
Schiff & Bates NEJM 2010 29
Role for Electronic
Documentation
Goals and Features of Redesigned Systems
Ensuring coordination and
continuity
Aggregate and integrate data from all care episodes and
fragmented encounters to permit thoughtful synthesis.
Enabling follow-up
Facilitate patient education about potential red-flag symptoms;
track follow-up.
Providing feedback
Automatically provide feedback to clinicians upstream, facilitating
learning from outcomes of diagnostic decisions.
Providing prompts
Provide checklists to minimize reliance on memory and directed
questioning to aid in diagnostic thoroughness and problem
solving.
Providing placeholder for
resumption of work
Delineate clearly in the record where clinician should resume
work after interruption, preventing lapses in data collection and
thought process.
Schiff & Bates NEJM 2010
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Role for Electronic
Documentation
Goals and Features of Redesigned Systems
Calculating Bayesian
probabilities
Embed calculator into notes to reduce errors and minimize biases
in subjective estimation of diagnostic probabilities.
Providing access to
information sources
Provide instant access to knowledge resources through contextspecific “info buttons” triggered by keywords in notes that link
user to relevant textbooks and guidelines.
Offering second opinion or
consultation
Integrate immediate online or telephone access to consultants to
answer questions related to referral triage, testing strategies, or
definitive diagnostic assessments.
Increasing efficiency
More thoughtful design, workflow integration, easing and
distribution of documentation burden could speed up charting,
freeing time for communication and cognition.
Schiff & Bates NEJM 2010
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Clinical Documentation
CYA
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Canvass for
Your
Assessment
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-Differential Diagnosis
-Weighing Likelihoods
-Etiology
-Urgency
-Degree of
certainty
Canvass for
Your
Assessment
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What is an Assessment -5 D’s
• Defining the problem(s)-describe, justify, group
• Diagnosis –DD, etiology, cause of exacerbation
• Doing – how is patient doing?: time course,
response to rx, interpretation of response
• Do -- what needs to be done, and why
• Don’t Know – what are uncertainties, need to f/up
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Summary: Practical Next Steps
Building Better Clinical Documentation
• Better integration of problems/list into note workflow
• Realizing role for voice recognition
• Real time support
– High level just-in time-support
– Coupled with advanced learning from users
• Pro-active error, problem reporting
– ↑ Vendor transparency, accountability
• Better learning from observations, testing
– Learn from documentation practices
– Measure “S:S ratio” (sailing vs. stuck) (also for Help Desk)
• Re-conception, design, evaluation, metrics to support
needed redesign functions.
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• End of Dr. Schiff’s presentation
(4 additional slides, for reference, follow)
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Note Quality Attributes
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Clear
Complete
Concise
Current
Organized
Prioritized
Burke et al JAMIA 2014
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High Sensitivity
High Specificity
Cogency
Actionable
AMIA Future of High Quality
Clinical Information 2011
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What belongs in notes?
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Meds?
Allergies?
Labs?
Next appointment?
Preventive medicine data/schedule
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Who Does What, and How they Like it
• Home grown EMR- 1088 physicians
• 85% used a single method to document majority of visits
• PCPs predominantly used templates (60%)
vs. specialists (34%)
• 38% of specialists predominantly dictated.
• Survey: 383 responders most satisfied w/notes module,
regardless documentation method.
Pollard et al Int Jl Med Inform 2013
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Note Quality & Chronic Disease Quality Scores
• Evaluated 239 DM, CAD notes written by 111 physicians
– 110 notes written by PCPs, 52 cardiologists, 77 endocrinologists.
•
•
•
•
Reason for visit absent in 10% of notes
Medication list not present in note in 19.7%
Timing for follow-up absent in 18.0%
Laboratory quality indicators were more often found in other
EHR sections than in physician note.
• Clinical quality scores for DM & CAD showed no significant
association with subjective note quality
• Overall note quality did not correlate w/clinical quality scores,
suggesting writing high-quality notes and meeting quality
measures are not mutually reinforcing activities
Edwards et al BMJ QSHC 2014
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RTI International
Today’s Presenter
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Brief Biography:
Dr. Wright is an Associate Professor of Medicine at Harvard
Medical School and a researcher in biomedical informatics at
Harvard Medical School. Dr. Wright studies clinical decision
support and data mining in electronic health records. His specific
areas of research include problem lists, using EHRs to reduce
medical errors and malpractice and learning from large clinical
databases.
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Presentation:
“Making more accurate problem lists—challenges and
recommendations.”
Making More Accurate Problem Lists:
Challenges and Recommendations
Adam Wright, Ph.D.
©2015
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The Problem List
©2015
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©2015
The Problem List
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An accurate, complete problem list is important
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Used for decision support
Used in medical decision making
Some evidence that patients with complete problem lists have
better outcomes
A communication tool for providers
©2015
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The Problem List
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A good problem list is challenging
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Who owns the problem list?
What is a problem?
What is the role for the patient?
Problem lists are often inaccurate or incomplete
©2015
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Problem List Completeness
Breast Cancer
Sickle Cell
Hemophilia
Glaucoma
Stroke
Diabetes
Hyperthyroidism
CAD
Hypothyroidism
Hypertension
Myasthenia Gravis
Osteoporosis/Osteopenia
ADHD
Asthma/COPD
Rheumatoid Arthritis
CHF
Renal
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
©2015
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The Problem List and P4P / MU
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Total at risk for BWPO is $735,000
BCBS: 75% complete for DM, HTN and CVD (combined)
HPHC: 70% complete for DM, HTN and CVD (must
clear 70% for each problem)
80% problem list completeness is also a requirement for
meaningful use
©2015
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Problem List Completeness
Breast Cancer
Sickle Cell
Hemophilia
Glaucoma
Stroke
Diabetes
Hyperthyroidism
CAD
Hypothyroidism
Hypertension
Myasthenia Gravis
Osteoporosis/Osteopenia
ADHD
Asthma/COPD
Rheumatoid Arthritis
CHF
Renal
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
©2015
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Association Rule Mining for Problems
©2015
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Association Rule Mining: Transactions
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Pt 1: {lisinopril, multivitamin, hypertension}

Pt 2: {insulin, metformin, lisinopril, diabetes,
hypertension}
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Pt 3: {insulin, metformin, diabetes}

Pt 4: {metformin, PCOS}
©2015
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Association Rule Mining: Transactions
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Pt 1: {lisinopril, multivitamin, hypertension}

Pt 2: {insulin, metformin, lisinopril, diabetes,
hypertension}
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Pt 3: {insulin, metformin, diabetes}

Pt 4: {metformin, PCOS}
©2015
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Association Rule Mining: Transactions
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Pt 1: {lisinopril, multivitamin, hypertension}
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Pt 2: {insulin, metformin, lisinopril, diabetes,
hypertension}
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Pt 3: {insulin, metformin, diabetes}

Pt 4: {metformin, PCOS}
©2015
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Association Rule Mining: Transactions
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Pt 1: {lisinopril, multivitamin, hypertension}

Pt 2: {insulin, metformin, lisinopril, diabetes,
hypertension}
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Pt 3: {insulin, metformin, diabetes}

Pt 4: {metformin, PCOS}
©2015
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Association Rule Mining: Transactions
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Pt 1: {lisinopril, multivitamin, hypertension}

Pt 2: {insulin, metformin, lisinopril, diabetes,
hypertension}
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Pt 3: {insulin, metformin, diabetes}

Pt 4: {metformin, PCOS}
©2015
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Applying Association Rule Mining
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Dataset
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100,000 BWH patients
442,658 medication orders (2,128 unique medications)
23,003,290 lab results (21,964 unique tests, 1,251
LOINC)
272,749 coded problems, 1,756 unique coded problems
Analysis
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Carried out association rule mining using custom software
Characterized rules by support, confidence, chi square,
interest, conviction
Compared results to LexiComp (for medications) and
Mosby’s lab manual (for labs)
©2015
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Building a Knowledge Base
©2015
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The Process
1.
2.
3.
4.
5.
6.
Selection of problems of interest.
Automated identification of problem associations with
other structured data.
Development of preliminary rules.
Characterization of preliminary rules and alternatives.
Selection of a final rule.
Validation of the final rule.
©2015
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Problems of Interest
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ADHD
Asthma/COPD*
Breast Cancer
CAD
CHF
Diabetes
Glaucoma
Hemophilia/Congenital Factor XI deficiency/von Willebrand disorder*
Hypertension
Hyperthyroidism
Hypothyroidism
Myasthenia Gravis
Osteoporosis/Osteopenia*
Renal Insufficiency/Renal Failure*
Rheumatoid Arthritis
Sickle Cell
Stroke
©2015
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Candidate Diabetes Rules
100.00%
95.00%
90.00%
85.00%
Sensitivity
Specificity
80.00%
PPV
75.00%
NPV
70.00%
65.00%
60.00%
Max A1c>=9 OR Max A1c>=9 OR Max A1c>=9 OR Max A1c>=7 OR Max A1c>=5 OR
at least 3
at least 3
at least 3
billing>=2 OR
billing>=2 OR
A1cs>=7 OR
A1cs>=7 OR
A1cs>=7 OR
metformin OR any metformin OR any
billing>=7 OR
billing>=7 OR
billing>=2 OR
insulin
insulin
metformin and metformin OR any metformin OR any
billing>=2 OR any
insulin
insulin
insulin
Decided at 9/1 Meeting
©2015
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Final Diabetes Rule
Rule 1:
 Any lab result #749 GHBA1C greater than or equal to 7
Rule 2:
 2 or more billing codes in 250, 250.0, 250.00, 250.01, 250.02, 250.03, 250.1,
250.10, 250.11, 250.12, 250.13, 250.2, 250.20, 250.21, 250.22, 250.23, 250.3,
250.30, 250.31, 250.32, 250.33, 250.4, 250.40, 250.41, 250.42, 250.43, 250.5,
250.50, 250.51, 250.52, 250.53, 250.6, 250.60, 250.61, 250.62, 250.63, 250.7,
250.70, 250.71, 250.72, 250.73, 250.8, 250.80, 250.81, 250.82, 250.83, 250.9,
250.90, 250.91, 250.92, 250.93 (Diabetes)
Rule 3:
 At least one medication in:

ETC classes:


5886 (Injectable Antidiabetic Agents)
154 (Oral Antidiabetic Agents)
©2015
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Performance of Rules
©2015
Results
©2015
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Screenshot
©2015
Study Design
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Cluster-randomized trial
Ran May 16, 2010 – Nov 15, 2010
Implemented in LMR across all primary care clinics at
BWH, Faulkner and health centers
Randomized by sub-clinic: 14 in intervention and 14 in
control
©2015
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Date
11
10
/1
3
/1
6
/1
0
/1
0
/1
0
/1
0
/1
0
/1
0
12000
9/
18
8/
21
7/
24
6/
26
10
10
10
10
/1
0
5/
1/
4/
3/
3/
6/
2/
6/
10
/0
9
/0
9
1/
9/
/1
2
/1
4
5/
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12
11
Cumulative Number of Problems
Addition of MAPLE Problems
14000
Intervention
10000
5,491
8000
6000
Control
4000
2000
0
©2015
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Problems Added
Problem
Intervention Period
Unadjusted** Comparison
Adjusted*** Comparison
Control
Intervention
Relative rate
p-value
Odds ratio
p-value
ADHD
69
157
2.086
< 0.0001
2.234
<.0001
Asthma / COPD
529
1291
2.416
< 0.0001
2.981
<.0001
Breast cancer
180
246
1.678
0.0004
1.783
<.0001
Coronary artery disease
178
576
3.960
< 0.0001
4.655
<.0001
Congenital coagulopathy
5
19
3.800
0.0133
2.055
0.0384
Congestive heart failure
97
373
4.922
< 0.0001
7.563
<.0001
Diabetes mellitus
535
814
2.037
< 0.0001
1.971
<.0001
Glaucoma
61
263
3.088
< 0.0001
3.783
<.0001
1,031
3,082
3.530
< 0.0001
4.118
<.0001
Hyperthyroidism
72
124
1.543
0.0308
1.298
0.2928
Hypothyroidism
205
823
3.506
< 0.0001
3.987
<.0001
3
5
3.333
0.2850
2.098
0.114
Osteoporosis/osteopenia
582
1,521
2.776
< 0.0001
3.396
<.0001
Rheumatoid arthritis
24
75
4.018
< 0.0001
3.966
<.0001
CKD
87
521
6.891
< 0.0001
8.223
<.0001
Sickle cell disease
13
23
1.327
0.3538
1.659
0.2897
Stroke
68
103
2.088
0.0023
2.353
0.0002
3,739
10,016
2.983
< 0.0001
Hypertension
Myasthenia gravis
Total
©2015 3.431
<.0001
Acceptance Rate
Total
Rule Firings
Acceptance
Rate*
225
45.3%
2,452
34.3%
245
47.3%
Coronary artery disease
1,069
41.1%
Congenital coagulopathy
45
33.3%
Congestive heart failure
914
36.2%
1,330
39.0%
336
55.7%
5,362
42.5%
Hyperthyroidism
141
32.6%
Hypothyroidism
1,291
49.5%
15
20.0%
2,285
42.1%
Rheumatoid arthritis
231
26.4%
Renal failure / insufficiency
991
41.7%
Sickle cell disease
12
8.3%
Stroke
99
54.5%
17,043
41.1%
Disease
ADHD
Ashtma / COPD
Breast cancer
Diabetes mellitus
Glaucoma
Hypertension
Myasthenia gravis
Osteoporosis / osteopenia
Total
©2015
* Overall acceptance rate = number of alerts accepted / unique rule firings
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Next Steps
©2015
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Overall Study Design
©2015
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RTI International
Today’s Presenter


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Brief Biography:
Dr. Orlova is the Senior Director for Standards at AHIMA, Visiting
Associate Professor, Johns Hopkins School of Medicine, and Clinical
Associate Professor at the School of Public Health and Health
Sciences, University of Massachusetts, Amherst. Her expertise
includes the adoption of health IT standards for knowledge
representation and systems interoperability in healthcare.
She is the member of the International Board of the Integrating the
Healthcare Enterprise, a collaborative supporting interoperability
standards. She teaches on-line courses on health IT standards and
systems interoperability at Johns Hopkins, and on public health
informatics at UMASS.
Presentation:
“Putting Standards to Work - Improving Clinical Documentation”
Putting Standards to Work Improving Clinical Documentation
RTI Health IT Safety Webinar Series, July 30, 2015
EHR Documentation and Health IT Safety
Anna Orlova, PhD,
Senior Director, Standards, AHIMA, [email protected]
Visiting Associate Professor, Division of Health Sciences Informatics
Johns Hopkins School of Medicine
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Outline
• The Challenge
• Interoperability
• Enabling Interoperability through Standards and
Trained Workforce
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The Challenge
“The next challenge for healthcare
industry is ensuring consistency in content
and meaning of clinical information as it
evolves from manual to an electronic
practice.”
Hess PC. Clinical Documentation Improvement. Principles and Practices. American Health
Information Management Association (AHIMA). 2015. URL:
http://www.ahimapress.org/hess5023
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Clinical Documentation Supports
• Quality Care
• Accurate Reimbursement
• Regulatory Compliance
• Health Knowledge Generation
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Published
in 2015
Pamela Carroll Hess MA, RHIA, CCS, CDIP, CPC
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Collaborative Intelligence
PHYSICIAN
NURSE
CODER/CDS
CDI Alerts
Concurrent
Review
Concurrent
Coding
ABSTRACTOR
Concurrent
Abstraction
CONTENT SERVER
Signed Clinical
Notes
Nurses
Notes
Medication
Admission Records
Content
Tagging
Laboratory Results
Hess PC. 2015. URL: http://www.ahimapress.org/hess5023
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Multidisciplinary Team Model
PHYSICIAN
NURSE
CODER/CDS
CDI Alerts
Concurrent
Review
Concurrent
Coding
ABSTRACTOR
Concurrent
Abstraction
CONTENT SERVER
Signed Clinical
Notes
Nurses
Notes
Medication
Admission Records
Content
Tagging
Laboratory Results
Hess PC. 2015. URL: http://www.ahimapress.org/hess5023
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Successes: Children’s Health, Dallas TX
• Natural language
processing to auto-assign
ICD and CPT codes
• Edits by professional
coders
• Copy & Paste
compliance
• Content validation
• Query response rate
• Benchmarking
Computer
Assisted
Coding
Automated
Physician
Queries
•
•
•
•
Content verification
Query notification
Template queries
Built into MDs
workflow
EHR
Data
Analytics
Templates
for Data
Capture
• Clinical Pathways
Documents and
• Case Definition
Templates
Lusk K. and Fackrell L. Technology Backbone –
Clinical Documentation Improvement. AHIMA Convention. 2014. San-Diego, CA
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Successes: Children’s Health, Dallas TX
29 Clinical Pathways documents and case Definition
Templates for documenting
• Malnutrition
• Morbid or Severe Obesity
• Anemia
• Respiratory Failure
• Types of Heart Failure
• Chronic Kidney Diseases
• Renal Failure and other conditions
Lusk K. and Fackrell L. Technology Backbone –
Clinical Documentation Improvement. AHIMA Convention. 2014. San-Diego, CA
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Collaborative Intelligence at CHILDREN’S
PHYSICIAN
NURSE
CODER/CDS
CDI Alerts
Concurrent
Review
Concurrent
Coding
ABSTRACTOR
Concurrent
Abstraction
CONTENT SERVER
Signed Clinical
Notes
Nurses
Notes
Medication
Admission Records
Content
Tagging
Laboratory Results
Hess PC. 2015. URL: http://www.ahimapress.org/hess5023
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Collaborative Intelligence at HOPKINS
PHYSICIAN
NURSE
CODER/CDS
CDI Alerts
Concurrent
Review
Concurrent
Coding
ABSTRACTOR
Concurrent
Abstraction
CONTENT SERVER
Signed Clinical
Notes
Nurses
Notes
Medication
Admission Records
Content
Tagging
Laboratory Results
Hess PC. 2015. URL: http://www.ahimapress.org/hess5023
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Collaborative Intelligence at MAYO CLINIC
PHYSICIAN
NURSE
CODER/CDS
CDI Alerts
Concurrent
Review
Concurrent
Coding
ABSTRACTOR
Concurrent
Abstraction
CONTENT SERVER
Signed Clinical
Notes
Nurses
Notes
Medication
Admission Records
Content
Tagging
Laboratory Results
Hess PC. 2015. URL: http://www.ahimapress.org/hess5023
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Collaborative Intelligence at HEALTHCARE
Health Information Manager (HIM) Perspectives
Content Managers (Specialists in Vocabulary and
Terminology Services (Coders), Clinical Documentation
Improvement (CDI), Decision Support, etc.)
Physician Perspectives
Content Managers (Specialists in Evidence-based
Medicine, Patient Care, Translational Research, etc.)
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Collaborative Intelligence at HEALTHCARE
Clinicians, patients and researchers need to
share data!
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Collaborative Intelligence at HEALTHCARE
Children’s Health
Hopkins
Mayo Clinic
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Interoperability
To share data with the means of information
and communication technology requires
interoperability of health information
systems.
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Interoperability
“Interoperability” means the ability to
capture*, communicate and exchange data
accurately, effectively, securely, and consistently
with different information technology systems,
software applications, and networks in various
settings, and exchange data such that clinical or
operational purpose and meaning of the data
are preserved and unaltered.” (HL7, 2007)
Health Level Seven (HL7). Coming to Terms: Scoping Interoperability for Health Care.
White Paper. 2007. URL: https://www.hln.com/assets/pdf/Coming-to-Terms-February2007.pdf
* AHIMA proposed addition to the HL7 definition of interoperability
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Interoperability
“Today interoperability has proven to be very
difficult to establish.”(US Senate, 2013)
Thune J, Alexander L, Roberts P, Burr R, Coburn T, Enzi M. Reboot: Re-Examining the Strategies Needed to
Successfully Adopt Health IT. White Paper. US Senate. April 13, 2013. URL:
http://www.thune.senate.gov/public/index.cfm/files/serve?File_id=0cf0490e-76af-4934-b53483f5613c7370
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Interoperability Pillars
Semantic interoperability—shared content
Technical interoperability—shared information
exchange infrastructure
Functional interoperability—shared rules of
information exchanges, i.e., business
rules and information governance
(“the rules of the road”)
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Interoperability Example: Auto Industry
Semantic
(content)
Technical
(infrastructure)
Functional
(“rules of the road”)
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Interoperability Example: Auto Industry
Semantic
(content)
Technical
(infrastructure)
Functional
(“rules of the road”)
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Semantic Interoperability
CONTENT
Guidelines
Use
Cases
Information
Data Sets
Value Sets
& Codes
I N F O R M A T I C S AND H I M
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Semantic Interoperability
CONTENT
Guidelines
Use
Cases
Information
Data Sets
Value Sets
& Codes
I N F O R M A T I C S AND H I M
Clinical Documentation Improvement (CDI)
Healthcare
Knowledge
Clinical Pathways
Documents
Case Definition
Templates
Data Analytics
Coding
Quality
Data
Health Information Management (HIM) Practices
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Semantic Interoperability Workforce
Content Managers (Specialists in Vocabulary and
Terminology Services (Coders), Clinical
Documentation Improvement (CDI), Decision
Support, etc.)
CONTENT
Guidelines
Use
Cases
Information
Data Sets
Value Sets
& Codes
I N F O R M A T I C S AND H I M
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Functional Interoperability
RULES OF MANAGING CONTENT
Guidelines
Use
Cases
Information
Data Sets
Value Sets
& Codes
I N F O R M A T I C S AND H I M
Clinical Documentation Improvement (CDI)
Healthcare
Knowledge
Clinical Pathways
Documents
Case Definition
Templates
Data Analytics
Coding
Quality
Data
Health Information Management (HIM) Practices
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Functional Interoperability
RULES OF MANAGING CONTENT
Guidelines
Use
Cases
Information
Data Sets
Value Sets
& Codes
I N F O R M A T I C S AND H I M
Clinical Documentation Improvement (CDI)
Healthcare
Knowledge
Clinical Pathways
Documents
Case Definition
Templates
Data Analytics
Coding
Quality
Data
Health Information Management (HIM) Practices
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Functional Interoperability Workforce
Information Governance Specialist (Specialists
in Information Governance, e-Discovery,
Information Brokerage, Consumer Advocacy, etc.)
RULES OF MANAGING CONTENT
Guidelines
Use
Cases
Information
Data Sets
Value Sets
& Codes
I N F O R M A T I C S , H I M AND L A W
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Interoperability Standards
2005-2009 Health Information Technology
Standards Panel (HITSP) – developed
Interoperability Specifications (IS) for national
use cases
2014-now ISO Technical Committee 215 Health
Informatics – is developing Reference
Standards Portfolio (RSP) for healthcare
domains, e.g., clinical imaging
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Interoperability Standards Methodology
Process
DEVELOP
PROPOSE
DEFINE
Use case
Requirements
SELECT AND
HARMONIZE
STANDARDS
Reference
Standards
Portfolio
(RSP)
TEST
RSP
PUBLISH
MAINTAIN
ADOPT
RSP
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Interoperability Standards Methodology
Reference Standards Portfolio (RSP) for Selected Domain
Use Case 1
Use Case 2
Use Case 3
Requirements: Workflow and Data Flow
Use Case 5
Data Sets
Data Elements,
Value sets, Codes
Case Definition
Templates
Clinical
Pathways
Use Case 4
Health Information Technology (HIT) Standards
Semantics
Terminology
Standards
Information Content
Standards
HCPCS
HL7 V3
CPT HL7 V2.5
SNOMED-CT
CCC
ICD 9/10 LOINC
NCCLS
UCUM
UB-92
URL
FIPS 5-2
Technical
HAVE
HL7 CDA
HL7 RIM
HL7 CCD
HL7 FHIR
Information Exchange
Standards
Identifier
Standards
HL72.X IHE XD*
IHE DSUB IHE RFD
NPI UDI
NPIs
Functional
Workflow
Standards
Privacy &
Security
Standards
ATNA
NPI BPPC
Information
Governance
Standards
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Enabling Collaborative Intelligence in Healthcare
through Interoperability Standards and Workforce
PHYSICIAN
NURSE
CODER/CDS
CDI Alerts
Concurrent
Review
Concurrent
Coding
ABSTRACTOR
Concurrent
Abstraction
CONTENT SERVER
Signed Clinical
Notes
Nurses
Notes
Content
Tagging
&
Standardization
Medication
Admission Records
Laboratory Results
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Next Steps
Join AHIMA in
1. Developing interoperability standards at ISO
Technical Committee 215 Health Informatics
2. Building a workforce for interoperability by
– Adopting Global Competencies for HIM, Informatics
and HIT developed by AHIMA Foundation
– Building partnerships with academic informatics
programs (e.g., Johns Hopkins) to train


content managers (clinicians and HIM professionals) and
information governance specialists for interoperable HIT
solutions
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RTI International
Questions and Wrap Up
Speaker Contact
Information
August Webinar:

Gordon Schiff
[email protected]
Adam Wright
[email protected]
September Webinar:

Health IT Safety Center
Roadmap
–
Anna Orlova
[email protected]

105
Information Transparency and
Health IT Safety
August 20, 2015 / 1-2:30p EDT
(not yet confirmed)
Discuss the proposed national health
IT safety center
Please visit: www.healthitsafety.org
or contact [email protected] for
more information on the entire
webinar series
RTI International
Final Webinar:
September 2015
(Date and time tbd)
Need for a national
Health IT Safety Center
Roadmap development
process
Proposed public-private
partnership
Center goals, activities,
operations, and funding
Access the roadmap:
www.healthitsafety.org