Amdis documentation panel nick van terheyden

AMDIS Documentation Panel

Nick van Terheyden, MD CMIO – CLU Nuance Communications Inc

Paper is no longer fit for purpose

Slide Courtesy of Dr Michael Bainbridge

Current Methods for Data Capture

Unstructured Data

Structured Data Dictation and Transcription

System generated or interfaced data

Direct data entry, not physician

Direct data entry, physician

Handwritten

Future Concepts from 1992 Imagine…..!

∗Tel the patient story ∗Fill in the data Gaps ∗Unambiguous Sharing of information

The Purpose of the EMR

∗ Conventional Wisdom: ∗ The EMR is the solution ∗ Documents are the problem

∗ Questions: ∗ Are EMRs and documents mutually exclusive or

complementary? ∗ Can eDocuments bridge the gap between

physicians and EMRs? … and enable Computer-Assisted Coding too?

More EMR planetary wisdom … and some questions

∗ Why do documents have such a bad rap? ∗ Can’t compute ∗ Can’t automate decision support ∗ Can’t validate conformance to content requirements

∗ And why are documents still prevalent? ∗ Nuanced & precise ∗ Support human decision making ∗ Can be supplemented by multiple coded entries

(optimized for reimbursement, decision support, quality metrics, research)

∗ Retains current workflow, favored by physicians ∗ Interoperable

Documents and narrative text

8 CONFIDENTIAL | © 2002-2011 Nuance Communications, Inc. All rights reserved. HEALTHCARE SOLUTIONS

Supporting the Clinician in the Avalanche of Increasing Demands

POA/HAC Medical Necessity

Core Measures

MU

Patient Safety

Outcome Measures

CMI

Severity of Illness

For really tough problems …

Try a different perspective!

PAST MEDICAL HISTORY

CHIEF COMPLAINT

• Meaningful Use • Quality Reporting • Decision Support

• Value-Based Purchasing • Coding/CMI • POA/HAC

• Medical Necessity • Coding • Documentation Integrity

Financial Integrity

Compliance

Patient Care

Narrative

In EHR MT-editing

Feedback

With a RIS/PACS

In EHR Self-editing

On the Go

On a PC

At a Dictation Station

On an MFP

EHR

Key Challenges with Current Process

DISRUPTIVE CDI QUERIES

CDI SPECIALIST “The patient has respiratory failure”

What is the acuity?

Fits Your Workflow

• Interactive clarifications while physician is documenting

“Patient has altered mental status, abnormal

liver function and treatment with

lactulose”

Evidence suggests that this patient has hepatic

encephalopathy. Do you agree?

“Yes” Hepatic Encephalopathy

Hepatic Encephalopathy

Fuel for intelligent clinical applications DETAILED, ACTIONABLE PATIENT RECORDS

Fine Grained problem lists

Up to date allergies

Current medications

Diabetes, Tumor, CHF Registry Automated Extraction

From dictated notes to patient care

Fuel for intelligent clinical applications GRANULAR PATIENT DATA FOR CLINICAL DECISIONS

Sepsis Screening

Cardiac Monitoring

Venous Thromboembolism

Stroke Indicators

From dictated notes to patient care

∗ As Greg Shorr Said ∗ Patients want the doctor to focus on me not on the

technology ∗ Showing Empathy improves Outcomes

Focus on the Patient

∗ Study done by the Mayo Clinic in 2006 identified the most important characteristics patients feel a good doctor must possess

∗ The Ideal clinician is ∗ confident, ∗ empathetic, ∗ humane, ∗ personal, ∗ forthright, ∗ respectful, and ∗ thorough

∗ You won’t get these by focusing on the Technology

Focusing on the Patient

Mayo Clin Proc. 2006;81(3):338-344

Nick van Terheyden, MD CMIO, Nuance Communications AboutMe http://about.me/obiwan Twitter http://twitter.com/drnic1 LinkedIn http://www.linkedin.com/in/nickvt Voice of the Doctor http://drvoice.blogspot.com/ Plaxo http://nvt.myplaxo.com FaceBook http://profile.to/drnick E-Mail drnick@nuance.com, drnic1@gmail.com GrandCentral (301) 355-0877

Where You Can Find Me

AMDIS Documentation Panel

Nick van Terheyden, MD CMIO – CLU Nuance Communications Inc