June 23, 2008

Satisfying a Craving
By Selena Chavis
For The Record
Vol. 20 No. 13 P. 20

Experts say that EHRs are hungry for data. New industry guidelines may set the stage for feeding that appetite by creating a standard for common document templates.

Consider this typical scenario: A client utilizing a healthcare network may go to a small community hospital for basic diagnostics or minor emergencies. That same patient may also drive an hour to take advantage of a large tertiary academic medical center’s expertise for more complex issues. Alongside these two entities, there may be a scattering of physician practices and subspecialties used for various healthcare needs.

It’s healthcare’s foremost communication and information exchange challenge, according to Liora Alschuler, principal with Vermont-based Alschuler Associates, LLC, and a developer of XML-based standards for the exchange of electronic healthcare information. “To get a complete picture of my care, they all need to see what the other physicians are thinking and doing,” she says.

In this real-world example, the challenge becomes interoperability. And while database-centric electronic health record (EHR) systems are making inroads across healthcare, one of the puzzle’s missing pieces has been a standard for the creation and use of “documents” across networks.

As a strategic step toward tackling this challenge, the Clinical Documentation Architecture for Common Document Types (CDA4CDT) project was initiated by speech recognition vendor M*Modal, the AHIMA, and the Association for Healthcare Documentation Integrity (AHDI). Soon, providers looking for interoperable healthcare reports that conform to standards for information exchange will have a new set of implementation guides from Health Level Seven (HL7) via the efforts of the CDA4CDT workgroup.

“Every hospital, clinic, and doctor’s office wants their documents to look a certain way,” says Scott Faulkner, CEO of Interfix Ventures and the Medical Transcription Industry Association’s liaison to the workgroup, adding that, for the most part, key documents used for patient care tend to be unusable outside of the network where they reside. “These document style requirements actually compound the problem of interoperability.”
Because the documents typically cannot be shared across networks, Faulkner suggests that they essentially become little islands of information of no real value to the electronic patient record.

The CDA4CDT project develops CDA implementation guides for common types of electronic healthcare documents, according to Faulkner, naming the “big five” as the history and physical (H&P), progress notes, discharge summaries, operative reports, and consults.

The standardization and adoption of these electronic documents are expected to enlarge and improve the flow of data into the EHR and speed the development of interoperable clinical document repositories for use within regional and national networks.

According to Peter Preziosi, PhD, CAE, executive director of the Association for Healthcare Documentation Integrity, the project is also expected to help bridge the gap between narrative documents produced through dictation and the structured, computable records within an EHR. “About 60% of the record is the transcription and documentation process,” he notes. “When you talk about the complexities of healthcare delivery, you need to have more of that information than less of it.”

According to CDA4CDT project manager Alschuler, the H&P and consult were the first to go through the balloting process and were published in May. Diagnostic imaging reports and operative notes are expected to be published by the end of the year following another balloting process.

Recognizing the Need
“Starved for information” is how Alschuler describes the present state of affairs for most EHR systems. “Most information in my chart does not come from the EHR,” she says, pointing out that without a “critical mass” of data, providers are not realizing the full benefit of working with an EHR. “My favorite picture of opportunity is that we get this massive amount of information on these networks. We just haven’t had that much total information available because the emphasis has been on coded data.”

Pointing to collaborative initiatives such as the HL7 Continuity of Care Document (CCD) to “harmonize” the data format between the American Society for Testing and Material’s (ASTM) Continuity of Care Record (CCR) and HL7’s CDA specifications, Alschuler notes that while progress was definitely being made, the focus was on fully “coded” data.

“We need to make the connection between the EHR and structured electronic documents,” she says. “The time is right to shine the light on standardizing these EHR documents.”

Jim Klein, senior vice president of product management and chief technology officer at QuadraMed, concurs, noting that the HIM world is historically insufficiently integrated with the EHR world because the documents within an EHR are typically free text. “EHRs contain a lot of structured information that can drive process automation; however, the ‘signed’ documents that the typical EHR sends to the HIM application suite don’t provide the structured information that could help coders and HIM do their jobs,” he says. “That lack of integration is going to become ever more costly for the business of healthcare delivery in a world of pay for performance and increasing regulation focused on patient safety and outcomes.”

By using these implementation guides, transcription documents can be imported directly into the EHR and aggregated along with EHR summaries such as the CCD in document repositories and document management systems for exchange, reporting, and analysis. Alschuler points out that of the more than 1 million transcription documents produced each day, tens of thousands are already CDA. Ideally, this project will complete the framework required to integrate these notes into interoperable, accessible, and computable electronic records.

“Free text and unstructured language is going to be with us for a long time. What [EHR] vendors have promised for years, they have failed to do miserably,” Faulkner says, adding that the “dirty secret” of electronic patient records is that they really don’t have that much in them that is useful for automating key HIM processes. “The documentation of patient care just varies all over the map. [CDA4CDT] was a way to stop that nonsense.”

Defining the Process
From the beginning, Alschuler says the committee realized there was no need to reinvent common document types. “We were able to draw from a lot of resources,” she notes, pointing to their analysis and use of precedents and patterns set forth by such resources as the HL7/ASTM’s CCD and other HL7 document resources; the ASTM’s Standard Specifications for Healthcare Document Formats (E2184-02) (headings and subheadings used in medical and associated with specific report types); Logical Observation Identities, Names and Codes; Integrating the Healthcare Enterprise content profiles; and sample documents from various provider institutions.

Faulkner notes that many questions were posed to determine what protocols and sections (data elements) the forms should possess, as well as the best format for presentation. “The complexity of this project took some real time,” he says. “Everyone who touches this process had to buy in.”

The first phase—lasting from late 2006 until early this year—established the coalition, extending it to more than a dozen organizational and commercial participants and securing funding for the completion of the first implementation guides. According to Faulkner, this group set priorities for the first year, supported the development of the first draft implementation guides, and participated in the HL7 ballot process. Document types were then identified and tackled by order of priority—the H&P and consult being the first to publish.

Alschuler notes that the key resource for the development of the H&P implementation guide was a statistical analysis that had been completed by M*Modal, encompassing the review of 15,000 H&P reports. “We normalized it,” she says, adding that it was important to the committee that the guides be realistic to reflect what was in practice today. “We had a clear picture of what sections were in common use. We didn’t want to be too far ahead [of present practices].”

One immediate goal of the next phase is to develop an implementation guide for the operative report. In addition, CDA4CDT established a working relationship with the HL7 Imaging Integration Special Interest Group and Digital Imaging and Communications in Medicine (DICOM) to finalize and bring to ballot a pair of documents—one is an implementation guide for diagnostic imaging reports, and the other is a guide to transforming reports created as DICOM structured reports to a compatible CDA Release Two representation.

According to Alschuler, these communities of standards developers have worked for years to specify the structure and semantics of imaging reports in the DICOM structured reporting standards. These documents went to ballot during the first quarter of this year.

In addition to the new document guidelines, the CDA4CDT committee hopes to launch a phase two recruitment drive to extend and broaden the range of participation to include allied fields such as natural language processing, document management, and EHRs.

“I think what is exciting is that people are starting to recognize the importance of working together,” says Preziosi. “The CDA4CDT coalition is really starting to broaden out. It’s going to really take all of us working together collaboratively … and that’s very challenging in such a fragmented industry.”

Moving in the Right Direction
Proponents agree that widespread adoption of the standards will be the challenge in the years to come. “Most decision makers in healthcare may not see the real need for it,” Preziosi says. However, he points out that as all the pieces of the electronic movement come together, there will be a “tipping point” that will slowly get the industry aligned with standards. “You can’t transfer [document] data across enterprises. Now, with CDA4CDT, you can.”

Rolling it out under the HL7 standard will definitely jump-start the process, says Faulkner. “That way it gets international recognition,” he notes.

Preziosi agrees, adding that “this is the right step in the process for us. We need to continue to work with standards organizations.”

Promoting the use and adoption of the document types within the industry is also a focal point of this next phase of the coalition’s strategy, Alschuler says. The group will rely on the efforts of benefactors, who are considering several available paths to increase visibility and acceptance, including increased involvement with provider organizations, demonstrations of the power and utility of electronic documents, and direct participation in the agenda-setting activities of the national and regional exchange networks.

Klein notes that the long-term goal of this process is to bring the electronic medical record (EMR) and transcribed documents more closely together to better utilize advances in natural language processing to enrich ordinary documents with a payload of structured, encoded information. CDA allows standard codes to be associated with various terms within the document’s text.

“If [HIM professionals] are able to extract the embedded code information, we have a very [useable] standard for extracting information,” he notes, adding that, currently, transcription solution vendors are making attempts to define this process, but all are producing it differently. “The potential of CDA4CDT is to create a standard where EMR vendors can bring these systems much more closely together.”

Are EHRs Ready?
Klein points to EHRs’ general inability to capture structured information from the unstructured language in physician-dictated clinical documentation as a difficulty.

“The EHR has been around a long time, and big investments have been made in the development [of these systems], but the adoption rate by physicians for the clinical documentation features of commercial EHRs is pretty low for most vendors,” he says, adding that the idea that physicians would adapt to structured data entry has just not caught on because dictation is a much more user-friendly mechanism. “Doctors generally can’t afford to slow down and interact with a program that is forcing them to structure their input. An important goal is to produce clinical documents through the ‘natural’ mechanisms of dictation and transcription that can present the EHR with the structured, encoded information that it requires. I see CDA4CDT as kind of the missing link between documents and databases.”

With an associate charter agreement with HL7 in place and several successful ballots under the coalition’s belt, Faulkner believes EHR companies will make the effort to meet the standards.

“They are going to scramble to make sure that their solutions are equipped to handle the flood of data getting ready to come to them,” he says. “No vendor wants standards to succeed. … Their idea of a standard is ‘their standard.’ The drivers that will make it successful are when [HIM professionals] start demanding this from vendors.”

Proponents agree that forward-thinking EHR vendors will be ready to meet this challenge. “The typical EMR vendor should not be overlooking documents that can provide structured information in the electronic patient record,” Klein says.
Alschuler agrees, noting that “if they do what they need to do for the Certification Commission for Healthcare Information Technology and do it right, then they can manage these documents.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.