amdis documentation panel nick van terheyden
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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 [email protected], [email protected] GrandCentral (301) 355-0877
Where You Can Find Me
AMDIS Documentation Panel
Nick van Terheyden, MD CMIO – CLU Nuance Communications Inc