2. American Recovery & Reinvestment Act Health Information Technology for Economic and Clinical Health (HITECH) Act
3. Dr. Nick van Terheyden Dr. Nick van Terheyden brings a distinctive blend of medical practitioner and business strategist, both national and international, to the realm of healthcare technology. A graduate of the Royal Free Hospital School of Medicine, University of London, Dr. van Terheyden is a pioneering creator in the evolution of healthcare technology. After several years as a medical practitioner in London and Australia, he joined an international who's who in healthcare, academia and business, in the development of the first electronic medical record in the early 1990's and later, as a business leader in one of the first speech recognition Internet companies. In addition to writing and lecturing on futuristic trends in healthcare technology, his advice and counsel is sought by hospitals, physicians and other allied healthcare professionals -- all of whom are trying to figure out how to integrate and use technology to make the healthcare system work from the perspectives of quality and financial success.
5. Electronic Health Record Universe Critical to the success of EHRs is to reconcile two opposing needs Enterprise need for structured and coded information capture Physician’s practical need for a fast and easy method for creating clinical notes. Slide courtesy of M*Modal
10. Meaningful Clinical Documents Meaningful Clinical Documents are a blend between free form text and fully structured documentation that represent the thought process, and capture the clinical facts
11. 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
14. Project Members Promoter Contributor Aprima Software | Digitech Systems Scribe Healthcare Technologies Participant All Type | Dictation Services Group | Healthline, Inc. MD-IT | Broward Sheridan Technical Center
19. Thank you for joining us! Questions about Standards: The underlying infrastructure to the success of EHRs Log in to our Subscribers Only page and visit our “Ask Our Experts” forum
Hinweis der Redaktion
ARRA includes at least $19.2 billion in fundsBut there is more associated with incentives linked to Medicare/Medicaid and quality initiatives such as PQRI
American National Standards InstituteONC properly funded as of this year
Incentives linked to meaningful use and a set of
Structured and encoded clinical content enables…pre-signature alerts, decision support, best documentation practices,multiple output formats, multi-media reporting, data miningImplements HL7 CDA4CDT standard compliant document typesIncreases quality of documentationMedical text “typed” from dictation has “no meaning”black marks on a page… info must be tagged as discrete data elements in order to assign meaning Clinical documentation uses wide variety of terms with same meaning….and terms that sound the same that have different meanings…..authors have a wide variety of styles, accents, methods of dictation…
Procedure Note focus is on endoscopy report
Lakeland Regional Medical Center, FL is live with HL7/Health Story Diagnostic Imaging Reports; reports and discrete data are then integrated into Centricity EMRM*Modal supports dictation/transcription vendors generating 3,000,000 CDA documents each yearCCHIT: Road.HIE.157: The HIE shall provide the ability to receive and forward a HITSP C/84 document. (2011)