Telling the Full Story

For the Record magazine did an excellent front page cover story on the Health Story project "Telling the Full Story". With less than 3% of the typical patient record composed of direct clinician input and somewhere in the region of 60% of clinical data coming from transcribed documents we need to find a way to capture and utilize this information to feed the data hungry EMR.

The Healthstory project represents that leap across the chasm. The opportunity to bridge the divide between the human readable and essential detailed free form narrative and the data elements necessary to drive the the EMR systems and automated tools available today but struggling to work as they sit starved of discreet structured, encoded clinically actionable data. As part of this initiative is the recognition that transcription and medical editors are a value added service bringing extensive knowledge, skills and data analysis skills to bear on the over burden documentation industry. As Liora Alschuler points out:

for a number of years, the “narrative” has been the EMR’s enemy, a relationship that the Health Story Project aims to reverse. “If you look at even the most sophisticated IT environments in healthcare, they still need this because their EMR does not eliminate the narrative form,”

Changing this perception of the narrative as the enemy and embracing the rich capacity of expression possible in narrative language is an essential first step. With the inclusion of narrative not just alongside but linked to the structured encoded clinical data creates meaningful clinical documents "that handle structured data and natural language narratives with equal ease". Providing both the computer and the clinicians with information suited to their needs.

“Data is structured to support rich links between clinical documents and electronic health records. That makes it easy to share information across provider and computer system boundaries while still retaining the essential human-readable, detailed narrative in one document.”

There was also other recent coverage including this piece in the JAHIMA April edition (pdf copy here or online here). If you don't know what it is or what is means to your organization you should.

If you are going to be at the MTIA conference this week - come along and find out more on Thursday April 23 at 7:30 - 8:15 (warning pdf). If not take the time to review the standards the "Shovel Ready" nature of the project, the benefits and the membership options)

The project has momentum and participation and needs your support. We should all be insisting on receiving the full story. If not

• press 1 to fill in all your information again at yet another clinical office,
• press 2 if you are fed up filling in forms and complete them half heartedly despite the fact that information is critical background to help your clinician make diagnostic and decision
• press 3 to have your blood work and x-rays redone since the information is not available to the one of multiple clinicians you visit each year
• Press 4 To skip a question since it does not have an suitable answer in the list of choices
• Press 5 To hear these choices, again and again and again

I know I want the full story and have been collecting mine for years.....are you?