The Healthstory project is carrying the torch for the inclusion of narrative in a written response: Written Testimony Regarding “Meaningful Use” (Word document). Narrative and free expression has been under fire for some years as inefficient and requiring replacement with semantically interoperable information. But since the vast majority (by Gartners estimates 60%) of content is created using the traditional dictation and transcription methodology we fail to leverage this information by discounting it. Trying to force a behavior that is not natural and removes much of the value contained in the fine detail in our rich and expressive language is counter intuitive.
Meaningful use of the Certified Electronic Health Record (EHR) must encompass dictation for creation and exchange of standards-based clinical documentation. This comprehensive view of the EHR supports the immediate needs of front-line physicians and patients, is complementary with structured data, and lays the ground work for increasing EHR adoption and information reuseNarrative documentation enhances clinical care and the use of free form narrative is essential to the delivery of high quality care ensuring that the care team get the full story and all the fine details necessary to contribute to high quality health care
The Healthstory format - CDA for CDT or Clinical Document Architecture for Common Document Types (CDA4CDT) uses HL7 Clinical Document Architecture (CDA) documents that are XML representations of familiar clinical documents designed for exchange, recognized by ISO, ANSI, NCVHS, CHI, HITSP, CCHIT.
Healthstory represents disruptive technology that has the greatest capacity to transform practice and deliver the benefits of standardization of dictated notes. This is an achievable step for providers that will inject massive amounts of important information into our fledgling networks, lower costs, and provide a clear pathway towards standardized computable data.
Get on board - join now and start insisting on getting the Full Story from your provider, hospital, vendor.....
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1 comment:
Thanks for today's blog. I can totally relate to what you wrote in your recent blog and to your child's sentiments. Been there, done that, and promptly switched to a new physician! My current physician pushes her laptop into the room for every patient and enters information into the EMR. However, the difference is that she has also mastered being able to balance inputting information, writing prescriptions, etc., with listening and addressing the issues of the patient. She makes eye contact. She pays attention when you are speaking to her. She really recognizes the necessity of interacting with the patient and showing that she cares and is here for them. People want to be heard and validated. Hopefully more physicians will take notice and apply these principles. And patients need to speak up too.
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