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Feb 2 2012   12:16PM GMT

Clinical Document Architecture and meaningful use stage II: If you do nothing else, do this now

Posted by: Jenny Laurello
CCD, CDA, Clinical Document Architecture, Continuity of Care Documentation, meaningful use stage 2

Guest post by: Peter Bedell, Business Development Manager, Fujitsu

With the ever-changing requirements for meaningful use stage II lingering just out of reach, it can be hard to determine which step to take first.  Investment in technology is a major commitment, and the wrong choices can be a costly mistake.  In fact, with the official announcement from the ONC still in the offing, some might think it is best to not take any action at all.  However, while time continues to tick, there is one critical decision that can be made today with confidence and meaning that extends beyond the terms of meaningful use: creating a strategy to preserve the full patient narrative.

Even though it is easy to capture most health care information in an electronic medical record (age, height, weight, temperature and even diagnostic and treatment codes), there is an enormous amount of information that lives in a narrative that can be challenging to fit into the fields of a database.  It is within these “outliers” that vital medical data is contained – information that is crucial to providing a comprehensive and holistic approach to medicine.

Meaningful for ‘’meaningful use” sake

What is meaningful use anyway?  There are two definitions: one created by administrators and legislators, and the other by practitioners in the trenches of health care. Regardless of the source, most would agree that the incentives for reimbursement provisioned under the HITECH Act are merely nice- to-have and not the primary driver behind technology adoption. Instead, they are designed to motivate action from laggards and, perhaps secondarily, reward early adopters for being pioneers. Yet anyone who has ever had first-hand experience with technology knows no amount of compensation can offset a solution that is complicated or disruptive, nor replace a solution that makes providing quality care easier and more affordable… and that is the real litmus test of meaningful use. 

Enter the Clinical Document Architecture (CDA).  On its surface, CDA is just another industry standard that the Government will (soon) require needs to be met.  Go a layer deeper and you can see how defining a process for preserving the patient narrative is at the core of health care, both here in the U.S. and everywhere throughout the world.

Think back to a bygone era when physicians still made house calls.  Beyond the convenience of coming into your home (where care can be provided with the greatest comfort), these visits represented more than clinical examinations; they fostered trust and bred loyalty that can be hard to replace.  And with the nature of health care becoming increasingly transactional these days, that sense of relationship has been jeopardized.

Fast-forward to today: modern technology has made it plausible to once again offer personalized care, and it has done so by reintroducing the full patient narrative as a permanent part of the Continuity of Care Documentation (CCD).  Now every care provider can quickly and easily add or exchange patient information in a medical record, across broad geographies and between provider networks, regardless of whether it originates electronically or on paper, with the complete confidence of knowing that it will interoperate with every other system downstream, no matter what.

How does it work?  EMR software allows for hospitals and physicians to aggregate discrete data about their patients with ease.  These systems can provide treatment and diagnostic codes to help with the process of both treatment and billing and house them in a database designed to produce quality outcomes.  But when it comes to including information that may fall outside of vital signs and diagnostics – for instance, how a patient’s home or work life is impacting his or her health – it becomes necessary to have the means to capture these outlying data elements with similar ease, even though the information may often exist in unstructured form.

CDA provides a framework for structuring the unstructured.  Created under the guidelines of HL7 by a consortium of health care professionals, CDA was designed to provide a means for capturing data and exchanging information in a manner that is both internationally accepted and universally interoperable across all health care systems.  Accomplishing such a feat can only be made possible by defining industry standards, which is why CDA (and other standards like it) are so fundamental to accomplishing the goals of technology adoption, including meeting meaningful use requirements. 

If you do nothing else, do this now: develop a strategy for preserving the full patient narrative today by adopting technology built on CDA standards. There is no more meaningful step you can take no matter how you define the term meaningful use.

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