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Jan 10 2012   12:58PM GMT

Developing standards for unstructured documents: What you need to know

Posted by: Jenny Laurello
Clinical Document Architecture (CDA), Clinical Document Architecture for Unstructured Documents, Continuity of Care Document (CCD), Data standards, Unstructured documents

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

Did you know that on average, up to 60% of a patient’s complete medical history can reside in unstructured documents?  If you haven’t considered the implications of what this could mean for your organization, you’re missing a critical first step toward achieving meaningful use.

What is at Risk? 

Think back to the days when your family doctor was a trusted confidant and possessed a comprehensive understanding of your medical history.  It was the kind of trust that could only be established through a long-lasting relationship, sometimes spanning across multiple generations. Well back then, even if only half of that information made it into your paper chart, you had faith that the other half was somehow catalogued in your GP’s brain, which is what kept you and other members of your family coming back as loyal patients for years.  These days the opportunity for such a holistic approach is rare, placing the full patient narrative at risk because it presents a challenge for clinical coding and can be difficult to fit neatly within the fields of a database. Fortunately there is technology that exists which can address this gap and help restore that sense of a relationship with a care provider even from the very first appointment.

Fact: For the majority of health care providers in the US, most of the historical patient narrative exists in paper form.  There are 1.2 billion new documents created annually in health care, and that number is predicted to grow despite the increasing adoption of EMR software designed to make hospitals and practices paperless.  This is the primary business driver for the dramatic growth in sales of document scanning technology over the last several years.  But there is a major difference between simply making images of documents versus turning them into “actionable” or useable data.  Capturing the full patient narrative from these document images requires applying a contextual framework in order to make them meaningful. And the process to do so needs to be quick and easy, or it will not fit in a busy clinical setting.

Attachments are NOT “Actionable” Data

Once upon a time, the idea of being able to search the Internet for images seemed like a monumental leap forward in technology.  Nowadays, the reality is that anyone who has ever used Google to search for a picture understands that there is no sophisticated image processing software operating behind the scenes — the images are being searched by contextual data that is associated with the image file.

This same concept applies to charts that have been scanned into an EMR system.  If you simply “attach” images to patient records using legacy document linking methods (similar to email attachments), the information in the document itself will not be “actionable” or searchable.  Instead, you must have a way to assign contextual information to that document image – patient first name, patient last name, date of birth, medical record number, date of service – before it can be used in a meaningful way.

Seek Solutions Based on Established Industry Standards

The power an industry standard can have is easy to demonstrate: imagine if every mobile phone manufacturer used the same type of charger for their phones.  How many inconveniences would be avoided?  How many lost chargers would find new homes? This is the same vision as interoperability, although perhaps on a grander scale.  The federal government wants all certified EMR software products on the market to be able to communicate with one another by 2014. Imagine the current technology barriers that would overcome!

Although stage 2 requirements for meeting meaningful use have yet to be released, one thing is for certain: interoperability of systems will be at the core. In order to achieve this, standards are being created by stakeholders within the industry.  Standards like the Continuity of Care Document (CCD) and Clinical Document Architecture (CDA) have been designed with the purpose of interoperability in mind. These open standards allow for a logical path to data exchange by being universal across all technology vendors —  much like having a universal charger for all mobile phones.

If You Do Nothing Else, Do This Now

When faced with an enormous decision —  like choosing which technology investment makes the most sense for your organization — it can often be challenging to know exactly where to begin.  The good news with the task of going paperless, the obvious starting point is the purchase of document scanners.  However, before you dedicate any budget to scanning hardware, make certain that you have a solution designed not only to address the “paper problem,” but to preserve the full patient narrative those pages represent.  It takes completing this critical first step before any downstream decisions can be made about interoperability or meaningful use, or else care providers risk losing up to 60% of a patient’s complete medical history.

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