A Vision for Truly Meaningful Health Information

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This article comes on the heels of the AHDI – CDIA Advocacy Summit in Washington, DC, where members of AHDI and CDIA worked together to speak to members of Congress about the value of narrative health information and the part that medical transcription plays in helping to preserve the patient story.  This article is a joint effort from Liora Alschuler, CEO of Lantana Consulting and me, and also appears on Excellence in Health Information.

Physicians have long used narrative documentation as an effective means of information capture.  Dictation in particular is a widely used method of creating clinical reports such as history and physical documents, operative reports, consultation reports, discharge summaries, and progress notes.  In addition to serving as important communication tools, these documents are an excellent source of the information used by providers for HIM, medico-legal, and administrative functions.  These documents can contain the subtleties of the physician thought process in addition to important clinical facts. They contain a level of expressiveness that cannot easily be captured using other methods of information capture.  According to the Health Story Project, the amount of the nation’s total clinical information captured as narrative documents is approximately 60%, with 1.2 billion documents produced in the United States every year (2011).1

Now that it is accepted that electronic health information will lead to more efficient and effective health care, the belief that information must be captured as discrete metadata-tagged elements in order for the data to be semantically interoperable has led to the assumption that narrative forms of documentation are no longer of value.  When physicians lose the option to dictate narrative notes, they typically are asked to enter the data into the EHR manually, using “point-and-click” methods to capture clinical data. But adoption of electronic health records has been slow, largely because of the increased level of effort and time required to enter information into the EHR, and also because care givers do not find the clinical facts available to them through EHR templates to be a sufficient representation of the patient’s health and clinical history.

The Health Story Project (originally CDA4CDT) was founded for the purpose of creating implementation guides for the electronic exchange and use of health information captured in narrative clinical documents.

The Health Story guides address content requirements for the most common document types and create data standards for exchange of information captured within the original “primary source” documentation of the delivery of care. They represent the original capture of key observations and results, as well as data elements required for the electronic record. The component parts are described through CDA templates, the reusable building blocks of Clinical Document Architecture, most of them developed initially for the HL7 Continuity of Care Document (CCD).

Meanwhile, IHE and HITSP were also developing CDA implementation guides which enable and facilitate Meaningful Use requirements, but which led to some duplication and disconnects with the Health Story guides.

A new initiative, the HL7/IHE Health Story Consolidation Project, joins the two efforts. This project creates a standard which provides the ability to capture and encode discrete data elements while also structuring narrative information such that its value is persisted in the electronic health record.

The collaboration between Health Story, IHE, and HL7 will:

  • Republish all eight Health Story guides for the original common document types plus the related/referenced templates from CCD in a single source.
  • Update the templates to meet the requirements of Meaningful Use, augmenting the base CCD requirements to meet the requirements of HITSP C32/C83.
  • Reconcile discrepancies between overlapping templates published by HL7, IHE and HITSP.

This collaboration is a volunteer effort hosted within the ONC’s Standards and Interoperability (S&I) Framework.  If widely adopted, a standard for health information exchange based on this project could resolve many current challenges by enabling the capture, exchange, and use of clinical data in the EHR in a way that is also meaningful and understandable by human caregivers.

The resulting implementation guides will facilitate meaningful use of electronic health information by:

  • Increasing adoption by allowing physicians to document patient encounters using methods that are efficient, effective, and convenient.
  • Improving the usefulness of the data by increasing the likelihood that the required level of specificity and comprehensiveness will be provided.
  • Enabling the expressive information that is relevant to the documentation of patient care but which does not accommodate entry by point-and-click methods of information capture.

This project gives us the best of both worlds by enabling the exchange and use of clinical facts tagged as discrete data elements without losing the narrative information which still remains the most effective tool for communication and collaboration between the human members of the patient care team.

Dr. David Blumenthal, in his introduction to the ONC’s Federal Health Information Technology Strategic Plan 2011 – 2015, refers to electronic health information as the “’lifeblood’ of modern health care” (2011).2 This collaboration between the Health Story, HL7, and IHE take us one step closer to that vision.

All my best as always,



1 – Health Story Project.  (2011).  HL7/IHE Health Story Consolidation Project.  Health Story

Project: Integrating narrative notes with the EHR. http://www.healthstory.com/standards/sec/consolidate.htm

2 – Office of the National Coordinator. (2011).  Federal Health Information Technology Strategic

Plan: 2011 – 2015.  David Blumenthal, MD, MPP.  Retrieved April 21, 2011 from http://healthit.hhs.gov/portal/server.pt/document/954074/federal_hit_strategic_plan_public_comment_period

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