In brief, what's happened is this: The groups and associations that developed and continue to work on the DICOM and HL7 standards have agreed on a set of what are called implementation guides, essentially formatting standards for text-based diagnostic imaging reports.
These guides are expected to help vendors standardize electronic document formats according to precise specifications as they develop and enhance products in the diagnostic imaging report area. The guides should also help coax IT and health information management (medical records) leaders to align their documentation process to follow the newly suggested formats.
Moving clinical practice forward
This development should mean the enhanced searching capability of text-based diagnostic imaging reports in a healthcare organization's EMR, and thus greater usability for clinicians, data analysts, and researchers, says Liora Alschuler, principal in the East Thetford, Vt.-based Alschuler Associates consulting firm.
As the project manager of “CDA for Common Document Types (CDA4CDT),” Alschuler works on the implementation guide project. The “CDA” in that name stands for Health Level Seven Clinical Document Architecture, the documentation framework being used by numerous health information management (HIM) and healthcare IT documentation initiatives.
“This development affects both the electronic content and the meta-data content, similar to other HL7 specifications,” says Alschuler. And it will definitely help move the industry forward in terms of achieving searchable, more usable documentation in the diagnostic imaging reports area, she adds.
According to Harry Rhodes, this move means a lot to the industry. “This is a step forward, but isn't so disruptive that you're asking people to scrap their systems or purchase new hardware or software. Instead, you're taking advantage of standards that already exist.”
Rhodes, the director of practice leadership at the Chicago-based American Health Information Management Association (AHIMA), sees the development of the implementation guides — which will establish standard ways of organizing diagnostic imaging reports and standardized nomenclature for subheads within those reports — as a sign of the healthcare industry's gradual move toward improving clinical computing for the sake of enhancing patient care.
“For 18 years, I worked as a HIM director or consultant,” Rhodes notes. “And what we call today the electronic health record is really based a lot on free-text documents. The problem is that there isn't a lot of structure. Within a single patient care entity, there may be some structure as far as content goes; but in general, it's a free-for-all out there.”
Now, with the implementation guides rolling out in the diagnostic imaging reports area, physicians and other clinicians will be able to more quickly and easily locate and retrieve discrete pieces of clinical information inside electronic patient records. It is, experts agree, another step towards making the EMR more usable by clinicians, analysts and researchers.
Those who have long been involved in data and IS standardization efforts say they are pleased with this recent development.
“We've worked for many years to ensure compatibility between the core specifications developed for imaging and for the electronic health record,” Fred Behlen, co-chair of DICOM Working Group 20 and HL7 Imaging Integration SIG, states.
Meanwhile, executives of vendor organizations involved in this effort see strong potential. Michael Finke — CEO of Pittsburgh-based M*Modal, whose company helped perform the technical groundwork that supported CDA4CDT — says, “The reality is that if a diagnostic imaging report is pure-text, it's meaningless in terms of usability within the EMR.” The CDA4CDT initiative essentially is giving guidance for vendors and providers with regard both to how to format the various sections of imaging reports, and the elements that should be included in each section.
Getting everyone on board
Will vendors across the spectrum embrace this initiative? Peter Preziosi, Ph.D., CEO of the Association for Healthcare Documentation Integrity (which represents the dictation/transcription vendor industry), says yes.
“We want EHR and dictation vendors to adopt these standards, so that when you see different history-and-physical reports, they can talk to each other across healthcare systems,” Preziosi says. “Right now, it's very much customized from one hospital to the next and one physician to the next in one hospital. So we're going to need to have better uniformity in that regard.”
Preziosi adds, “As we develop new data-capture technology, such as speech-recognition capabilities, it's going to enable people to capture information more quickly. But just because you capture that information doesn't mean that you'll be able to use it well. You'll have to make sure it's placed into your record quickly and in a usable way.
CIOs look to move clinicians forward
One of the biggest advantages of the evolving CDA4CDT standards is that they will help improve the efficiency and effectiveness of physicians’ clinical practice, says AHIMA's Rhodes.
“Making data more uniform, and making sure it's documented and presented in a more uniform way,” he says, “will make things easier to index and search, and will save clinicians time and increase patient safety.”
In addition, Rhodes says, “Doctors will still get to dictate their reports, but you're also getting them to follow an outline in terms of the formats of their imaging reports, in areas like section-heading terminology and report organization. And, in that way, you're bringing more structure to the document.”
On the horizon
There are clear implications for CIOs in all this, says Liora Alschuler. “As CIOs think about purchasing decisions going forward,” she says, “they should think broadly about their strategic purchasing process, and their ongoing reliance on dictation/transcription, and ensure that their vendors are going to be prepared to produce standardized reports.”
And things are already moving along.
“We'll publish the standards for history-and-physical reports and for consult notes first, and then for surgical reports (op notes), and diagnostic imaging reports,” Alschuler says. “Those first two are already available in draft standard form for trial use; the others will be final sometime in the first half of the year.”