What's the Story?

An excerpt from the article published by Nurse Practitioners

Once upon a time, electronic health records (EHRs) held the promise of better, more efficient healthcare. But as the drive for quick, coded data pushed details off the record, healthcare providers found it wasn't the fairy tale they imagined. So a group of health information management (HIM) organizations have banded together to capture the full patient story -- the Health Story.

"This is something so new and important," said health information technician Susan Lucci, RHIT, CMT, AHDI-F. "Maybe the most important thing you've never heard of."

Chapter 1: Details in Distress

Liora Alschuler, principal of Alschuler Associates, LLC, saw the inefficiencies of EHRs after her mother had an appointment following a hospital stay. The cardiologist had her lab results, but didn't have the discharge summary; he had no details on the hospitalization and didn't know her medications. Her mother hadn't brought her meds, so there was no way to fill in the blanks.

Such scenarios are the reason Alschuler helped found the Health Story Project, a collaborative effort by the Association for Healthcare Documentation Integrity (AHDI), Medical Transcription Industry Association, American Health Information Management Association (AHIMA), M*Modal, Alschuler Associates and other organizations and vendors to develop standards for a comprehensive EHR.

According to those involved in the project, current EHR systems overemphasize discrete data and neglect the story behind those values. "People are focused on the data elements almost to the exclusion and detraction of the free-form narrative," said Nick van Terheyden, MD, chief medical officer of M*Modal.

Van Terheyden recalled a radiologist working with EHRs who said the system "squeezed out" the specific, valuable details about the patient that codes couldn't capture. Point-and-click technology also kept providers entering data instead of seeing patients.

Chapter 2: Answering the Call

Looking for a simple way to standardize narrative text in EHRs, the Health Story Project enlisted the help of the Clinical Document Architecture (CDA), a Health Level Seven (HL7) standard for creating interoperable electronic documents.

CDA is stringent enough to establish a consistent format for file sharing, but flexible enough to include detailed text, according to van Terheyden. "The beauty of CDA is you can still produce that nice formatted, rich text word document, but you can also produce other information from that CDA structure," he explained.

To ensure EHRs include the whole patient story, the Health Story Project defines specific sections that must be included in the record, such as history of present illness and medications. Definitions are published in implementation guides, which are balloted, approved and published by HL7.

The definitions not only help providers fit all details into a formatted chart, but they can also send the document to another provider without having to explain what section headings mean or where to find medication history, van Terheyden said. In other words, providers are on the same page.

The project is currently targeting the most common documents used in patient care; implementation guides for history and physical, consultation note, operative note and diagnostic imaging have already been approved and published by HL7. The diagnostic imaging guide was also produced in conjunction with the Digital Imaging and Communications in Medicine (DICOM) standard.

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