HL7 CDA: The Missing Link in Healthcare IT

From the September 2006 Issue

Claiming Victory

Using an Evidence-based Process for Integrating New Healthcare Technologies

IT Can Play a Critical Role in the Development of Rapid Response Teams

Speaking of Efficiency: Case History

Preparing for Interoperability: EHRs and the Law

Opaque Answers

By James R. Klein

James R. Klein is executive vice president of product management and chief technology officer at QuadraMed Corp., headquartered in Reston, Va. Contact him at jklein@quadramed.com.

Historically, electronic medical record (EMR) systems and healthcare information management (HIM) systems have been poorly integrated. Each has evolved independently of the other to serve different purposes. The more complex the accreditation, regulatory and reimbursement environments become for providers, the more problematic the lack of integration between EMR and HIM systems becomes. Now, the rise of pay for performance (P4P) as a central strategy for healthcare cost containment by payers promises to dramatically increase the business cost of this disconnect to provider organizations.

While it may be possible for HIM department personnel to manually audit for the quality measures specified in the initial five areas covered by the CMS and JCAHO Combined National Hospital Quality Measures, when this program expands shortly to 21 areas, reliance on manual processes will swamp HIM departments. Somehow the structured, encoded information in an EMR must be leveraged to document that quality of care standards have been met as a byproduct of the use of the EMR system.

The hybrid nature of XML documents compliant with Health Level Seven’s (HL7) clinical document architecture (CDA) provides the missing link between HIM and EMR domains, improving the processes of coding and abstracting, and boosting the accuracy of fully compliant claims that maximize reimbursement.

The lineage of HIM applications has evolved to embrace electronic document management and workflow. Long before the commercialization of computer technology, state laws regulated the content and archival requirements of medical records. Today, HIM departments are responsible for insuring the completeness of the medical record in compliance with state laws and JCAHO accreditation criteria, as well as for insuring that all the required clinical information from the official record is marshaled for submission to the payer for reimbursement.

EMRs are based on online transaction processing and database management system technologies and have evolved to serve the needs of teams of care providers. The more structured and encoded the information that finds its way into an EMR, the better the EMR can harness the power of computers to support clinical decisions, facilitate adherence to best practices and safeguard the patient. The challenge remains to capture encoded information from physicians without slowing them down or forcing them to serve the computer.

What Matters Is What the Doctor Wrote
The process of coding medical records for submission of claims for reimbursement to Medicare, Medicaid and commercial insurers may only consider information that appears in a doctor’s assessment, interpretation, notes, orders and plans, as well as a doctor’s documentation of interventions and procedures performed. In short, if a doctor isn’t the author of the information, it cannot be considered. The structured information in an EMR, such as vital signs, I and O measurements and lab values, may not be considered unless they are referenced or “copied into” physician-authored documentation.

Even in hospitals with advanced EMRs, 60 percent of a typical patient’s medical record consists of narrative text, and the HIM processes of coding, abstracting and compliance monitoring rarely benefit from the structured or encoded information in the EMR. These core HIM processes remain almost entirely manual, albeit linked by workflow management systems.

Software such as ICD-9 encoders and DRG groupers are indispensable to HIM processes. However, the input to such software is gathered by HIM knowledge-workers reading documents exported from the EMR and imported into the HIM department’s electronic document management system. These documents are in the form of narrative text by the time they are processed by the HIM department, regardless of whether some of the information they contain exists in the EMR as concepts encoded in a controlled medical vocabulary (CMV), such as SNOMED-CT. Even if standard terminology and coded values from a CMV appear in the text of a document passed to HIM, the knowledge-worker must find, read and use the information appropriately in assigning and prioritizing ICD-9 codes and CPT codes to the medical record, which drive the claims submission process.

Bridging the Gap
HL7’s CDA brings together the worlds to HIM and EMRs because its XML-based documents are traditional human-readable documents, as well as nanorepositories of the equivalent structured, encoded representations of some or all of the human-readable content in the document. The dual nature of CDA documents makes them ideal interplanetary shuttles of information between EMR and HIM applications, regardless of where the information originates.

The two types of information in a CDA document can be created or derived in any order. Advances in speech recognition and natural language processing (NLP) are transforming how a physician’s dictated notes are transcribed into text. Because natural language processing is built on top of a rich ontology of medical knowledge and an associated controlled medical vocabulary, it generates the type of encoded information that an EMR thrives on as a byproduct of computer-assisted transcription.

CDA documents allow this encoded information to be permanently associated with the document in a way that does not interfere with its use as a human-readable artifact, but which allows CDA-aware applications to harvest it to feed the decision support capabilities of an EMR or drive computer-assisted coding in the HIM department. When physician documentation can be captured through a structured interaction between the physician and the computer, CDA documents provide a mechanism to communicate both the English language text and the encoded medical information to the HIM processes. If the HIM software is not CDA-aware, the documents will be read and used by the HIM professionals in the traditional way. However, commercially available, computer-assisted coding software is designed to take advantage of the encoded information embedded in the CDA document.

HL7’s CDA provides a framework for integration among the EMR and the reimbursement, regulatory and research processes of HIM and revenue cycle management. Healthcare organizations should require medical transcription applications to produce HL7 CDA compliant documents and should favor vendors’ products that can populate CDA documents produced from physician dictation with encoded information derived from NLP.