Can HL7 CDA Revolutionize the EMR for Physicians?

We started Salar ten years ago with the goal of developing the industry’s best electronic physician documentation platform. But while we knew plenty about software, we had only a vague idea how patient encounters were actually documented. So we cajoled as many physicians as possible to let us follow them on their daily rounds and pepper them with questions about their workflow.

In the decade since, we’ve rounded with hundreds of physicians and talked documentation with perhaps thousands more. Through all the rants, raves, anecdotes and more, we’ve picked up three “immutable laws” of the physician documentation workflow:

Almost every physician we’ve met agrees that dictation is the fastest method of capturing information from patient encounters. It’s hard to argue against its user-friendliness: Grab a microphone, telephone or recording device, and start talking.

But to a CIO or HIM director, dictation is anything but fast or accurate. To get charge codes for facility and practice billing – as well as procedure details, core measures and other key data – from clinical documentation, support staff (or sometimes physicians themselves) must rekey dictated notes as structured ‘high resolution’ clinical data for entry into the Electronic Medical Record.

It’s a slow, frustrating, error-prone and resource-intensive workflow for everyone involved. It’s also unnecessary, thanks to HL7 Clinical Document Architecture (CDA) standards.

HL7 is Health Level Seven International, a non-profit organization dedicated to establishing international health information exchange standards that enable true interoperability among all healthcare technology solutions. The HL7 CDA Version 2.0 standard provides a framework for clinical documents to exchange clinical data with EMR systems. While HL7 CDA is one of several standards published by HL7, it’s arguably the most important for achieving true interoperability between technology solutions.

The concept of “true interoperability” is a health information system in which every hardware or software solution, from any developer, uses a common data framework to seamlessly and accurately exchange all pertinent information with the EMR. Think of it as a wheel with the EMR as the hub – data can be pushed and pulled from the point-of-care to the EMR, or shared point-to-point throughout the network, in a single information ecosystem.

As the exchange standard for clinical documentation, HL7 CDA specifies that every electronic note can discretely carry a wealth of patient, provider and encounter data optimized for use in the EMR – regardless of whether the document is partly or wholly comprised of narrative.

Natural language processing can tag rich data from a narrative document to produce an HL7 CDA message. Once that document is sent to the EMR, all encoded data – from document type and time of encounter to charge codes, labs, test results and more – are routed appropriately. In other words, HL7 CDA enables documentation to accept unstructured input without wrecking the electronic workflow.

True interoperability of technology solutions can deliver several additional advantages for physicians, providers and patients:

Physician Preference - Rather than migrate physicians toward uniform, highly-structured workflows, hospitals have the freedom to offer physicians a variety of documentation systems designed for specialties and expert workflows. These systems can be customized to accommodate multiple methods of capturing information at the point of care.

Vendor Flexibility - Providers can use a best-of-breed approach that truly focuses on finding the right solutions for their workflow – and saves them money to boot.

Safer, More Efficient Care Delivery - By removing unnecessary administrative burdens, physicians can direct more time and attention to their patients.

So why aren’t these advantages being realized right now throughout the healthcare industry? Unfortunately, without buy-in from solutions providers at every step of the data lifecycle, interoperability won’t be fully realized. With so much at stake right now in the healthcare system, it’s imperative that physicians, providers and HIT solutions vendors work together to achieve a single, fully communicative health information ecosystem.