Of the 1.2 billion clinical documents produced in the United States each year, 60% are valuable information trapped in unstructured narrative documents (such as transcribed notes), unavailable for clinical use, quality measurement and data mining.
The Health Story Project is a collaborative of healthcare vendors, providers and associations working to develop and promote data standards through HL7 that support the flow of information between narrative documents and electronic medical records. Using the HL7-approved Clinical Document Architecture (CDA), Health Story standards create structured narrative data by using XML to tag, sort and export transcribed narratives into EHRs.
As a member of the Health Story Project, Nuance is helping create the complete patient health story by enriching EHRs with important information created through dictation and transcription.
Structuring the unstructured
Nuance technology allows dictated voice files to be processed through a background speech recognition engine and clinical language understanding (CLU) system and then edited for accuracy. The result: Structured narrative notes that EHRs can use.
Bridging the informational divide
The health story bridges the divide between the physician’s need for fast, easy ways to create clinical documentation to support quality care and the enterprise’s need for structured, coded information capture to support meaningful use.
The alternative to cookie-cutter medicine
Many EHR systems eliminate narrative notes in favor of template patient notes, data elements supplemented by free text fields. While allowing physicians to enter data directly, templates may prohibit them from documenting important clinical observations. Nuance’s background- and front-end speech recognition and Natural Language Processing (NLP) solutions enable the alternative: Structured narrative notes, with specific data fields (such as lab values) that can be tagged, extracted and stored to the appropriate EHR fields.