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

"This is something so new and important," said 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, East Thetford, VT, 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, Pittsburgh.

Dr. 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 physicians 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 Dr. 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, Dr. 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.

Chapter 3: Prepare for Action

Adopting Health Story standards may require a few adjustments, but many providers and medical transcription

service organizations (MTSOs) will already have most of the architecture in place. "Most transcription companies use some kind of

templated entry. What [Health Story] does is make it consistent across the industry," Alschuler explained.

The biggest changes will be behind the scenes. IT staff at EHR vendors and health care providers will need to make sure systems

are Health Story-compliant. That means building constraints into EHRs so patient records match the defined structure and can flow in and out of facilities without losing valuable, detailed text.

Once the technical side aligns with Health Story's implementation guides, MTSO owners and MTs will need to learn why the standard layout is necessary and how to incorporate new headings in the patient record. They're not expected to read the implementation guides, but understand them enough to see the value, Lucci said.

For physicians, things won't be much different. Health Story definitions will be contained in extensible markup language (XML), but doctors won't see that, Dr. van Terheyden said. For them, the EHR template will look similar to what they're used to-it just may include more sections or demand additional details.

Alschuler said physician training will focus on the clinical perspective, rather than IT changes. "They need a reference guide of 10 pages or less-four would be good-for clinical users," she suggested.

The guide would tell physicians which sections of the patient chart are needed to meet Health Story requirements and how to properly complete those sections.

Chapter 4: Battle for Attention

Ultimately, Health Story's success hinges on EHR adoption. In a rare case for the health care industry, the Health Story Project has put the cart before the horse, establishing definitions and standards before providers ask for them.

"A lot of standards, the vendors have to be dragged kicking and screaming to them. But here, what we've found is the vendors themselves are advocating the use of standards," Alschuler said. "They're already using these standards, even when the providers aren't aware of them."

Recognizing low EHR adoption rates, the collaborative is being careful to avoid setting too many standards before physicians and MTs have input. The implementation guides are open to refinement; as providers identify new sections they'd like to include in the patient record, those definitions can be added to the guide.

Studies have found most physicians prefer dictation to point-and-click data entry, Lucci explained. By using a Health Story-compliant MTSO, physicians could bene-

fit from advanced, searchable EHRs

backed up with narrative details without

having to ditch dictation. The challenge, she said, is letting physicians know the option is out there.

As part of her awareness campaign, Lucci is spreading the word among AHIMA members, explaining why it's important for HIM departments to use documents that are Health Story-compliant. The defined sections not only improve patient care, she said, but can alsoincrease reimbursement. When coded data doesn't justify a procedure, the narrative text explains why the treatment was needed, which helps avoid denials.

Chapter 5: The Story Continues .

As Health Story progresses, the collaborative plans to publish more implementation guides. Dr. van Terheyden said the group is eyeing billing and reimbursement requirements; ambulatory, clinic and inpatient progress notes; and PDF as future targets.

Health Story leaders are also working to beef up membership and bring more attention to the project. Dr. van Terheyden and Lucci have written about Health Story on their blogs, and several members have presented the team's progress at conferences.

"If we can continue to make this information available and show people how this [project] will bring value to the EHR and patient care while saving time and research downstream, then it becomes an easy decision for folks to make," Lucci said.

Cheryl McEvoy is an editorial assistant with ADVANCE.