Making the change to structured reporting in the cath lab is not easy, simple, fast or fun. But it can be done, according to interventional cardiologists who have taken the challenge and succeeded.
There are no ready-to-use software programs, training is only one small step in the process and getting doctors to check boxes when they have spent their careers dictating prose doesn’t just happen overnight.
A “fundamental change in the dynamics of the workflow in the cath lab” is what’s needed to successfully transition to structured cath lab reporting, according to H. Vernon Anderson, MD, co-author of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions 2014 Health Policy Statement on Structured Reporting for the Cardiac Catheterization Laboratory (J Am Coll Cardiol 2014;63:2591-2623).
“You are asking people to redesign workflow processes that have been in place for decades. That requires fundamental organizational change that is difficult to achieve,” says Anderson, a professor of cardiovascular medicine at The University of Texas Health Science Center at Houston.
Even though the process requires substantial commitment of time and resources, several strategies have proven successful for cath labs that have made the shift.
Find your motivation
Identifying a motivator that physicians, staff and hospital administrators understand and support is a first step, says Timothy C. Ball, MD, PhD, medical director of the cath lab at Carilion Roanoke Memorial Hospital in Virginia.
Ball and his team got motivated to adopt structured reporting in part because they wanted to be known as a cath lab of excellence. To earn that distinction, they set the goal of full accreditation from Accreditation for Cardiovascular Excellence (ACE).
“Having that motivational driver was key because [ACE] gave us a template to follow. It was very helpful as we moved forward,” says Ball, whose lab received accreditation in 2013.
Other cath lab teams have gotten motivated by the increasing
demand for data on compliance with practice guidelines and for quality metrics reporting.
“Achieving structured reporting will ultimately bring down costs, will save resources, and will produce a better working environment. Your systems will run more smoothly … and you can argue that a smoother running hospital will be better,” he says.
Choose your workflow model
No workflow model works for every cath lab, which is why Anderson advises hospital administrators and cath lab managers to start by studying the system diagrams in the Health Policy Statement and talking about workflow changes that make sense for their institution. “The hospital has to sit down and decide what applies to them,” Anderson says.
“It takes some of the documentation burden off the physician if they can create the right workflow, and [the change] can engage other members of the cath lab team in that process,” says Bonnie H. Weiner, MD, MSEC, MBA, chief medical officer at ACE and an author of the Health Policy Statement.
For example, Weiner says many physicians prefer to dictate patient and procedure information in prose format. So, for some facilities, workflow change might mean hiring medical scribes who enter data for physicians.
At Duke University School of Medicine, the cath lab transitioned to structured reporting by expanding staff roles so that they now contribute to procedure reports that had traditionally been the domain of physicians. Trained staff enter details on computers as physicians work and talk throughout procedures.
Duke physicians now spend less time generating and correcting reports and more time with patients, according to James Tcheng, MD, vice-chair of the Health Policy Statement, professor of community and family medicine (informatics) at Duke and director of both Performance Improvement for the Duke Heart Center and of the Duke Cardiovascular Data Bank.
“Transcription errors that physicians would make or just wouldn’t remember when they did the reports a few days later and when they were dictating a note have all been removed,” Tcheng says.
Take small steps to build consensus
Making change in small, incremental steps helps build consensus. Staff at Carilion were encouraged to get involved in the process, understand the goals, attend training and give input so that the changes were not “something thrown on them,” Ball says. “If they wanted to have input they could have all the input they wanted.”
Educating physicians about the reasons for changes and how individual reporting would be improved also built consensus over time.
Taking it slow gives the whole team time to reach agreement on vocabulary, on definitions for common terms such as mild and moderate, and when certain terms should be used, such as “luminal irregularity” or “disease.”
“Physicians would meet, and we negotiated to a position of agreement,” Ball says. “We came together as we had consensus about what the reports would contain and what they were going to say.”
It helps to recognize that the process “involves real pain,” says Anderson. “You have to commit yourself to that. You have to say that you need to get from point A to point B and that you need to do it incrementally. It will cost money but if you do it in bite-sized increments, it won’t be too painful.”
Partner with a software vendor
Software challenges are a major hurdle for hospitals moving to structured reporting.
“It has been the biggest challenge for folks who are trying to implement something meaningful. Systems are not yet designed, not built, not programmed to incorporate all the data that we would want to have in a standalone report,” Weiner says.
According to the experts interviewed, all cath labs that have successfully moved to structured
reporting have customized their own electronic systems by giving designated staff time to collaborate with a commercial software vendor.
For example, the electronic health record (EHR) that Carilion initially rolled out was not designed for structured reporting.
The first product sparked “near mutiny,” Ball remembers. “Even I was thinking this is not going to work. We allowed people to dictate in the interim until we could get it fixed. We realized it was not perfect, and we told physicians to do what you need to do while we make changes.”
In the meantime, Ball assembled a team of personnel who worked with the software vendor to design a program that could perform as a medical search engine. The program could not only collect all of the data about individual patients and procedures but also generate concise and organized data-intensive reports with information to be extracted for clinical trials, performance and quality measures, and registries.
“We had teams of people … who worked on this project for six to eight months. [They] worked with knowledgeable IT personnel to build a package that looked like it would work,” says Ball. “It wasn’t as though we bought it and it worked.”
Some hospital systems are now working with industry to devise a template to use consistently across their organization. While it may be tempting to wait for a program that will provide everything needed right off the shelf, the risks of delaying will come at financial and other costs, according to Anderson.
His advice: “Start approaching this now, deal with it in tiny pieces, and don’t wait until you are confronted with massive change.”