The cath lab is itself high-tech but some reports generated by its physicians still rely on old-fashioned dictation and transcription. Structured reporting offers a way into the present.
The American College of Cardiology’s (ACC) Clinical Quality Committee partnered with the American Heart Association (AHA), the Society for Cardiovascular Angiography and Interventions (SCAI) and eight collaborating organizations to develop a health policy statement to promote the use of structured reporting for cardiac catheterization procedures. In a statement directed toward cardiovascular physicians, payers, EHR and software vendors, regulators and accreditors, they listed a litany of reasons to embrace structured reporting. The bottom line: It provides a concise and efficient way to package critical information, not the least of which is serving as the legal medical record (Circulation 2014;129:2578-2609).
Ultimately, if designed and instituted properly, structured reporting can lead to better patient care, a coordinated and smoothly run operation, a strong sense of team work and a satisfied workforce. Here are a few highlights from the report.
Talk the talk
Structured reporting requires data and formats. But to be truly effective, it needs data and formats that are consistently used and compatible with other systems to allow for interoperability and meaningful analytics—and that means standardization.
The authors emphasized the use of standardized, controlled vocabularies, a fundamental first step that will facilitate communication among people and machines both. Using standardized clinical data elements, for instance, reduces ambiguity and enhances a health system’s ability to assess everything from outcomes to inventory. Standardization allows systems to extract and share data externally for registries, quality initiatives, device and drug surveillance and other purposes. Uniformity in terminology also may help physicians, providers and payers better understand the reports.
The writing committee acknowledged challenges to the adoption of controlled vocabularies, given that established vocabulary lists lack the granularity needed to capture critical catheterization information. They recommended using the ACC’s National Cardiovascular Data Registry data dictionary and the Canadian Cardiovascular Society list of terms. In the meantime, they wrote that the ACC and the AHA have projects under way to harmonize cardiovascular terminology.
They also recognized that the system needed to be flexible to accommodate circumstances that aren’t accounted for within the format. While they discouraged free text, they allowed for the unusual cases that might necessitate a brief history or more details.
Data are passive; it takes someone to gather, validate and integrate them into a system to make them useful. Identifying who and how these functions get performed within the workflow helps to ensure that the final report is accurate and complete. That takes a team effort, but it also requires a clear understanding of individual responsibilities at each step.
For instance, the scheduling office may have the opportunity to gather and import demographic and basic clinical information. Intraprocedurally, a clinician assigned to monitor the patient may have the role of simultaneously entering clinical data. Physicians, nurses and technologists may inform the appointed clinician of pertinent details, and they also may contribute to data entry. The key, the committee emphasized, is handling data as they become available and not retrospectively, all the while balancing the need to be thorough with brevity.
As author of the structured procedure report, the physician operator bears the primary responsibility for its interpretation, description and documentation of results and findings and validity of the data. That may require reviewing or amending the data, but the committee argued that giving initial data duties to others should ease the time burden for physicians. The data then can be used to automatically generate the report. The data also may be exported to files for other purposes.
The final step
The authors recommended organizing the final catheterization procedure report into three sections: a front-page summary, a graphics and image section and the body.
If possible, the first section should be contained to a page and serve as a summary of the top-level clinical information. It serves as the vehicle for informing the patient’s care providers. It should include the key information such as patient identifiers, facility information, procedure date; referring and operator physicians; primary indication of the procedure and a brief description of the presentation for context; procedure details; adverse events; medications and contrast use; and recommendations.
The graphics and imaging section acknowledges the contribution of visuals to the process, particularly related to angiography. The section allows physicians to provide an annotated diagram of the vascular anatomy, diagnostic findings and results. Optionally, it can include captured images such as angiographic still frames and ultrasound images.
Remaining data go in the body section. This section holds administrative data, which includes patient, facility, staff, operator and the encounter category; the procedure; diagnostic findings; interventions; and summaries.
Although the statement specifies structured reporting in the cardiac cath lab, the writing committee included representatives from cardiac surgery, interventional radiology, thoracic surgery, vascular surgery, general cardiology and echocardiography. While the statement is designed as a model for interventional and invasive cardiology, the writers proposed the concepts could be applied to other procedures performed in cath labs, hybrid operating rooms and interventional suites.