Structured Reporting: The Road Map for Better Data, Workflow and Reports

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 - James E. Tcheng, MD
James E. Tcheng, MD, FACC, FSCAI

Creating the structured cardiac cath lab procedure report is the first step to improving patient care and data accuracy, coordinating intraprocedure workflow across the clinical team, making registry reporting seamless, and reducing overall cost of care.

With just 10 percent of U.S. cath labs utilizing structured reporting today, it is time to spread the word, says James E. Tcheng, MD, FACC, FSCAI, who is vice-chair and co-author of the ACC/AHA/SCAI 2014 Health Policy Statement on Structured Reporting for the Cardiac Catheterization Laboratory that came out last year and has been gaining attention ever since. “Right now is the time to jump on board; it’s time to start exploring,” he says.

In developing the guidance, the coalition of 14 professional societies, led by members of the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions, set out to establish normative behavior for professionals and for the expectations of services and practices. The statement defines the clinical standards for structured reporting in the cath lab with the goals of improving patient care by making clinical data more timely, accessible, consistent, effective and useable. Information should be captured as data rather than prose; these data should flow bidirectionally to and from the EHR for subsequent presentation and analysis (Circulation 2014;129:2578-2609).

“You can get the computer to do whatever you want,” says Tcheng, a professor of Community and Family Medicine in Informatics at Duke University Medical Center in Durham, N.C., director of Performance Improvement for the Duke Heart Center and director of the Duke Cardiovascular Data Bank.  “Really it’s the people and the processes that have to change for structured reporting to be successful. That’s what we put together and crafted as a health policy statement.”

Structured reporting is part data, part teamwork, part workflow, part patient record, part analytics, part inventory management, part process improvement, part cost-cutter, part patient educator, and someday, part comparative effectiveness research enabler.

As its name implies, step one of structured reporting is structure. “Structured reporting has at its core structure, meaning that the information that is captured is actually data rather than analog information that cannot be further processed without a lot of work by computers or by computational algorithms,” says Tcheng. “You are documenting what is happening in the cardiac cath lab as much as possible at a discrete data level that can then be easily processed or interpreted by computer systems as those numbers are needed somewhere down the road. We use numbers—like blood pressure of 120 over 80 or a 3.5mm by 28mm diameter and length stent—for analysis and comparisons, especially with future data.”   

Step two is what Tcheng calls the secret sauce: the collection and capture of data integrated into the workflow. Think clinicians handling the information and documenting the data as care is being delivered. No more remembering and recalling numbers, nor the associated inaccuracies. Quality increases. The documentation system then guides the physician through the course of the procedure, presenting the data captured during it in a logical way. For example, in treating a lesion, the system prompts the physician to include the location of the lesion, percentage of stenosis and other important characteristics while automatically collecting information about the devices used to treat it.

“Maximizing the usability, based on human factors engineering, is built into the concepts of structured engineering,” he notes. “As you move through a procedure, the system is actually anticipating what’s going to happen in ways that allow you to stop thinking about the job of documentation per se and instead focus on the data itself. Every person on the team does his or her share. The structured reporting concept really is the integration of the workflow into the management of data, and as a byproduct of that, the quality of that data improves quite dramatically.”

Integrating workflow means team-based healthcare delivery. Team-members rely upon each other for the execution of each portion of care, including data and documentation. The final report is a play by play of what happened during a procedure. “In fact, this increases the accuracy of both the procedure log and the physician’s procedure report,” Tcheng says. “[Post-procedure], the system will recompile the data [which is] 90% of what the physician needs to create the physician’s report…The sanctity of the data remains whole.”

The data also are used for the procedure log report and to create handoff reports to communicate with staff receiving the patient.

Step three is creating the procedure report proper, so that 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). Its tabular format is easier to visualize and interpret versus the often verbose standard sentence-based report. “The structured tabular way is much easier to understand. It’s much easier to see exactly what happened,” Tcheng notes. “It also allows for very easy reporting to data registries…and in performance improvement.”

In addition to improving care and performance, structured reporting also helps improve the bottom line. One of the drivers of structured reporting is that it’s cheaper and can reduce FTE headcount, according to Tcheng. “Administrators are saying this is the direction they need to go: fewer electronic health record entities, health IT systems, more alignment, more interoperability and fewer FTEs.”

Adopting structured reporting

Tcheng knows first-hand the move to structured reporting isn’t easy, but it is definitely worth it. “When we went live, we had all kinds of people who were thinking the sky was falling and there was gnashing of teeth leading up to that day. We went live and people said, ‘oh this was not a big deal, actually this is better.’ So it’s fear of the unknown.”

It didn’t take long for physicians to realize that structured reporting takes less time. “Physicians complete reports in about 5 minutes—and they have about three times the amount of data with a much higher level of quality of that data,” according to Tcheng. “It’s less time for more information in a way that is more easily interpreted and understood while being available for other purposes down the road.”

With less time spent reporting, physicians can add an additional cath lab procedure a day, see other patients or go home earlier. Structured reporting also enhances efficiency from a staffing perspective, namely in registry reporting.

Duke participates in more than 20 registries. One FTE can manage three to four registries, a new model that is working well.

Registries are all about data. And in the big picture, Tcheng sees momentum building for knowledge and evidence-based medicine powered by structured reporting. “We are in need of structured reporting where there’s high-risk, high-cost medicine being delivered.”

Are you ready for the future?

Cardiovascular disease sits in the cross-hairs of both high-risk and high-cost medicine. Tcheng cites reasons for declines in cardiovascular mortality: Better drugs, better imaging and better devices. “This is what we do in the cath lab. Understanding what the problem is in the first place is one thing. If we can get much better data on the inside then we can get much better analysis going on the outside of the equation. Long term, data are what matter.”

Looking further into the crystal ball, Tcheng sees a day when cardiologists will utilize the structured data in patients with heart failure, atrial fibrillation, or chest pain during an office or ER visit to compare him or her with data from similar patients to help guide the most effective and efficient care. “We then start getting closer to a healthcare data-intensive ecosystem where we can reuse data that’s collected even through routine encounters. We could use this for device followup or comparative effective research. But until we actually start collecting this thin layer of data with every encounter, we are not going to get there. [We need to] think about areas which are not good for structured reporting but still would benefit from the acquisition and accumulation of small amounts of data for the purpose of therapeutic decision making and the determination of outcomes in device surveillance.”

The needs and goals are significant, but so are the stakes. Structured reporting answers healthcare’s challenges: improving care, enabling more effective communication and coordination, reducing costs, allowing data to be used in multiple ways and over time, and improving quality over the long-term. Tcheng quips: “It is all the things that you want to be able to do with healthcare data that you can imagine.”