By Scott Mace
Structured reporting systems are expected to dramatically improve patient care and data management.
A coalition of 14 professional societies, led by the American College of Cardiology and by the Society for Cardiovascular Angiography and Interventions, estimates that only 10% of United States cardiac catheterization labs use structured reporting to improve efficiency and bolster patient outcomes.
In this HealthLeaders Q&A, MediReport co-founder and CEO Serge Makowski, MD, an interventional cardiologist, explains how unified cardiovascular information systems (CVIS) are ushering in a new era in cardiology reporting. This interview has been lightly edited for clarity and brevity.
HealthLeaders: How does this guidance conform to best practices in clinical documentation overall? EHRs, and the standards defined by meaningful use, have specified discrete data input fields that feed into quality measures being used to implement value-based care. Do structured narratives conform to these meaningful use guidelines?
Serge Makowski: The adoption of structured reporting in the cardiovascular space is being recommended with the goal of improving the quality of cardiovascular reporting and patient care. The use of dictation and free text makes it difficult for physicians to search for and locate valuable information and procedure findings retroactively. In this regard, structured reporting can bolster improved quality of care, as it ensures that clinical data such as patient history, past treatments, findings, and procedure results are standardized and easily retrievable for any caregiver that will treat the patient throughout the entire care continuum.
Embedded in the EHR as a single platform or standalone, these platforms allow the clinician to access data captured directly in the EHR as well as have access to unstructured data like diagnoses, summaries, notes, etc. By using consistent vocabulary and cardiology specialty-specific report templates, this also ensures that the communication between different patient care teams is complete and clear without any ambiguity.
To comply with Meaningful Use, various specialties, including cardiovascular, are adopting structured reporting with such benefits as reduced errors for future diagnostic or care decisions, lower semantic errors and increase in care quality and consistency while abiding to the latest clinical guidance.
Directly acquiring data from the clinicians (unstructured data) may create obstacles in fully leveraging the EHR’s potential, including the secondary use of data. But modern and flexible structured reporting systems employ discrete data fields to collect structured and standardized data from all physicians. This allows the facility to reuse the discrete data in various instances, like clinical research or registries.
The technology intelligently guides the clinician on the required and important procedural data and generates near real-time reports, which are automatically incorporated into the facility’s existing electronic health record (EHR).
The solution integrates discrete data fields in a precise order to collect structured pertinent data, relying on a structured database that incorporates requested criteria from registries (for instance, NCDR and SCAI) or international classifications like SNOMED.
HL: Of the 10% using structured reporting today, how is this being accomplished — through which platforms, practices, or workflows?
Makowski: Different facilities are at different levels in their structured reporting initiative. The basic stage is the use of procedure documentation to record all relevant procedure and patient information as structured data.
Other facilities go even further by integrating this documentation system via HL7 to allow communication and with other departments and the hospital EHR. A third, more advanced level in the structured reporting process is embedding additional value-based functionalities via customization of reports per physician or facility specifications.
The most advanced stage in structured reporting implementation is maximum interoperability with different systems or platforms, such as integration with industry-specific registries. We have seen more modern and sophisticated CVIS systems offering all these functionalities and other business-oriented features as real time analytics and inventory management.
All of this results in greater physician satisfaction, as it allows them to save a great amount of time and resources when performing their clinical reporting and administrative tasks with better outcomes. This, in turn, has a strong downstream effect on improving billing accuracy and reducing costs.
HL: These findings come at a time when health IT systems are augmenting reporting systems with querying of “live” data. Does structured reporting facilitate this?
Makowski: Absolutely. Modern structured reporting systems facilitate the acquisition of live data by seamlessly interfacing with the EHR, the HIS, and modalities (like the PACS, Hemodynamic system, X-ray station) in real-time. This allows the system to automatically, and effortlessly, capture pertinent live data, before (i.e. patient history, consent), during (i.e findings, hemodynamic values, dosimetry, measurements) and after (i.e. patient recovery, adverse event) the procedure.
This data then automatically populates the structured report, and the doctor only has to review and sign the final report before it is automatically sent to the referring doctor and the EHR.
HL: What industry standards support structured reporting? To what degree do such standards now need to be defined to assure compatibility between different structured reporting implementations?
Makowski: It is essential that standards are defined. Systems that follow standards work together better, they are easier to implement, and they improve efficiency, resulting in better patient care. Effective platforms are fully connected to the hospital system be adhering to the Integrating the Healthcare Enterprise (IHE) Profiles. They use the IHE as a baseline, and may also follow main standards such as HL7, FHIR, and DICOM. They also have the ability to support proprietary standards from other vendors; for example, in electrophysiology they might communicate with pacemakers and defibrillators via the Implantable Device Cardiac Observation (IDCO) profile, while In the catheterization lab they use HL7 and DICOM to communicate with Hemodynamic and x-ray systems.
Scott Mace is a contributing writer for HealthLeaders.