The Standardized Cath Report: Let's All Agree on This

James E. Tcheng, MD, FACC

Duke University Health System

ARS: How Do You Create Your

Cardiac Cath Procedure Reports?

1. Dictaphone – human (assisted) transcription

2. Voice recognition (e.g. Dragon) – transcription

3. Templated text (e.g., “dot phrases”)

4. Templated data entry (e.g., most CVIS systems)

5. Structured reporting

ARS: In Structured Reporting, How is

a Procedure Report Generated?

1. MD creates the report, using a structured template

2. Tech creates a templated report, MD edits the report

3. Computer compiles the report, MD adds

interpretation

4. Computer generates the report, MD over-reads

Clinician Documentation 2017

Dictation recorder

Pen

Clinician Documentation 2017

• Mired in ancient paradigms (the document paradigm)

– Authoring of descriptive, play-by-play novella– Demonstrates physician prowess, justification of actions– (Misbelief) that it will be a good defense in malpractice

• 75% is garbage!– E&M coding requirements, EHR Meaningful Use, …

• Team-based documentation actively discouraged– By regulation, job description, EHR systems

Where’s Waldo?

• The left ventricle is small in size due to severe left ventricular hypertrophy but has normal overall contractility. Diastolic relaxation is about as expected. The estimated ejection fraction is >55%. The anterior wall, septum and apex have normal systolic motion. The inferior, posterior, and lateral walls also contract normally.

The Clinical Informatics Model• Clinical lexicon as the foundation of controlled

vocabularies rich clinical data + transactions = insight

• Common Data Model (enabling data exchange)

• Dependence on high quality data (NOT documents)

• Documentation: team-based, data capture at the POC, via structured / semi-structured reporting

• Data privacy, data securityIn theory there is no difference between theory and practice. In practice there is. Multiple attributions

What is Structured Reporting?

• Team-based documentation: specific data captured by the person closest to that data in the clinical workflow

• Use of universal, well-defined common data elements

• Data model that parallels clinical care model

• Data compiled to produce (vast majority) of report

• MD: focuses on data quality, cognitive interpretation –NOT report authoring

• ROI: data quality /quantity, redundancy / repetition, time to final reports, FTE requirements

“You never change

things by fighting

the existing reality.

To change

something, build a

new model that

makes the existing

model obsolete.”

-- Buckminster Fuller

Standardized Cath Report – Page 1

• Header: site, patient identifiers

• Summary

– Procedures performed (list – based on CPT coding)

– History (1-3 sentences)

– Encounter category (urgency)

– Vascular access / hemostasis

– Diagnostic / guide catheters (list)

– Diagnostic findings (tabular summary)

– Intervention results (tabular summary with devices)

– Complications

– Impressions and Recommendations

Page 2

Standardized Cath Report – Page 3+

Patient demographics

Healthcare facility information

Operators, staff

Referring provider information

H&P (categorical) data

Previous procedures

ICD diagnoses

AUC indications

High risk allergies (e.g., contrast)

Laboratory data

Logistics (e.g., time in, time out)

Baseline data (e.g. height, eGFR)

Technical details (e.g., max ATM)

Estimated blood loss

Specimens removed

Hemodynamic support

… and all the rest of the details …

Learned Helplessness

• Doing the incorrect thing over &

over again makes you really good at

doing the incorrect thing

• It is easier to repetitively act to new

beliefs, rather than to believe your

way to new actionsTimothy D. Wilson - Strangers to Ourselves: Discovering the Adaptive Unconscious

1. Informatics: clinical lexicon common data elements (CDE) controlled vocabularies common data model (CDM) data exchange

-- YOU NEED INFORMATICS!

2. Clinical industrial (process) engineering & implementation science to describe, model, & implement best-practice workflows

-- ENVISION CHANGE, FOCUS ON EFFECTIVENESS / EFFICIENCY

3. New MD professionalism standards, staff roles and responsibilities: and conversion from the dictation (document) to information model

-- TEAM-BASED CARE AT ITS BEST – and is a patient expectation

4. ACC partnership with IT vendors, healthcare systems

-- PRESSURE VENDORS (& ACC): STRUCTURED REPORTING!

Where Are We Going?

Artifacts at ACC.org

• Health Policy Statement on Structured Reporting– Informatics and Health IT Task Force

– Clinical Quality Committee

• Data standards publications (ACC/AHA TFDS)– EHR “Top 100”

– Cardiovascular endpoints

– CV research infrastructure (and more) …

• Prototype cath report

• Procedure report Style Guide

• Integrating the Healthcare Enterprise (IHE) profiles