Structured reporting on procedures performed in catheterization laboratories should convey all relevant technical and clinical information concisely, consistently, and in a data-intense format that can be shared across various information technology systems. This is the goal set forth in a new health policy statement developed by experts from the American College of Cardiology, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions in collaboration with 11 other professional societies.

The document was published online March 28, 2014, ahead of print in the Journal of the American College of Cardiology and Circulation.

The writing committee, chaired by Timothy A. Sanborn, MD, of the University of Chicago Pritzker School of Medicine (Chicago, IL), says that despite endorsement in several earlier documents, “adoption of structured reporting has been slow, and even today the majority of catheterization reports are dictated and transcribed in unstructured formats.” Moreover, even when structured reporting is used, the approach is often inconsistent from lab to lab and from vendor to vendor, the authors note.

Elements of a Structured Report

The policy statement addresses both the final lab report and the reporting process. The latter, the authors explain, should include all information relevant to clinical care and operational administration, with an emphasis on data, which should be clear, concise, organized, and relatively easy to comprehend.

Importantly, the authors say, clinical data elements should be standardized to provide the basis for accurate assessment of operator performance. Key to this goal is digital formatting to allow easy data exchange with registries, they add.

In addition, data acquisition should be integrated into the natural workflow of a procedure, maximizing accuracy, completeness, and efficiency.

The final report, which can be readily generated from workflow data, should be divided into 3 sections:

• A single-page ‘executive summary’ of information most relevant to providing patient care
• Graphical representations of the findings and images specific to the procedure
• All remaining data, presented in formatted tables, to serve as a reference for regulatory compliance, administrative purposes, quality assessment, etc.

The specific content should be tailored to the particular procedure, which can range from diagnostic catheterization and PCI to structural interventions.

According to the authors, the purpose of the final report is to:

• Document key data used to assess indications and appropriateness of care
• Detail technical aspects of the procedures
• Describe findings and observations
• List results and calculations
• Provide the interpretation of the case
• Convey patient recommendations

This information is vital to communication between physician operators and the team of healthcare providers, who in turn interpret it for patients, enabling them to understand and participate more fully in their care, the statement explains. The final report also facilitates:

• Billing and inventory management
• Process and performance improvement
• Patient outcome analysis
• Teaching and education
• Participation in registries
• Assessment of compliance with practice guidelines

Good-bye to Dictation

In a telephone interview with TCTMD, Dr. Sanborn said the policy statement provides a model of “what a structured cath lab report and the process of structured reporting should be.

“Historically, cath reports were kind of wordy,” Dr. Sanborn noted, “and some of the important data got lost in the text.” Even today, the way in which reports are generated is quite variable, he added.

Not only is the recommended report format more clear and concise, Dr. Sanborn said, but “it is more readily abstracted for some of the databases that we participate in, such as the American College of Cardiology’s NCDR,” which enables operators to measure their performance against nationwide benchmarks.

In addition, a consistent report ‘vocabulary’ is important, Dr. Sanborn remarked. “For example, you want to know the specific indication for the procedure, and those diagnoses are put in with their codes. This [template process] forces you to summarize in bullet points what the patient’s condition is.”

Often a cath lab member records the procedure in a chronological log, Dr. Sanborn observed, “but you want to be able to extract information to put in the final report. For example, if you use catheter x, y, or z, that is automatically pulled from the log into the final report. That can be very helpful for inventory purposes.”

Cath lab directors and hospital administrators are crucial to implementing this approach, Dr. Sanborn said, but importantly, software vendors, who were represented on the writing committee, have been heavily involved in designing reporting platforms. He reported that he and others have worked with vendors to ensure that, for example, they incorporate fields for recording contrast volume used and cumulative radiation exposure, elements that until recently were often overlooked or buried in reports. “The major vendors are already achieving about 90% of what we’re asking for,” Dr. Sanborn commented, adding that they often provide training in use of their software.

Dr. Sanborn said electronic platforms enhance efficiency by allowing cath lab members such as technologists, nurses, and fellows to enter data during the workflow process. This reduces the documentation burden on physician operators, giving them more time to focus on patient evaluation and treatment, he noted. Moreover, the delay inherent in the old process of dictation and transcription is eliminated.

A Political Issue?

This latest initiative to bring cath lab reports up to date is just 1 chapter in “a long, ongoing story,” Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), told TCTMD in a telephone interview, that is “tied in with the concept of a nationwide repository” of data.

Disagreeing somewhat with the authors’ assessment, Dr. Brener asserted that most cath labs already use some version of the structured reporting advocated in the policy statement. “The problem is that they are not standardized because there are many vendors, and each one creates a different report,” he said, adding that the proprietary platforms typically do not communicate with one another. Moreover, it is difficult and very expensive to switch software systems, he added.

The key stakeholders in the drive to adopt standardized, interoperative reports are the national organizations and payers, Dr. Brener contended. “Ultimately, it is all about money,” he said. “If, for example, tomorrow [the Centers for Medicare and Medicaid Services] said, ‘If you [cath labs] don’t produce a report in this format, we won’t pay you,’ you would produce a report in this format,” he commented, adding that countries with a single-payer healthcare system do not have this issue because they set a nationwide standard.

“The idea [of structured reporting] is great; it’s the implementation that is problematic,” he concluded, adding, “This is not a technological challenge; this is a political issue.”

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