Three C’s of Cardiovascular Structured Reporting – Completeness, Consistency, and Comparisons – Achieved using a Decision Support Process Neil L. Greenberg, PhD Heart and Vascular Institute, Cleveland Clinic Adjunct Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University @SIIM_Tweets #SIIM18
Cardiovascular Informatics: Key Components • People – cardiologists, sonographers, but also vendors, IT, data management, administrators, billing specialists and USERS • Imaging Modalities • EMR / CVIS – schedules, orders, results, images • Cardiovascular PACS • Advanced Analysis/Processing Tools • Structured Reporting • Image Archive • Data Warehouse @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Essential attributes • Structured format of the clinical report • Consistent organization of reported content • Standard language utilized within the report @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Objectives • Ensure completeness and compliance with reporting protocol • Improve reporting efficiency • Ensure comparability of reports • Standardize language in reports to minimize ambiguity. • Facilitate automatic functions, integration with other clinical parameters and data sharing. @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Data Mining and Business Analytics • Produce statistical summaries and departmental reports • Improve departmental efficiency and reduce costs by monitoring daily operations • Extract clinical information for use in research • Compile statistics required for accreditation • Intersocietal Accreditation Commission (IAC) • Provide data directly for registry submission • National Cardiovascular Data Registry (NCDR) @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Policy Statements • http://circ.ahajournals.org/content/119/1/187 ACC/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging Pamela S. Douglas, Robert C. Hendel, Jennifer E. Cummings, John M. Dent, John McB. Hodgson, Udo Hoffmann, Robert J. Horn, W. Gregory Hundley, Charles E. Kahn, Gerard R. Martin, Frederick A. Masoudi, Eric D. Peterson, Geoffrey L. Rosenthal, Harry Solomon, Arthur E. Stillman, Shawn D. Teague, James D. Thomas, Peter L. Tilkemeier, Wm. Guy Weigold • http://www.onlinejacc.org/content/63/23/2591 ACC/AHA/SCAI 2014 Health Policy Statement on Structured Reporting for the Cardiac Catheterization Laboratory Timothy A. Sanborn, James E. Tcheng, H. Vernon Anderson, Charles E. Chambers, Sharon L. Cheatham, Matthew V. DeCaro, Jeremy C. Durack, Allen D. Everett, John B. Gordon, William E. Hammond, Ziyad M. Hijazi, Vikram S. Kashyap, Merrill Knudtson, Michael J. Landzberg, Marco A. Martinez-Rios, Lisa A. Riggs, Kui Hian Sim, David J. Slotwiner, Harry Solomon, Wilson Y. Szeto, Bonnie H. Weiner, William S. Weintraub and John R. Windle @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Templates • ECHO (TTE, TEE, STRESS) • CATH (diagnostic and interventional procedures) • Vascular US (carotid, venous duplex, …) • PEDs / Congenital • Nuclear Medicine (SPECT / PET) • Cardiac MR @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: TEE Template @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Why? • Integrate and carry forward clinical history • Define Normal vs. Abnormal observations and measurements • Automate conclusions/impressions – abnormal / significant findings • Enhanced discrete data export such as LV EF directly to the EMR • Improve billing accuracy - Diagnosis and Indications driven by Study Type • Diagrams (bulls-eye plots and coronary tree) for ‘simple’ visual representation • Trend plots for easy data comparison • Clinical Decision Support • Completeness -- ECHO / VASC - Intersocietal Accreditation Commission (IAC) • Consistency – measurements/observations and billing CPT and ICD-10 code generation • Comparisons -- Automate prior exam comparison findings @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Missing Data from QA Analysis We assessed 2500 QA exams in 2014-15 to determine the percentage of missing data in key areas. Prior comparison and missing segmental LV function (LV seg fx) were the most frequent missing elements. Left Ventricular diastolic function (LV dia fx) and assessment of pulmonary hypertension (RVSP) also demonstrated a higher percentage of missing data based on QA peer review. @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Missing Data from Echo Results • Six month review of complete echo exams • Our reporting template has a mandatory component that aids in reporting an ejection fraction (EF) for each exam and as such EF was reported on 99.4% of all exams. However, segmental functional assessment on all complete exams was not mandatory and just over 28% of all exams are missing this assessment. • Two other sampled variables that should be valued when moderate valve disease is identified are mitral valve regurgitant orifice area (MV ROA) and aortic valve (AV) area. Given that our echo reporting template has a default AV area reported, but requires MV ROA to be specifically reported, it is not surprising that the degree that MV ROA is unreported is much higher. @SIIM_Tweets #SIIM18
Why is Decision Support Needed? • Have you completed a preliminary report and been called by the cardiologist and told that you forgot to include aortic valve area on a case you described as having moderate aortic valve stenosis? • Have you been called by a referring physician to clarify findings in an echo report where a normal EF of 64% was specified, but the conclusion states that LV function is mildly impaired? • Have you reported an echocardiographic exam and not realized that the ejection fraction decreased 10% from the prior exam performed last year? • Completeness, Consistency, and Comparisons! • Completeness of report based on IAC and laboratory guidelines • Consistency between measurements and observational descriptions • Comparison of measurements and findings with prior exam @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Decision Support in syngo Dynamics • syngo Dynamics (Siemens) developed a mechanism to create rules that allows customers to improve the quality in terms of completeness and consistency in the structured reporting process. • A rules engine from the Microsoft BizTalk environment is available to syngo Dynamics. • The decision support policy has been defined (and evolves by the customer) as a set of rules in a tool called the BizTalk Rules Composer. @SIIM_Tweets #SIIM18
Decision Support Architecture @SIIM_Tweets #SIIM18
Rules: ECHO Report Completeness (Exam Type specific) • If complete ECHO (vs limited or focused exam), then Blood Pressure, HR, Rhythm, LV size/function, regional wall motion, RV size/function, LA size, RA size, Ao size • If STRESS, then stress result required, blood pressures required; METS required, … • If TEE, then procedural stop time, sedation information, … @SIIM_Tweets #SIIM18
syngo Dynamics TEE report @SIIM_Tweets #SIIM18
syngo Dynamics TEE report @SIIM_Tweets #SIIM18
syngo Dynamics TEE report @SIIM_Tweets #SIIM18
syngo Dynamics TEE report @SIIM_Tweets #SIIM18
syngo Dynamics: TEE Billing @SIIM_Tweets #SIIM18
syngo Dynamics TEE report @SIIM_Tweets #SIIM18
ECHO Rules: Consistency of Observations and Measurements • LV systolic function – Ejection Fraction (EF); gender • LV cavity size – LV End-Diastolic Volume index (LVEDVi) • Pulmonary hypertension – RV Systolic Pressure (RVSP) • MR severity – Regurgitant Orifice Area (ROA) @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: CDS Rules @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Trends • Variable trending available during reporting process • Trend plots can be added to reports • Data linked to images can facilitate image comparisons • Trend plots allow invalid data (perhaps an incorrect measurement) to be investigated @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Conclusion with prior exam comparison @SIIM_Tweets #SIIM18
Cardiovascular Structured Reporting: Semi-Automated Prior Comparison • Prior data access with decision support is available for semi-auto comparison • Potential to add phrases to the conclusion (confirmed by reader) which would indicate changes. • EF has changed by 10% • MR severity has changed @SIIM_Tweets #SIIM18
Goal of Decision Support Process • Improve quality of cardiovascular reporting through data analysis examining: • Completeness of report based on IAC and laboratory guidelines • Consistency between measurements and observational descriptions • Compliance with billing code selections based on the procedure and findings • Comparison of measurements and findings in prior exam(s) @SIIM_Tweets #SIIM18
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