Three Cs of Cardiovascular Structured Reporting Completeness, - - PowerPoint PPT Presentation

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Three Cs of Cardiovascular Structured Reporting Completeness, - - PowerPoint PPT Presentation

Apr 17, 2023 281 likes •694 views

Three Cs 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

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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

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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
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Cardiovascular Structured Reporting: Essential attributes

  • Structured format of the clinical report
  • Consistent organization of reported content
  • Standard language utilized within the report
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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.

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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)
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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
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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
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Cardiovascular Structured Reporting: TEE Template

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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
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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.

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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.

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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
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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.

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Decision Support Architecture

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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, …
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syngo Dynamics TEE report

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syngo Dynamics TEE report

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syngo Dynamics TEE report

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syngo Dynamics TEE report

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syngo Dynamics: TEE Billing

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syngo Dynamics TEE report

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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)
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Cardiovascular Structured Reporting:

CDS Rules

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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

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Cardiovascular Structured Reporting: Conclusion with prior exam comparison

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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
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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)
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Discussion

  • Cardiovascular Informatics is much more than image storage

and report generation. There is great value from structured data collection and it’s utilization is growing.

  • Decision support rules create additional layer of complexity for

users, but are valuable and help to improve quality of diagnostic reports (completeness and consistency).

  • Comparisons of data within and across modalities are possible.
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Thank you

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syngo Dynamics

  • Enables:
  • High performance / robust system for image review and reporting
  • Consistency and accuracy in reporting
  • Data warehouse
  • Electronic billing process
  • Quality assessment
  • Administrative reporting
  • Research investigations
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syngo Dynamics Key Functionality

  • Image review
  • Enterprise patient context
  • Image layouts including Stress stage/view
  • Clip Playback - real-time, performance
  • Portal for web access
  • Structured Reporting
  • Prior exam comparisons of images and data
  • Trend plots
  • Integrated measurement tools
  • Access to advanced US analysis tools
  • QLAB, EchoPac, Tomtec, sUSAS
  • Decision Support
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Cleveland Clinic: Echocardiography

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CCHS Volume: Echo/Vasc/NM

April 16, 2018

  • 589 ECHO exams performed and reported
  • Main Campus + Family Health Centers (357)
  • Regional Hospitals: EUCLH (13), MARYH (8), HILLH (25), SOUTH

(12), MEDIH (14), FAIRH (23), LUTHH (6), AVONH (12)

  • Florida - Weston + FHCs (75)
  • ACMC (19)
  • CC Canada (4)
  • PEDS (21)
  • Akron (3rd Quarter 2018)
  • 243 VASC exams performed and reported
  • 96 NUCMED exams performed and reported
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Cardiovascular Structured Reporting: Diagrams

  • Bulls-eye plots to capture and visualize segmental wall motion

abnormalities, myocardial strain, and other segmental parameters like myocardial perfusion.

  • Coronary artery diagrams allow entry of vessel disease –

location, type, etc. as well as illustrate treatments. These have been extended to vascular diagrams as well.

  • Possibilities exist for further diagrams – valve structure
  • Data can be entered in tabular format and displayed on

diagrams or entered on diagrams and mapped to element structure.

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Structured Reporting

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Data Warehouse

  • Warehouse provides common framework for all cardiovascular

data sources

  • Creation of administrative reports
  • Volume by location, sonographer, reader
  • Turn-around time for exam reporting
  • Quality reports
  • Electronic billing
  • Support research investigations
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Rules – Valve Pathology

  • If MR (>= moderate), then mechanism/etiology, ROA, PISA, MR

Vmax, vena contracta

  • If MS, then pressure half time, peak/mean gradients, valve area
  • If AS, then valve area, dimensionless index, peak/mean

gradients

  • If AR, then deceleration time, vena contrata
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Cardiovascular Structured Reporting: Terminology Standards

  • International Health Terminology Standards Development Organization

(http://www.ihtsdo.org/) developers of the Systematized Nomenclature of Medicine—Clinical Terms) (SNOMED-CT).

  • The SNOMED-CT lexicon is a primary source for medical terminology in cardiology

and other disciplines. Structured reporting standards like those from DICOM and HL7 utilize SNOMED terms and provide feedback for improvements to SNOMED.

  • SNOMED-CT is a very comprehensive clinical healthcare terminology, including

terms for anatomy, morphology, procedures, and clinical findings. This terminology is routinely updated twice per year for adult imaging, and less frequently for pediatric or congenital cardiovascular imaging.

  • Logical Observation Identifiers Name and Codes (LOINC) (http://loinc.org)

and the Radiological Society of North America’s RadLex (http://www.rsna.org/Radlex/index.cfm)

  • extend SNOMED terminology to include operational procedures, document indexing,

and document structuring, providing standard identifiers for many cardiovascular measurements and documenting structuring concepts (report and section titles).