Structured Procedure Reporting: Changing Roles and - … · · 2017-08-31Structured Procedure...
Transcript of Structured Procedure Reporting: Changing Roles and - … · · 2017-08-31Structured Procedure...
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Structured ProcedureReporting: Changing
Roles andResponsibilities
James E. Tcheng, MD, FACC, FSCAI, FESCRAPID Think Tank
14 September 2016
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Objectives
• Describe the team-based, workflow-orientedstructured reporting paradigm
• Discriminate structured reporting (a process)from the structured report (a document)
• Acknowledge barriers to clinician adoption –and the role of professional societies inaccelerating adoption
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What is Structured Reporting?
• Data management integrated intoworkflow, with data acquisition by theperson closest to (handling) the data
• Collect data once, use many times• Multiple contributors to documentation• MD focus on cognitive functions• ROI: data quality /quantity, time to
final reports, FTE• Result: efficient and effective
documentation and communication
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• Clinical vocabulary interoperabledata standards
-- clinical to standard to CVIS to EHR to registry
• Understanding, implementing best-practice workflows
-- who does what when, where, and how(industrial engineering)
• New MD professionalism standards-- conversion from dictation to information model
• Partnership with IT vendors-- information model, HIT systems aligned with
clinical care
What is Needed for Structured Reporting?
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J Am Coll Cardiology2013;61: 1835
• CV vocabularies – NCRI• Balloted via HL7 CIC• Available on NCI-EVS
(caDSR)
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Procedure ReportsBe a poet, not a novelist …
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The Structured Report:Recompile and Interpret
• Who– Physician (with the aid of the computer)
• What information– Findings and interpretations (physician)
• What information as data– Compiled H&P, compiled procedure data– Structured findings
• Output– Procedure log– Procedure report – “just the facts”
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Artifacts at @ACC.org
Health Policy StatementInformatics and HealthIT CommitteeClinical QualityCommittee
Prototype procedurereport
Style guideIHE profileTask Force on Data
Standards documents
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Proposal• Co-publication of an (abbreviated) PVI
Structured Reporting Health Policy StatementACC/AHA – James TchengSVS – Jack CronenwettSIR – Jeremy DurackWith extensive referencing ofACC/AHA/SCAI 2014 HPS
• Workflow diagrams (cath lab, IR, surgery)• Prototype procedure report (with style guide)• Develop RAPID core data elements as the
foundational data standard