The Use of ProVation MD for Structured Reporting in the Cath Lab

Kristi Baden, BSN, Manager of Cardiac Cath and Echo Vascular Lab, Boone Hospital Center, can be contacted at kbaden@bjc.org. 

Paige Klein, MSN, FNP-BC, Director of Clinical Services, Missouri Heart Center, can be contacted at debrak@moheartcenter.com. 

Dr. William Woods can be contacted at wmlwoods@moheartcenter.com.

I. Kristi Baden, BSN, Manager of Cardiac Cath and Echo Vascular Lab, Boone Hospital Center, and Paige Klein, MSN, FNP-BC, Director of Clinical Services, Missouri Heart Center:

Can you describe the unique set up of the labs at Boone Hospital Center and Missouri Heart Center?

Kristi Baden, BSN, Manager of Cardiac Cath and Echo Vascular Lab, Boone Hospital Center: Boone Hospital Center has 4 labs and then the outpatient lab across the street is housed in the Missouri Heart Center office. The physicians have one lab at Missouri Heart Center and there are 4 rooms that they also work out of at Boone. We only have one group of physicians, Missouri Cardiovascular Specialists, that works out of both areas. 

Paige Klein, MSN, FNP-BC, Director of Clinical Services, Missouri Heart Center: Our labs are right across the street from each other. Missouri Heart Center is connected by a walkway to the main campus, so it is easy access.

What about diagnostic cases at Missouri Heart Center that turn into interventions?

Paige: We can handle many of the diagnostics that turn into interventions, but there are specialty situations where we will roll them across the street.

How do the two of you interact?

Paige: We support each other, but it is unique in that I don’t deal with inpatients very often, and Kristi does, the majority of the time. Most of my patients are outpatients, so it is a little different focus.

How long have you been using ProVation MD from Wolters Kluwer?

Paige: Since May of this year.

Was it simultaneous implementation in both your labs?

Paige: Yes. It was a joint effort. We had people from both labs go to the training. Our teams worked very hard

Why did you decide to implement structured reporting? 

Kristi: It had actually been a physician request for some time. Physicians were using dictation and then had somebody from medical records transcribe it. ProVation MD seemed to be a great way to put it all together without needing to do the dictation. So it was by physician request that we started the process.

What didn’t they like about using dictation?

Paige: Oh, I think they liked it a lot! However, one of the things we have always tried to do is make sure our modalities are accredited by their related organizations. The idea behind going to structured reporting was to make sure that everything is covered and a consistent report exists. It means that when somebody calls and asks a question, we know where to go in the report to find that answer, instead of pulling something out and thinking, okay, let me read this whole thing so I can tell you what you need to know. We were looking for efficiencies, consistency, and better overall documentation.

What kind of turnaround time did you have with dictation as your reporting system?

Kristi: Some physicians wouldn’t dictate for about a week, although that was just a couple of outliers. Most physicians probably would dictate within a couple days. It then took a day or two to get the report transcribed. ProVation MD is instantaneous. Once the physician hits the button, the data flows and is available in the medical record.

Now physicians will work in the ProVation MD system directly after a case?

Kristi: Mostly, they will, yes.

Paige: If not immediately, they try to do it within 24 hours, which is a big improvement.

How many locations for reporting are there?

Kristi: There are multiple locations in both labs. 

Was there something about ProVation MD in particular that appealed to your facility?

Kristi: We did look at other options. However, the GI lab in Boone Hospital Center was already using ProVation MD. The physicians, because they talk to each other, learned how well the GI lab was doing, and that the GI physicians liked the system. 

How has the use of structured reporting affected everyone?

Paige: We are still learning, but we are making good progress. We had to learn not to be quite as detailed, but to get the basic information out, which helped with the consistency and the structure. You have your road bumps, but I think everyone is starting to embrace it and things are going much smoother. 

What kind of training did Wolters Kluwer offer your team?

Paige: There was off-site training that two of the technologists, one from each lab, attended in order to help get the reports ready, learn how to navigate through the system, and be able to come back and train. Wolters Kluwer had support people for when we went live to sit with the doctors and help them walk through each report. 

ProVation MD offers a diagram as part of their report, called the DocuDiagram. How has that been received by your physicians?

Kristi: Actually, it wasn’t new for us, because we already used a diagram in our previous reporting. Some physicians will show the DocuDiagram to patients. 

Paige: Our physicians want to make sure everything they see during a procedure is on a diagram, but you get to the point where you get lost in the detail. The DocuDiagram only permits documentation of the main, important parts. Perhaps there was a small, ectactic vessel that really doesn’t impact what they did. ProVation MD has redirected them a little. There has been a little bit of a learning curve with that.

What was the procedure for reviewing old cases prior to ProVation MD? 

Paige: Most of the time, the staff would pull up the report from our medical records, and the doctors would look at the images on the PACS system. We would then have that document as a backup, once they got into the procedure and wanted to know where a particular graft went, for example. 

Is the process any different with ProVation MD?

Kristi: It is the same. Our documentation used to be attached to the PACS system, so if they pulled up a film, they could actually view the documentation that occurred by the staff also, at the same time. I don’t think that occurs with ProVation MD, although you can still pull up ProVation MD easily in the medical record. Staff documentation seeds ProVation MD, but we also print off our own documentation. The “time out” of the procedure is documented in our staff documentation. The physicians document that a time out was performed, but they don’t document the exact time, so staff notes when it is done on their documentation. The exact time of hemostasis or exact time a stent is placed is on staff documentation and not necessarily in ProVation MD. 

Paige: Blood pressures and Aldrete scores are all on the procedure log done by the staff, and not replicated in the ProVation MD report.

What about coding and billing?

Paige: I haven’t seen any fallout from the technical sides. On the professional side, we’ve had some things where we had to go back in and take another look. I think ProVation MD is definitely built for a hospital facility, and it is going to be helpful. But we have some billers that have done this for a long time and there were some inconsistencies that we had to work on to get them right. Wolters Kluwer has been very receptive to helping us make the changes we need to make.

Have you been doing some tweaking to the system?

Paige: Not so much now. At first we did a lot. It’s funny, if you knew then what you know now, you might have done a few things a little differently. But I think that happens any time you implement a new system.

What are your future plans for work with ProVation MD?

Paige: There are some things we would like to bring into the system that aren’t there yet. We have a new physician coming in for peripheral vascular work, and will have an opportunity to get that module and make it a little more robust. EP is not something that ProVation MD has available yet, but we’d be interested, once it becomes available.

Do you have any recommendations for other labs that might be considering a move to structured reporting?

Paige: It might have been helpful for us to actually see how the system was used in a live situation instead of demos. In training, you learn to do certain things and don’t know their importance until you get into system use for a little while. Then you realize, oh, maybe I should have spent a little more time doing (that particular thing)! 

Also, getting the reports ready is important. You will want to evaluate all the reports your physicians currently use so that you can customize them in the system.

Kristi: IT was a very important partner. Make sure all of the players are together at the beginning. I think we did a good job. It is not easy, because we are part of a big system, the BJC HealthCare system out of St. Louis, so the transition did not necessarily involve people that are housed out of our facility. We had to bring people out of St. Louis to have our meeting in mid Missouri. That was something to make sure we had all mapped out in advance.

Paige: We were integrating ProVation MD with a system that was already in place — there were some specifics where if you make a change in the system, it doesn’t just affect you, it affects everybody that is using that same server. The IT aspect took a very large portion of time and expertise.

Has structured reporting with ProVation MD been a positive step forward?

Kristi: I think so.

Paige: I do think so, because we are not missing anything. ProVation MD is going to keep us where we need to be in order to be competitive, get reimbursement from insurance, and all those things you have to think about in addition to taking care of the patient. ProVation MD was definitely a good move. It was a change during a time when things are continuing to change. In the medical profession right now, I don’t think we are going to get away from that at all. I once attended a lecture where someone said that if he held all the regulations for everything that he did, he would have to wear a lab coat that had a thousand pockets, and it would weigh so much he couldn’t go from one room to the next. It kind of feels that way sometimes. ProVation MD has really helped with that piece of it, and that’s been nice.

II. William L. Woods, MD, FACC:

What made you want to begin with structured reporting?

The obvious problem was that we had multiple cardiologists dictating their own cath reports in their own style. There was no standardization. Everyone did it in a different way; you had to look for information in different ways from different reports. Some people would tend to leave things out that other doctors would include, and so forth. It also could take a while to dictate, especially for a complex procedure. We did have a diagram people could draw on to show where the blockages were in a visual way, but some doctors didn’t use it. It took time to manually do a diagram on a piece of paper. The DocuDiagram, something that ProVation MD allows, is very valuable when showing the report to patients, when trying to explain blockages, or even when other people look at the chart later and just want to know, with a quick snapshot, what it shows. I had been interested in a structured reporting system for a number of years. I saw ProVation MD demonstrated at a meeting, and was very interested because of how user-friendly it was. We had a formal demonstration at Boone Hospital, and everyone thought it was an excellent product and would suit our system well. Wolters Kluwer already had a similar package in place for the GI lab, so our hospital was already familiar with the system. The company came in and did a very good job with their go-live. Wolters Kluwer made sure we had adequate training so people knew what they were doing. Nobody was left out in the cold with a software program they didn’t know how to use. That was the key thing. Wolters Kluwer made sure there were some super users here, too, who were trained ahead of time, and that could help us, especially after the formal trainers left. 

How did physicians react to the implementation of structured reporting?

Especially with a large group of physicians, any time there is a mention of change, there is some consternation. We get settled in our own ways and used to the way we do things. However, we all recognized from a theoretic standpoint what the benefits would be from structured reporting, particularly regarding coding and billing, documentation, and having a standardized report that looks the same no matter which physician does it. ProVation MD also offers a much more professional-appearing report than the ones we had before. I think once everybody realized how user-friendly ProVation MD was, the concern melted away. At this point, everyone seems to be very happy with the system. I know the company is working on the concerns that I have. There is some difficulty in indicating, in a visual way, a balanced coronary system, where the posterior wall is supplied by both the right coronary artery and the circumflex. The diagram does not perform well with different anatomies, and there are a few other minor glitches here and there that Wolters Kluwer is working on. The key point for me is that they are working on it. They are aware of it, it has been brought to their attention, and they are working to fix it. Generally speaking, ProVation MD is a very nice package. 

Is there a place where you can insert a note?

If you choose to do it, you can always type in manually what happened. I have done that on a few occasions; in fact, I did it on a case yesterday, where I felt that there was more information that needed to be there, so I just typed it in on the final page before I saved it and finalized the report. 

Does the use of ProVation MD save time?

We have a particular referring physician that likes to be called after each case with one of his patients. I had two of his patients referred to me on the same day. I waited until I finished the second case before I called him to discuss what had happened. When I called, he was very impressed. He said he had already gotten a fax on the first patient and realized the report from the first patient had already been completed. He thought it was pretty great that he had received the fax literally minutes after the case was over. Referring physicians get the full report, including the DocuDiagram showing what the blockage looks like, just an hour or so after the case, if that long. In the past, if you dictated that a copy was to be sent to the referring physician, first you had to remember to insert that when you dictated. Then you had to wait a day or two or three for it to be transcribed, then the report had to be mailed or maybe faxed to the referring physician, and then all it contained was words. There was no diagram. To my knowledge, the previous diagram, which only some of us used, was never sent to the referring physician, but went into the patient’s chart immediately from the cath lab, along with all the cath lab data. 

Have you gotten to the point where you are pulling up old cases with reports created through ProVation MD?

Yes. I’m not real happy with that yet, because after 26 years of doing cases and looking back, I knew right where to look on the report for specific things and I dictate things in specific ways. I can read between the lines of my own report and know exactly what I was thinking about. That doesn’t happen on ProVation MD because it is so standardized, so when I look back, it takes me a little longer to look at a report (at least so far, because I’ve only done it a few times) and figure out what happened and what I did. The report doesn’t have the narrative I would put on there sometimes. 

What if it’s another physician’s patient?

Then it is easier with ProVation MD, because I know nothing about their nuances of dictation. Of course, I’ve been working with them for a number of years and figured most of it out, but it is probably easier to look at the other physicians’ reports now, because it is so standardized.

What have you seen in terms of the impact of ProVation MD on coding and billing?

It helps with physician billing, but I haven’t asked our coders and experts whether it has made a difference on the hospital side. I do know that for them to submit a bill, they have to have a copy of the actual report, and in this case, our billing now has it immediately. 

Do you have any future plans for the system?

ProVation MD does not yet involve device implantations like pacemakers or electrophysiology studies. That might be something that could be added. Obviously we’d like the problems we have identified to be fixed. I am confident they will. I know Wolters Kluwer is working on it. As far as advice for other physicians, I would say that if you are not using a structured reporting system like ProVation MD or something similar, it is definitely worth looking into. The learning curve is not as bad as it seems. If the hospital is supportive and is willing to pay the cost of it, in the long run, structured reporting saves them money. So if they are willing to come up with the upfront capital, it’s definitely worth it. n