Structured Reporting in the Cath Lab Space

 The authors can be contacted via Anne Beekman, RN, BSN, at Anne.Beekman@spectrumhealth.org.

The Fred and Lena Meijer Heart Center at Spectrum Health in Grand Rapids, Michigan, opened in 2004. This free-standing building, which is connected to the main hospital, contains 330,000 square feet, providing space for inpatient and outpatient needs, surgical and cath lab procedures, and clinic visits. The cath lab space consists of 24 prep and recovery beds, three dedicated coronary rooms, and two peripheral vascular/coronary combo rooms. 

ProVation^® MD structured reporting (ProVation Medical) is used by 36 cardiologists at the Fred and Lena Meijer Heart Center. Our cardiologists come from seven different groups that range from a single group of 39, with 13 providers who work in the cath lab, to a “group” of one. The Center is utilized by both employed and independent physicians. The electrophysiology (EP) service line is in the cath lab and consists of four dedicated rooms; it does not use this tool.

How long has Spectrum Health been involved with ProVation Medical’s structured report?

Our cardiology department implemented ProVation MD Cardiology structured reporting in 2010. The initial request came from the department medical director, Dr. David Wohns. He had seen the technology at the hospital when the ProVation Medical team came here to do a demonstration for the GI/GU service line. We started on platform 4.2 and implemented version 5.0 in March 2014. 

What was your situation prior to implementation? 

Before we implemented structured reporting, we relied on the traditional physician phone dictation model. The process was cumbersome for the department. Someone needed to update their dictated notes with demographic or patient identifiers, and then forward those documents to the physicians for signature. Often, the documents would be “lost” in a sea of emails to physicians; there was not a good way for the physicians to prioritize their work. This process also promoted a system where the physicians would need to touch the documents twice and electronically sign without a purposeful review. All of this required the support of two full-time employees (FTEs) for document management. The turnaround time was about 90 minutes, compared to today’s preferred state of an immediate population to the electronic medical record (EMR).

How does structured reporting aid users at Spectrum Health? 

Today’s healthcare environment encourages the data management concept of “collect once and distribute often,” meaning data interoperability is extremely important in developing a productive model. A specific example would be when the hemodynamic data gathered in a right heart cath procedure feeds directly to the structured report. This process eliminates the potential for manual data entry errors while improving workflow and efficiency. 

ProVation MD Cardiology provides interface options to capture discrete, defined, reusable real-time data that integrates with physician notes, referral letters, coding, billing, and registry submissions through the ProVation Registry Reporter tool. However, we have chosen to use the structured reporting, data abstraction, and system reporting functions to date. We are working toward registry submission from the tool. We currently do not use the billing and coding functions directly, but do include input from this department for the body of the report. We elected not to use the coding/billing component in order to remain aligned with our standard coding software for cardiology procedures. Having the document populate the EMRs in real time has improved the process for coding/billing (without having to open up access to ProVation). The deep clinical content has allowed us to improve the documentation.

Many people have been positively affected by the move from a dictated note where data cannot be extracted to our current model of collecting defined, discrete, computable, reusable data. The patient report now lands almost instantaneously in the EMR.  

To date, the effect on the physicians has been time-neutral at best, but the time to access the report has been greatly improved. We have seen the greatest benefit in diagnostic or interventional cases that are standard. Very complex patients — such as those in cardiac arrest who require emergent mechanical circulatory support or complex chronic total occlusion cases who use exponentially more product — continue to be a challenge overall for the field of structured reporting. It is important to note that physician comfort and proficiency with computers and typing has a significant influence on adaption and satisfaction, regardless of whether providers use the system frequently or infrequently.

How was the installation process in terms of time, effort, and learning curve?

The implementation took less than four months, from May to August 2010, and we were able to pull the date forward two months to prevent a timing conflict with a computerized physician order entry (CPOE) implementation. ProVation Medical set clear roles for us and had a wonderful implementation team. We accomplished 100% pre-go-live training with the physicians, which enabled us to get off to a strong start. The initial adoption rate was very high. We are currently running at 90% utilization for right heart catheterization, 80% for diagnostics, and 70% for interventional cases. The adoption has not reached 100% for two primary reasons: (1) the challenges in general associated with extremely complex patients, and (2) the reality that our leadership has not made using the tool mandatory.

What changes have resulted, both in terms of lab management and patient care?

We have been able to reduce staffing by the two FTEs who were dedicated to “prepping” the phone-dictated reports with patient identifiers. One of these individuals now supports other project needs in the department. The tool also helps prompt the physicians to address core measures. ProVation MD Cardiology anticipates relevant clinical scenarios by leading physicians with questions that enhance the depth of the note. This level of documentation supports registry questions, best practice standards, and research data. ProVation MD is also ICD-10 compliant, prompting for the documentation specificity required under the new code set. We have not seen a significant effect on direct patient care. However, it seems reasonable that having the results in the chart immediately allows for better coordination of care and timely decisions.

Is ProVation Medical part of your long-term strategic plans?

We have been pleased with ProVation MD Cardiology so far, and we hope to utilize the ProVation Registry Reporter tool. We see great value in creating a report that supports clinical and financial requirements. As payment continues to align with quality metrics, we need a tool that is responsive enough to help prompt for key clinical questions. We believe ProVation MD Cardiology will continue to move us in the direction of an EMR that has key documentation available in real time. Ultimately, any time we reduce redundant documentation we show respect for our patients, staff, and providers.

What are your recommendations for labs that may wish to consider structured reporting?

• Start by defining what your team needs the tool to do. This can range from inventory documentation to registry submission.  
• Make sure all the stakeholders are involved and present for the first step. In our experience, physician interest and support is the key to starting the process.  
• Make sure you have a dedicated team to support the physician group, not just at go-live but in an ongoing fashion.
• If your facility does not have residents or other medical students to take on some of the responsibilities for documentation, be prepared to help with the process of crafting a desirable workflow for physicians. You do not want to risk negatively affecting turnaround times and physician satisfaction. 
• There may be additional time needed at the end of a case. Structured reporting tools are set up to effectively capture the majority of work done in a cath lab, but any outlier or complex cases will be more labor intensive. 
• You must include the quality and revenue teams in the process to take full advantage of the tool.
• Consider setting a date for mandatory usage at the front end of the project.  
• Take advantage of the vendor’s eagerness to include customer feedback in their product development cycles.  

Finally, be prepared for a journey. Cath lab structured reporting is complex, and requires buy-in and support from a wide range of stakeholders.