The ACC, American Heart Association and Society for Cardiovascular Angiography and Interventions, in collaboration with 14 other professional societies, have released a health policy statement that defines the clinical standards for structured reporting in the cardiac catheterization suite.

The goal of the statement, published March 28 in the Journal of the American College of Cardiology, is to provide a standardized means for how to report a variety of cardiac catheterization procedures and improve patient care by making clinical data more timely, accessible, consistent and usable.

Importantly, the statement expands beyond the narrow concept of the structured report to include the entire data acquisition and reporting process. Structured reporting includes the integration of data management with workflow, involving all members of the cardiac care team who contribute to the management of data before, during and after the cardiac catheterization procedure.

Currently, only a small number of cardiac catheterization laboratories effectively implement structured reporting, and lack consistency and vary widely among catheterization labs and vendors. The result of this new, standardized approach should produce clear, concise, thorough and organized reports on catheterization procedures that include all information relevant to both clinical care and operational administration.

"These data-intense reports will efficiently convey the details of the procedure, findings, analyses and recommendations of care for the patient," said James E. Tcheng, MD, FACC, interventional cardiologist, director of Duke Information Systems for Cardiovascular Care, Duke University Health System, Durham, NC, and vice chair of the project. "They will reduce the documentation burden and allow physicians to focus more on care recommendations for the patient."

The new published statement also offers specific report templates to illustrate the principles of structured reporting. They provide a step-by-step process from scheduling to analysis and outlines how to compile a report once the procedure is complete. They also identify when, where, and how the processes of data are integrated into the workflow. In providing these report templates, the joint effort will help accelerate the development and application of this new approach to reporting catheterization procedures.

Widespread adoption of structured reporting will require a substantial transformation that will affect administrators, physicians and staff. However, this transformation is aligned with federal initiatives promoting the universal adoption of electronic health records. Also critical to the success of this effort is for health information technology vendors to build and implement systems that enable structured reporting.

Moving forward, the authors of the statement note that the "cardiovascular community recognizes the critical importance of structured reporting and calls for its uniform adoption." They add that "structured reporting [should] be considered one component of the overall quality improvement imperative for cardiovascular care."

Keywords: Electronic Health Records, Cooperative Behavior, Health Policy, Quality Improvement, Patient Care, Cardiology, Cardiac Catheterization, Documentation, Catheterization, Medical Informatics, Cost of Illness