To be the most effective, structured reporting uses the application of vocabulary and data interoperability standards, as well as the use of best practice workflows (industrial engineering). This has the benefit of reducing provider time to complete reports, as well as improving clinical communication among physicians, the care team, and patients. The ACC encourages cardiovascular clinicians to convert from a dictation model to a structured data model in the Cath lab.
Structured Reporting in the Cath Lab
Converting from a dictation model to a structured model does require some initial work. It will require cooperation with internal IT systems and vendors in order to ensure the information model and systems are aligned with clinical model. A sample structure is below:
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Pre-Procedure
Who: Ordering physician [Pre-procedure evaluation by operator]
What information: Patient demographics, requested procedure, scheduling logistics, procedure indications, clinical history
What information as data: Demographics, ICD-9 indications, structured history
Output: Structured H&P
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Procedure
Who: CV Technologist / Nurse
What information: Procedure log, procedure findings
What information as data: Hemodynamics, medications, procedures performed, devices used / implanted, medications – basically everything
Output: Structured procedure data (in tables)
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Analyze and Recompile
Who: Physician (with the aid of the computer)
What information: Findings and interpretations (physician)
What information as data: Compiled H&P, procedure data, and structured findings
Outputs: Procedure log and Procedure report
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