Early Adopters: The Valley Hospital’s Structured Reporting Journey With ProVation MD Cardiology
Disclosures: The authors report no conflicts of interest regarding the content herein.
The authors can be contacted via Cathy Ilardi at cilardi@valleyhealth.com.
Could you tell us about your facility and cath lab?
Cathy Ilardi, RN, Nurse Manager: The Valley Hospital is proud to be the hospital of choice for hundreds of thousands of residents of northern New Jersey. Valley is a 451-bed, acute-care, not-for-profit hospital located in 
Ridgewood, New Jersey. Key services include cardiology, oncology, women’s and children’s services, emergency care, orthopedics, and neurosciences.
Cathy Ilardi, RN, Nurse Manager (continued): Our cardiac catheterization suite consists of 6 labs: two are dedicated electrophysiology labs and the other four are coronary and peripheral dedicated labs. We do approximately 4,800 procedures per year, including electrophysiology, peripheral, structural, and coronary diagnostic and interventional procedures.
Dr. Janet Strain, Cath Lab Director: The cath lab does all of the routine diagnostic cath procedures and interventions. We also do structural heart work, including atrial septic defect closures and transcatheter aortic valve replacements, although those are not done in the cath lab, but in our hybrid labs in the OR. Our cardiologists also perform peripheral interventions.
How long have you been involved with the structured reporting system from ProVation Medical?
Dr. Strain: Our kickoff meeting with ProVation was in May 2010 and the go-live was in January 2011.
Randy Sturm, RT(R): We wanted an accurate, structured report generated with a quicker turnaround time. At the time, our reporting consisted of a checklist of 8 to 10 pages that the physicians had to work through after each case. That would get transcribed and brought back to the physician for review. If there were any corrections, it would only delay the final report. This process took anywhere from 7 to 10 days. With ProVation, the physicians are done with an accurate report minutes after their procedure.
What were some of the challenges of a 7- to 10-day turnaround for dictated reports?
Dr. Strain: The challenge of a long turnaround was accuracy of the reports. When the reports came back for review, it was time consuming to recall what was done a week ago to confirm the accuracy of the reports.
Cathy: The long turnaround time also made it difficult to comply with producing an electronically signed report within the mandated 24 hours. We have seen some additional benefits associated with using ProVation.
Can you describe some of the additional benefits?
Dr. Strain: All of our physicians creating a report in ProVation use a DocuDiagram. You actually put the lesions on an electronic coronary tree as a visual and it then creates verbiage that goes along with it. Over the years, the ability to be relatively specific about the size of side branches and the location of lesions has gotten much, much better. We now have a greater than 95 percent one-day turnaround time in cath lab reports. We don’t handwrite any preliminary reports, because the reports go straight from ProVation into the hospital chart.
Cathy: We have also found that the ProVation reporting system is completely aligned with the American College of Cardiology Health Policy Statement on Structured Reporting for the Cardiac Catheterization Lab1 that came out last year. ProVation has the consistent verbiage described by the Health Policy Statement, meaning that if Dr. Strain documents a blockage and stent in her report, and another physician documents something similar in his report, the same verbiage is used.
Was there any skepticism at the beginning of the change to structured reporting?
Dr. Strain: Change is difficult for most, and there was skepticism, because everyone had their way of dictating. Structured reporting was a priority, along with rules and regulations. The move to structured reporting was the first time we 
were able to mandate how physicians did something in the cath lab. We simply made it the policy that the physicians would no longer have transcriptionists available as of such-and-such a date and that ProVation was the only way to do a cath report.
It wasn’t nearly as bad as most people feared it would be. Everyone can be trained. We have super-users to sit with the people who do fewer reports, because perhaps they do most of their work at another institution and don’t have a lot of facility with the ProVation. If anybody needs help, we have a super-user on site.
Cathy: Randy is our primary super-user. The other super-users are Dana Velez and Sindhu Kurup. I do want to emphasize what Dr. Strain said earlier. I think the transition wouldn’t have been as successful had we not done a hard stop on transcription. But the real success is with the super-users and their engagement with the system. They worked with ProVation to understand and customize the system. It took many hours of interfacing with our hemodynamic system to get it right so that it was as painless as possible when the physicians did finally start learning the system. Our system had been scrubbed by the super-users multiple times. It wasn’t perfect when it came out, but ProVation worked with us to get it to a good point.
Randy: Prior to implementation, IT and I really tried to tangle up this system any which way we could, throwing it curveballs to see how we could work around any potential problem. By the time we were ready for the physicians to start learning, and with ProVation on site, we were confident that we could walk the physicians through the reporting process. ProVation was here for 2 weeks. I was fortunate in that I was allowed to be dedicated just to the physicians for a 
couple weeks. This is not rocket science; it’s simply something new. We just had to teach the physicians a different way of doing what they had been doing for years. Now, if a physician asks me a question, it’s a 15- to 20-second fix to show them what to do. It was a very large change for them in the beginning, but each time we have an upgrade, it’s less and less of an issue. There is nothing about the ProVation system that can’t be learned or taught.
Dr. Strain: We recently had a number of new physicians come into the cath lab and they have all picked it up. We haven’t had anybody have a problem with learning how to use the system and become independent. The ProVation system is really very user-friendly. It also does a very reasonable job of generating a billing report, which I use on every case and then give to my billing staff, which makes billing much easier.
Cathy: A coding report is generated at the end of the procedure. So while Dr. Strain takes that report for billing when she goes back to her office, we also use that coding report to bill our procedures. The beauty of that is our physician documentation, our hospital billing, and the physician billing are all aligned.
How has the coding ability of the system kept pace with the increase of complex procedures?
Dr. Strain: Randy worked on a project testing the coding.
Randy: Yes, just to make sure that the billing was appropriate, we combed through and found complex cases such as Rotablator cases, intravascular ultrasound, fractional flow reserve, patent foramen ovale cases, chronic total occlusions, bifurcating lesions — we really challenged the system to see how well it would code these difficult cases. We handed the results over to our hospital coders, and when they would do their cross walk, the ProVation billing report was very accurate. Rarely was there a time when the hospital came back to us and said, no, use a different code. It’s a very accurate system right now. We are pretty confident going forward and when we do go into the ICD-10, we expect ProVation is going to work well for us and it will be as smooth as any ICD-10 transition could be.
Cathy: What is unique about ProVation is that they manage the coding themselves. With other systems we have looked at for other areas of the hospital, when they say that they have coding features, it means the hospital has to maintain it. The coding is not maintained by the vendor.
ProVation updates the system with any coding changes?
Cathy: Yes.
Dr. Strain: At the beginning of 2014, when new angioplasty codes came out that were relevant to, for example, acute myocardial infarction, it showed up in ProVation as soon as it was available. It does make it very easy for the physician billing especially.
Cathy: You don’t experience downtime with those sorts of updates for the billing.
Does ProVation notify you of a coding change?
Randy: We get a quarterly email to say there are updates coming up, but it occurs automatically.
Can you talk about the reduction in turnaround time for the reporting? It was originally 7 to 10 days and now reports are done within 24 hours. Is that consistent?
Cathy: Yes. We actually monitor that monthly. We monitor the compliancy, just to make sure we aren’t slipping.
Dr. Strain: It can be tracked with the push of a few buttons. You don’t need to maintain logbooks checking when the report comes in and when it goes out. It is tracked automatically in the system.
Randy: Each morning, based on the cases that were done the day before, I check to see if there are signed reports. If I see a report that has not been done, I will let the physician know that they have a report outstanding. Report compliancy is one of our Heart & Vascular Institute’s goals.
How long does it typically take for a physician to complete the report after a case?
Dr. Strain: Let’s say we have a diagnostic plus an angioplasty case. If it takes 4 or 5 minutes, that would be a lot, I would say. I don’t think that our original process of checking off the checklist took much more time than that, but then the physician had to wait to get it back, read it, correct it, and then get corrections back and check the corrections. Now all of those extra steps are gone. I do read through the ProVation report to make sure that everything is correct. The very last thing the system does is show you the report on the screen. I look at it to make sure I haven’t forgotten something, but it really doesn’t take much more than 5 minutes.
Cathy: ProVation accepts an interface from our hemodynamics system (Siemens Sensis), so the report can include equipment and medication used in the case. Along with the hemodynamics, it’s all pushed over at the end of the case.
What are your long-range plans for the ProVation structured reporting system?
Dr. Strain: We want to open it up to peripheral procedures. You can do peripheral reports in ProVation; I don’t do a lot of complicated peripherals, so I don’t know how well it does with complicated cases, but it is the same structure as with a cath report. ProVation also does a very nice job of doing the billing in the peripherals, which can be very confusing.
Randy: I’m currently working with the development team at ProVation on their peripheral module, coordinating with the physicians. I am helping physicians walk through a report and finding out what they want to see on the report, with the idea that ProVation can make their peripheral DocuDiagram as simple as the coronary DocuDiagram. Some of our newer physicians are also doing peripheral work, so our peripheral volume has gone up and I suspect that it is going to continue to increase. Now that our physicians are used to electronic reporting, they want to be able to do it for the peripherals as well, so they are really pushing us along to get the peripheral module finalized.
Do you have any recommendations for labs that might be interested in structured reporting?
Dr. Strain: When you look for a system, I think it is extremely important to visit a lab where it is actually up and working. You can hear this, that, and the other thing from salespeople about how wonderful something is, and then find out later that it’s not so true. I’ve had some experience with computerized medical records in the office where they tell you it can do anything, and then when you ask it to do that thing, it really can’t. Our lab is certainly a reasonable example of where structured reporting does work and people from a different lab could come in to verify that. There’s probably nothing about our facility that is tremendously different from another facility. People can come and watch it in action.
Cathy: I think, too, it is important to dedicate the time to the system, as Randy, Dana, and Sindhu have, and to pull the super-users out from regular case work and allow them that time. If the super-users don’t believe in the system or aren’t engaged in it, then the physicians aren’t going to be 100 percent. Pulling super-users out and allowing them to dedicate time to the system means there will be less frustration during the learning curve.
How did you pick the super-users?
Randy: I volunteered.
Cathy: My motto is, ask for volunteers before you mandate anyone do something. Randy came from a background of being very involved in hemodynamic and documentation systems in the lab. He stepped up, he was the perfect choice, and he flew with it in many ways. It’s really about tapping into those who want to make a difference, and Randy did. Dana and Sindhu, our other two super-users, are also very involved in the cath lab operations aside from doing cases. They are both well-versed in our hemodynamic system and tailoring of this. They volunteered as well, and they were a perfect fit for the super-user role.
It must help to have a physician champion, too.
Dr. Strain: Well, these days, the physician director of the cath lab has to buy into it, because clearly, if I was obstructionist, things would have been much more difficult. But there is no question in my mind that ProVation makes everything easier. You know exactly what the cath report is going to look like. When I come back to a cath report done by someone else two years ago, I get the information out of ProVation that I want. Most of the time, all I do is look at the DocuDiagram. All of the information is in a clear, visual format. So while you need to have buy-in and people have to want to do structured reporting, there is a reward. Reporting is easier, the report is quickly finalized, you don’t have to do a lot of proofreading, and you get a reasonable billing report. In this day and age, to document that you have done something and then bill it properly is very important.
You make an interesting point about looking at reports from prior procedures.
Dr. Strain: Anything done in ProVation is easily available. You can get to old reports and look at them before you do the cath or while you are doing the reporting. I will often print out the report of a patient that has been done before so I have a picture of how I’m going to document it when I do the new procedure. It’s easy.
Cathy: It’s about increased time for more patient care, too, because less time is spent on completing the checklist, reviewing, and then not being able to fully trust that the reports are accurate. Now when the physician leaves the department, everything in their report is complete. They don’t have to think about coming back and remembering what they did. It saves time for the physicians.
Dr. Strain: Sometimes I will print out the DocuDiagram and show it to the patient. Even though it is not a photograph of a cine image, the DocuDiagram is a picture that shows patients what coronary anatomy looks like, how many blockages they have and where they are. We can draw bypass grafts on it or stents, so the patient has a visual idea of what you are proposing to do about their disease. We still include before and after cine images when a stent is placed, because the “before” image isn’t part of the DocuDiagram. I mostly print it for diagnostic patients who are not having an intervention at that moment. It has been very helpful and patients love it. n
Reference
- Sanborn TA, Tcheng JE, Anderson HV, Chambers CE, Cheatham SL, DeCaro MV, et al. ACC/AHA/SCAI 2014 health policy statement on structured reporting for the cardiac catheterization laboratory: a report of the American College of Cardiology Clinical Quality Committee. J Am Coll Cardiol. 2014 Jun 17; 63(23): 2591-2623. doi: 10.1016/j.jacc.2014.03.020.
