Getting ready for work, you quietly move around the house, following your routine. You’re on autopilot, steps so practiced that your brain has checked out, perhaps working on other information in the background. And then it hits. A hypothesis — an idea for scheduling, a better way to route patients, a research paper, a question. You’ve amassed data from education and practice and are passively making connections to answer questions or address problems you didn’t even know you had.
In the above example, it seems as if data are always present, waiting for a calm moment to bring to our attention possible quests for new adventures. However, conscious data-gathering and processing outside of our minds, particularly in healthcare, require a small amount of upfront work to be so connective. But according to Neil J. Halin, DO, FSIR, FAOCR, chief of cardiovascular-IR at Tufts Medical Center, the future of IR depends on it.
PARTICIPATING IN THE REGISTRY
Halin serves as co-chair of the Standardized Reports Committee at the Society of Interventional Radiology (SIR). His committee has been tasked with developing structured reports to both improve the reporting process and also facilitate registry use and data extraction. “It is critical to understand how structured reports serve as a way to get information into a registry and then to comprehend
how important registries are for our own survival, economically and as a profession,” says Halin. “Every other major profession we deal with has some form of registry, and participation is required. And they’re way ahead of us in having data so they can write the papers that need to be written and can go to the regulatory agencies and insurance companies with actual performance data.”
SIR Standardized Reports Committee Co-Chair Mark G. Kleedehn, MD, assistant professor in the department of radiology at the University of Wisconsin School of Medicine and Public Health, and more than a dozen IRs and specialists on the committee have been essential to the development of SIR’s latest structured reports. These structured reports are the keys to the treasure chest of data that is VIRTEX, the IR registry SIR launched in 2020.
“I believe that structured reports and registry participation are truly how we as radiologists and interventional radiologists grow and defend our own existence,” says Halin. “It’s always better to go to the government or insurers with data. It also helps with industry, who are interested in collaborating with us on devices, so we need to have data.”
Like many registries, VIRTEX also allows participants to compare their data to that of similar practices, with the goal of improving quality, the primary reason to participate in registries, according to ACR CEO William T. Thorwarth Jr., MD, FACR. “For example, for inferior vena cava filters, you can look at how often those are being retrieved, and if your retrieval percentage is substantially lower than similar facilities then maybe you should look at what your process is to call those patients back,” Thorwarth says.
CATCHING UP TO OTHER SPECIALTIES
More than 20,000 papers on PubMed are related to structured reporting in radiology, with the greatest number of papers on the topic published between 2019 and 2020. The number is not surprising. Data-gathering has flourished since the mid-1990s, skyrocketing with the allure of “Big Data” and its seemingly limitless applications. However, structured reporting in IR, as a way to input and extract such data, has lagged behind that of other radiology subspecialties.
“We’re behind other fields in data that support the effectiveness and value of many of our procedures,” says Katharine L. Krol, MD, FSIR, FACR, immediate past chair of the SIR Foundation. “We take it for granted that the procedures we’ve done for 50 years are valuable because we know they help people, but we don’t have a lot of data to demonstrate the value to patients and hospitals.”
For other medical specialties in which registry participation is required for payment, hospitals and practices must invest in making it easy to submit data elements for procedures and patients, such as
through structured reports. “IR covers such a wide breadth of disease processes and body parts, and every practice is different,” notes Krol. “For these reasons and because hospitals don’t always recognize the value of IR to the hospital and patients, they are mostly unwilling to underwrite or voluntarily participate in registries to the same extent as other specialties.”
DEFINING THE VALUE OF IR
“Any specialty can do procedures, and there’s a lot of overlap between IR and other specialties,” says Kleedehn. “Part of proving your value is that you can do these things better than other specialties can. You have to offer great clinical service as well; it’s not just about the procedural care. The VIRTEX registry includes procedural data but also can add lots of clinical follow-up. We’ve integrated clinic note-related data elements as well. The EHR will directly be able to send info via the structured reports into the VIRTEX registry, and things like lab values, pathologic results, etc., can be directly sent to the registry, so it’s not just looking at the procedural component. It’s much more holistic and clinically oriented.”
To round out the key areas of data collected across the continuum of care, VIRTEX also includes the patient perspective with a patient-reported outcomes component. Patients will be able to directly provide feedback on their quality of life, health, and function, which will enable VIRTEX to track and improve outcomes and well-being longitudinally.
As a specialty, IR often struggles with some procedures being categorized as off-label or not medically necessary. “We are hoping to be able to use registry data to support the efficacy of our procedures and proper reimbursement,” says Stephanie L. Dybul, MBA, RT(R)(VI), CIRCC, a key member of the SIR Standardized Reports Committee.
Although seasoned radiologists will recall a time when data wasn’t required to receive payment for procedures and services, as IR and medicine have matured, data are essential. “So the way to ensure we have the data on the breadth of what IR does is through a registry,” says Krol. “And how to do that in a way that’s inexpensive and that every IR could participate in is using structured reports because they don’t require staff on the ground at every hospital to manually pull that data.”
I believe that structured reports and registry participation are truly how we as radiologists and interventional radiologists grow and defend our own existence.
USING THE NEW REPORTS
SIR’s Version 3.1 structured reports have evolved from initial efforts more than 10 years ago, and an impressive array of opinions — and language recommendations — have helped make the reports friendlier for those who prefer their own way of dictating. “We’ve tried to open up the scope of this project to bring in more input, going to other groups within the ACR and the SIR to get their input,” says Halin. “We consulted with pediatric interventionalists, peripheral vascular specialists, the ACR’s LI-RADS® group, and others, which has been very beneficial. Based on input from the pediatric
group, for example, we were able to eliminate a lot of unnecessary language and streamline things.”
To understand how these structured reports are unique, it’s helpful to view early structured reports as templates that help radiologists know how and what to dictate in an interventional case. The new SIR reports go beyond a basic framework, with named data elements and a data structure that specifically allow for automated extraction of data elements to a registry. The non-registry elements can be changed for personal preference or facility use.
In developing the reports, the committee considered the normal workflow an interventional radiologist might use when reading a case. “You have to look at the image, process it, come up with something to say, say it. Then the system must accept it, it must accurately transcribe it, you have to edit it, and the clinician has to read it and understand it,” says Halin. “That’s a lot of steps. It’s important that the conveyance of information be as streamlined and as accurate as possible because there are too many steps and opportunities for error.”
Those radiologists who struggle to depart from their narrative style shouldn’t panic. The reports include a free-text block “so that the inner Hemingways can wax poetic,” jokes Halin. “You can say whatever you want in that block because the registry isn’t looking at that information.”
PLANNING FOR THE IMPLEMENTATION
Jeremy Durack, MD, FSIR, began the structured reporting and registry initiatives at SIR and has followed the development of the latest report versions and, like many “new” things, understands that adapting to change can be difficult. “I’m extremely proud of the way the project has evolved,” says Durack. “The challenge now is to gain more uptake on the part of clinicians and practices. There’s a real task to convince practices of the value of standardized reports when they’ve used their own custom reports for many years. But research and quality efforts can really be propelled with broader adoption.”
Although it takes effort to integrate the reports into the transcription system (reports are available in .rtf and XML PowerScribe formats), they can be customized for an institution or an individual provider or even for each patient. “At first it seems daunting, but the learning curve is very quick,” says Kleedehn. “If you don’t take the time to get used to the reports, you won’t be very happy with them. Use them for at least a couple of weeks before you make any judgment.”
ASKING AND ANSWERING QUESTIONS
Big Data, such as the information provided by registries, offers new ways to answer questions, including “How well am I doing my job?” In radiology and IR, both asking and answering this question is critical to patient care, quality and safety, and reimbursement — the trifecta of needs for any physician. Without the information that comes from the registry, that question and others may remain unanswered, and the specialty will suffer.
“I really see registry participation as a must-do,” says Krol. “If we don’t have people participate, IR is at significant risk in the future because I don’t think the payment and coverage will be where we want it to be, we will not be able to attract candidates to the specialty, and it will limit patient access.”
It can be difficult to understand the big picture promised by Halin and Kleedehn, but any temporary discomfort of adaptation can give way to improved efficiency. “I can dictate a report so much faster now,” says Halin. “I hope people out there will see this and see it’s a good idea. Any one of us on the committee or in SIR support staff would be happy to provide support on how to make the reports work for someone, how to make them their own. Once people adopt them, there’s very little downside.”