Structured data reporting has become the goal of a recent collaboration between the ACC's PINNACLE Registry and Epic - an electronic health record (EHR) software company. Fostered by the ACC's Information Technology Taskforce, the CardioEncounters beta program uses a documentation tool called NoteWriter, which allows for structured data collection within outpatient cardiology practices to improve the quality of patient medical information in EHRs. Jeffrey Westcott, MD, FACC, medical director of the Cardiac Catheterization Lab at the Swedish Heart and Vascular Institute and author of the CardioEncounters note, continues to revise the documentation tool used in his practice in order to accurately and effectively capture patient data. The collaboration allows for integration between registries and EHRs and is a way to move data electronically between the two. Westcott has spent four years working with the CardioEncounters program, and currently half of his practice uses NoteWriter to document patient notes. The Swedish Heart and Vascular Institute takes a team approach to the new technology, with the notes typically started by a medical assistant or a registered nurse and completed by a physician or advanced practice clinician. "Quality is improved when variation is minimized," says Westcott, noting that he anticipates more of his practice will begin to use the documentation tool. "Its structure makes it less likely that [we] will forget to address important details in the management of coronary artery disease, hypertension, heart failure and atrial fibrillation," says Westcott. With content-rich information based on the latest cardiology guidelines, the documentation tool allows clinicians to have focused and efficient conversations with each patient. The APSO (assessment, plan, subjective, objective) format within the note also ensures that clinicians see the most important information about a patient first. As an innovative project in medicine, Cardio- Encounters is an example of future collaborations between registry databases and EHRs to transform outpatient cardiovascular care. Westcott states that "value-based care is the future," and notes that outpatient practices such as his must keep patient quality as a top priority as big data continues to evolve in the medical sphere. "Structured notes such as [the one that CardioEncounters provides] are necessary for quality improvement, registry reporting, outcomes research and creating a culture of value," he says. Through this collaboration, the ACC hopes that PINNACLE Registry data captured by clinicians using the documentation tool will improve care in chronic cardiovascular diseases and increase the effectiveness of clinical encounter documentation. The data extracted will support the development of new guidelines and performance measures, as well as facilitate further outcomes research in specialty fields of cardiology. Westcott adds that "as we develop a more standard data lexicon, these registries [like the NCDR] will become even more important," allowing the ACC's committees on quality and guidelines to access relevant patient data and current research that can transform cardiovascular care. As the beta-stage of CardioEncounters advances, the ACC will continue to provide guidance on the development of the collaboration.
Published by American College of Cardiology. View All Articles.