Center for Evidence-Based Imaging, Boston, MA, USA.
Acad Radiol. 2013 Aug;20(8):1032-6. doi: 10.1016/j.acra.2013.04.007.
Medicare requires documented teaching physician involvement (attestation) in trainee-generated radiology reports. Automated attestation statement insertion in reports expedites the process but does not comply with requirements for active attestation. We evaluated an informatics-enabled quality improvement (QI) intervention to improve health record documentation requirements for active attestation.
Institutional review board approval was not needed for this QI project performed in a 776-bed tertiary/quaternary teaching hospital. The intervention consisted of (1) policy requiring staff radiologists to actively attest to trainee-generated reports by personally activating a "macro" in the reporting system and (2) a semiautomated process to detect reports missing attestation; radiologists received daily e-mail reminders until the attestation statement was inserted. A random sample of 600 of 123,561 trainee-generated radiology reports created 17 months after the intervention (May 2011) was manually reviewed to determine attestation policy adherence. The number of attestation statements added in response to reminders throughout the entire study period was also evaluated. Trend analysis of the number of report addenda containing solely the attestation statement (proxy for missing initial attestation) was performed.
Of 600 reports, 594 (99%) contained the attestation statement. Monthly attestations in response to email notifications decreased from 585 to 227 by the sixth month, a 2.6-fold reduction (P < .01). No significant trend was observed the following year, indicating a sustained effect.
Informatics-enabled QI techniques resulted in 99% adherence to our teaching physician attestation policy with sustained results. Similar approaches may help improve adherence to other mandated performance measures in radiology reports.
医疗保险要求记录教学医生参与（证明）实习生生成的放射学报告。在报告中自动插入证明声明可以加快这一过程，但不符合主动证明的要求。我们评估了一种信息学支持的质量改进（QI）干预措施，以改善主动证明的健康记录文档要求。
这项在一家拥有 776 张床位的三级/四级教学医院进行的 QI 项目不需要机构审查委员会的批准。该干预措施包括（1）要求工作人员放射科医生通过在报告系统中亲自激活“宏”来主动证明实习生生成的报告，以及（2）一个半自动过程来检测缺少证明的报告；放射科医生每天都会收到电子邮件提醒，直到插入证明声明。在干预后 17 个月（2011 年 5 月）随机抽取 600 份 123561 份实习生生成的放射学报告进行人工审查，以确定证明政策的遵守情况。还评估了整个研究期间为响应提醒而添加的证明声明数量。对仅包含证明声明的报告附录数量进行趋势分析（缺少初始证明的代理）。
在 600 份报告中，有 594 份（99%）包含证明声明。每月对电子邮件通知的证明次数从第六个月的 585 次减少到 227 次，减少了 2.6 倍（P <.01）。次年没有观察到明显的趋势，表明效果持续。
信息学支持的 QI 技术使我们的教学医生证明政策的遵守率达到 99%，效果持续。类似的方法可能有助于提高放射学报告中其他强制性绩效措施的遵守率。
