University of Chicago, Chicago, Illinois.
Philips Healthcare, Andover, Massachusetts.
J Am Soc Echocardiogr. 2015 Jan;28(1):88-92.e1. doi: 10.1016/j.echo.2014.09.005. Epub 2014 Oct 16.
Facilitated reporting using a discrete set of finding codes (FCs) is a common method of generating echocardiographic reports.
The investigators developed a tool that allows echocardiographic reports to be evaluated in real time for errors, omissions, and inconsistencies on the basis of a defined group of "rules" applied to the FCs present in the report. At the time of report finalization, conflicts were displayed for the interpreting physicians, and their responses to each rule conflict were logged.
Over the course of 1 year, 7,986 transthoracic echocardiographic reports were analyzed prospectively during study interpretation. Overall, 30 ± 4.7 FCs were used to generate finalized reports. An average of 2.4 ± 2.0 conflicts were detected per finalized study. Eighty-three percent of studies had at least one conflict identified. There was no significant correlation between physician experience and conflict rates, but time of day (earlier) and rate at which studies were being finalized (faster) were both correlated with increased conflict rate. Overall, physicians ignored identified conflicts 52% of the time and altered their readings to eliminate the conflicts 48% of the time. Overall, at least one change was made in 54% of all finalized studies. There was a small but significant trend for physicians to produce more conflicts over time as the tool was used.
This study demonstrates that facilitated reporting of echocardiographic studies, using a discrete set of FCs, allows the generation of rules that can be used to identify discrepancies in echocardiographic reports before finalization. Conflicts are common in clinical practice, and the identification of these conflicts in real time allowed readers to review their interpretations and frequently resulted in alterations to echocardiographic reports.
使用离散的发现代码 (FC) 进行辅助报告是生成超声心动图报告的常用方法。
研究人员开发了一种工具，该工具可以根据应用于报告中存在的 FC 的一组定义规则，实时评估超声心动图报告中的错误、遗漏和不一致。在报告定稿时，为解释医师显示冲突，并记录他们对每个规则冲突的响应。
在为期 1 年的时间里，7986 份经胸超声心动图报告在研究解读期间进行了前瞻性分析。总体而言，使用 30 ± 4.7 个 FC 生成最终报告。平均每个最终研究检测到 2.4 ± 2.0 个冲突。83%的研究至少发现了一个冲突。医师经验与冲突率之间没有显著相关性，但一天中的时间（较早）和研究完成的速度（较快）都与冲突率的增加相关。总体而言，医师有 52%的时间忽略了已识别的冲突，并在 48%的时间里改变了他们的读数以消除冲突。总体而言，在所有最终研究中，至少有 54%的研究进行了更改。随着工具的使用，医师生成更多冲突的趋势很小，但很明显。
这项研究表明，使用离散的 FC 进行超声心动图研究的辅助报告，可以生成规则，以便在最终定稿之前识别超声心动图报告中的差异。在临床实践中，冲突很常见，实时识别这些冲突可以让读者审查他们的解释，并经常导致对超声心动图报告的修改。
