Coté Gregory A, Elmunzer B Joseph, Forster Erin, Moran Robert A, Quiles John G, Strand Daniel S, Uppal Dushant S, Wang Andrew Y, Cotton Peter B, McMurtry Michael G, Scheiman James M
Department of Medicine, Medical University of South Carolina, Charleston, SC.
Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA.
Tech Innov Gastrointest Endosc. 2021;23(2):129-138. doi: 10.1016/j.tige.2021.01.005. Epub 2021 Jan 18.
Measuring adherence to ERCP quality indicators (QIs) is confounded by variability in indications, maneuvers, and documentation styles. We hypothesized that incorporation of mandatory, structured data fields within reporting software would permit accurate measurement of QI adherence rates and facilitate generation of a provider ERCP report card.
At two referral centers, endoscopy documentation software was modified to generate provider alerts prior to finalizing the note. The alerts reminded the provider to document the following components in a standardized manner: indication, altered anatomy, prior interventions, and QIs deemed high priority by society consensus, study authors, or both. Adherence rates for each QI were calculated in aggregate and by provider via data extraction directly from the procedure documentation software. Medical records were reviewed manually to measure the accuracy of automated data extraction. Accuracy of automated measurement for each QI was calculated against results derived by manual review.
During the 9-month study period, 1,376 ERCP procedures were completed by 8 providers. Manual medical record review confirmed high (98-100%) accuracy of automatic extraction of ERCP QIs from the endoscopy report, including cannulation rate of the native papilla and complete extraction of common bile duct stones. An ERCP report card was generated, allowing for individual comparison of adherence to ERCP QIs with colleagues at their institution and others.
In this pilot study, use of mandatory, structured data fields within clinical ERCP reports permit the accurate measurement of high priority ERCP QIs and the subsequent generation of interval report cards.
内镜逆行胰胆管造影术（ERCP）质量指标（QI）的依从性测量因适应证、操作及记录方式的差异而受到干扰。我们推测，在报告软件中纳入强制性结构化数据字段将有助于准确测量QI依从率，并有助于生成医疗服务提供者的ERCP报告卡。
在两个转诊中心，对内镜检查记录软件进行修改，以便在完成记录前生成医疗服务提供者提醒。这些提醒促使医疗服务提供者以标准化方式记录以下内容：适应证、解剖结构改变、既往干预措施，以及经社会共识、研究作者或双方认定为高度优先的QI。通过直接从手术记录软件中提取数据，汇总计算并按医疗服务提供者分别计算每个QI的依从率。人工查阅病历以评估自动数据提取的准确性。根据人工查阅得出的结果计算每个QI自动测量的准确性。
在为期9个月的研究期间，8名医疗服务提供者共完成了1376例ERCP手术。人工查阅病历证实，从内镜检查报告中自动提取ERCP QI的准确率很高（98%-100%），包括对天然乳头的插管率和胆总管结石的完全清除率。生成了一份ERCP报告卡，可对本机构及其他机构的同事遵守ERCP QI的情况进行个体比较。
在这项试点研究中，临床ERCP报告中使用强制性结构化数据字段能够准确测量高度优先的ERCP QI，并随后生成间隔报告卡。
