Quality reporting – finally achievable?

The endoscopy report represents a vital component of all endoscopy practice as the primary means of communicating findings, procedures, and recommendations. Although endoscopists typically do report their procedures, the content, format and structure of such reports vary widely. Originally, reports were created in free text, similar to other medical record entries. These were unstructured, highly variable, and constructed in a format that was solely at the discretion of the endoscopist. Unfortunately, all too often such reports were incomplete and otherwise suboptimal as clinical and legal documents [1] [2]. Moreover, the language of endoscopy has typically not been standardized and no proper definitions or usage have been agreed.

In an effort to remedy some of these shortcomings, a standardized language was developed for gastrointestinal endoscopy [3], which further evolved into the so-called “Minimal Standard Terminology” [4], offering recommended terms and term structure for endoscopy reports. This terminology is published free of charge [5], primarily to serve as input to reporting software developers. Recently, further standardization recommendations were published for report structure and image documentation [6].

However, imposing structure and compulsory reporting elements has proven difficult, and adoption of structured reporting has been slow and somewhat hesitant. While some endoscopists have faithfully and comprehensively recorded their examinations, current systems have failed to secure quality reporting from those less focused on report content or accuracy.

The introduction of colorectal cancer screening has provided impetus for the development of quality endoscopy. The quality focus includes the endoscopy report, with summary reporting of endoscopy activities being used for quality monitoring. Because the “license to screen” is typically linked to financial incentives, screening programs can also be coupled with various compulsory quality requirements.

One of the challenges of structured reporting for clinical and quality purposes is the extra time and effort needed to input the data, particularly if this activity represents dual data entry. Such problems may easily jeopardize quality reporting, although things may be improving [7]. At the very least, it appears clear that computerized endoscopy reporting per se is no guarantee of accurate output [8] [9].

In this context, the group from Amsterdam is to be congratulated for their effort to streamline quality endoscopy reporting. In the current issue of Endoscopy [10], van Doorn et al. report the process, structure, and initial experience using their colonoscopy reporting system. Utilizing a commercially available system (the “Endobase” software system; Olympus, Winter & Ibe GmbH, Hamburg, Germany) the authors have developed a structured input matrix that ensures a complete endoscopy report as well as documentation of all relevant quality parameters. Furthermore, the structured input serves a normative purpose by enforcing the recommended terms and granularity in the description of procedure data and features of findings. The data are entered into a database, which subsequently reports back cumulative data on the entire unit, as well as performance data for individual endoscopists. It has been shown previously that the mere recording of quality parameters improves quality. Moreover, it is to be expected that a running comparison of own performance with the group average will promote internal motivation for underachievers.

The present efforts from Amsterdam represent a pivotal step forward in the implementation of quality reporting in standard hospital software, avoiding double entry and other issues associated with add-on research registries. However, there is room for improvement, and the current solution presented by van Doorn et al. addresses the issue in only a limited range of endoscopy practice.

To date, the center where the system was tested offers a very specialized service, performing colonoscopy in a particular patient group. This results in a very standardized population of patients, and makes the structuring of data easier. Although this offers an excellent testing ground for principles, a typical endoscopy unit would require a more diverse reporting system. This adds to the complexity of the structure; however, it is likely that the lessons learned in the present system will be very valuable for future development.

Structured reporting typically adds time to the data entry process, although smart software can probably counter this to some extent. Information on the data entry time for the present system, ideally with comparable data from a similar nonstructured reporting system would be useful. It would also be interesting to consider the acceptance of the system by its users, as low acceptance would be likely to reduce data quality.

The accuracy of the data entered is not a topic in the van Doorn paper. However, it would be interesting to know more about the specific data that are entered, rather than just the completeness of the registration. Although one might assume that structured data would be of a higher quality, this may not necessarily be the case. As one example, the selection of relevant and sufficient list items is critical to assure quality; errors may occur in fixed item selections or if the correct or desired item is not listed, suboptimal alternatives may be selected instead.

The connection to hospital-wide systems is of interest. The endoscopy report should be made accessible as a part of the general medical record, outside of the endoscopy reporting system which is usually accessible to only a selected few. Moreover, all endoscopy activity has a financial implication, and typically this information has to be entered manually after the procedure. Systems for automatic transfer of diagnosis and procedure information to administrative mechanisms will be important, but so far this has proved difficult, at least in our country.

Finally, the solution described for post hoc entry and manual linking of postprocedure information is suboptimal, though workable. Pathology report data should ideally be transferrable electronically to the pertinent locations in the endoscopy software once finalized. In addition, it should be possible for other relevant information, particularly late complications, to be included and linked to the procedures in order to ensure complete complications data as part of the quality work.

Nevertheless, the present work holds promise of more automated systems for combined endoscopy reporting and quality work. Further software improvements, particularly to the interface, may simplify the input of data (e. g. lists that are adapted according to likelihood of findings and personal patient profile). More of the data points may be entered by other personnel, and in the future, hopefully more information can be traced directly from connected hardware (e. g. endoscope information, monitoring data, timings). For quality work, we would also like to see systems for collection of nationwide data. It is unlikely that endoscopy software can (or even should) be fully standardized, but a standardized output of well-defined quality data from the systems to a joint nationwide server should be within reach. The more structure that is implemented locally, as shown in the present report, the better the foundation for such a joint registry system for future quality work.

• References

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• 2 de Lange T, Moum BA, Tholfsen JK et al. Standardization and quality of endoscopy text reports in ulcerative colitis. Endoscopy 2003; 35: 835-840
• 3 Maratka Z. Terminology, definitions and diagnostic criteria in digestive endoscopy. With the collaboration of the members of the Terminology Committee of the World Society of Digestive Endoscopy/OMED. Scand J Gastroenterol Suppl 1984; 103: 1-74
• 4 Delvaux M, Crespi M, Armengol-Miro JR et al. Minimal standard terminology for digestive endoscopy: results of prospective testing and validation in the GASTER project. Endoscopy 2000; 32: 345-355
• 5 Aabakken L, Rembacken B, LeMoine O et al. Minimal standard terminology for gastrointestinal endoscopy – MST 3.0. Endoscopy 2009; 41: 727-728
• 6 Aabakken L, Barkun AN, Cotton PB et al. WCOG 2013 Working party report: Standardized endoscopic reporting. J Gastroenterol Hepatol 13.12.2013; [Epub ahead of print] DOI: 10.1111/jgh.12489.
• 7 Soekhoe JK, Groenen MJ, van Ginneken AM et al. Computerized endoscopic reporting is no more time-consuming than reporting with conventional methods. Eur J Intern Med 2007; 18: 321-325
• 8 Lieberman DA, Faigel DO, Logan JR et al. Assessment of the quality of colonoscopy reports: results from a multicenter consortium. Gastrointest Endosc 2009; 69: 645-653
• 9 de Jonge V, Sint Nicolaas J, Cahen DL et al. Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice. Gastrointest Endosc 2012; 75: 98-106
• 10 van Doorn SC, van Vliet J, Fockens P et al. A novel colonoscopy reporting system enabling quality assurance. Endoscopy 2014; 46: 181-187