NEWS & VIEWS ENDOSCOPY
Gastrointestinal endoscopy reporting: time for standardization? Todd H. Baron
With the increased emphasis on quality and standardization in gastrointestinal endoscopy, a need exists for minimum standardized information to be provided in endoscopy reports. A group of international colleagues provide a consensus document of standardized endoscopy reporting, including nomenclature and imaging, which is an important framework for all endoscopists, especially trainees. Baron, T. H. Nat. Rev. Gastroenterol. Hepatol. 11, 145–146 (2014); published online 11 February 2014; doi:10.1038/nrgastro.2014.14
Standardization in medicine is increasingly emphasized as a way to improve quality in health-care delivery. This standardization includes implementation of evidenced-based medicine and assessment of outcomes identified through reporting.1 Gastrointestinal endoscopy is an area ripe for such standardization, particularly with regards to endoscopic reporting. Aabakken et al.2 present a working party report prepared during the 2013 World Congress of Gastroenterology (WCOG) meeting held in Shanghai, China. The authors of this report are a distinguished group with representatives from many countries, including the USA, Europe and Asia. In this document, the authors propose the minimum and standardized information to be incorporated into an endoscopy report that enables information from the report to be conveyed. Such information includes minimal standard terminology (MST), minimal standard reporting and minimal standard imaging, documentation of normal and patho logical findings and endoscopic therapy, and coding (the most commonly used coding systems both internationally and in the USA are International Classification of Diseases [ICD]‑9 and ICD‑10). Notably, the ICD-9 will be supplanted by ICD-10 by the end of the year, which better defines what is performed procedurally; ICD-9 is somewhat outdated and running out of descriptors as technology and techniques continue to evolve. Moreover, SNOMED CT (Systemized Nomenclature of Medicine Clinical Terms), another set of medical terminology, can be used hand-in hand
with ICD-10 to provide terminology for mapping codes. In the WCOG document,2 details are provided for the most commonly performed endoscopic procedures: upper endoscopy, colonoscopy, enteroscopy, capsule endoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography. The report by Aabakken et al.2 is not only timely, it is important for many reasons beyond standardization. Delivery of quality medical care relies on presentation of concise, accurate information that can be conveyed not only to other gastroenterologists, but to other health-care specialists and providers. Uniform reporting enables comparison of outcomes within and between institutions. This improved reporting facilitates data collection and analysis on a wide-scale basis (for example, outcomes of ERCP for palliation of pancreatic cancer and effectiveness of colonoscopy on cancer screening 3) as well as on an individual basis (for example, to identify need for quality improvement for specific endoscopists) and to assess practice variations.4 From a medicolegal perspective, the inclusion of the proposed information in this document is essential to protect caregivers and patients alike. National health-care systems with shared health information systems are already in place around the world and forth coming in the USA (the Nationwide Health Information Network). In these systems, standardized reporting is essential. Providing the information in the endoscopy report, as suggested by Aabakken et al.,2 enables precise coding and reimbursement. This information
NATURE REVIEWS | GASTROENTEROLOGY & HEPATOLOGY © 2014 Macmillan Publishers Limited. All rights reserved
Brian Jackson | Thinkstock
is important in globally tracking resource utilization and for reimbursement, whether through private insurance or governmentfunded medical care. Gastrointestinal endo scopy reporting has gradually moved away from dictation to electronic reports, which are easily included into electronic medical records using procedure documentation software.5 Although such programmes utilize dropdown menus and facilitate standardization, it is important for the user to know what information should be included in such reports. With the advent of the internet and electronic access to medical reports, patients and family caregivers are increasingly more aware, educated and involved in the delivery of health care. Comprehensive and standardized reporting (including incorporation of endoscopic images into reports) is valued by patients, and endoscopy reports will probably have a major effect on patient satisfaction,6 as well as scrutiny of care received. Patients have the benefit of more immediate reports that can be viewed and shared, which feeds into the perception of quality care. Although the WCOG report 2 is certainly not the first to provide a framework for use of MST and for generating procedural reports,7–9 it is certainly the most up-to-date. In addition, it encompasses the views of an international group of authors. However, it must be emphasized that the report is not a datadriven document; although this caveat does not necessarily detract from its importance, the report is currently not evidence-based nor validated at this time. However, the WCOG report can be used as a framework for many types of studies on quality, outcome and patient satisfaction (among others) in gastro intestinal endoscopy. Finally, this inform ation is vital to our young endoscopists and VOLUME 11 | MARCH 2014
NEWS & VIEWS endoscopists in training,10 in medicine, and most certainly in endoscopic training programmes in which the endoscopy reports are often generated by trainees. Gastrointestinal training programmes benefit when trainees provide accurate reports to be ‘signed’ by the supervising faculty as it frees up time for the faculty member. Ultimately, the trainee will benefit upon his or her entry into practice (private or academic) as an increased familiarity with such documentation decreases one’s learning time and increases efficiency. In summary, the working document on standardized endoscopic reporting 2 is a must-read article for all specialists who perform gastrointestinal endoscopy. To distribute this document to fellowship training directors, endoscopy unit directors (physicians and nurse managers), and to individuals involved in designing and maintaining endoscopy reporting systems seems prudent. By necessity, these standards will continue to evolve as new endoscopic procedures are developed. However, it must be emphasized that these standardized reports are most easily implemented and delivered for routine endoscopic procedures and diagnosis. Complex procedures outside the usual are
MARCH 2014 | VOLUME 11
difficult, as inputting text outside the normal constraints or insertion of dictated reports is often required to precisely convey what has occurred during the procedure, which makes data searching less effective as these data are not identified in searches and might not be translated to billing codes. Nonetheless, standardized reporting could facilitate future research on a topic in that a unified dataset is available for analysis. Division of Gastroenterology & Hepatology, University of North Carolina at Chapel Hill, 41041 Bioinformatics Boulevard, CB 7080, Chapel Hill, NC 27599‑0001, USA. [email protected] Acknowledgements The author expresses appreciation to R. A. Kozarek for editorial suggestions. Competing interests The author declares no competing interests. 1.
2.
3.
Lehmann, C. U. & Miller, M. R. Standardization and the practice of medicine. J. Perinatol. 24, 135–136 (2004). Aabakken, L. et al. WCOG 2013 Working party report: standardized endoscopic reporting. J. Gastroenterol. Hepatol. 29, 234–240 (2014). Beaulieu, D., Barkun, A. & Martel, M. Quality audit of colonoscopy reports amongst patients
screened or surveilled for colorectal neoplasia. World J. Gastroenterol. 18, 3551–3557 (2012). 4. Cotton, P. B. et al. Colonoscopy: practice variation among 69 hospital-based endoscopists. Gastrointest. Endosc. 57, 352–357 (2003). 5. Groenen, M. J., Kuipers, E. J., van Berge Henegouwen, G. P., Fockens, P. & Ouwendijk, R. J. Computerisation of endoscopy reports using standard reports and text blocks. Neth. J. Med. 64, 78–83 (2006). 6. Loftus, R. et al. Patient satisfaction with the endoscopy experience and willingness to return in a central Canadian health region. Can. J. Gastroenterol. 27, 259–266 (2013). 7. Beaulieu, D. et al. Endoscopy reporting standards. Can. J. Gastroenterol. 27, 286–292 (2013). 8. Aabakken, L. et al. Minimal standard terminology for gastrointestinal endoscopy —MST 3.0. Endoscopy 41, 727–728 (2009). 9. Crespi, M., Delvaux, M., Schaprio, M., Venables, C. & Zwiebel, F. Working Party Report by the Committee for Minimal Standards of Terminology and Documentation in Digestive Endoscopy of the European Society of Gastrointestinal Endoscopy. Minimal standard terminology for a computerized endoscopic database. Ad hoc task force of the Committee. Am. J. Gastroenterol. 91, 191–216 (1996). 10. Roorda, A. K. & Triadafilopoulos, G. A fellow’s guide to generating the endoscopy procedure report. Gastrointest. Endosc. 72, 803–805 (2010).
www.nature.com/nrgastro © 2014 Macmillan Publishers Limited. All rights reserved
Gastrointestinal endoscopy reporting: time for standardization? Todd H. Baron
With the increased emphasis on quality and standardization in gastrointestinal endoscopy, a need exists for minimum standardized information to be provided in endoscopy reports. A group of international colleagues provide a consensus document of standardized endoscopy reporting, including nomenclature and imaging, which is an important framework for all endoscopists, especially trainees. Baron, T. H. Nat. Rev. Gastroenterol. Hepatol. 11, 145–146 (2014); published online 11 February 2014; doi:10.1038/nrgastro.2014.14
Standardization in medicine is increasingly emphasized as a way to improve quality in health-care delivery. This standardization includes implementation of evidenced-based medicine and assessment of outcomes identified through reporting.1 Gastrointestinal endoscopy is an area ripe for such standardization, particularly with regards to endoscopic reporting. Aabakken et al.2 present a working party report prepared during the 2013 World Congress of Gastroenterology (WCOG) meeting held in Shanghai, China. The authors of this report are a distinguished group with representatives from many countries, including the USA, Europe and Asia. In this document, the authors propose the minimum and standardized information to be incorporated into an endoscopy report that enables information from the report to be conveyed. Such information includes minimal standard terminology (MST), minimal standard reporting and minimal standard imaging, documentation of normal and patho logical findings and endoscopic therapy, and coding (the most commonly used coding systems both internationally and in the USA are International Classification of Diseases [ICD]‑9 and ICD‑10). Notably, the ICD-9 will be supplanted by ICD-10 by the end of the year, which better defines what is performed procedurally; ICD-9 is somewhat outdated and running out of descriptors as technology and techniques continue to evolve. Moreover, SNOMED CT (Systemized Nomenclature of Medicine Clinical Terms), another set of medical terminology, can be used hand-in hand
with ICD-10 to provide terminology for mapping codes. In the WCOG document,2 details are provided for the most commonly performed endoscopic procedures: upper endoscopy, colonoscopy, enteroscopy, capsule endoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography. The report by Aabakken et al.2 is not only timely, it is important for many reasons beyond standardization. Delivery of quality medical care relies on presentation of concise, accurate information that can be conveyed not only to other gastroenterologists, but to other health-care specialists and providers. Uniform reporting enables comparison of outcomes within and between institutions. This improved reporting facilitates data collection and analysis on a wide-scale basis (for example, outcomes of ERCP for palliation of pancreatic cancer and effectiveness of colonoscopy on cancer screening 3) as well as on an individual basis (for example, to identify need for quality improvement for specific endoscopists) and to assess practice variations.4 From a medicolegal perspective, the inclusion of the proposed information in this document is essential to protect caregivers and patients alike. National health-care systems with shared health information systems are already in place around the world and forth coming in the USA (the Nationwide Health Information Network). In these systems, standardized reporting is essential. Providing the information in the endoscopy report, as suggested by Aabakken et al.,2 enables precise coding and reimbursement. This information
NATURE REVIEWS | GASTROENTEROLOGY & HEPATOLOGY © 2014 Macmillan Publishers Limited. All rights reserved
Brian Jackson | Thinkstock
is important in globally tracking resource utilization and for reimbursement, whether through private insurance or governmentfunded medical care. Gastrointestinal endo scopy reporting has gradually moved away from dictation to electronic reports, which are easily included into electronic medical records using procedure documentation software.5 Although such programmes utilize dropdown menus and facilitate standardization, it is important for the user to know what information should be included in such reports. With the advent of the internet and electronic access to medical reports, patients and family caregivers are increasingly more aware, educated and involved in the delivery of health care. Comprehensive and standardized reporting (including incorporation of endoscopic images into reports) is valued by patients, and endoscopy reports will probably have a major effect on patient satisfaction,6 as well as scrutiny of care received. Patients have the benefit of more immediate reports that can be viewed and shared, which feeds into the perception of quality care. Although the WCOG report 2 is certainly not the first to provide a framework for use of MST and for generating procedural reports,7–9 it is certainly the most up-to-date. In addition, it encompasses the views of an international group of authors. However, it must be emphasized that the report is not a datadriven document; although this caveat does not necessarily detract from its importance, the report is currently not evidence-based nor validated at this time. However, the WCOG report can be used as a framework for many types of studies on quality, outcome and patient satisfaction (among others) in gastro intestinal endoscopy. Finally, this inform ation is vital to our young endoscopists and VOLUME 11 | MARCH 2014
NEWS & VIEWS endoscopists in training,10 in medicine, and most certainly in endoscopic training programmes in which the endoscopy reports are often generated by trainees. Gastrointestinal training programmes benefit when trainees provide accurate reports to be ‘signed’ by the supervising faculty as it frees up time for the faculty member. Ultimately, the trainee will benefit upon his or her entry into practice (private or academic) as an increased familiarity with such documentation decreases one’s learning time and increases efficiency. In summary, the working document on standardized endoscopic reporting 2 is a must-read article for all specialists who perform gastrointestinal endoscopy. To distribute this document to fellowship training directors, endoscopy unit directors (physicians and nurse managers), and to individuals involved in designing and maintaining endoscopy reporting systems seems prudent. By necessity, these standards will continue to evolve as new endoscopic procedures are developed. However, it must be emphasized that these standardized reports are most easily implemented and delivered for routine endoscopic procedures and diagnosis. Complex procedures outside the usual are
MARCH 2014 | VOLUME 11
difficult, as inputting text outside the normal constraints or insertion of dictated reports is often required to precisely convey what has occurred during the procedure, which makes data searching less effective as these data are not identified in searches and might not be translated to billing codes. Nonetheless, standardized reporting could facilitate future research on a topic in that a unified dataset is available for analysis. Division of Gastroenterology & Hepatology, University of North Carolina at Chapel Hill, 41041 Bioinformatics Boulevard, CB 7080, Chapel Hill, NC 27599‑0001, USA. [email protected] Acknowledgements The author expresses appreciation to R. A. Kozarek for editorial suggestions. Competing interests The author declares no competing interests. 1.
2.
3.
Lehmann, C. U. & Miller, M. R. Standardization and the practice of medicine. J. Perinatol. 24, 135–136 (2004). Aabakken, L. et al. WCOG 2013 Working party report: standardized endoscopic reporting. J. Gastroenterol. Hepatol. 29, 234–240 (2014). Beaulieu, D., Barkun, A. & Martel, M. Quality audit of colonoscopy reports amongst patients
screened or surveilled for colorectal neoplasia. World J. Gastroenterol. 18, 3551–3557 (2012). 4. Cotton, P. B. et al. Colonoscopy: practice variation among 69 hospital-based endoscopists. Gastrointest. Endosc. 57, 352–357 (2003). 5. Groenen, M. J., Kuipers, E. J., van Berge Henegouwen, G. P., Fockens, P. & Ouwendijk, R. J. Computerisation of endoscopy reports using standard reports and text blocks. Neth. J. Med. 64, 78–83 (2006). 6. Loftus, R. et al. Patient satisfaction with the endoscopy experience and willingness to return in a central Canadian health region. Can. J. Gastroenterol. 27, 259–266 (2013). 7. Beaulieu, D. et al. Endoscopy reporting standards. Can. J. Gastroenterol. 27, 286–292 (2013). 8. Aabakken, L. et al. Minimal standard terminology for gastrointestinal endoscopy —MST 3.0. Endoscopy 41, 727–728 (2009). 9. Crespi, M., Delvaux, M., Schaprio, M., Venables, C. & Zwiebel, F. Working Party Report by the Committee for Minimal Standards of Terminology and Documentation in Digestive Endoscopy of the European Society of Gastrointestinal Endoscopy. Minimal standard terminology for a computerized endoscopic database. Ad hoc task force of the Committee. Am. J. Gastroenterol. 91, 191–216 (1996). 10. Roorda, A. K. & Triadafilopoulos, G. A fellow’s guide to generating the endoscopy procedure report. Gastrointest. Endosc. 72, 803–805 (2010).
www.nature.com/nrgastro © 2014 Macmillan Publishers Limited. All rights reserved
