Electronic Procedural Reporting for Colonoscopy; Challenges (Discrepancies) in Data Entry and Report Generation

Electronic Procedural Reporting for Colonoscopy; Challenges (Discrepancies) in Data Entry and Report Generation

Tahseen Rahman, David Armstrong, Khurram J. Khan

McMaster University, Hamilton, ON

Open Journal of Gastroenterology and Hepatology

Aims: Computerized reporting systems that generate standardized endoscopy reports are available and facilitate easy retrieval of data for quality assurance review. We aim to compare the accuracy of extracted database fields in our reporting system (endoPRO) for key measures of quality to the final edited endoscopy report for colonoscopy procedures.
Methods: In a retrospective analysis, we compared data retrieved from endoPRO to the final colonoscopy reports at Hamilton Health Sciences (HHS). The data included demographics, indications for procedures, bowel prep quality, findings, extent of exam, and recommendations. Discrepancies, changes or missing information pertaining to key quality indicators for colonoscopies were recorded.
Results: In total, 1843 colonoscopy procedures were done at HHS from January to March 2010, and reports for 592 colonoscopies, randomly selected, were analyzed for this study. Discrepancies were seen in: Indication – 34 cases (5.7%), Assistants present during colonoscopy – 94 cases (15.9%), Quality of bowel preparation – 35 cases (5.9%), Findings & impressions – 38 cases (6.4%) including polyps, inflammation, diverticulosis and haemorrhoids.
Conclusions: Our study demonstrates the variability between data found in patients’ final colonoscopy reports and data retrieved from the endoscopy databases. Structured endoscopy reporting and the use of databases facilitate quality assurance but editing of procedure reports after structured data entry compromises accuracy of the data in key quality measures. Inaccurate or incomplete data recording will compromise the enhancements in quality assurance that would accrue otherwise from regular audit processes.

Keywords: Endoscopy reporting, Quality Assurance, Colonoscopy

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How to cite this article:
Tahseen Rahman, David Armstrong, Khurram J. Khan. Electronic Procedural Reporting for Colonoscopy; Challenges (Discrepancies) in Data Entry and Report Generation..Open Journal of Gastroenterology and Hepatology, 2019, 2:8. DOI: 10.28933/ojgh-2019-02-2406

1. Douglas DK, Johnson DA, Anderson JC et al. American College of Gastroenterologists Guidelines for Colorectal Cancer Screening 2009. Am J Gastroenterol. 2009;104(3): 739-50.
2. Rex DK, Petrini JL, Baron TH et al. Quality Indicators for Colonoscopy. Gastrointestinal Endoscopy. 2006;63 (4Suppl), S16-S28.
3. Rex DK, Bond JH, Winawer W et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: Recommendations of the U.S. Multi-Society task force on colorectal cancer. Am J Gastroenterology. 2002;97: 1296-1308.
4. Armstrong D, Barkun A, Bridges R, et al. Canadian Association of Gastroenterology consensus guidelines on safety and quality indicators in endoscopy. Can J Gastroenterol. 2012;26 (1):17-31
5. Bair D, Pham J, Seaton MB et al. The quality of screening colonoscopies in an office-based endoscopy clinic. Can J Gastroenterol. 2009; 23 (1), 41-47.
6. Rathgaber SW, Wick TM. Colonoscopy completion and complication rates in a community gastroenterology practice. Gastrointest Endosc. 2006; 64, 556-62.
7. Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL.. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006; 355, 2533-41.
8. Denis B, Weiss A, Peter A, Bottlaender J, Chiappa P. Quality assurance and gastrointestinal endoscopy: an audit of 500 colonoscopic procedures. Gastroenterol Clin Biol, 2004;28:1245-1255
9. De Jonge V, Nicolaas J, Cahen D. Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice. Gastrointestinal Endoscopy. 2012; 75:1
10. Shaukat A, Oancea C, Bond J, Church T, Allen J. Variation in Detection of Adenomas and Polyps by Colonoscopy and Change Over Time With a Performance Improvement Program. Clinical Gastroenterology and Hepatology. 2009;7:1335–1340
11. Wyse J, Joseph L, Barkun A, Sewitch M. Accuracy of administrative claims data for polypectomy. CMAJ, 2011;Aug 9;183(11)
12. Kaminski M, Regula J, Kraszewska E, et. al. Quality Indicators for Colonoscopy and the Risk of Interval Cancer. NEJM. 2010;362;19

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