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Intraoperative Transesophageal Echocardiography in the Electronic Documentation Era

Troianos, Christopher A. MD

doi: 10.1213/XAA.0000000000000241
Editorials: Editorial

From the Department of Anesthesiology, West Penn Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania.

Accepted for publication July 6, 2015.

Funding: None.

The author declares no conflicts of interest.

Address correspondence to Christopher A. Troianos, MD, Department of Anesthesiology, West Penn Hospital, Allegheny Health Network, 4800 Friendship Ave., Pittsburgh, PA 15224. Address e-mail to

Billing for medical services requires proper documentation of medical necessity; an accurate description of the services provided; and the findings, results, or outcome of the procedure. In this issue of A&A Case Reports, Sanford et al.1 describe the development and adoption of an electronic medical record (EMR) that facilitates the documentation of intraoperative transesophageal echocardiography (TEE). The authors used agile development methodology to amend their EMR and create a template for reporting intraoperative TEE findings into their anesthesia record in real time. They compared the amended EMR with the former process of creating a report at a separate workstation after completion of the surgical procedure. This new process improved compliance with the American Society of Echocardiography (ASE) and Society of Cardiovascular Anesthesiologists recommendations and guidelines for continuous quality improvement in perioperative echocardiography for the TEE report to be placed in the patient’s medical record within 24 hours of the surgery.2 The authors illustrated how attention to workflow patterns and removing barriers improved the timely generation of a TEE report from 36% to 84.6%, thus improving their ability to generate a bill for services.

Generation of a TEE interpretation and report is a requisite for billing a reimbursable TEE service. Departments that have traditionally documented TEE findings by paper or electronically with a structured entry documentation program that is not integrated with the institution’s EMR must adapt their recording system in this new era of EMRs. Sanford et al. outline their process of workflow examination, extending the capabilities of their institution’s EMR through agile development and rapid iteration of stakeholder feedback to create a system that allows for a more timely generation of the intraoperative TEE report. Their process and lessons learned are of benefit to other institutions adopting an EMR system. One valuable aspect of their process is the timely entry of TEE findings. Their previous process requiring that the intraoperative TEE examination be closed and finalized was problematic because of the inability to document findings in the operating room. Report generation was performed after the case had ended, as these clinicians moved on to care for other patients requiring TEE. The importance of real-time documentation in generating reports was an important revelation that was discovered through their process of stakeholder feedback.

Another useful aspect of intraoperative TEE reporting through an integrated electronic recording system is that the TEE reports are indexed within a searchable database and available to other clinical teams. It is important that all clinicians within and outside the anesthesiology department are able to easily retrieve intraoperative TEE reports. The reports should be easily retrievable by cardiologists, surgeons, and primary care physicians in a manner similar to the reports from the echocardiography laboratory. Besides the narrative report, digital images and loops should appear within or alongside the narrative echocardiography report and be similarly available to all clinicians caring for the particular patient. This availability of TEE information follows the recommendation of ASE for a digital capture, storage, and review process that enables interoperability within and between various clinical sites of care.3

The process described by Sanford et al. for documentation of TEE findings is useful to other departments performing the intraoperative TEE that are adopting EMR systems. EMRs should allow clinicians performing TEE to more easily conform to the ASE/Society of Cardiovascular Anesthesiologists guidelines so that a TEE report appears promptly within the patient’s medical record within 24 hours of the operation.2 Departments should aspire to develop systems in which the electronic TEE report and digital images are stored in the medical record immediately after the completion of the study and thus be available to other clinicians caring for the patient postoperatively. This will allow for improved patient care, because intraoperative TEE findings may impact the patient’s course after surgery.

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1. Sanford JA, Kadry B, Oakes D, Macario A, Schmiesing C. The heart of the matter: increasing quality and charge capture from intraoperative transesophageal echocardiography. A&A Case Rep. 2016;6:249–52
2. Mathew JP, Glas K, Troianos CA, Sears-Rogan P, Savage R, Shanewise J, Kisslo J, Aronson S, Shernan SCouncil for Intraoperative Echocardiography of the American Society of Echocardiography. . ASE/SCA recommendations and guidelines for continuous quality improvement in perioperative echocardiography. Anesth Analg. 2006;103:1416–25
3. Thomas JD, Adams DB, Devries S, Ehler D, Greenberg N, Garcia M, Ginzton L, Gorcsan J, Katz AS, Keller A, Khandheria B, Powers KB, Roszel C, Rubenson DS, Soble JDigital Echocardiography Committee of the American Society of Echocardiography. . Guidelines and recommendations for digital echocardiography. A Report from the Digital Echocardiography Committee of the American Society of Echocardiography. J Am Soc Echocardiogr. 2005;18:287–97
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