Includes article by Rhodes Scholar U.Tor Dalla Lana School of Public Health (Health Policy ) Prof.Adalsteinn D. BROWN MA MPH(Harvard) DPhil (Oxon.) pp 47-50 "The Challenge of Quantity Improvement at the System Level. Whither CCO? (Cancer Care Ontario)
Prof.Brown discusses the Cancer System Quality Index (CSQI) and the use of "SYNOPTIC PATHOLOGY". (Etymology:: taking a General or Comprehensive view)
Definition of Synoptic Reporting (COLLEGE of AMERICAN PATHOLOGISTS)
The CAP has developed this list of specific features that define synoptic reporting formatting:
1. All required cancer data from an applicable cancer protocol must be included in the report and must be displayed using a format consisting of the required checklist item (required data element), followed by its answer (response), e. g. “Tumor size: 5.5 cm”. Outline format without the paired required data element (RDE): response format is not considered synoptic.
2. Each diagnostic parameter pair (checklist RDE: response) is listed on a separate line or in a tabular format, to achieve visual separation.
Note: the following are allowed to be combined on the same line:
a. Anatomic site or specimen, laterality and procedure
b. Pathologic Staging Tumor Node Metastasis (pTNM) staging elements
c. Negative margins, as long as all negative margins are specifically enumerated
For example:
o Headers may be used to separate or group data elements
o Any line may be indented to visually group related data elements or indicate a subordinate relationship
o Text attributes (e.g., color, bold, font, size, capitalization/case, or animations) are optional
o Blank lines may be used to separate data elements and group related elements
3. If multiple responses are permitted for the same data element, the responses may be listed on a single line.
4. The synopsis can appear in the diagnosis section of the pathology report, at the end of the report or in a separate section, but all RDE and responses must be listed together in one location.
5. Additional items (not required for the CAP checklist) may be included in the synopsis but all required RDE must be present.
6. Narrative style comments are permitted in addition to, but are not as a substitute for the synoptic reporting. It is not uncommon for narrative style comments to be used for clinical history, gross descriptions and microscopic descriptions.
Additional Specifications and Options
• Data elements may be presented in any order in the report.
• Two data element names may not be listed on the same line, with the following exceptions:
o Anatomic site or specimen, laterality, and procedure
o Negative margins. Example: for colorectal carcinoma resection specimens, negative proximal, distal, and radial margins may be listed on one line
o Pathologic staging: pT, pN, and pM categories may be listed on one line. It is not necessary to include definitions of the pT, pN, and pM categories in the report.
Otherwise, only multiple values pertaining to the same data element may be listed on the same line.
• Diagnostic headlines may be included that contain some data elements in non-standard format (e.g., "INVASIVE CARCINOMA OF THE RIGHT BREAST.") However, if information in the headline includes a required element and the headline does not use the single line or multi-line format, the required information in the headline must also appear in the single line or multi-line format in the same report. December 13, 2011 - v2.0
• Narrative comments may reference required or optional data elements. However, data
elements and values that appear in narrative comment may not be properly abstracted
and auditors are not to consider the data element and its value as having been included in a report, unless the information also appears in a properly formatted single line or multi-line statement.
• Data that are not listed as required or optional in an applicable cancer protocol may be included in any format. Examples include patient identification data (name, date of birth) or administrative data (report date, accession number)
• Required and optional data elements listed in the applicable cancer protocol may be combined into one report or broken up into separate reports. For example, separate paper reports or computer screens might be used to report histological and molecular findings, or to report gross and microscopic findings, or to report examinations of different specimens.
The CAP has developed a few examples of synoptic reporting (attached) for the use of the COC as training tools for COC inspectors. Sample reports 1-6 are examples of acceptable synoptic reporting; Sample reports 7 and 8 do not show acceptable synoptic style reporting. CAP recommends that CoC surveyors focus their evaluation of synoptic reporting only on definitive resection specimens and not biopsies at this time.
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With synoptic
reports,
big picture in a small package
July 2003
Eric
Skjei
Labs nationwide
are working to ensure that their pathology reporting systems conform
to the CAP cancer protocols, which accredited hospital cancer programs
must begin using by Jan. 1, 2004.
Fearful that
traditional free-text reports might not do the trick, many labs
have implemented backup systems ranging from templates in Word or
Word Perfect to simple paper checklists and notebook-based reference
systems to try to ensure that the reports meet the new requirements
of the American College of Surgeons Commission on Cancer.
A hospital-based
laboratory system in Sioux Falls, SD, is pioneering the use of a
digital synoptic reporting system for CoPathPlus, from Cerner Corp.
The system functions as a database devoted to pathology reporting
functions—in this case, cancer protocols. Cerner also provides
a synoptic reporting solution for its Millennium PathNet platform.
The synoptic
reporting that Keith Anderson, MD, is doing in Sioux Falls is a
“concise standardized reporting that includes all data needed
for accurate staging, treatment, and prognosis,” he says.
“‘Synoptic’
implies that you’re condensing things, making it more tight,
if you will,” says Dr. Anderson, chief of pathology, Sioux
Valley Hospital, University of South Dakota Medical Center. “My
bias is that we’re not making it less, but we’re standardizing
it and making sure we get everything in there that we want to get
in there.”
In pathology
reporting, “synoptic” traditionally has referred to
checklists of various types intended to ensure that essential elements
are not omitted from reports. In Cerner’s synoptic reporting
product, as implemented by LCM Pathologists, P.C., at Sioux Valley
Hospital, synoptic translates into preformatted templates or worksheets,
developed by Dr. Anderson and
his colleagues, in which specific fields are assigned to given elements
in the protocol.
The key to using
worksheets is to be able to retrieve answers to questions quickly
and accurately. Having to read free-text reports to do so is time
consuming and error prone. Sioux Valley has found that using the
synoptic reporting coding product allows it to reduce as many as
45 pages of cancer protocol to two to three pages of worksheet on
the computer screen.
The Sioux Valley
worksheets are not only comprehensive and efficient, they are standardized,
which may make it easier to share data across reports
in the future. “Our bias is that we want to try to capture
that data for future clinical research as well,” says Dr.
Anderson. “That would be an ultimate goal.”
Better
than free text
A product with database-like capabilities offers distinct advantages
over traditional free-text reporting systems. Consider the simple
task of searching for tumors of a specific size. “If you wanted
to look for all the cases that had a particular tumor size, for
example, you could select the appropriate tumor type, search for
all those of a certain size, or even sort by size in ascending or
descending rank order,” says Tom Schnabel, LCM Pathologists’
business manager.
To do something
even remotely comparable in a free-text report would require manually
inspecting each report and would be prohibitively time consuming.
“The problems with free-text searching are many and varied,”
Schnabel says. If you specify “tumor size” as your search
term, for example, you might, depending on your search function,
get every report that contains the word “tumor” and
every report that contains the word “size”—in
other words, a lot of material you don’t want. Or if you search
for a specific numerical value, Schnabel says, you might, depending
on your search capabilities, receive everything that has that number
associated with it, whether it’s related to tumor size or
not. Or your search might find the word or phrase in the text accurately
and repeatedly but fail to keep track of the number of instances
found.
“But in
the CoPath product,” he says, “‘tumor size’
is in the synoptic value dictionary under the value of ‘tumor
size,’ and it will search for just those cases that have that
value point populated and for just the value or range of values
you specify.”
LCM went live
with the new synoptic coding product in January, and Dr. Anderson
estimates that the group has been adding about two worksheets per
month ever since. “I think it’s working pretty well,”
he says. “There are plenty of bumps in the road because biologic
systems are highly variable, and we keep coming across oddball cases
that don’t fit quite the way we had envisioned them fitting
in this digitized report format.”
Dr. Anderson
says the reports themselves do not have a digitized or preformatted
appearance; they look very much like their free-text brethren. “We’ve
tried to make it look like close to what we were dictating as reports
before, but we’re able to standardize more from my report
to my partner’s report,” he says. Every worksheet also
supports a fair amount of additional free-texting capability to
capture information that doesn’t lend itself to preformatted
coding solutions.
Top
five cancer types
Only a small percentage of the reports Dr. Anderson’s
group issues are produced using the synoptic reporting system since
it is targeted only at cancer reporting. But within the cancer report
function, a high percentage of the most common cancers seen by the
group are being reported using the product. “If you were to
say, look at all the breast cancers, for example, the product is
basically handling all of them,” Dr. Anderson says.
“We’re
proceeding by tumor type,” Schnabel adds. “We did breast
tumors first; then we did colon resections, lymph nodes, and then
endometrium, uterine tumors.” The group’s understanding
is that the Commission on Cancer inspection focuses on the top five
most common cancers seen in a hospital program. “So we’re
trying to get our worksheets out for our most common tumors and
not worry too much about the 40th most common type,” Dr. Anderson
says.
The product
can be designed to prompt the user if a required field is
not completed. It can even predesignate a set of specific choices,
allow the user to select from that list, and require the user to
make only one selection.
It also supports
additional explanatory material. “We can build in educational
notes,” says Dr. Anderson. “If somebody is not sure
what a term means and it’s something we don’t address
very often, we might note, for example, that this diagnosis requires
X percent of something, specifying what that percentage is so the
user is reminded as they move through
the worksheet.”
Support from
Cerner has been excellent, according to Dr. Anderson and Schnabel.
“Part of that is because we were the first site to start using
this on a live basis, and they really dedicated resources to us
to get it developed and up and running,” says Dr. Anderson.
The synoptic
product is available on the Millennium PathNet version 2003.02 or
the CoPathPlus version 2.3 or higher. “We were the fourth
site in the country to go live on version 2.3,” Schnabel notes.
“But as they roll out 2.3, there will be more people that
have this available to them.”
Consistency
and productivity
Clinicians, of course, benefit from consistency across pathology
reports. “Even if we’re not worried about having all
the appropriate staging information and treatment information in
the report, it can be very confusing for clinicians to read my report
and then see that of a partner who has a totally different approach
to the way they put their report together,” Dr. Anderson says.
“Clinicians can find it difficult to pull out the correct
information.” That any pathology report produced by the system
can offer the same information in the same order is an important,
if intangible, benefit.
Clinicians offer
positive feedback about the reports when asked, but perhaps more
important is that the implementation has been relatively seamless
and has not provoked a lot of negative comments or queries. “As
the business manager,” Schnabel says, “I think that
not getting any negative comments is in itself proof that we’re
meeting their needs—or we would certainly be hearing about
it.”
Although productivity
has not been targeted as a primary benefit, there is little doubt
that the CoPath product is making it easier to comply with the protocols
than would paper-based methods.
“In terms
of how fast we can do this versus how fast we can dictate it, I
don’t think we’re going to see a whole lot of difference,”
Dr. Anderson says. “But I do strongly believe what we’re
doing is faster than what we could do if I were pulling out the
workbook, finding page 15 that has colon cancer on
it, and stepping through that page to make sure I had done all of
those things right.”
While dictating
from memory is faster than working through the worksheet on the
computer, knowing that it’s critical to get in all those staging
points and not miss any is the higher priority, analogous to the
checklist an airline pilot uses, says Dr. Anderson. A pilot might
be able to get in the air quicker if he or she doesn’t have
to step through the checklist, but neither the pilot nor anyone
flying with the pilot is going to feel as comfortable.
Dr. Anderson’s group of 16 pathologists runs the gamut with regard to
comfort in using computer tools. “If you have someone who is very computer
savvy, they can be up and running in a matter of minutes,” he says. “If
you have somebody who is totally computer phobic, they’re going to be
dictating it off a piece of paper and the secretarial staff is going to be putting
it in. We’ve got all ends of the spectrum here.” |
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