Practical APLIS-based Structured/Synoptic Reporting

Transcription

1 Practical APLIS-based Structured/Synoptic Reporting Friday, August 18, 2006 David L.Booker, MD Anil Parwani, MD., PhD

2 Synoptic Reporting Workshop: Goals In this workshop, we will describe our experience in creating the synoptic tools with the overall goal of promoting easy data sharing between the Anatomic Pathology LIS, Cancer Registry and other Clinical and Research systems in Oncology.

3 Synoptic Reporting Workshop: Scope Synoptic Worksheet entry in Cerner s CoPathPlus and its incorporation into existing Pathology Reports. Synoptic data entry as methods of producing standardized reports, leading to improved pathology reports. The role of the Cancer Registry in extracting common data elements from a completed pathology report. Experience of UPMC in production of synoptic data entry worksheets and comparison to CAP checklists. Use of Synoptic Reports in the clinical environment, their impact on work flow and potential applications in oncology/research settings.

4 Why do Synoptic Reporting? Templated data entry Uniformity and accuracy Gross and diagnostic content Templated data presentation on reports Format and prioritize diagnostic information Streamlines access by clinicians Capture of distinct data elements Enhancement of retrieval Transmission to other db systems

5 Synoptic/Checklist Reporting Gross and Microscopic Examination of Surgical Specimens, particularly large resections yields comprehensive information with implications for ongoing and future medical and oncology care. Traditionally, narrative descriptive reports have been used in surgical pathology to convey this valuable information to the patients and their health care teams. Such information is of immense value in making treatment decisions such as adjuvant therapy, radiation, chemotherapy and other interventions. This information is of great value to the cancer patient with providing them measures of prognosis and outcomes.

6 Synoptic/Checklist Reporting Traditional narrative and descriptive reports in free text format have significant variability because different pathologists use a multitude of different reporting styles to describe their findings. More often such variability results in pathology reports missing important data elements such as margins, lymphatic invasion etc. Synoptic Reporting, either as part of the pathology report or replacing the free text component, has uniformity with standardized data elements in forms of checklists thus ensuring the pathologist makes note of these findings in their reports.

7 Synoptic Reporting Background The College of American Pathologist Cancer Protocols and Checklists were created with the objective of improving the quality and uniformity of information in pathology reports. Currently, most LIS Systems do not support discrete data elements for synoptic data elements thus, the CAP checklists have been incorporated as unstructured text blocks which are embedded in the pathology reports. The latter arrangement results in the presentation of pertinent pathology data in a cumbersome and difficult to access format.

8 Experience at UPMC Development of text-based synoptic outlines started in (prostate ca), resulting in set of >40 outlines for neoplastic resections Text-only format less than optimal for entry of selected data elements and presentation on reports, and many obstacles to data retrieval by distinct data elements Student project in early 2004 audited data elements in textbased outlines against required and other data elements defined in CAP checklists, preliminary to converting to synoptic worksheets in CoPathPlus.

9 Experience at UPMC At UPMC, we have used a synoptic reporting tool (Cerner CoPathPlus) to incorporate the CAP checklists as discrete data elements, allowing for storage of data elements in a relational table within the LIS. We have modified the CAP checklists into these synoptic worksheets for select organ systems and malignancies such as prostate, melanoma, breast and lung. We have also used CAP checklists created by Cerner DHT to supplement the library of checklists available for use in pathology reports.

10 Experience at UPMC: Staff Access via SEA

11 Experience at UPMC: Staff Review via SEA

12 Synoptic Reporting: Implementation Factors Data element (DE) structure Synoptic entry design Data content & maintenance Workflow integration Synoptic data in reporting Compliance (!!)

13 Data element structure Provides organization Synoptic Reporting: DE Structure Defines distinct concepts Relation to data entry CoPathPlus Synoptic Values Synoptic Categories Synoptic Worksheets

14 Synoptic Reporting: Text-based Outline

15 Synoptic Reporting: Dictionary Structure Synoptic Categories Synoptic Values Synoptic Worksheet < 5% of specimen involved by invasive tumor Extent of Tumor 5-25% of specimen > 25% of specimen Unknown or N/A Yes, high grade PIN, NOS High Grade PIN Yes, HG PIN, 1-2 foci in region of tumor Yes, HG PIN, 1-2 foci away Yes, HG PIN, multifocal No, high grade PIN absent

16 Synoptic DE s: CoPath Synoptic Category Links to SNOMED CT, LOINC or other code set

17 Synoptic DE s: CoPath Synoptic Value Default name/text for worksheet Fill-in attribute, numeric or text format Links to SNOMED CT, other code set

18 Synoptic DE s: CoPath Synoptic Worksheet

19 CoPathPlus: Synoptic Data Table Structure Synoptic Data Dictionary Tables Synoptic Data Tables linked to Specimens

20 Synoptic Reporting: Entry Design Synoptic entry design Simple UI for entry/selection of DE s Provides controls on data integrity required elements and multiple answers Variable formatting capabilities Integrates with workflow CoPathPlus: Synoptic Worksheets

21 CoPathPlus: Synoptic Worksheet

22 Synoptic Reporting: Content Data content and maintenance Editing and version capabilities Compliance with CAP checklists American College of Surgeons Commission on Cancer requires for approval of cancer programs Annual updates from CAP Pre-built worksheets available from Cerner

23 Synoptic Reporting: Workflow Integration into workflow Gross data entry activities Diagnosis entry - transcribed or voice-entered? Availability at sign out Access for special procedures, et al?

24 Specimen accessioned SynWksh defaults on specimen from part type OR attached to case by gross entry staff Resident or Pathologist dictates final diagnosis and synoptic values from SynWksh copy Transcriptionist attaches SynWksh if not done previously UPMC Pathology Synoptic Worksheet Processing 2006 Transcriptionist enters values into on-line SynWksh and marks complete as pertinent, sends case to pathologist Pathologist enters values into on-line SynWksh, or edits values if needed Pathologist dictates changes to synoptic values IF Not editing in on-line SynWksh OR AFTER Specimen is amended Pathologist reviews final diagnosis and default SynWksh text, signs out specimen

25 Synoptic Reporting: Workflow, Primary Entry Standard text entry before or after synoptic entry Worksheet defaults or entered from lookup

26 Synoptic Reporting: Workflow, Primary Entry

27 Synoptic Reporting: Workflow

28 Synoptic Reporting: Reporting Synoptic data on reports Formatting, replacement text Location in reports Replacing final diagnosis (?)

29 Synoptic Reporting: Leveraging Data Data mining/searching capabilities Usage monitoring Transmission of synoptic data Cancer registry databases Research databases need for coding of synoptic elements

30 Synoptic Reporting: Data Mining

31 Synoptic Reporting: Data Mining

32 Synoptic Reporting: Usage Monitoring

33 Synoptic Reporting: Usage Monitoring

34 SUMMARY: Resistance to Uniformity In general, people don t like change Pathologist desire for flexibility and creativity in content and language, aka the poetic license of the historical practices of pathologists Checklists seen as limiting in nature, disagreements with importance of items selected by CAP vs. omitting others of potential importance The more standardized elements there are, the higher the risk of doing something wrong thus leading to possible legal actions

35 SUMMARY: Importance of Uniformity With the CAP protocols and checklists, providing data of clinical importance is in the hands of the pathologist. The Global nature of cancer care - cancer patients are being diagnosed and treated in variety of settings require need for uniform documentation for communication between health care facilities. With checklist items, consistent data elements and values would enable quicker access to desired information and improved communication for proper cancer management. A Report signed out in Clevelnad, OH should have same common data elements as the one from Pittsburgh. UNIFORMITY is the key.

36 SUMMARY: Importance of Uniformity Clinicians rely on accurate and consistent diagnosis and staging information dictated by pathologists as basis to treatment recommendations and ultimate survival predictions. With checklist items, the answers would be more clear and consistent reducing the need to re-review slides Cancer diagnoses make up a majority of the specimens reviewed by pathology labs Using checklists could reduce time spent on signing out and re-reviewing such cases. Discrete checklist values can lend to improved assessment of quality of care studies, marketing and research activities.

37 References cols_intro.html ies/cancer_protocols_feature.html 04/Session%202%20B- %20Ken%20Gerlach.pdf#search='Reporting%20Path ology%20protocols

38 Acknowledgements Anthony Piccoli Sharon Winters Susan Urda Bill Gross

39 DISCUSSION Experiene of other Centers? Experience of other vendors? Synoptic reporting for biopsy specimens? Synoptic reporting for special procedures? Post-signout synoptic reports with ancillary data such as flow cytometry, molecular diagnostic information? Share experience working with other cancer registries Thoughts about CAP protocols in general.