synoptic reports - Pathology Informatics Summit

MASSACHUSETTS
GENERAL HOSPITAL
HARVARD
MEDICAL SCHOOL
PATHOLOGY
Implementation and Optimization
of Electronic Synoptic Reporting at
a Large Academic Hospital
Veronica E. Klepeis, M.D., Ph.D.
Massachusetts General Hospital
May 7, 2015
Disclosures
• mTuitive – consulting (salary)
• SunQuest CoPath – collaboration agreement
with MGH/Partners Healthcare
• CAP PERT committee – recent appointment
The past and present…
• Traditional pathology
reports are written in
free text
• Results in creation of
a few large text fields
correlating with specific
parts of the surgical
pathology report
• Variability in reporting
styles
• Missing important data
elements
Some History….
• Early 1990’s: a number of pathology professional societies
began issuing recommendations specifying a minimum set
of data elements that should be included in pathology
reports for particular tissue types or pathologic diagnoses
• 2004: American College of Surgeons’ Commission on
Cancer required as a condition of cancer program
accreditation that surgical pathology cancer reports contain
validated or regularly used data elements in their reports
for each site and specimen
• To facilitate this, College of American Pathologists (CAP)
developed site-specific cancer protocols and checklists as a
resource
• Today: CAP requires CAP-accredited laboratories to include
all report elements specified in CAP cancer protocols in
surgical pathology reports
Kang HP. Am J Clin Pathol. 2009;132:521-30.
CAP Cancer Protocols
• Set of standardized, evidence based protocols (over 75)
• Goal: Improve quality and uniformity of information in
pathology reports
• Developed by the CAP cancer committee
• Consist of data elements structured as a set of questions and
prospective answers
• Staging is based on the AJCC Staging Manual
• Includes reference information and is updated annually
• Available in doc and pdf versions
• Electronic cancer checklists (eCC) were released in early 2007
to advance use in computerized pathology reporting
– Data elements are encoded with SNOMED codes
– Managed by the CAP PERT Committee
CAP Cancer Protocols
Benefits of Synoptic Reporting
• Significantly improves completeness of cancer reports
across a broad range of tumor types
• Simplifies and prioritizes the recording of information
• Ensures that pathologists are kept abreast of the latest
minimum reporting standards for all tumors
• Secondary users, such as cancer registries, can more
efficiently extract meaningful staging and prognostic
data than from narrative reports
• Improved information to support clinical decision
making, i.e. increased clinician satisfaction
Lankshear S, et al. Arch Pathol Lab Med. 2013;137:1599-1602.
Synoptic Reports vs. Structured Data
• Not all synoptic reports contain structured data
• Many synoptic reports are simply word processing
documents that appear structured to humans
– Only visually structured blocks of free text
• Discrete structured data requires discrete data elements be
entered in many smaller specific text fields
– Each data element has its own predefined place in a database
– Each discrete data element is directly linked to its inherent
context
• Electronic synoptic reporting inserts discrete, structured
data elements into a database
Synoptic reports clarify findings for clinicians while
structured data clarifies findings for computers
Amin W, et al. Open Access Bioinform. 2010;2:105-112
Benefits of Electronic Synoptic Reporting
• Beyond the benefits of synoptic reporting,
truly structured data in the form of discrete
data elements allows for
– Advanced data-querying capabilities
– Automated analysis
– Decision support
– Predefined comment generation or staging
Ellis DW. Pathology. 2011;43:404-9.
MGH Anatomic Pathology
• Highly subspecialized
– 17 subspecialties, around 50
anatomic pathologists
– Weekly rotations
• Accredidation: JCAHO
• LIS: SunQuest CoPath Plus
• Electronic Synoptic
Reporting: mTuitive
Electronic Synoptic Reporting Project
• 2 synoptics per subspecialty
converted to electronic format
• Paper versions of electronic report
also developed
• mTuitive used as standalone
(separate from CoPath)
• Modifications made to standard
CAP cancer protocols
Inv breast ca
DCIS
Bone
Soft Tissue
Valves
Rejection
Lung Carcinoma
Lung Rejection
Melanoma
Merkel cell
Thyroid
Salivary gland
Thymoma
WHO Class
Colorectal
Pancreas
Kidney
Prostate
Endometrium
Ovary
GTD
Medical renal Bx
Key Factors Influencing Implementation
• Workflow issues
• Synoptic design
– For the pathologist (data entry)
– For the clinician (report readability)
• Synoptic content
Key Factors Influencing Implementation
• Workflow issues
• Synoptic design
– For the pathologist (data entry)
– For the clinician (report readability)
• Synoptic content
Workflow Complications
• Some pathologists resistance to introducing
more computer work into their workflow
• Poor computer access in many sign out rooms
• Residents involvement in a case
Prior Workflow for Synoptic Reporting
Transcriptionist
Resident-free
Attending
Signed out case
New Workflow for Electronic Synoptic Reporting
Transcriptionist
Resident-free
Attending
Key
with trx
w/o trx
Signed out case
Recommended Workflow
Transcriptionist
Resident-free
Attending
Key
with trx
w/o trx
Signed out case
Recommended Workflow
Transcriptionist
Resident-free
Attending
Key
with trx
w/o trx
Signed out case
Prior Workflow for Synoptic Reporting
Attending
Resident
PREVIEW
SIGN OUT
New Workflow for Electronic Synoptic Reporting
Attending
Resident
SIGN OUT
PREVIEW
Key
No computer, paper only
Computer, with paper
Computer, no paper
Recommended Workflow
FIRST YEAR RESIDENTS
Attending
Resident
SIGN OUT
PREVIEW
Key
No computer, paper only
Computer, with paper
Computer, no paper
Recommended Workflow
Attending
Resident
SIGN OUT
PREVIEW
Key
MORE SENIOR RESIDENTS
No computer, paper only
Computer, with paper
Computer, no paper
Workflow for Electronic Synoptic Reporting
Attending
Resident
SIGN OUT
PREVIEW
Key
No computer, paper only
Computer, with paper
Computer, no paper
Workflow for Electronic Synoptic Reporting
Key
Transcriptionist
Transcriptionist involved
Resident involved
Attending only
Attending only
Resident
POST
SIGN OUT
Signed out case
Attending
Workflow Issues
• Environment (computer accessibility)
• Use of paper versions of the electronic
synoptic reports (transcriptionist involvement)
• Resident experience and confidence in making
a particular diagnosis
• Attending comfort level using computers
Key Factors Influencing Implementation
• Workflow issues
• Synoptic design
– For the pathologist (data entry)
– For the clinician (report readability)
• Synoptic content
Optimization of Synoptic Design
• Goal: Decrease the number of “clicks” for the
pathologist
mTuitive Software
• Agile Author 2.0 – for creating and/or
editing templates
• xPert 3.0 – used by pathologists to fill
out the electronic templates
– Used as standalone software for this
project (i.e., not integrated with CoPath)
Optimization of Synoptic Design
• Modifications made to decrease number of
clicks for the pathologist
– Removal of duplicate data entry
– Combining sections
– Branching
– Calculations
– Defaulting answers
– Adding list functionality
Removal of duplicate data entry
• Data already collected
elsewhere (but not structured)
– Gross description
– Part type/part description
– Clinical history
Green = hidden
Combining Sections
• Laterality for certain
procedures or locations is
often asked as a separate
question
• Combine into one
question
Branching
• Treatment effect (Snapshots)
• Margins (snapshots)
Calculations: ICD-9/ICD-10
• ICD9
• pTNM Staging
Calculations: ICD-9/ICD-10
• ICD9
• pTNM Staging
Calculations: Staging
• ICD9
• pTNM Staging
Calculations: Staging
• ICD9
• pTNM Staging
Calculations: Staging
• ICD9
• pTNM Staging
Examples of Calculations
• ICD9
• pTNM Staging
Defaulting Answers
• Answered the
same way >90%
of the time
• Can be changed
Added List Functionality
• Action buttons
• Can expand specific
portions of the list
Added List Functionality
• Action buttons
• Can expand specific
portions of the list
Added List Functionality
• Action buttons
• Can expand specific
portions of the list
Added List Functionality
• Action buttons
• Can expand specific
portions of the list
Added List Functionality
• Action buttons
• Can expand specific
portions of the list
Added List Functionality
• Action buttons
• Can expand specific
portions of the list
Added List Functionality
• One click to select
multiple answers
Added List Functionality
• One click to select
multiple answers
Added List Functionality
• One click to select
multiple answers
Added List Functionality
Added List Functionality
Added List Functionality
Added List Functionality
Optimization of Synoptic Design
• Improvements for the clinician reading the
final report
– Clearly define parts of case included in the
synoptic report
– Re-order sections of the report
– Summary statements
– Ample opportunity for free text
– Hide information not relevant for final report
Parts of Case Included
• Snapshot
Parts of Case Included
• Snapshot
Reorder Sections of Report
• pTNM Stage
Reorder Sections of Report
• pTNM Stage
– Top of report
– Concise one line
summary
Summary Statement
Free Text Opportunity
• Snapshots of examples
Free Text Opportunity
• Snapshots of examples
Free Text Opportunity
• Snapshots of examples
Free Text Opportunity
• Snapshots of examples
Free Text Opportunity
• Snapshots of examples
Hidden Sections
• Snapshots of examples
Hidden Sections
• Snapshots of examples
Key Factors Influencing Implementation
• Workflow issues
• Synoptic design
– For the pathologist (data entry)
– For the clinician (report readability)
• Synoptic content
Synoptic Content
• Not necessarily related to “electronic” synoptic
reporting
• Modifications made
– Incorporation of margin information from separately
submitted parts of the case
– Incorporation of lymph nodes the entire case
– Reporting multiple tumors
• Capturing more discrete data elements from multiple
tumors
• Calculation stage when multiple tumors present
– Amendment comment
Reporting Margins
• How to clearly present information on margins
separately submitted from the main specimen?
Reporting Margins
• How to present information on margins
separately submitted from the main specimen
Reporting Lymph Nodes
• How to indicate
lymph nodes
from main
specimen vs.
separately
submitted?
Reporting Lymph Nodes
• How to indicate
lymph nodes
from main
specimen vs.
separately
submitted?
Reporting Lymph Nodes
• How to indicate
lymph nodes
from main
specimen vs.
separately
submitted?
Reporting Multiple Tumors
Reporting Multiple Tumors
Separate primaries
Single tumor
Multiple tumors
Single primary
Unsure
Total number of tumors
Number of separate primaries
Number to fully characterize
Number to partially describe
Reporting Multiple Tumors
• Show series of questions I developed
Reporting Multiple Tumors
• Show series of questions I developed
Reporting Multiple Tumors
• Show series of questions I developed
Reporting Multiple Tumors
• Show series of questions I developed
Reporting Multiple Tumors
• Show series of questions I developed
Amendment Comment
Amendment Comment
Amendment Comment
Amendment Comment
Summary and Conclusion
• Electronic synoptic reporting can introduce
complicated workflow variations when
computers are poorly accessible during sign
out, requiring use of paper versions of the
synoptics.
• Resident participation in previewing and
writing up cases complicates the electronic
synoptic reporting workflow.
Summary and Conclusion
• In order to improve compliance and minimize
complaints with electronic synoptic reporting, we
enhanced efficiency of data entry using either
features and tools available in the mTuitive
software or by modifiying the standard CAP
cancer protocols.
• Synoptic report design (output) was modified to
optimize report readability.
• Synoptic content was modified to better handle
complicated specimens.
Follow-Up Studies
• Turnaround time
– +/- Residents, transcriptionists
– Paper vs. no paperless
• Pathologist satisfaction
– workflow
• Clinician satisfaction
– Report readibility
• Error/amendment rate
– +/- Residents, transcriptionists
• Further modifications of synoptic report
Thank you!
• Questions?
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Acknowledgements
Dr. John Gilbertson
Dr. Tom Gudewicz
Dr. Vania Nosé
Dr. Chris Garcia
James Floyd
Nancy Gifford
• mTuitive team