College of American Pathologists
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cap today

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.”

Eric Skeji is a writer in Stinson Beach, CA.