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Pathology Reports

Larry H. Bernstein, MD, FCAP, Curator

LPBI

 

Complete Pathology Reports and Clinical Decision Making

Posted by Michael Doyle on Jan 15, 2015   http://www.softworksgroup.com/blog/complete-pathology-reports

(Synoptic Reporting)

Pathology reports provide care teams with crucial diagnostic and prognostic data. For population-level research and quality assurance initiatives, it’s important that reports are consistently complete. But report consistency can also be important for the medical outcomes of a single person.

Today, I’ll discuss the unique experience of a friend of mine, and I’ll explain how his isolated incident is connected to large-scale initiatives in pathology reporting quality assurance.

Incomplete Pathology Reports

A friend of mine has particularly fair skin and is at thus at increased risk for skin cancers. His family physician has recommended he have various moles removed to prevent the development of possible skin cancers.

Over time, my friend and his family physician became troubled by the inconsistencies they found in comparing the pathology reports from his five different biopsies.

Five out of five pathology reports identified that the moles were dysplastic—irregular and potentially cancerous. Yet only three reports identified that this dysplasia was in his skin’s basal cells as opposed to squamous cells or melanocytes.

The the type of skin cells exhibiting dysplasia is important to clinical decision making: dysplasia affecting melanocytes is the basis for melanomas, the most serious forms of skin cancer. Lacking this information makes it more difficult for care teams to develop the comprehensive understanding of an individual’s medical history that guides clinical decision making.

In response to the incompleteness of the pathology reports, the family physician remarked, “I rarely have to query a pathologist about what’s in a report. It’s usually about what’s left out.”

And it’s not just one physician who’s seeking better reports.

Synoptic Reporting for Complete Consistency in Pathology

For over 20 years, the College of American Pathologists (CAP) has been developing protocols and templates to standardize pathology reporting, substantially improving the completeness and consistency of pathology reports through the use of the synoptic—i.e. structured—format.

Synoptic reporting uses coded data templates to produce standardized reports that are more complete and consistent than reports generated using narrative methods.

Cancer Care Ontario introduced synoptic reporting for pathologist across the province—the largest jurisdiction to do so. Clinicians have shown over-whelming support for this initiative, finding that synoptic reports have facilitated consistent intepretation of diagnostic and prognostic data.

The Canadian Partnership Against Cancer is building on Ontario’s success to help implement synoptic pathology reporting across Canada, strengthening provincial cancer registries and fostering cross-jurisdictional research and quality assurance initiatives.

Clinical research has continually found that the use of synoptic reporting improves the completeness of pathology reports [123, 4]. These conclusions have been upheld in research on synoptic reporting for surgery as well [5, 6].

An important goal of synoptic reporting implementation initiatives is equipping pathologists and surgeons with clinical documentation software that enables them to provide each other with specific, reliable and actionable data—through complete and consistent reports.

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