90% of Cancer Pathology Reports Need to Include Synoptic Reporting

pathology lab reporting There are many changes facing healthcare today - changes in coding, billing, how information is collected, entered and processed. While many things are in a state of flux, the ultimate goal of healthcare remains the same - provide better care. Better care relies on informed physicians who, in turn, rely on quality (and qualified) data.

But in order to make sure that data is gathered properly - that the same information is captured using the same set of language - some standards have been put in place. By using these standards, physicians - particularly pathologists - can now all use the same words to describe important surgical specimens. This eliminates subjectivity of interpretation by researchers, and it reduces the amount of time spent re-formatting the reports. The result is a larger pool that is faster to search and understand in order to better assess and address the cancer issues facing the populace.

One way to ensure that standards are being followed is to tie them to accreditation. If the choice is to go with one cancer program that is accredited by the American College of Surgeons (ACS) or go with one that is not - most people will seek out that stamp of approval. Furthermore, no pathology lab wants to be the reason that the cancer program isn't accredited - again, the cancer program will find another pathology facility that will keep the program accredited. That is why, to ensure that the standards of reporting are being met and that this vital cancer data is captured in an identical systematic manner, the American College of Surgeons has mandated that "90% of pathology reports include all scientifically validated or regularly used elements of the appropriate protocols." (Via College of American Pathologists' website)

But what are "scientifically validated or regularly used elements of the appropriate protocols?" 

In January 2004, American College of Surgeons' Commission on Cancer (CoC) mandated new standards that require pathologists at CoC-approved cancer programs include all scientifically validated data elements (SVDE) in their surgical pathology reports for each site and specimen. In order to meet this criteria, College of American Pathologists (CAP) and other groups have pushed for pathologists to adopt synoptic reporting - that is a structured, electronic report that captures each of these elements in a standardized way that can easily be gather and organized for treatment and research purposes.

synoptic reporting cancer checklistNow there are many different ways to structure data and many different ways to create a "synoptic" report. But, in order to fulfill the ACS criteria and keep the cancer program accredited, there are five specific features that define synoptic reporting format:

  1. Data is displayed as the required checklist item (SVDE) followed by its response
  2. Each diagnostic parameter pair (checklist SVDE & response) is listed on a separate line
  3. 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 SVDE and responses must be listed together in one location.
  4. Additional items (not required for the CAP checklist) may be included in the synopsis but all required SVDE must be present.
  5. Narrative style comments are permitted in addition to, but are not a substitute for the synoptic reporting.

 What does this all mean? For starters - if you're working in a cancer program and the overwhelming majority of pathology reports are not using synoptic formatting in some respect, then you may be at risk to lose your ACS accreditation. If you work for a pathology facility and you want to ensure that your facility isn't responsible for violating the ACS accreditation of a cancer program, then you need to make sure that 90% of your pathology cancer reports are using some of these synoptic reporting elements.

structured pathology reportingPathologists need to adopt this formatting. But where can pathologists and lab managers find solutions for synoptic reporting? How will they know if they are capturing things correctly? CAP has issued electronic Cancer Checklists (eCCs) that pathologists can use to ensure they conform to this reporting criteria.  Pathology reporting vendors - like mTuitive - have adopted these checklists and guidelines and work to guarantee compliance with national and organizational standards. (In fact, if you'll allow me one moment to brag, mTuitive was the first company to license the SNOMED CT Encoded CAP Cancer Checklists) Solutions currently exist for your pathology lab to begin using synoptic reporting on cancer cases. They can be integrated into your current workflow and interfaced with your laboratory information system.

There's no reason to delay in adopting these solutions because adhering to these synoptic requirements positively affects many people in multiple ways. Members of a cancer program don't have to worry about accreditation lapsing due to an oversight, since the lab is already using synoptic reporting. Pathologists and their lab will gain (or at least, not lose any) customers since they can boast that their practices won't break a cancer program's accreditation. 

Most importantly it will lead to better care of patients. Structured data captured in synoptic reports is much easier to use in research or when sending in to the National Cancer Registry. These points of data are now ordered so that like will be compared to like, providing a much clearer view of the current state of Cancer in our patients in much faster time. The physicians are better informed about particular outcomes and recent trends in cancer diagnoses and treatments. The better informed the physician, the better care the patient receives. And no matter what else might change in healthcare - better care remains the top goal for all of us.


(For more information about the Commission on Cancer's program standards, you can read the whole thing right here in a PDF or, again, here is CAP's site with pertinent information for pathologists about the CAP cancer protocols)


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