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Implementing Synoptic Reporting in Medicine

The Lessons Learned from Pathology Synoptic Reporting and the Goals Needed for Surgical Synoptic Reporting

But first, what is synoptic reporting? And why should it be used for medical reports?

Synoptic (or structured) reporting of the operative procedure allows for an easy-to-follow format where information can be located quickly and in a standardized manner from report to report. Additionally, structured reporting allows for the capture of discrete data fields that can be more easily mined and reported.

Formal evaluation has shown that systematically developed templates for reporting a surgical procedure consistently outperform traditional narrative reports in capturing key information that informs important clinical decisions for cancer patients.

Furthermore, such reporting mechanisms have the potential to reduce transcription costs, accelerate completion of health records, and allow the evolution of clinical databases that are useful for outcomes research and quality improvement.

mTuitive is implementing its OpNote product in Nova Scotia to satisfy requirements of the province's surgical synoptic reporting project. Nova Scotia is working in tandem with the Canadian Partnership Against Cancer (CPAC) to create the clinical content standard as well as establishing a national informatics standard with a uniformity of values for each element, in turn supported by international medical codes.

For several years mTuitive has been at the forefront of the Cancer Care Ontario (CCO) initiative to implement pathology synoptic reporting across the province. As Nova Scotia is working with CPAC to create standards, CCO long ago made the decision to adopt the College of American Pathologists' (CAP) checklist to make it possible to capture standardized and comparable pathology data. This data can be used to facilitate more advanced reporting for hospitals, Local Health Integration Networks (LHINs) and the province on cancer planning, research, and surveillance. mTuitive’s xPert for Pathology is being used in about two dozen hospitals in Ontario to help hospitals meet CCO’s strict data standard.

The two major keys to a successful implementation are Commitment and Support.

There must first be a commitment by the organization to realize change and stick with it through the tough times - as there will be some rocky roads in the beginning. There will be slight changes to workflow, adjustments to new processes, and adherence to these new practices - but as long as the facility remains focused on achieving its goals, personnel will work together to make the project a success.

Support must come from multiple key areas in the facility: lab, IT, and administration. mTuitive prides itself on successful implementations, but these initiatives can only be successful if the client has a solid support network in those three areas. Key personnel in each of those areas of the facility must not only understand and be committed to the goals of implementing these synoptic reporting projects, but they also have to understand the practical implications of doing so as well as the "mechanics" of using the solutions and adhering to these standards. Changes in "how things are done" will cause anxiety, and it's important that there is staff in place that can explain not only how to use the new solution but also why the new solution is being used.

Anthony Robbins said, "change is inevitable. Progress is optional." Technology is constantly improving. Our understanding of the world is being refined every day. The current situation is never the current situation for long - we are all always working together to gain more knowledge, to do things more efficiently, and to make things better for all of us. Nowhere is this truer than in health care where these advancements directly affect how we feel and how we live. In order to meet the challenge that change brings, it's important that we communicate frequently, accept that there will be difficulties, but as long as we all work towards the same specific goals, the projects will be successful and progress will be made. photo credit: wistechcolleges, DarthNick via photopin cc

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