Synoptic Reporting Research Articles

Improving Discrete Data Capture in Synoptic Reports With Optional Free-Text Modifiers.

Upfront, discrete data capture in synoptic reporting fails when pathologists choose a response not associated with discrete data. We sought to determine the factors associated with this event. The results of all "Other" entries in four common tumor sites in synoptic reports were reviewed. "Other" entries occurred in 329 of 13,421 questions (2.5%). In 306 of these 329 questions (93.0%), the pathologist appeared to choose this response because they wished to add additional information to an already existing response that was associated with discrete data capture. As a result, the addition of a free-text modifiers to existing responses would allow pathologist to add this additional information while still selecting a response associated with discrete data capture, significantly improving the total discrete data capture (13,092 of 13,421 questions [97.5%] v 13,398 of 13,421 questions [99.8%]; P < .001). The addition of free-text modifiers to structured responses in synoptic reports could significantly improve the discrete data capture rate.

Can pathological reports of rectal cancer provide national quality indicators?

Rectal cancer care has become increasingly complex and requires accurate information. The pathology report is a vital tool for accessing information to gauge a patient's prognosis and to guide treatment decisions. The aim of this study was to assess the quality of histopathological reporting and surgery for rectal cancer in New Zealand using defined quality indicators. This is a retrospective audit of pathological reports of all resected rectal cancer pathology reports submitted to the New Zealand Cancer Registry (NZCR) in 2015. The quality of reporting was assessed using specified criteria: synoptic report, adequate lymph node retrieval, reporting of circumferential resection margin (CRM) and mesorectal excision quality. Surgical outcomes were sphincter preservation rate, CRM clearance and complete mesorectal excision. A total of 803 patients with rectal cancer were reported to the NZCR in 2015, 505 underwent proctectomy. A total of 89.5% of reports were structured, 81.8% reported mesorectal excision quality and 86.7% reported CRM status. Adequate lymph node retrieval was obtained in 65.1%, complete mesorectal excision in 84.6% and positive CRM in 6.2% of cases. Quality varied between laboratories and district health boards. High-volume laboratories had higher quality reporting. Surgeon volume and training was related to adequate lymph node retrieval but not CRM clearance nor mesorectal excision quality. High-quality pathological reporting is associated with the use of synoptic reporting templates. Surgical outcomes for rectal cancer in New Zealand, especially the low rate of CRM involvement, compare favourably with international audits.

Synoptic Reporting: Evidence-Based Review and Future Directions.

Synoptic reporting is a process for reporting specific data elements in a specific format in surgical pathology reports. Previously, surgical pathology reports were free text, highly narrative, and prone to omission of necessary data and inconsistencies in formatting.1 Synoptic reporting not only ensures that all reports contain all necessary data elements, but also is amenable to scalable data capture, interoperability, and exchange. Efforts are ongoing to create national2 and international3-7 health care meaningful use standards by using cancer registries and health information exchanges for storing and accessing data. Ideally, data will be fed dynamically and seamlessly into and out of these data exchanges by using lean and streamlined automated processes. In practice, the College of American Pathologists (CAP) has been promoting synoptic reporting for > 20 years,8 has published protocols with both required and optional data elements for at least a decade, and has required reporting of these elements for the past 2 years as part of its Laboratory Accreditation Program (LAP) checklist.9 The contents of the CAP protocols along with the contents of the American Joint Commission on Cancer (AJCC) TMN staging system, which the protocols use, are both copyright protected. The AJCC copyright includes all computable representations of its TNM staging system, which raises issues to be discussed later. Internationally, the Royal College of Pathology (United Kingdom), the Royal College of Pathology Australasia, the European Task Force for Structured Reporting, the American Society of Clinical Pathologists, the Canadian Association of Pathologists, and CAP have worked with the International Collaboration on Cancer Reporting to produce a standard data set for the international community.3-7 A detailed road map was outlined by those involved in the CAP effort, which went from free-text narrative reports (level 1), to synoptic reporting (level 3), toward fully structured reporting. The final product includes discrete data embedded in laboratory information systems (LISs) and structured messaging/data exchange standards (level 6).10,11 Synoptic reporting has many different connotations, which depend on the stakeholder. For practicing pathologists, synoptic reporting refers to specific elements in the cancer protocols and a specific format required by the CAP LAP checklist.9 For clinicians, synoptic reporting provides a checklist that ensures completeness of reported data elements. For registrars, researchers, and data scientists, synoptic reporting denotes a means to populate structured databases. Although substantial overlap exists, the requirements for these various stakeholders can differ. This review details the components of synoptic reporting that affect its utility for these stakeholders and the components of synoptic reporting from the perspective that synoptic reporting actually exist as two layers. These layers comprise a front-end presentation layer and a back-end computational data layer. This understanding becomes sharper as components of synoptic reporting are discussed in context throughout this review.

Adenocarcinoma of the Uterine Cervix: Measuring, Staging, and Synoptic Reporting

Abstract Adenocarcinoma of the cervix is increasing in incidence in relative and real terms given the reduction in cervical squamous carcinomas in many developed countries. In this review, various aspects relating to the pathological staging of cervical carcinomas are discussed with emphasis on adenocarcinomas. These include the distinction between adenocarcinoma in situ and invasive lesions and the measurement of invasive adenocarcinomas; both of these issues are often more difficult than with the corresponding squamous lesions. The measurement of multifocal cervical carcinomas is covered with discussion of the International Collaboration on Cancer Reporting recommendations, although these were chiefly proposed for multifocal squamous carcinomas. The issue of adnexal involvement in cervical adenocarcinoma is discussed. A checklist of parameters that should be included on the pathology report of resection specimens of cervical carcinomas is presented, again with particular reference to the International Collaboration on Cancer Reporting recommendations. The advantages of synoptic reporting, in comparison to free text reporting, are discussed.

Uptake and impact of synoptic reporting in a community care setting

BackgroundBreast cancer surgeries have traditionally been documented in narrative reports. Narrative reports have been shown to be incomplete. Synoptic reports utilize standardized templates to record data and have emerged as an alternative to narrative reports. This study evaluates the uptake and impact of synoptic reporting for breast cancer surgery in a community care setting. MethodsA retrospective review of operative reports documenting breast cancer surgeries over a consecutive 3-year period. Results772 narrative reports and 158 synoptic reports were reviewed. Synoptic reports were associated with a higher degree of overall completeness (60% vs 45%) when compared to narrative reports. 6 out of 7 surgeons that produced at least 5 synoptic and 5 narrative reports had increases in completeness with use of synoptic reporting. ConclusionsUse of synoptic reporting improves breast cancer operative report completeness and decreases superfluous content when compared to narrative reports. While synoptic report uptake during the study period was suboptimal there exists several means by which it can be improved, including investment in information technology infrastructure and emphasis on stakeholder engagement.

Tabular Versus Synoptic Reporting of Prostate Core Needle Biopsies.

To compare synoptic versus tabular formats for reporting prostate core needle biopsy results. The format of a report can significantly affect the accuracy, speed, and preference with which a reader can retrieve information. We compared the performance of 20 nonpathologists in the identification of specific information in synoptic and tabular reports using a computerized quiz that measured both accuracy and speed. Tabular formatting was significantly more accurate (97% v 93%; P = .001) and faster (mean normalized time, 0.74 + 0.40 v 0.99 + 0.52; P < .001) than synoptic formatting. The improvement in accuracy was a result of questions that involved combining results from two different biopsies (96% v 92%; P = .03). The improvement in speed was observed for both single-value questions (0.77 + 0.41 v 0.87 + 0.39; P = .03) and combination questions (0.73 + 0.40 v 1.05 + 0.56; P < .001). Data extraction from a tabular format into a structured data file using free text extraction on the basis of punctuation was 100% successful. Tabular reporting of prostate needle biopsies allows significantly faster and more accurate identification of data by the user, especially when the data involve combining data from several biopsies. The tabular format does not impact the ability to create structured data files.

Synoptic operative reporting: assessing the completeness, accuracy, reliability, and efficiency of synoptic reporting for Roux-en-Y gastric bypass.

Synoptic reporting (SR) is one solution to improve the quality of operative reports. However, SR has not been investigated in bariatric surgery despite an identified need by bariatric surgeons. SR for RYGB was developed using quality indicators (QIs) established by a national Delphi process. The objective of this study is to assess the completeness, accuracy, reliability, and efficiency of synoptic versus narrative operative reports (NR) in Roux-en-Y gastric bypass (RYGB). A NR and SR were completed on 104 consecutive RYGBs. Two evaluators independently compared the reports to QIs. Completeness and accuracy measures were determined. Reliability was calculated using Bland-Altman plots and 95% limits of agreement (LOA). Time to complete SR and NR was also compared. The mean completion rate of SR was 99.8% (±SD 0.98%) compared to 64.0% (±SD 6.15%) for NR (t=57.9, p<0.001). All subsections of SR were >99% complete. This was significantly higher than for NR (p<0.001) except for small bowel division details (p=0.530). Accuracy was significantly higher for SR than NR (94.2%±SD 4.31% vs. 53.6%±SD 9.82%, respectively, p<0.001). Rater agreement was excellent for both SR (0.11, 95% LOA -0.53 to 0.75) and NR (-0.26, 95% LOA -4.85 to 4.33) (p=0.242), where 0 denotes perfect agreement. SR completion times were significantly shorter than NR (3:55min±SD 1:26min and 4:50min±SD 0:50min, respectively, p=0.007). The RYGB SR is superior to NR for completeness and accuracy. This platform is also both reliable and efficient. This SR should be incorporated into clinical practice.

A computable pathology report for precision medicine: extending an observables ontology unifying SNOMED CT and LOINC.

BackgroundThe College of American Pathologists (CAP) introduced the first cancer synoptic reporting protocols in 1998. However, the objective of a fully computable and machine-readable cancer synoptic report remains elusive due to insufficient definitional content in Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC). To address this terminology gap, investigators at the University of Nebraska Medical Center (UNMC) are developing, authoring, and testing a SNOMED CT observable ontology to represent the data elements identified by the synoptic worksheets of CAP.MethodsInvestigators along with collaborators from the US National Library of Medicine, CAP, the International Health Terminology Standards Development Organization, and the UK Health and Social Care Information Centre analyzed and assessed required data elements for colorectal cancer and invasive breast cancer synoptic reporting. SNOMED CT concept expressions were developed at UNMC in the Nebraska Lexicon© SNOMED CT namespace. LOINC codes for each SNOMED CT expression were issued by the Regenstrief Institute. SNOMED CT concepts represented observation answer value sets.ResultsUNMC investigators created a total of 194 SNOMED CT observable entity concept definitions to represent required data elements for CAP colorectal and breast cancer synoptic worksheets, including biomarkers. Concepts were bound to colorectal and invasive breast cancer reports in the UNMC pathology system and successfully used to populate a UNMC biobank.DiscussionThe absence of a robust observables ontology represents a barrier to data capture and reuse in clinical areas founded upon observational information. Terminology developed in this project establishes the model to characterize pathology data for information exchange, public health, and research analytics.

Electronic synoptic reporting: assessing the completeness of synoptic and narrative reports for Roux-en-Y gastric bypass

BackgroundOperative reporting is the foundation of surgical communication. The quality indicators (QIs) contained in these reports can be used to document the performance of processes that affect patient care and may afford quality assurance with improvement in healthcare. ObjectivesWe assessed the degree to which the electronic synoptic report (SR) documents the operative QIs compared with narrative reports (NR) for Roux-en-Y gastric bypass (RYGB). The time to report availability on patient chart was also identified as a secondary measure. SettingAcademic center, public hospital, Canada. MethodsA total of 40 prospectively collected RYGB synoptic reports and 40 case-matched historical NRs were compared against checklist QIs that were established by a national Delphi process. These checklist QIs are validated and have high interrater agreement at our institution. Time from dictation to report availability on patient chart was measured. ResultsSR had a mean completion of 99.7% (±standard deviation [SD] 1.3%) compared with 64.0% (±SD 6.3%) for NR (t = 36.0, P<.0001). All subsections of SR were>99% complete and significantly higher than NR (P<.001). The mean time from NR dictation to report availability was 4.14 days (SD±3.17, range 0–10 d). All SRs were in the operative area after the procedure and were available immediately. ConclusionThe RYGB synoptic report is superior to the narrative report for inclusion of accepted quality indicators and time to availability. Important elements, including process of care, demographic characteristics, and anatomic-related data, were often missing from the NR. SR is a promising method for improving documentation for RYGB.

Performance of a Web-based Method for Generating Synoptic Reports

Context: The College of American Pathologists (CAP) requires synoptic reporting of all tumor excisions. Objective: To compare the performance of different methods of generating synoptic reports. Methods: Completeness, amendment rates, rate of timely ordering of ancillary studies (KRAS in T4/N1 colon carcinoma), and structured data file extraction were compared for four different synoptic report generating methods. Results: Use of the printed tumor protocols directly from the CAP website had the lowest completeness (84%) and highest amendment (1.8%) rates. Reformatting these protocols was associated with higher completeness (94%, P < 0.001) and reduced amendment (1%, P = 0.20) rates. Extraction into a structured data file was successful 93% of the time. Word-based macros improved completeness (98% vs. 94%, P < 0.001) but not amendment rates (1.5%). KRAS was ordered before sign out 89% of the time. In contrast, a web-based product with a reminder flag when items were missing, an embedded flag for data extraction, and a reminder to order KRAS when appropriate resulted in improved completeness (100%, P = 0.005), amendment rates (0.3%, P = 0.03), KRAS ordering before sign out (100%, P = 0.23), and structured data extraction (100%, P < 0.001) without reducing the speed (P = 0.34) or accuracy (P = 1.00) of data extraction by the reader. Conclusion: Completeness, amendment rates, ancillary test ordering rates, and data extraction rates vary significantly with the method used to construct the synoptic report. A web-based method compares favorably with all other methods examined and does not reduce reader usability.

Development of consensus-derived quality indicators for laparoscopic Roux-en-Y gastric bypass surgery

BackgroundSynoptic operative reporting is a solution to the poor quality of narrative reports. ObjectiveTo develop operative report quality indicators (QI) for laparoscopic Roux-en-Y gastric bypass (LRYGB) to generate validated parameters by which these reports can be evaluated and improved. SettingUniversity hospital in Canada. MethodsA Delphi protocol was used to determine QIs for LRYGB reporting. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Participants initially submitted potential QIs. These were grouped by theme. Items were rated on 9-point Likert scales in subsequent rounds. Scores of 70% or greater were used for inclusion consensus, and 30% or less denoted exclusion. Elements scoring 30% to 70% were recirculated by runoff in subsequent rounds to generate the final list of QIs. ResultsFour community and 4 academic bariatric surgeons were invited, representing all provinces performing LRYGB. The 4 multidisciplinary invitees included 1 minimally invasive/acute care surgeon, 1 tertiary abdominal radiologist, 1 gastroenterologist performing advanced endoscopy, and 1 general surgeon with expertise in synoptic reporting. Round 1 achieved an 83.3% (10/12) response and identified 91 potential items for consideration. Round 2 had a 100% response, and 69 items reached inclusion consensus. The third round achieved a 100% response and resulted in 75 QIs reaching final inclusion consensus. ConclusionThis study established consensus-derived multidisciplinary QIs for LRYGB operative reports. This will allow further assessment of the quality of narrative reports and afford the development of a synoptic operative report that may ameliorate identified deficiencies.

Key gaps in pathologic reporting for appendiceal mucinous neoplasms: time for universal synoptic reporting?

The prognosis of appendiceal mucinous neoplasms (AMN) is directly related to their histopathology. Existing classification schemes encompass tumors with widely divergent clinical behaviors within a single diagnosis, making it difficult for clinicians to interpret pathology reports to counsel patients on optimal management. We sought to examine pathology reports generated for AMN for inclusion of essential histologic features. Pathology reports of appendectomy specimens with a diagnosis of AMN (2002-2015) at our center ("internal") and from referring institutions ("external") were retrospectively reviewed for inclusion of the following 5 essential items: layer of invasion, mucin dissection (low grade neoplasms only), perforation, margins, and serosal implants. Sixty-nine patients were included, 54 with external reports available. Benign/low grade tumors comprised 29.0% and 27.8% of internal and external reports, respectively. Thirty-seven internal reports (53.6%) were signed out by specialist gastrointestinal pathologists. External reports were 66.7% complete for layer of invasion, 26.7% for mucin dissection, 64.8% for perforation, 68.5% for margins, 53.7% for serosal implants, and 18.5% for all items. Internal reports were 75.4% complete for layer of invasion, 40.0% for mucin dissection, 40.6% for perforation, 82.6% for margins, 69.6% for serosal implants, and 17.4% for all items. Eight external (14.8%) and 24 internal (34.8%) reports were synoptic. Synoptic reports were more likely to be complete for all key items both external and internal. Most pathology reports are incomplete for essential features needed for management and discussion of AMN with patients. Synoptic reports improve completeness of reporting for these tumors.

The effects of implementing synoptic pathology reporting in cancer diagnosis: a systematic review.

Pathology reporting is evolving from a traditional narrative report to a more structured synoptic report. Narrative reporting can cause misinterpretation due to lack of information and structure. In this systematic review, we evaluate the impact of synoptic reporting on completeness of pathology reports and quality of pathology evaluation for solid tumours. Pubmed, Embase and Cochrane databases were systematically searched to identify studies describing the effect of synoptic reporting implementation on completeness of reporting and quality of pathology evaluation of solid malignant tumours. Thirty-three studies met the inclusion criteria. All studies, except one, reported an increased overall completeness of pathology reports after introduction of synoptic reporting (SR). Most frequently studied cancers were breast (n = 9) and colorectal cancer (n = 16). For breast cancer, narrative reports adequately described ‘tumour type’ and ‘nodal status’. Synoptic reporting resulted in improved description of ‘resection margins’, ‘DCIS size’, ‘location’ and ‘presence of calcifications’. For colorectal cancer, narrative reports adequately reported ‘tumour type’, ‘invasion depth’, ‘lymph node counts’ and ‘nodal status’. Synoptic reporting resulted in increased reporting of ‘circumferential margin’, ‘resection margin’, ‘perineural invasion’ and ‘lymphovascular invasion’. In addition, increased numbers of reported lymph nodes were found in synoptic reports. Narrative reports of other cancer types described the traditional parameters adequately, whereas for ‘resection margins’ and ‘(lympho)vascular/perineural invasion’, implementation of synoptic reporting was necessary. Synoptic reporting results in improved reporting of clinical relevant data. Demonstration of clinical impact of this improved method of pathology reporting is required for successful introduction and implementation in daily pathology practice.Electronic supplementary materialThe online version of this article (doi:10.1007/s00428-016-1935-8) contains supplementary material, which is available to authorized users.

Functional Assessment of Synoptic Pathology Reporting for Ovarian Cancer

Background: Ovarian cancer has one of the highest death/incidence rates and is commonly diagnosed at an advanced stage. In the recent WHO classification, new histotypes were classified which respond differently to chemotherapy. The e-standardized synoptic cancer pathology reports offer the clinicians essential and reliable information. The aim of our project was to develop an e-template for the standardized synoptic pathology reporting of ovarian carcinoma [based on the checklist of the College of American Pathologists (CAP) and the recent WHO/FIGO classification] to introduce a uniform and improved quality of cancer pathology reports. A functional and qualitative evaluation of the synoptic reporting was performed. Methods: An indispensable module for e-synoptic reporting was developed and integrated into the Hospital Information System (HIS). The electronic pathology system used a standardized structure with drop-down lists of defined elements to ensure completeness and consistency of reporting practices with the required guidelines. All ovarian cancer pathology reports (partial and final) with the corresponding glass slides selected from a 1-year current workflow were revised for the standard structured reports, and 42 tumors [13 borderline tumors and 29 carcinomas (mainly serous)] were included in the study. Results: Analysis of the reports for completeness against the CAP checklist standard showed a lack of pTNM staging in 80% of the partial or final unstructured reports; ICD-O coding was missing in 83%. Much less frequently missed or unstated data were: ovarian capsule infiltration, angioinvasion and implant evaluation. The e-records of ovarian tumors were supplemented with digital macro- and micro-images and whole-slide images. Conclusions: The e-module developed for synoptic ovarian cancer pathology reporting was easily incorporated into HIS.CGM CliniNet and facilitated comprehensive reporting; it also provided open access to the database for concerned recipients. The e-synoptic pathology reports appeared more accurate, clear and conclusive than traditional narrative reports. Standardizing structured reporting and electronic tools allows open access and downstream utilization of pathology data for clinicians and tumor registries.

Electronic operative reports to support quality improvement and patient-centered care.

95 Background: Operative reports (OP) for cancer surgery are usually narrated, although they provide inconsistent and incomplete information for patient care. National standards for cancer OP were unavailable until 2007. Over 10 years, surgeons in four Canadian provinces have transitioned from narrative to electronic synoptic reporting (ESP) for specific cancers. The electronic OP are now considered a patient medical record and integral to subsequent patient care. Surgeons are using electronic reports for quality assurance, billing, medical-legal conflict resolution and research. Methods: Disease-site expert panels were formed to bring together surgeons to discuss, identify, develop and form consensus on a core set of elements for breast, colorectal, ovary, endometrial, lung, prostate, and thyroid cancer surgeries and 64 quality indicators to set practice standards to consistently and comprehensively record pre-operative, operative procedures, intra-operative observations and pathology, clinical stage findings, complications and outcomes. These standards were implemented using ESP in four provinces and a mixed methods evaluation was carried out. Results: 245 surgeons in academic and community hospitals piloted and implemented pan-Canadian standards and generated 2000 synoptic reports and 729 discharge summaries over six months. In comparison to narrative reports, surgeons reported that the electronic synoptic reports: Capture complete and essential content (89% - 96%), 50% more; Contain 25 – 50 items vs. 2000 narrated words; Faster completion and turnaround time (5- 15 minutes) vs. 5 days; Rapid transmission to patient charts (91% in 1 hour and 97% within 24 hours) vs. 30 – 90 days; Result in cost savings $90/case; Enable performance measurement of surgical care to assess quality and outcome of surgery (e.g., residual disease and survival in patients) and length of aggressive vs. non-aggressive surgery and hospital stay (5.49 hours and 8.39 days vs. 3.06 hours and 6.83 days). Conclusions: Surgeons are building partnerships with key players to strategize best approaches to enable a system-wide adoption and implementation of synoptic operative reporting and quality of care measurement across Canada.

Electronic Synoptic Reporting of Thyroid Nodules: Potential for Reduction in Number of Patients Undergoing Thyroid Nodule Biopsies

Purpose: The objective of the study was to design and implement an electronic synoptic report for thyroid sonography that incorporates the thyroid imaging reporting and data system (TIRADS) and assess potential for reducing unnecessary fine needle aspiration biopsies (FNAB) of thyroid nodules. Methods: The electronic synoptic report was developed using a relational database based on elements from TIRADS and a multidisciplinary consensus statement for thyroid reporting. A retrospective analysis of 138 patients with previously reported thyroid sonographic exams was evaluated for the presence of these elements. The electronic synoptic report calculates the TIRADS score and generates a formal report. Using the TIRADS score the potential decrease in unnecessary FNAB was estimated. Results: Key TIRADS elements were variously reported ranging from 43% for the thyroid nodule’s architecture as solid or cystic. Thyroid nodule echogenicity and calcification was commented in 27% and 23%, respectively. Other features of the TIRADS score were commented in 0% to 8% of the official reports. Estimated reduction for potentially reduced need for FNAB was 34.5%. Conclusions: This study is the first implementation of synoptic reporting using a relational database for sonography of thyroid nodules. Implementation of an electronic standardized synoptic reporting system may facilitate more accurate, and more comprehensive reporting for thyroid ultrasound scanning of thyroid nodules. The use of TIRADS was estimated to be able to potentially reduce the need for FNAB which was significant.

Sa1504 “Shaken, Not Stirred.” Towards Standardized Synoptic Reporting in GI Endoscopy Electronic Medical Records (EMRs)

Sa1504 “Shaken, Not Stirred.” Towards Standardized Synoptic Reporting in GI Endoscopy Electronic Medical Records (EMRs)

The Operative Dictation: A Review of How This Skill is Taught and Assessed in Surgical Residency Programs

The operative dictation (OD) is the cornerstone of surgical communication, yet there appears to be a lack of formal education of this skill by training programs. We conducted a review of the literature to assess the teaching and quality of OD in surgical residency programs. Multiple databases were searched for studies pertaining to "OD," "surgical education," and "formal teaching." Of 50 the studies, 13 were retained and assigned to one or more of the following categories: (1) surveys of the surgical community evaluating current perceptions of formal OD education (n = 5), (2) studies assessing the quality of OD performed by residents (n = 5), and (3) educational interventions for improving OD skills (n = 4). (1) Between 12% and 25% of survey respondents reported formal teaching of OD skills in their surgical programs. Surveyed residents and program directors were in favor of the implementation of structured teaching 60% to 91% of the time. (2) Multiple studies demonstrated significant deficiencies in residents' ODs, with key information missing in up to 76% of cases. The completeness of OD did not consistently correlate with level of training. (3) In one of the studies, a formal educational session was found to improve OD quality scores (p < 0.001). In 2 studies, the use of synoptic report maximized the completion rate of OD up to 92% from less than 70%. Synoptic reports were significantly more complete than conventional ODs with regard to general information (p < 0.001) and procedural aspects (p < 0.001). A single randomized trial demonstrated an improvement in junior residents' ODs after the implementation of a template (p = 0.02). Current evidence suggests that only a small proportion of residency programs offer formal OD instruction, despite a demonstrable need for improvement in residents' OD skills. Educational interventions and synoptic reporting present possible solutions, although this continues to be an area of evolving interest.

Use of Synoptic Reporting to Drive Reflex Testing, Quality Assurance, and Discrete Result Reporting

Use of Synoptic Reporting to Drive Reflex Testing, Quality Assurance, and Discrete Result Reporting

Using data sets in surgical pathology reporting of larynx carcinoma

It is imperative that anatomical pathologists report malignancy in a consistent, uniform method for many purposes including therapeutic management and database maintenance. Worldwide, surgical pathology reporting is shifting from the traditional text-based format, with specific information contained in the narrative, to synoptically structured communications. A synoptically structured report is a narrative report that is formally divided into explicit items covering specific observations on a specimen, and laid out in a predefined format, and may use Logical Observation Identifiers Names and Codes (LOINC). A synoptic report is one where the information has been fully separated into an explicit set of defined question and answer pairs of data items, and fully LOINC encoded for all questions, and for all answers that are not numeric values or free text entry. This standardisation of anatomical and microscopic information of malignancies facilitates the electronic transmission to cancer databases and registries for cancer surveillance. Both the North American Association of Central Cancer Registries (NAACCR) and the Royal College of Pathology (RCPath) have issued guidelines on synoptic reporting and an example for larynx carcinoma with brief reference to some of the important dataset criteria will be discussed.