Synoptic Reporting Workshop

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Synoptic Reporting Workshop

• Friday, August 26, 2005
• Anil Parwani, MD., PhD
• Anthony Piccoli, BS
• Sharon Winters, MS, RHIA, CTR
• Susan Urda, BS, CTR
• Bill Gross, BS

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Synoptic Reporting Workshop Goals
In this workshop, we will describe our experience
in creating the synoptic tools with the overall
goal of promoting easy data sharing between the
Anatomic Pathology LIS, Cancer Registry and other
Clinical and Research systems in Oncology.
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Synoptic Reporting Workshop Scope

• Synoptic Worksheet entry in Cerners CoPathPlus
  and its incorporation into existing Pathology
  Reports.
• Synoptic data entry as methods of producing
  standardized reports, leading to improved
  pathology reports.
• The role of the Cancer Registry in extracting
  common data elements from a completed pathology
  report.
• Experience of UPMC in production of synoptic data
  entry worksheets and comparison to CAP
  checklists.
• Use of Synoptic Reports in the clinical
  environment, their impact on work flow and
  potential applications in oncology/research
  settings.

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Why do Synoptic Reporting?

• Templated data entry
• Uniformity and accuracy
• Gross and diagnostic content
• Templated data presentation on reports
• Format and prioritize diagnostic information
• Streamlines access by clinicians
• Capture of distinct data elements
• Enhancement of retrieval
• Transmission to other db systems

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• Synoptic/Checklist Reporting
• Gross and Microscopic Examination of Surgical
  Specimens, particularly large resections yields
  comprehensive information with implications for
  ongoing and future medical and oncology care.
• Traditionally, narrative descriptive reports
  have been used in surgical pathology to convey
  this valuable information to the patients and
  their health care teams.
• Such information is of immense value in making
  treatment decisions such as adjuvant therapy,
  radiation, chemotherapy and other interventions.
• This information is of great value to the
  cancer patient with providing them measures of
  prognosis and outcomes.

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• Synoptic/Checklist Reporting
• Traditional narrative and descriptive reports
  in free text format have significant variability
  because different pathologists use a multitude of
  different reporting styles to describe their
  findings.
• More often such variability results in
  pathology reports missing important data elements
  such as margins, lymphatic invasion etc.
• Synoptic Reporting, either as part of the
  pathology report or replacing the free text
  component, has uniformity with standardized data
  elements in forms of checklists thus ensuring the
  pathologist makes note of these findings in their
  reports.

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Synoptic Reporting Background

• The College of American Pathologist Cancer
  Protocols and Checklists were created with the
  objective of improving the quality and uniformity
  of information in pathology reports.
• http//www.cap.org/apps/docs/cancer_protocols/prot
  ocols_index.html
• Currently, most LIS Systems do not support
  discrete data elements for synoptic data elements
  thus, the CAP checklists have been incorporated
  as unstructured text blocks which are embedded in
  the pathology reports.
• The latter arrangement results in the
  presentation of pertinent pathology data in a
  cumbersome and difficult to access format.

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Experience at University of Pittsburgh Medical
Center

• Development of text-based synoptic outlines
  started in 1992-1993 (prostate ca), resulting in
  set of gt40 outlines for neoplastic resections
• Text-only format less than optimal for entry of
  selected data elements and presentation on
  reports, and many obstacles to data retrieval by
  distinct data elements
• Student project in early 2004 audited data
  elements in text-based outlines against required
  and other data elements defined in CAP
  checklists, preliminary to converting to synoptic
  worksheets in CoPathPlus.

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Experience at University of Pittsburgh Medical
Center

• At UPMC, we have used a synoptic reporting
  tool (Cerner CoPathPlus) to incorporate the CAP
  checklists as discrete data elements, allowing
  for storage of data elements in a relational
  table within the LIS.
• We have modified the CAP checklists into these
  synoptic worksheets for select organ systems and
  malignancies such as prostate, melanoma, breast
  and lung.
• We have also used CAP checklists created by
  Cerner DHT to supplement the library of
  checklists available for use in pathology reports.

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Synoptic Reporting Implementation Factors

• Data element (DE) structure
• Synoptic entry design
• Data content maintenance
• Workflow integration
• Synoptic data in reporting

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Synoptic Reporting DE Structure

• Data element structure
• Provides organization
• Defines distinct concepts
• Relation to data entry
• CoPathPlus
• Synoptic Values
• Synoptic Categories
• Synoptic Worksheets

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CoPathPlus Synoptic Data Table Structure
Synoptic Data Tables linked to Specimens
Synoptic Data Dictionary Tables
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Synoptic Reporting Dictionary Structure
Synoptic Categories
Synoptic Values
Synoptic Worksheet
lt 5 of specimen involved by invasive tumor
5 - 25 of specimen
Extent of Tumor
gt 25 of specimen
Unknown or N/A
Yes, high grade PIN, NOS
Yes, HG PIN, 1-2 foci in region of tumor
High Grade PIN
Yes, HG PIN, 1-2 foci away
Yes, HG PIN, multifocal
No, high grade PIN absent
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Synoptic Reporting Entry Design

• Synoptic entry design
• Simple UI for entry/selection of DEs
• Provides controls on data integrity
• required elements and multiple answers
• Variable formatting capabilities
• Integrates with workflow
• CoPathPlus Synoptic Worksheets

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CoPathPlus Synoptic Worksheet
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Synoptic Reporting Content

• Data content and maintenance
• Editing and version capabilities
• Compliance with CAP checklists
• American College of Surgeons Commission on Cancer
  requires for approval of cancer programs
• Annual updates from CAP
• Pre-built worksheets available from Cerner

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Synoptic Reporting Workflow

• Integration into workflow
• Gross data entry activities
• Diagnosis entry - transcribed or voice-entered?
• Availability at sign out
• Access for special procedures, et al?

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Specimen accessioned
SynWksh defaults on specimen from part
type OR attached to case by gross entry staff in
dev
Resident or Pathologist dictates final
diagnosis and synoptic values from SynWksh copy
UPMC Pathology Synoptic Worksheet Processing 2005
Transcriptionist attaches SynWksh if not done
previously
Transcriptionist enters values into on-line
SynWksh and marks complete as pertinent, sends
case to pathologist
Pathologist dictates changes to synoptic
values IF Not editing in on-line SynWksh OR
AFTER Specimen is amended
Pathologist enters values into on-line SynWksh,
or edits values if needed
Pathologist reviews final diagnosis and
default SynWksh text, signs out specimen
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Synoptic Reporting Reporting

• Synoptic data on reports
• Formatting, replacement text
• Location in reports
• Replacing final diagnosis (?)

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Synoptic Reporting Leveraging Data

• Data mining/searching capabilities
• Usage monitoring
• Transmission of synoptic data
• Cancer registry databases
• Research databases
• need for coding of synoptic elements

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Cancer Registries Re-Defining Roles

• Cancer registries have historically been highly
  standardized incidence-based information systems
  designed for the collection, management, and
  analysis of data on persons with the diagnosis of
  a malignant or neoplastic diseases

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Cancer Registries The New Frontier at UPMC

• UPMC is dedicated to enhancing the basic
• role of a cancer registry through marketing of
  this consistent, high quality, standardized
  cancer specific incidence, treatment and outcomes
  data through collaborative efforts in disease
  specific environments supported by grant funded
  initiatives

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Cancer Registry Standard Setting Agencies

• National Program of Cancer Registries (NPCR)
  established in 1992
• North American Association of Central Cancer
  Registries (NAACCR) data set, coding, data
  quality and data export standards
• Centers for Disease Control (CDC) - funding
  allocation for the NPCR
• Published first National Cancer Data Statistics -
  November 2002
• American College of Surgeons Commission on Cancer
  (ACOS COC) cancer program and data standards
• American Joint Committee on Cancer (AJCC) site
  specific staging
• 6th Edition - effective with cases diagnosed as
  of 01/01/2003
• World Health Organization (WHO) - ICD-O3 coding
  standards
• Based on ICD-10 (topography) and SNOMED
  (histology)
• State Departments of Health - incidence reporting
• Hospital - hospital specific data needs,
  reportable-by-agreement

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American College of Surgeons Commission on Cancer

• Cancer Program Standards Manual 2004
• 38 standards
• All standards mandatory for approval of program
• Beginning with cancer programs surveyed as of
  January 1, 2004, pathologists working in
  CoC-approved cancer programs must include all
  scientifically validated or regularly used data
  elements of the checklists in their reports for
  each site and specimen.
• All non-asterisked checklist items required at a
  minimum
• No specific format required

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American College of Surgeons Commission on Cancer

• The Standard related to CAP checklist
• Standard 4.6 The guidelines for patient
  management and treatment currently required by
  the CoC are followed.
• Definition and Requirements (page 38 of 2004
  Program Standards)
• 90 of pathology reports that include a cancer
  diagnosis will contain the scientifically
  validated data elements outlined on the surgical
  summary checklist of the College of American
  Pathologists (CAP) publication, Reporting on
  Cancer Specimens.

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American College of Surgeons Commission on Cancer

• Survey Evaluation Process
• 25 records from the top 5 sites seen at the
  particular facility will be randomly selected by
  the surveyor. Associated pathology report will
  be assessed for the CAP validated elements.
• If standard is not met
• One deficiency would be earned
• A three-year approval with contingency is granted
  for one to seven deficiencies.

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UPMC Pathology and Network Cancer
RegistryCollaborative Projects

• NCI Cooperative Prostate Cancer Tissue Resource
  (CPCTR) - 2000
• Disease Specific Registry Specialists - 2002
• Pennsylvania Cancer Alliance Bioinformatics
  Consortium (PCABC) - 2002
• Collaborative Honest Broker Service 2003
• CoPath Synoptics Development 2004
• CDC RPP2 Demonstration Project Reporting
  Pathology Protocols for Cancers of the Breast,
  Prostate and Melanomas - 2005

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CDC Demonstration Project Reporting Pathology
Protocols (RPP) for Cancers of the Breast,
Prostate and Melanomas

• Collaborative Project between the Centers for
  Disease Control and Prevention (CDC), NPCR
  Registries and Hospital Pathology Labs and Cancer
  Registries
• April 2005 December 2007

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CDC Demonstration ProjectBackground

• gt90 of all cancers are histologically confirmed
  in AP labs
• We have confirmed this to be 90 for Presbyterian
  Shadyside, 92 when adding Magee
• Electronic receipt of AP lab data by registries
  is essential to complete reporting
• 42 new CAP protocols and checklists

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CDC Demonstration ProjectPurpose

• Utilize and enhance NPCR data collection systems
• Receive data electronically from path labs using
  CAP protocols and checklists for breast, prostate
  and melanoma
• Labs will format data into messages consistent
  with national data standards (PHIN) and transmit
  data to both hospital and central registry

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CDC Demonstration ProjectQuestions to be Answered

• Is data from CAP cancer protocols and checklists
  more accurate and complete than traditional
  text-based reports?
• Are pathologists willing to use the CAP cancer
  protocols and checklists as a routine part of
  reporting?
• Will use of CAP cancer protocols and checklists
  result in more timely and complete information in
  hospital and central registries?
• What are the challenges and/or barriers for use
  (for cancer registries and AP labs)?

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CDC Demonstration ProjectTasks and Timelines

• Phase I Develop Strategies and Assessment
  Criteria
• Start April 2005
• Phase II Implementation
• Phase III Conclude Implementation and Develop
  Reports
• End December 2007

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CDC Demonstration ProjectParticipant Tasks

• Develop electronic reporting capabilities
• Cancer related pathology report data
• Patient identifier and demographic data
• Implement CAP cancer protocols and checklists for
  breast, prostate and melanoma
• Develop assessment measures to evaluate project
• Develop and implement plans to share expertise
  and experience
• Develop messaging guide and conformance software
• Compile results of assessment measures
• Provide feedback and recommendations to CAP to
  improve cancer protocols and checklists

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CDC Demonstration ProjectSelected Participants

• Three NPCR states selected, each bringing their
  own expertise to the table (or lack thereof)
• California experience with CAP checklists
• Maine no experience, small state
• Pennsylvania experience with electronic
  reporting
• UPMC AP laboratories and UPMC Network Cancer
  Registry (PUH/SHY and Magee to be included)

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UPMC Network Cancer Registry Current vs. Planned
Casefinding Process
Weekly Pathology SNOMED Report Compare To MRS
IMPAC MRS New Suspense
True New
Registrar Review
New Case
SMS.dta format
Monthly Medipac Batch File
F/U
Manual Review
Demographics
NPU
Report of Readmits, New Suspense, Possible
Matches
6 months to Central Registry
IMPAC MRS New Suspense
4-6 months to Central Registry
HL7 batch format
Weekly CoPath Batch File
All other steps the same except would load
Medipac data after pathology populates the new
abstract more timely creation of reportable
case??
Demo and Synoptic
Report of Readmits, New Suspense, Possible
Matches
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UPMC Network Cancer Registry Categories of Data
Collected
257 NAACCR items 305 Non-NAACCR items 115 Code
descriptors 162 Supplemental 639 data elements
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Cancer Registry Data Sources Pathology Common
Data Elements - direct (CAP) or derived values

• primary site
• laterality
• histology
• tumor behavior
• grade/differentiation
• place of diagnosis
• tumor size/depth of invasion
• extension to regional
• /distant tissues
• TNM, AJCC Stage Group
• regional nodes removed
• regional nodes positive

• date of 1st positive biopsy
• date of initial diagnosis
• perineural invasion
• lymphatic invasion
• margin involvement
• diagnostic confirmation
• dx staging procedures
• metastatic site(s)
• progression/recurrence
• date(s) of pathologically confirmed
• mets or recurrence
• microscopic confirmation

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Cancer Registry Data Sources PathologyCommon
Data Elements - direct (CAP) or derived values
Cancer Identification Staging Categories

• Considering cancer id and staging items,
  direct feeds of CAP checklist elements could
  potentially save cancer registrars time and
  improve quality of data eliminating guesswork
  from misinterpretation of pathology text

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SUMMARY Resistance to Uniformity

• In general, people dont like change
• Pathologist desire for flexibility and creativity
  in content and language, aka the poetic license
  of the historical practices of pathologists
• Checklists seen as limiting in nature,
  disagreements with importance of items selected
  by CAP vs. omitting others of potential
  importance
• The more standardized elements there are, the
  higher the risk of doing something wrong thus
  leading to possible legal actions
• In all actuality, following protocols can provide
  protection in medico-legal actions

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SUMMARY Importance of Uniformity

• With the CAP protocols and checklists, the power
  of clinical importance is in the hands of the
  pathology realm.
• The Global nature of cancer care - cancer
  patients are being diagnosed and treated in
  variety of settings require need for uniform
  documentation for communication between health
  care facilities.
• With checklist items, consistent data elements
  and values would enable quicker access to desired
  information and improved communication for proper
  cancer management

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SUMMARY Importance of Uniformity

• Clinicians rely on accurate and consistent
  diagnosis and staging information dictated by
  pathologists as basis to treatment
  recommendations and ultimate survival
  predictions.
• With checklist items, the answers would be more
  clear and consistent reducing the need to
  re-review slides
• Cancer diagnoses make up a majority of the
  specimens reviewed by pathology labs
• Using checklists could reduce time spent on
  signing out and re-reviewing such cases.
• Discrete checklist values can lend to improved
  assessment of quality of care studies, marketing
  and research activities.

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References

• http//www.cap.org/apps/docs/cancer_protocols/prot
  ocols_intro.html
• http//www.facs.org/cancer/coc/cocprogramstandards
  .pdf
• http//www.cap.org/apps/docs/cap_today/feature_sto
  ries/cancer_protocols_feature.html
• http//www.cdc.gov/phin/04conference/05-25-04/Sess
  ion20220B-20Ken20Gerlach.pdfsearch'Reporting
  20Pathology20Protocols

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Contact Us Via Email

• Anil Parwani parwaniav_at_upmc.edu
• Tony Piccoli piccolial_at_upmc.edu
• Sharon Winters winterssb_at_upmc.edu
• Susan Urda urdasj_at_upmc.edu
• Bill Gross grosswc_at_upmc.edu