Pathology Templates for Timely Reporting

Because pathology reports are crucial to designing cancer care plans, timely reports are a critical component of cancer care. This is one reason that pathologists are choosing electronic synoptic reporting templates.

Synoptic reporting is a structured method of electronic medical documentation that uses coded values to help clinicians produce more complete, accurate and interpretable reports.

But if you’re a pathologist who already excels with dictated or narrative reporting, you might be asking…

“Won’t digital templates take longer?”

Like any new practice, electronic synoptic reporting includes a learning curve, so your first few reports will likely take longer than your current method.

Synoptic operative reporting has been found to substantially reduce reporting turnaround time [1]. And research already suggests that electronic template reporting is faster than narrative methods—for surgeons [2] and for pathologists [3]. Turnaround times for report approval and distribution are improved, providing care teams and quality improvement initiatives with timely access to clinical performance indicators [4].

“But what about dictation?”

At first glance, dictation seems like a quick and simple method for pathologists to communicate their findings. After all, it only takes a few minutes to dictate, and dictation can be guided by the use of paper templates.

Dictating narrative reports seems efficient because it compartmentalizes a time-consuming task into several smaller steps. But let’s take a closer look at the effects of this compartmentalization.

When a pathologist dictates a report, that dictation has to be transcribed—often by a person with little familiarity with medical terminology. That transcription has to be reviewed and corrected—often by a clinician unsure of the details of the original case.

This process creates several opportunities for errors and makes correcting those errors more difficult. More sets of eyes do not ensure quality if those eyes are untrained.

Moreover, the lag time between these steps means that it will be days, if not weeks, before a dictation can be integrated into medical records and distributed to care teams. If the resulting report is lacking the data required for clinical decision making, it can be difficult for a pathologist to recite the particulars of an old case.

A safer solution is for error checking to be applied at the time of reporting through the use of responsive electronic templates. This method produces more reliable pathology reports and can take as little time as dictating.

Electronic Synoptic Pathology Reporting

Through timely and interoperable data, the synoptic format improves cancer registries and cross-jurisdictional quality improvement and research initiatives. For example, in Canada, the Electronic Synoptic Pathology Reporting Initiative is helping labs across the country to develop and implement pathology reporting best practices—like the CAP Cancer Protocols—to strengthen cancer registries and improve collaboration.

The College of American Pathologists (CAP) has been developing cancer reporting protocols for over 15 years. This valuable library of clinical templates is frequently updated and the use of their synoptic format is widely recognized as a best practice for pathology. The downloadable CAP Cancer Protocols are not automatically fillable. However, synoptic reporting software is helping to optimize template reporting.

Pathology Synoptic Reporting Software

A best practice for pathology is to choose reporting tools that turn the CAP Cancer Protocols into responsive electronic templates, ensuring reporting is both thorough and streamlined.

The following video provides a brief overview of how pathologists can use the Synoptec™ clinical documentation software to quickly produce and distribute synoptic reports:

  1. Edhemovic I, Temple WJ, de Gara CJ, Stuart GC. The computer synoptic operative report–a leap forward in the science of surgery. Annals of Surgical Oncolog2004;11(10):941–7.  
  2. Temple WJ, Francis WP, et al. Synoptic surgical reporting for breast cancer surgery: an innovation in knowledge translation. American Journal of Surgery 2010;199(6):770–5.
  3. Murari M, Pandey R. A synoptic reporting system for bone marrow aspiration and core biopsy specimens. Archives of Pathology & Labratory Medicine 2006;130(12):1825–9
  4. Srigley, John, et al. Closing the Quality Loop: Facilitating Improvement in Oncology Practice Through Timely Access to Clinical Performance IndicatorsJournal of Oncology Practice 2013;9(5):e255–61.