Authors (including presenting author) :
LAM KHL(1), MOK JHM(1), FUNG VH(1), KAN SM(2), YEUNG SWC(2)
Affiliation :
(1) Health Informatics, (2) Clinical Departmental Systems, Information Technology and Health Informatics Division, Hong Kong Hospital Authority
Introduction :
Pathology report plays an important role in disease diagnosis, therapeutic management and prognostic assessment for cancer patients. In recent decades, cancer pathology reporting has undergone a paradigm shift from highly narrative record of pathology findings, which are inconsistent in formatting and prone to omission of essential data, to the adoption of synoptic reporting. The contemporary reporting format facilitates the documentation of required data elements followed by its answer in a paired format which provides a more consistent and comprehensive reporting of essential findings and ultimately improve the overall quality of pathology reports. The use of standardized cancer dataset is an essential prerequisite for international benchmarking in cancer cases management. Various datasets have been published by different organizations, the International Collaboration on Cancer Reporting (ICCR) was established to reduce global burden and reduplicated efforts in dataset development by different institutes. It aims to produce globally-agreed and evidence-based cancer datasets for international community. By collaboration with Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) International, ICCR is making steady progress towards the development of computable cancer reporting tools with terminology binding to promote interoperability and support secondary uses of data.
Objectives :
To develop a computable synoptic reporting platform to solicit completeness of reported pathology data elements in a standardized format across HA hospitals.
Methodology :
We sought to study the pathology reporting workflow and conducted proof-of concept on adoption of ICCR datasets for synoptic reporting. A web-based synoptic reporting platform was developed and integrated in ECPath5 Laboratory Information System - Anatomical Pathology System (LIS-APS) that available throughout HA laboratories.
Result & Outcome :
Workflow and Proof-of-Concept study on adoption of ICCR datasets was conducted which proven that essential report sections including clinical information, specimen details, histological findings and staging were covered in the datasets to ensure the completeness of pathology reports. An electronic synoptic reporting platform with the adoption of 23 ICCR datasets of common cancer types was built and integrated with LIS-APS that accessible throughout HA laboratories. Fundamental checklist components including radio buttons for mutually exclusive answers, checkboxes for multiple choices and text box for narrative entries were developed to ease user reporting. The platform enables users to visualize and review the selected answers in an aligned format before authorization in the preview pane. User-centered checklist designs including customizable navigation options and verification measures for patient identities and report sections were encompassed to facilitate efficient and accurate reporting. Efforts are ongoing to promote the adoption of synoptic reporting approach to both pathologists and clinicians throughout the implementation in pilot hospitals. In the near future, we will be focusing on exploration on storage of structured data and reference terminology binding to SNOMED CT to achieve our goal to promote interoperability and support downstream data uses and ultimately to improve patient care.
