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Synoptic Pathology Reporting
 

What is synoptic pathology reporting?

Synoptic pathology reporting uses an electronic report in discrete data field format (i.e., each type of information has a specific place and format in the report) that allows for the standardized collection, transmission, storage, retrieval and sharing of data between clinical information systems.

Levels of standardized pathology reporting

In Ontario, from 2004 to present, we have seen the transition of pathology reporting from the traditional narratively structured pathology report to Level 6 pathology reporting based on the CAP content standard and NAACCR Volume V messaging and format standard as outlined in the CCO Data Book (see Informatics Reporting Tools for Data Book details).


Why use the synoptic format?

The need for standardization and completeness were the main reasons for embracing this format across Ontario. A standardized report in synoptic format with discrete data fields is preferred for more efficient querying and analysis.

Benefits:

  • Standardizes pathology reporting
  • Improves overall report completeness
  • Easier to decipher than narrative or paragraphs
  • All important diagnostic and prognostic factors are laid out in a structured list or table with headers and responses rather than being buried in text fields
  • Improves communication among healthcare providers
  • Facilitates decision-making for treatment
  • Can improve pathology report turnaround time when paired with voice-recognition software
  • Facilitates secondary uses of pathology data for purposes such as tumour registries, quality reporting, stage capture, quality management and evaluation, patterns of care and outcome analysis, system planning, population research

CAP cancer checklist standards

We have endorsed the College of American Pathologists (CAP) cancer checklists as the content standard for pathology reporting based on these benefits:

  • The checklists were derived by the CAP Cancer Committee, with extensive input from leading interdisciplinary disease site experts across North America, using the most currently available research and evidence.
  • The checklists comprise evidence-based protocols and lists of criteria.
The Canadian Association of Pathologists has endorsed the CAP checklists as the pan-Canadian standard for synoptic pathology reporting, as of July 2009.

Pathology Reporting Indicators

Adopting the College of American Pathologists (CAP) checklist standard makes 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.

Synoptic pathology data is being reported for four indicators so far from hospitals that have successfully implemented synoptic pathology reporting in discrete data fields.

Pathology data quality indicators:

  • discrete synoptic reporting
  • pathology reporting completeness

Surgical pathology indicators:

  • radical prostatectomy margin
  • colorectal resection lymph node

Last modified: Thu, May 17, 2012
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