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Synoptic Reporting and Structured DataCapture in Healthcare
Introduction
The amount of clinically significant findings a surgical pathologist is expected to report continues toincrease. Many clinicians see the need for a standardized terminology and pathology report structure inorder to clearly and quickly recognize the most important findings in determining treatment. The synopticreport (a synopsis or summary) addresses these issues by providing a standardized nomenclature, a setof universally required findings, and a very consistent report structure. The emergence of synopticreporting using published, peer-reviewed checklists is helping to standardize pathology reporting.Anatomic pathology reporting is still largely narrative text. In contrast to clinical pathology and cytology,the handcrafted narratives of anatomical pathology are of diagnostic importance due to the unique set of events that surround each patient’s case. With this in mind, any form of report standardization must notimpede the pathologist’s flexibility to offer individual diagnostic opinions on a case by case basis. Thusthe ideal anatomic pathology report blends synoptic elements with narrative descriptions to provide thebest assessment to the clinician. In this way, the clinician can find the most clinically significant elementsimmediately, but can still read the pathologist’s opinion regarding ambiguities in the specimen.
Synoptic Reporting and Structured Data
Synoptic reporting goes hand-in-hand with structured data. Because you are constraining the report toindividual data elements, it is possible for a computer to intelligently analyze individual elements for avariety of clinical and research purposes. However, not all synoptic reports contain structured data.Many are simply word processing documents that appear structured to human eyes. Thus, synopticreports structure and clarify findings for clinicians, while structured data clarifies findings for computers.There have been attempts to extract structured data from existing narrative pathology reports. Textparsing programs search through existing unstructured reports pulling out strings of text. Becauseparsing technology is imposed post facto, the process does not allow for quality control of data at thepoint of creation. Most importantly, natural language processing technology just isn’t advanced enough toproduce reliably, results without significant human intervention. Far better results are obtained by upfrontcapture of consistently structured data. In other words, by a human process of synoptic reportingtranslated into machine-readable structured data.
Data Entry Templates
With synoptic reporting, the pathologist completes prearranged data entry templates, often choosing fromfinite lists of options for consistency. Synoptic checklist reporting ensures quick, complete and concisedocumentation while decreasing questions from clinicians and cancer registers. It allows for accuratecollection and comparison of cancer data which directly impacts cancer screening and treatmentprotocols. Any report that can consistently offer an interpreting clinician the same data information in thesame format using medically consistent terminology has intangible benefits. The difference betweensynoptic reporting and structured data is a source of constant confusion. Synoptic simply means toprovide a summary of the pertinent findings. A synoptic report is capable of providing structured data setsthat correspond to the synoptic elements. If it does, then it is also structured data in addition to a synopticreport. The difference may appear to be question of semantics, but is more importantly one of theusefulness of information. Text can be copied into a file which can be parsed or mined for data elementsbut in an unstructured format it loses the power of a searchable database. Structured data by definition isinformation flowing into a database. Simply put, data has far more value than text in providing relevant,searchable information. Structured databases allow the task of data abstraction to be relegated to searchqueries rather than the manual task of report dissection and inspection in text driven systems. In thesetext systems, a certain percentage of the data is completely missed by text parsers. Structured datareporting carries the distinct advantage that 100 percent of data is captured and reported. Time andresources are saved and data integrity and patient safety are increased. Structured data reportingfacilitates coordination of care and reduces the chance for medical/clerical errors.
Recent Studies - Pathology Reporting Satisfaction Survey
Introduction
The following survey, facilitated by mTuitive Inc. (www.mtuitive.com), was sent out to 400 healthcareprofessionals and received a response rate of approximately 20%. The participants were surgeons,medical oncologists, radiation oncologists, pathologists, other physicians, and other health professionals.A summary of the significant findings follows the survey results.
The Survey Results
1.
Synoptic means to provide a synopsis or summary of the results, typically in a structuredquestion and answer format. The alternative is to receive a narrated report in a free text format.Prior to this survey, were you familiar with the term “synoptic reporting?”Response PercentYES
93.2%
NO6.8%
YESNO
2.
Are your pathologist or other clinicians providing synoptic reports to you?Response PercentYES
64.8%
NO35.2%
YESNO
3.What is your clinical specialty?Response PercentSurgeon21.9%Medical Oncologist19.2%Radiation Oncologist6.8%Pathologist
34.2%
Other Physician1.4%Other Health Professional 16.4%
SurgeonM.OncologistR.OncologistPathologistO. PhysicianO. Health
4.
Which reporting style is most conductive to:synopticnarrativeno preferenceClarity of results
86.3%
8.2%5.5%Reducing the need for further explanation
72.6%
16.4%11.0%Consistency of reporting
98.6%
1.4%0.0%Overall completeness
84.9%
9.6%5.5%Aiding in the staging process
87.3%
4.2%8.5%Streamlining cancer registry data collection
97.3%
1.4%1.4%Meeting standards for CoC accreditation
83.3%
1.4%15.3%Communication to patients
65.3%
11.1%23.6%Data collection for research
95.9%
2.7%1.4%
5.
Are you happy with the time it takes to receive a written pathology report?Response PercentYES36.1%
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