Structured Electronic Template for Histopathology Reporting on Colorectal Carcinoma Resections: Five-Year Follow-up Shows Sustainable Long-Term Quality Improvement

Abstract

Objective.-To investigate use and long-term effect of this structured template in one of the first laboratories implementing the template for routine diagnostic work.Design.-All histopathology reports (n = 123) in the 1-year period prior to implementation were evaluated with respect to presence of key parameters. Likewise, all histopathology reports (n = 1186) in the 5-year period after implementation were evaluated with respect to template use and presence of key parameters.Results.-The electronic template had been used in 1089 (91.8%) of the 1186 cases. Template use was stable in the entire 5-year period, and had significantly improved upon the presence of data on 7 of 11 key parameters valid for both the preimplementation and the postimplementation period. Eight hundred and twenty-two (75.5%) of the 1089 template reports contained information on all key parameters, compared to just 20 (16.3%) of the 123 free text reports in the 1-year preimplementation period.Conclusion.-Electronic template reporting has a significant and sustainable long-term, positive effect upon the quality of histopathology reports.

Comparison of Accuracy and Speed of Information Identification by Nonpathologists in Synoptic Reports With Different Formats

“…As previously mentioned, there is an abundance of evidence that mandating and requiring a specific list of elements for inclusion in synoptic reporting, along with the provision of a checklist of those items, can successfully improve the completeness of reports. [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] There are also published data concerning the accuracy of the data included in a synoptic report. Specifically, the words no and not are rarely but consistently left off of reports reducing accuracy, and ensuring that the phrases in the checklist contain as few of these elements as possible improves accuracy.…”

“…The CAP specifically requires that each element in a synoptic report be reported in a required data element (RDE) pair consisting of the element and the corresponding response (CAP Laboratory Accreditation Process Checklist question ANP.12385). 1 While there are significant data supporting the use of checklists in general, 2-14 and their use to improve the completeness of surgical pathology reporting specifically, [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] there are much fewer data concerning the significance of the specific formats. Valenstein 34 examined structured reporting and focused on diagnostic headlines, white space, standardized layout, continuity over time, and reduction of clutter but provided few data addressing the specific formats.…”

Qualitative and Quantitative Issues of Lymph Nodes as Prognostic Factor in Colon Cancer

“…First, the use of synoptic reporting, a protocol or a template has been proven superior in ensuring that key parameters are reported [54,55,56,57,58,59]. These are parameters that are essential in planning further treatment and follow-up.…”

Implementation and use of electronic synoptic cancer reporting: an explorative case study of six Norwegian pathology laboratories

“…The histopathology report has traditionally been in a free text (narrative) format. Many studies have however shown that the use of checklists or structured text elements improve the quality of the histopathology report with respect to the presence of key information deemed important for patient treatment [1-3]. With the introduction of electronic health records, structured histopathology reporting can be done using predefined drop down menus with automated coding.…”