Synoptic Reporting in Tumor Pathology Advantages …...Synoptic Reporting in Tumor Pathology Advantages of a Web-Based System Zhenhong Qu, MD, PhD,1 Shibu Ninan, MS,1 Ahmed Almosa,

898 Am J Clin Pathol 2007;127:898-903898 DOI: 10.1309/6VKCQDC69595KYVE

© American Society for Clinical Pathology

Informatics / SYNOPTIC REPORTING IN TUMOR PATHOLOGY

Synoptic Reporting in Tumor Pathology

Advantages of a Web-Based System

Zhenhong Qu, MD, PhD,1 Shibu Ninan, MS,1 Ahmed Almosa, MS,1 K.G. Chang, MD,2

Supriya Kuruvilla, MD,1 and Nghia Nguyen, MD1

Key Words: Cancer registry; Tumor reporting; Cancer report template

DOI: 10.1309/6VKCQDC69595KYVE

A b s t r a c t

The American College of Surgeons Commission onCancer (ACS-CoC) mandates that pathology reports atACS-CoC–approved cancer programs include allscientifically validated data elements for each site andtumor specimen. The College of American Pathologists(CAP) has produced cancer checklists in static textformats to assist reporting. To be inclusive, the CAPchecklists are pages long, requiring extensive textediting and multiple intermediate steps. We created aset of dynamic tumor-reporting templates, usingMicrosoft Active Server Page (ASP.NET), with drop-down list and data-compile features, and added areminder function to indicate missing information.Users can access this system on the Internet, preparethe tumor report by selecting relevant data from drop-down lists with an embedded tumor staging scheme,and directly transfer the final report into a laboratoryinformation system by using the copy-and-pastefunction. By minimizing extensive text editing andeliminating intermediate steps, this system can reducereporting errors, improve work efficiency, and increasecompliance.

Historically, surgical pathologists had confined theirreporting of malignant neoplasms to the identification oftumor type (diagnosis) and nodal involvement. However, rec-ognizing that a plethora of morphologic attributes have signif-icant predictive value for biologic behavior and therapeuticresponse of the malignant tumors, the Association of Directorsof Anatomic and Surgical Pathology (ADASP) issued its offi-cial recommendation in 1992 also to include important mor-phologic attributes in surgical pathology reports.1

Because of the large number of tumors encountered insurgical pathology practice and because the amount of infor-mation required in pathology reports is often extensive,pathologists usually cannot consistently remember all of theinformation required for each tumor and each tumor site.2,3 Asa result, important information is often omitted in pathologytumor reports. Based on a landmark study of 15,940 patholo-gy reports of colorectal cancer from 332 laboratories, Zarbo etal4 reported in 1991 that essential elements such as grosstumor size, depth of tumor invasion, status of resection mar-gins, and tumor grades were omitted in a significant portion ofsurgical pathology reports. Recently, Gomez and Tamboli,5 inan abstract, reported that 27% of referral and internal pathol-ogy reports in a highly specialized cancer treatment centerfailed to include at least 1 element with great clinical signifi-cance, such as the status of vascular lymphatic invasion.

In addition, diversity in terms, individual styles, andamount of information obtained constitutes another layer ofconfusion and obstacle for communication.2,6 The over-whelming diagnostic information and diverse styles, formats,and terminology have been the major sources of inconsistencyand lack of uniformity in pathology tumor reporting. Toaddress this issue, in 1993, Rosai,7 in a proposal to standardize

Am J Clin Pathol 2007;127:898-903 899899 DOI: 10.1309/6VKCQDC69595KYVE 899


Informatics / ORIGINAL ARTICLE

reporting of surgical pathology diagnoses of major tumortypes, formulated the checklist format in an attempt to makethe reporting process more efficient, uniform, and complete.In 1992, Zarbo8 also reported that the single practice that wassignificantly associated with increased likelihood of providinginformation on gross and microscopic features surveyed wasthe use of standardized report forms or checklists. In the ensu-ing years, the College of American Pathologists (CAP) and theAmerican Society for Clinical Pathology have made persistentefforts to establish guidelines for reporting the most common-ly encountered human malignant neoplasms.9-17

Effective implementation of these recommendationsgained momentum with the mandate by the American Collegeof Surgeons Commission on Cancer (ACS-CoC), whichaccredits more than 1,400 cancer treatment centers in theUnited States, that pathologists at its approved cancer pro-grams include all scientifically validated or regularly useddata elements in their reports for each site and specimen.18 Inaccordance, the CAP has developed more than 40 site-specif-ic cancer protocols and checklists as a resource for patholo-gists for effectively providing this information.19 To be inclu-sive, the CAP checklists are pages long, often containing toodetailed information. Despite being checklists, extensive textediting is inevitable. In practice, extensive deletion and typing(eg, measurements) are usually necessary to ensure that onlypertinent text or code data are retained for the cancer registry.Because the checklists or templates are in static text formats(ie, Microsoft Word [Microsoft, Redmond, WA] and portabledocument format [PDF]), multiple intermediate steps usuallyhave to take place before the reporting information can beincorporated into the final pathology report in the laboratoryinformation system (LIS).

Because the collected data must be incorporated into themain LIS, the reporting process comprises at least 2 majorsegments: data collection from specimen examination bypathologists and data transfer into the main LIS, most oftennow by transcriptionists. Currently, the workflow of tumorreporting using CAP checklists or other institutional statictemplates usually takes a tortuous route that includes down-loading and printing the checklist or template, list checkingand filling out during data collection by a pathologist, exten-sive text editing and transferring into the LIS by a transcrip-tionist, and final review and additional editing by the patholo-gist before the report is released. There are variations in theorder of the process, but extensive editing and multiple stepsinevitably take place.

Extensive text editing and multiple intermediate stepsinvolving at least 2 entities (pathologists and transcription-ists) have several weak links for potential reporting errors.Typographic errors are unavoidable. Because the generic CAPchecklist or an institutional static template is not an integral partof the pathology report and is without patient demographic

information, the resulting typographic separation of thetumor report, albeit transiently, from the rest of the pathologyreport creates another vulnerable link. The most dangerous ismismatch of the tumor report to the pathology report of thewrong patient. Conventional designation of data collectionand data entry into the LIS to different entities (ie, patholo-gists and office staff) has always been a third weak link unlessthe final report is transferred into the LIS by electronic copy-ing and pasting by pathologists. Although uniformity in thecontent is desired, inclusive information in a rigid format hasbeen viewed by many of our users as a major drawback ofCAP checklists.

In this report, we introduce a simple template-basedtumor reporting system that minimizes exhaustive list check-ing and extensive text editing, thereby markedly simplifyingthe process of routine reporting of tumor pathology.

Materials and Methods

A set of tumor-reporting templates on commonly encoun-tered tumors was created with reference to samples collect-ed from several academic institutions. These templates wereconverted to hypertext markup language (HTML), and toolcontrols such as drop-down menus, text boxes, and functionbuttons were created for dynamic presentation (ie, page dis-play in response to inputs by users via a Web browser) onthe World Wide Web. The static text was converted intoMicrosoft Active Server Page (ASP.NET) files. A MicrosoftAccess database table was created to store and organize thespecific morphologic attributes from the templates by thefile name and the name of specific organ sites. The storedinformation could be retrieved as the content of a drop-down list on the Web page for users to select. Specific com-mand source codes were programmed in ASP.NET toimplement the dynamic presentation. The completed fileswith the dynamic functionality were then uploaded andimplemented on our institutional server and were accessibleto all Internet users.

The specific organ sites are first presented in a drop-downlist on the initial Web page. The programmed ASP.NET codes,on selection of an organ site on the drop-down list by the useron the Internet, bring the corresponding HTML rendering ofthe ASP.NET page of the report form with multiple drop-down lists in categories, each containing specific attributes tobe selected. When the final selections are submitted, theASP.NET codes collate the selections and other text entriesand format them into HTML text output on the Web page.This HTML output can be copied and pasted to text-editingbuffers on any LIS system. The resultant Web page content(collated tumor report data) is cleared when the client brows-er is closed.



Qu et al / SYNOPTIC REPORTING IN TUMOR PATHOLOGY

Results

The synoptic reporting system can be accessed on theWorld Wide Web by all Internet users at http://dpalm.uth.tmc.edu/cap/webform1.aspx or http://www.urmc.rochester.edu/path/zqu/cap/Webforml.aspx. Along with brief back-ground information and specific instructions on how to use thesynoptic reporting system, the entry page provides a drop-down list of specific organ sites for which synoptic reportforms are available ❚Image 1❚.

Users can select an organ to bring up the complete synop-tic report form. In each form, in addition to general information(eg, surgical accession number, specimen type, and surgicalprocedure), specific histopathologic attributes are provided indrop-down lists to choose or marked as a blank field to be filledout. A pathology staging scheme for each tumor is also embed-ded in each form for reference. At the end of each form, a free-text comment field is provided for adding additional informa-tion or unique attributes not provided in the standard forms.

On completion of the form, users can compile all selec-tions and entries into a short, concise tumor synoptic report

containing only the selected attributes. The system also simul-taneously generates and appends to the final report a list of theattributes that have not been selected or included in the finalpathology report ❚Image 2❚, serving as a reminder of the infor-mation missing from the report. If changes to the tumor syn-optic report should be made, users can navigate in the brows-er back to the form and make any changes before compilingthe final report. The final tumor synoptic report in the Internetbrowser window can then be copied and pasted into text-edit-ing buffers in various LISs that accept plain text data. After thefinal pathology report is transferred into the LIS, all informa-tion in the tumor synoptic report on the Internet browser willbe permanently purged when the browser is closed. Althoughthe final synoptic pathology report can also be printed on reg-ular paper and submitted for transcription, most users under-standably prefer the direct copy-and-paste mode of informa-tion transfer to the LIS system.

The tumor synoptic reporting system is compatible withall common Internet browsers such as Microsoft InternetExplorer (Microsoft), FireFox (Mozilla, Mountain View, CA),and Netscape (Netscape Communications, Mountain View,

❚Image 1❚ Front page and site-specific form. The front page provides a drop-down list of specific organ sites to select (left). Whena specific site or organ is selected, a corresponding form appears that contains site-specific reporting information in a drop-downlist and staging scheme as a reference (right). In this image, the liver is selected as an example.




CA). The plain text transfer function with these browsers iscompatible with all LISs, allowing final report transfer into theLIS by using the copy-and-paste function. The synopticreports, of course, can be transferred electronically via e-mailor saved in a secured server for future retrieval.

Discussion

In this report, we introduced a simple Web-based tumorsynoptic reporting system with several practical features:drop-down list, reminder function, and convenient Web inter-face. Because users can directly access this reporting systemon the Web, enter reporting data by selecting from drop-downlists, eliminate irrelevant information, and directly transfer thefinal report into an LIS by simple copying and pasting, this sys-tem offers several practical benefits. First and foremost, itreduces the typographic efforts and errors by minimizing exten-sive text editing. Second, it greatly simplifies the reporting

process. The direct copy-and-paste mode of data transfer intoLIS by pathologists eliminates multiple error-prone intermedi-ate steps by bypassing the tortuous route of the paper copy ofthe CAP checklist from the pathologist to the transcriptionistand, after extensive editing, to the LIS, and then back to thepathologist. The pathologist, by this time, may not have theoriginal paper copy of the checklist and, thus, may be unableto ascertain accurate transcription. In addition, the addedreminder function helps avoid a common reporting defect, ie,missing required information.5

These features effectively counteract the inherent draw-backs of static checklists and templates considered to be themost serious potential risk in standardizing pathology reportsby using the checklist model.7 The drop-down list feature notonly provides a reporting advantage but is also consistent withspecific recommendation by Centers for Disease Control andPrevention National Program of Cancer Registries.18

Moreover, the system is made available on the Web. It adoptsthe modes of navigation and data input commonly encountered

❚Image 2❚ Data entry and final report page. The user can enter collected information by selection of relevant attributes from thedrop-down list or by typing (left). When completed, the collected information can be compiled as the final report by clicking the“submit” button at the end of the form (not shown). The final report contains only the collected (relevant) information (right). Atthe end of the final report, a note is present to remind of any missing information (right, lower portion). The final report can thenbe copied and pasted into the main laboratory information system (not shown).



Qu et al / SYNOPTIC REPORTING IN TUMOR PATHOLOGY

on the Web and, thus, is familiar to most Internet users. Usersdo not need training to use this tumor synoptic reporting sys-tem. The simplified process and its user-friendliness can helpincrease work efficiency and compliance.

This system helps collect and summarize diagnosticinformation independent of any LIS, yet it is compatible withmost, if not all, LISs in terms of reported data transfer (entryinto the standard LIS system). The independence of thisreporting system from existing LISs has 2 key advantages.First, it can be used in conjunction with a wide variety ofexisting LISs. This is particularly useful for laboratories orinstitutions that use more than one LIS for different clinicalclients. Second, implementation of this system requires nomodification of most existing LISs. Incorporation of a com-plex tumor reporting system in any existing LIS is usuallytechnically demanding because it may affect the underlyingsoftware architecture of the existing LIS. The incorporationand subsequent maintenance can also be costly. In contrast,update or modification of this independent tumor synopticreporting system is easily amendable because the changes arenot limited by the complexity of the main LIS and will notaffect the underlying architecture of the main systems.

This proposed system, however, has its drawbacks. Thedata generated by this reporting system are input en bloc intoexisting LISs, technically in a single field of the underlyingdatabase. This will make future data retrieval by singleattribute for a retrospective study difficult. However, if theformat of the form is consistent, specific data can still beretrieved by more sophisticated search modalities, althoughcertain computer programming (such as a parsing applica-tion) will be needed.

Ideally, the tumor reporting function should be embed-ded in the LIS as an integral component and should have fea-tures such as drop-down lists, error reminders, and other rel-evant functions. The task is expected largely, however, to bethat of main commercial LIS vendors. Because the needexists, it is reasonable to believe that LISs in the future willincorporate this capability.

An existing alternative is a hybrid of these two, a report-ing system with drop-down lists and other features that cancollect report data and disperse the data into specific fields inthe main LIS, using some sort of middleware. Generally,such smooth data transfer into LIS is at the expense of inde-pendence of the reporting system because this functionalitydepends on mutual compatibility. Implementation of the sys-tem with an individual LIS requires technical expertise andspecific modification of either or both systems. As a result,any changes or updates of either system will potentially cre-ate an impediment to the functionality of this tumor report-ing system. Most third-party reporting systems are also com-mercial products, and the cost is a significant considerationnot in its favor.

Although ACS-CoC–accredited cancer treatment centersare required to include all scientifically validated data elementsfor each site and tumor specimen, the ACS-CoC imposes norestriction on the format of the pathology report or requirementof variables for which the clinical importance and prognosticvalue have not been well established. To most users (practicingpathologists), concise tumor-reporting templates with scientif-ically validated data elements and clinically important infor-mation are highly desirable and more manageable than exhaus-tive, long checklists. Although it is not our intention to judgethe adequacy of existing tumor report formats or contents or totake a stance on which reporting system or method should beused, we thought it would greatly increase compliance andreduce clerical error if a user-friendly, simple, and flexiblereporting system or method could be made available.

Ideally, the tumor reporting system should be standardand uniform and also institution-specific. In practice, this bal-ance is difficult to achieve, if even possible, at the multi-insti-tutional level. However, this is a real need and should beaddressed. The best way, we believe, is to allow users to mod-ify the proposed system to meet their needs. We, therefore,have kept the HTML code an open source for users to copyand modify, although some programming (mainly HTML)knowledge, though quite rudimentary, is needed for this task.As described in the “Materials and Methods” section, a closecollaboration between the pathologists and LIS staff is neces-sary to create or modify such a Web-based reporting system.

At the time of this report, at least 1 major LIS vendor pro-vides an added module with this capability.20 However, a sig-nificant lag time is expected before it is widely adopted owingto the additional cost and compatibility with existing LISs.Although a new generation of LISs with tumor reporting func-tions in compliance with ACS-CoC requirements will bewidely available eventually, the length of the lag time is diffi-cult to predict. Given the facts that the ACS-CoC accreditsmore than 1,400 cancer treatment centers in the UnitedStates18 and that there are approximately 450,000 new cancercases each year in the United States,21 development of simpleand easily accessible systems to efficiently and accurately pro-vide the scientifically validated data, such as the one describedin this article, will have significant impacts on cancer reg-istries, at least during this transition period. It is reasonable tobelieve that a simple and user-friendly reporting system willalso increase voluntary compliance with the ACS-CoC man-date by many small non–ACS-CoC–accredited hospitals andimprove the overall standard of tumor reporting.

From the Departments of 1Pathology and Laboratory Medicine,The University of Texas Health Science Center in Houston; and2Pathology, Lahey Clinic, Burlington, MA.

Address reprint requests to Dr Qu: Dept of Pathology &Laboratory Medicine, University of Rochester Medical Center,601Elmwood Ave, Rochester, NY 14642.




Acknowledgments: We thank Cheryl Breitenbuecher forassistance in Web implementation of this reporting system at theUniversity of Rochester Medical Center, and Bob Brown, MD,University of Texas Health Science Center in Houston, for criticalreview of the manuscript.

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Synoptic Reporting in Tumor Pathology Advantages …...Synoptic Reporting in Tumor Pathology Advantages of a Web-Based System Zhenhong Qu, MD, PhD,1 Shibu Ninan, MS,1 Ahmed Almosa,