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Synoptic Checklist for Reporting of Hematologtical and Lymphoid Neoplasms Based on World Health Organization (WHO) Classification and College of American Pathologists (CAP) Checklist
Sambit K. Mohanty, MD, DNB, (mohantys2@upmc.edu)1; Ashokkumar A. Patel, MD1; Anthony L. Piccoli1; Lisa J. Devine1; Gross C. William1; Steven H Swerdlow2; Michael J. Becich, MD, PhD1; Anil V Parwani, MD, PhD1; 1Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania and 2Division of Hematopathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Content: Synoptic Reporting, either as part of the pathology report or replacing the free text component, results in standardized data elements in forms of checklists for pathology reporting. This ensures the pathologist makes note of these findings in their reports thereby improving the quality and uniformity of information in the pathology reports.
Technology: The purpose of this project was to develop the entire set of elements in the synoptic templates for Hematological and Lymphoid neoplasms (Bone marrow malignancies, Non-Hodgkin, Hodgkin and Gastrointestinal Lymphoma) using WHO Classification and CAP Checklists. Additions were made to the CAP checklists with the most updated classification scheme (WHO classification), specimen details, staging as well as information on various ancillary techniques such as cytochemical studies, immunophenotyping, cytogenetics including FISH studies and genotyping.
Design: We have used a digital synoptic reporting system as part of an existing laboratory information system (LIS), CoPathPlus, from Cerner DHT Corp. We have used the WHO Classification and CAP Checklist in these synoptic worksheets for Bone marrow malignancies, Non-Hodgkin, Hodgkin and Gastrointestinal Lymphoma. The data is presented as discrete data elements. A data element such as ‘tumor type’ is in the synoptic value dictionary under the value of ‘tumor type,’ allowing the user to search for just those cases that have that value point populated.
Result: These synoptic worksheets will be implemented for use in our LIS. The data is stored as discrete data elements that will appear as an accession summary within the final pathology report. In addition, the synoptic data will be exported to research databases for linking pathological details on banked tissues.
Conclusions: Synoptic reporting provides a structured way of entering the diagnostic as well as prognostic information for a particular pathology specimen or sample, thereby reducing transcription services and reducing specimen turnaround time. Furthermore, it provides accurate and consistent diagnostic information dictated by pathologists as a basis for appropriate therapeutic modalities. Using synoptic reports, consistent data elements with minimized typographical and transcription errors can be generated and placed in the LIS relational database, enabling quicker access to desired information and improved communication for appropriate cancer management. Thus our goal is to provide templates that will serve as a conduit for capturing and storing data in the virtual biorepository for translational research, in addition to the diagnosis and management of the patient. Such uniformity of data lends itself to subsequent ease of data viewing and extraction, as demonstrated by rapid production of standardized, high-quality data from the hematological malignancy specimens.