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2	Pretest – True/False The Pathology report is the least important report in a patient chart A good APLIS is not worth the expense APLIS’s are not helpful in reducing error Pathologists don’t really care about the quality of their pathology reports
3	Objectives Describe the shortcomings of current AP reporting systems Identify existing technologies that will correct these deficiencies Explain the importance of structured reporting to pathology practice, research, and teaching
4	Objectives (continued) Apply this information in selecting information systems for your laboratory Learn how to assist the pathology community in promoting the development of structured reporting tools
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6	What is Structured Reporting? Traditional “synoptic” report has minimal structure – display only! A truly structured report has structure from an information systems perspective May or may not involve Structured Data Entry (SDE)
7	What is Structured Data Entry? SDE is the use of predefined text or other data for documentation (as opposed to free-text data entry) SDE is the best way to achieve structured reporting
8	Why do we need structure? Productivity Error reduction (quality mandate) Promotes standardized reporting Interoperability with CPR systems Marketing
9	Workflow -- Productivity Decrease or eliminate transcription cost$ Faster TAT sign-out at scope - no proofing Automated retrieval and analysis quality, education, research, coding/billing -- compliance documentation Data mining??? -- discrete data, no (inaccurate) language processing required
10	Errors avoided with SDE Transcription Voice Recognition Omission Can encourage or enforce synoptic reporting, checklists Transposition Interpretation Decision Support (pathologist error) Standard for terminology and reporting of data elements (clinician error) – including abbreviations
11	CPR Compatibility Data must be available everywhere, all the time, in multiple appropriate views Use of templates, synoptic standards controlled vocabularies Decision support facilitated Tools for error reduction, workflow, analysis
12	Marketing Customers are physicians and patients Value-added services will be added by your competitors, and not just images! Must be automated to provide these cost-effectively
13	How do we achieve SD? Structured Data Entry Ex post facto text parsing (natural language processing) Error-prone No QC at the point of care No decision support Does not support standardization But useful for archival material (SPIN project)
14	How does SDE become SD? Defining data elements and items Ideal for XML
15	Geek Tip -- Data Elements and Items Data Elements = “Metadata”, or data describing data. Items = the actual data of interest Item-element pairs = machine-readable
16	Examples of Pathology Report Data Elements and Items
17	Standardization Common data elements (CDE’s) Items -- controlled medical vocabulary Both are needed! Data-transmission standards ( HL7)
18	Common Data Elements Can be used in Web-based namespaces to standardize XML DTD’s and Schema Permit different software implementations to share data Should be ISO 11179 compliant API namespace project is in progress Not sufficient to ensure data sharing
19	Controlled Medical Vocabularies CMV, aka medical lexicon or controlled medical terminology (CMT) Terms must populate delimited or non-delimited domains of CDE’s SNOMED -- prototype
20	Objections to SDE Debunked!
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22	Pathology Reporting Systems Systems in development by Mysis/CoPath, SCC William Shang, MD, Access-based APLIS, distributed as freeware, see eposter from APIII2000 Elizabeth Hammond, MD, IHC, Tamtron-based synoptic macros/VB/VBA Michael Glant, MD, DCL Inc., Indianapolis mTuitive, Cape Cod, MA
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24	Take Home Messages Structured reporting can help your practice Possibly the greatest impact of any emerging technology in pathology You now understand the basic technology You will have to use these tools to maintain quality and to remain competitive You must be an advocate for investment in this technology