Clearing the air for electronic cancer checklists

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Valerie Neff Newitt

May 2018—Length, cost, variability in vendor support, and lack of consistency have cast a cloud for pathologist users over the CAP’s cancer protocols and the electronic version of those protocols, the electronic cancer checklists. Work is underway to improve the user experience (Nakhleh RE, et al. Arch Pathol Lab Med. 2017;141[9]:1153–1154). Behind that effort is the undeniable: “Structured discrete data, using a controlled vocabulary, can be captured, stored, and reviewed much more readily than data in other formats,” says Mary Edgerton, MD, PhD, vice chair of the CAP’s Pathology Electronic Reporting (PERT) Committee and associate professor of pathology, University of Texas MD Anderson Cancer Center. A controlled vocabulary, she says, is the “most valuable, truest form of data because it maintains its own integrity.”

Dr. Berman

With the electronic cancer checklists, or eCC, users can create, within the anatomic pathology laboratory information system workflow, complete and concise reports that withstand the scrutiny of inspectors and meet requirements for accreditation. “Use of the eCCs standardizes terminology, improves completeness of reports, ensures reporting of up-to-date parameters, and makes data interoperable and data mining easier, all of which drives better patient care,” says Michael A. Berman, MD, chair of the PERT Committee and vice chair of pathology at Jefferson Hospital, Allegheny Health Network, Jefferson Hills, Pa.

“Pathologists are gifted in their descriptive abilities,” he says. “Two pathologists could describe the same thing using different terminology, and both could be correct. But by using standard data sets we are all speaking the same language.”

More than 60 cancer specimen reporting protocols are available free on the CAP’s website. While the cancer protocols can be copied and pasted to create pathology report documents, the eCC makes it possible to integrate discrete data into the LIS database. The synoptically formatted checklists are compliant with CAP accreditation requirements and have been revised to align with changes in the eighth edition of the American Joint Committee on Cancer Cancer Staging Manual. “There were a lot of changes to make,” Dr. Berman says. “It was a lot of hard work, but the eCCs are completely updated.”

The American College of Surgeons Commission on Cancer at one time offered a commendation rating for synoptic reporting, says Samantha Spencer, MD, director of the CAP Structured Reporting Team. “It was an ‘extra credit’ kind of thing. Now it’s not. As of Jan. 1, 2017, it became necessary for compliance and is a core part of their survey,” she explains.

To surveyors, how the report is created is not important. “They just care that all required elements are present in the report and are in a synoptic format that includes element-value pairs. Instead of having a narrative paragraph describing a tumor, information must be synoptic. Each data element must be formatted with an ‘element,’ such as ‘Procedure,’ followed by a ‘value,’ such as ‘Open biopsy.’” The CAP’s Laboratory Accreditation Program has a similar standard.

These element-value pairs give rise to the use of a controlled vocabulary that provides a great deal of utility. “Structured reporting is where the magic happens,” says Melanie Shedd, product manager at Voicebrook, one of the vendors that provides a software pathway into reporting using the eCC. “Yet there is a feeling among some pathologists that ‘structured data’ is a bad word. There may be a fear they will be unable to ‘own’ their report. We’d like to bring awareness of the efficiency gains that structured data across their entire report can provide while still allowing the flexibility needed.”

The eCC allow for the storage of discrete data in an LIS or other database, and, as a result, searches can locate specific vocabulary saved in specific data “buckets,” Dr. Berman says. “When data is stored discretely, it is much easier to pull cases based on specific data parameters. For example, I can easily find all my cases of breast cancer where the histologic type is ductal, the grade is grade two, the margins are negative, and the axillary lymph nodes are positive.”

If all of that information were entered as narrative text, Dr. Berman says, finding those data would be not impossible but difficult. “With discrete data, we can data mine very easily. Finding cases for teaching, research, or any type of conference where we want to find certain tumor parameters is much easier with the improved searchability.”

When pathologists adopt the same language for data, it becomes highly interoperable. “When pathologists across town, at national cancer centers, or anywhere else put data into the same database storage buckets, they can all access the patient data across sites,” Dr. Berman says. The interoperability and transfer of data also help in the tumor registry world. “Classically, when pathologists entered a narrative report, a registrar painstakingly had to go through the text to find certain data points needed for the registry, and then manually enter them into the registry system. But discrete data containing all those data points can go directly and timely into the registry electronically. That allows registries to maintain data that is up to date.” Doctors, patients, tumor registries, researchers, and epidemiologists all benefit from structured language, he says.

Data captured using the eCC also offer benefits to pathologists in practice who wrestle with changing reimbursement models and shifting models in physician care quality measures, Dr. Edgerton says. “Using eCC can help you ensure you meet your cancer-protocol-related MIPS reporting requirements for CMS,” she says, referring to the Medicare Merit-based Incentive Payment System. “If you have to go back and manually retrieve data, it can be a huge headache. But if you are collecting it throughout the year, you can quickly run a report.”

The ease of running that report makes up for the time spent entering data, she says. “We must adopt an attitude of deferred gratification and recognize that while we may need to enter more information in the beginning, we will reap the benefits and have a much easier, more efficient time on the other end.”

Why do some pathologists bristle at the idea of creating synoptic reports? “It represents an extra layer of work in an already overburdened environment,” says the CAP’s Dr. Spencer. Furthermore, some pathologists may not fully understand what the eCC can do for them, or even how to get it up and running at their sites. “They need greater clarity,” she says.

Of the 15,000 to 17,000 pathologists in the U.S. and Canada, the eCC are now licensed to about 4,600 of them, Dr. Spencer says. Laboratory information system and software vendors typically pay a small fee for the rights to have access to the CAP cancer protocols and eCC intellectual property. Users, usually a health care site as opposed to an individual pathologist, can be licensed directly by the CAP to use the contents in their LIS.

Once the eCC (a package of rules-based, computer-readable XML files) are purchased, they can be accessed in various ways. “Some LIS vendors provide eCC as part of their base system because they recognize that it is a critical part of what pathologists do,” Dr. Berman says. “Others make it an add-on module to their base system. You may need to pay for the module and for maintenance of it. And still others do not provide eCC directly but instead refer you to companies that provide third-party solutions to integrate it. There is a great deal of variability.”

There isn’t any major vendor that cannot provide a pathway to eCC, says Dr. Spencer, who notes that some invest more time and effort than others. The users’ needs and preferences largely determine the best pathway for any given department or site.