Synoptic Reporting and Structured Data

Capture in Healthcare
Introduction
The amount of clinically significant findings a surgical pathologist is expected to report continues to
increase. Many clinicians see the need for a standardized terminology and pathology report structure in
order to clearly and quickly recognize the most important findings in determining treatment. The synoptic
report (a synopsis or summary) addresses these issues by providing a standardized nomenclature, a set
of universally required findings, and a very consistent report structure. The emergence of synoptic
reporting using published, peer-reviewed checklists is helping to standardize pathology reporting.
Anatomic pathology reporting is still largely narrative text. In contrast to clinical pathology and cytology,
the handcrafted narratives of anatomical pathology are of diagnostic importance due to the unique set of
events that surround each patient’s case. With this in mind, any form of report standardization must not
impede the pathologist’s flexibility to offer individual diagnostic opinions on a case by case basis. Thus
the ideal anatomic pathology report blends synoptic elements with narrative descriptions to provide the
best assessment to the clinician. In this way, the clinician can find the most clinically significant elements
immediately, but can still read the pathologist’s opinion regarding ambiguities in the specimen.

Synoptic Reporting and Structured Data

Synoptic reporting goes hand-in-hand with structured data. Because you are constraining the report to
individual data elements, it is possible for a computer to intelligently analyze individual elements for a
variety of clinical and research purposes. However, not all synoptic reports contain structured data.
Many are simply word processing documents that appear structured to human eyes. Thus, synoptic
reports structure and clarify findings for clinicians, while structured data clarifies findings for computers.
There have been attempts to extract structured data from existing narrative pathology reports. Text
parsing programs search through existing unstructured reports pulling out strings of text. Because
parsing technology is imposed post facto, the process does not allow for quality control of data at the
point of creation. Most importantly, natural language processing technology just isn’t advanced enough to
produce reliably, results without significant human intervention. Far better results are obtained by upfront
capture of consistently structured data. In other words, by a human process of synoptic reporting
translated into machine-readable structured data.

Data Entry Templates

With synoptic reporting, the pathologist completes prearranged data entry templates, often choosing from
finite lists of options for consistency. Synoptic checklist reporting ensures quick, complete and concise
documentation while decreasing questions from clinicians and cancer registers. It allows for accurate
collection and comparison of cancer data which directly impacts cancer screening and treatment
protocols. Any report that can consistently offer an interpreting clinician the same data information in the
same format using medically consistent terminology has intangible benefits. The difference between
synoptic reporting and structured data is a source of constant confusion. Synoptic simply means to
provide a summary of the pertinent findings. A synoptic report is capable of providing structured data sets
that correspond to the synoptic elements. If it does, then it is also structured data in addition to a synoptic
report. The difference may appear to be question of semantics, but is more importantly one of the
usefulness of information. Text can be copied into a file which can be parsed or mined for data elements
but in an unstructured format it loses the power of a searchable database. Structured data by definition is
information flowing into a database. Simply put, data has far more value than text in providing relevant,
searchable information. Structured databases allow the task of data abstraction to be relegated to search
queries rather than the manual task of report dissection and inspection in text driven systems. In these
text systems, a certain percentage of the data is completely missed by text parsers. Structured data
reporting carries the distinct advantage that 100 percent of data is captured and reported. Time and
resources are saved and data integrity and patient safety are increased. Structured data reporting
facilitates coordination of care and reduces the chance for medical/clerical errors.
Recent Studies - Pathology Reporting Satisfaction Survey

Introduction

The following survey, facilitated by mTuitive Inc. (www.mtuitive.com), was sent out to 400 healthcare
professionals and received a response rate of approximately 20%. The participants were surgeons,
medical oncologists, radiation oncologists, pathologists, other physicians, and other health professionals.
A summary of the significant findings follows the survey results.

The Survey Results

1. Synoptic means to provide a synopsis or summary of the results, typically in a structured

question and answer format. The alternative is to receive a narrated report in a free text format.
Prior to this survey, were you familiar with the term “synoptic reporting?”

Response Percent

YES 93.2%

NO 6.8%

Y ES
NO

2. Are your pathologist or other clinicians providing synoptic reports to you?

Response Percent

YES 64.8%

NO 35.2%
 Y ES
NO

3. What is your clinical specialty?

Response Percent

Surgeon 21.9%

Medical Oncologist 19.2%

Radiation Oncologist 6.8%

Pathologist 34.2%

Other Physician 1.4%

Other Health Professional 16.4%

Surgeon

M.
Oncologist
R.
Oncologist
Pathologist

O. Physician

O. Health

4. Which reporting style is most conductive to:

synoptic narrative no preference

Clarity of results 86.3% 8.2% 5.5%

Reducing the need for further explanation 72.6% 16.4% 11.0%

Consistency of reporting 98.6% 1.4% 0.0%
Overall completeness 84.9% 9.6% 5.5%
Aiding in the staging process 87.3% 4.2% 8.5%
Streamlining cancer registry data collection 97.3% 1.4% 1.4%
Meeting standards for CoC accreditation 83.3% 1.4% 15.3%
Communication to patients 65.3% 11.1% 23.6%
Data collection for research 95.9% 2.7% 1.4%

5. Are you happy with the time it takes to receive a written pathology report?

Response Percent
YES 36.1%
 NO 44.4%
I DON’T KNOW 19.4%

Y ES

NO

I DON'T
KNOW

6. What is the approximate percentage of cancer reports that require an inquiry to the pathologist for
further explanation? (Please consider all inquiries by phone, email, or in person, by yourself and
your staff.)
Response Percent
Never or almost never 1.4%
Rarely (less than 2%) 29.6%
Occasionally (more than 2% but less than 5%) 29.6%
Frequently (between 5% and 10%) 22.5%
Often (more than 10% but less than 20%) 9.9%
Routinely (20% or more) 7.0%

Never
R arely
Occasional
Frequently
Often
R outinely

7. Do you think synoptic reporting would decrease the number of inquiries to the pathology
department?
Response Percent
YES 77.5%
NO 22.5%

Y ES
NO

8. Do you think synoptic reporting could be applied to any of the following disciplines?

YES NO MAYBE
Surgery- post operative notes 76.4% 4.2% 19.4%
Imaging- radiologist reporting 87.3% 0.0% 12.7%
Clinical lab- molecular, in situ testing, etc. 85.9% 1.4% 12.7%

Significant Findings and Highlights

 • Almost half (48%) of the responses were from “customers” of the pathologist- surgeons, medical
and radiation oncologists.
• With two exceptions, the survey revealed about a 90% preference rate for synoptic over narrative
reporting. The two exceptions were in “communication to patients” and “reducing the need for
further explanation.” This may have been due to a problem with the survey design; there was a
relatively high percentage of “no preference” answers. However, a large majority, but less than
90%, expressed preference for the synoptic style.
• More than half of those answering (32 versus 26) were not happy with the time it takes to receive
a pathology report.
• Somewhat surprisingly, more than ¾ of respondents felt that a synoptic report would reduce the
number of inquiries made to the pathology department.
• There was almost unanimous opinion that synoptic reporting could be extended to other
diagnostic- clinical areas.

Beyond Pathology

The power of synoptic reporting spreads beyond the field of oncology. The benefits of capturing
structured data and forcing best practices has widespread applicability in other areas of healthcare such
as Radiological Reports, Surgical reports, Emergency Room Triage , just to name a few. The future of
synoptic reporting demands applications designed by domain experts, that deliver knowledge, aid in
decision making and capture structured data. Synoptic reporting and more importantly structured data
capture are standards of practice that will not stop with pathology. The electronic health record of the
future will be one requires structured data, not unstructured text. One has to look no further than decision
of the Health and Human Services agreement with the College of American Pathologists to put SNOMED
codes into the public domain as confirmation. Within a decade, Medicare will require claims submissions
to include structured diagnostic data coded with SNOMED or a derivative. Even the federal government
recognizes the benefits of synoptic, structured data.

Synoptic Reporting and Structured Data Capture Solutions in Healthcare and Beyond

Process Simplification
The best approach to synoptic reporting simplifies the process of transforming subjective, essay
answers into objective multiple-choice, fill-in-the blank responses. The process results in the capture of
structured data. Structured data is captured once and transferred to an unlimited number of disparate
systems or databases, including, but not limited to, the surgical pathology system, the cancer registry and
research databases. This is all done automatically and improves quality control over data entered by
reducing costly and error prone practices of transcription and abstraction. The hospital embraces the
efficiency improvement because it supplies the transcription service. The cost of transcription is
exorbitant. The benefits are magnified when the process is extended to the cancer registry and research
functions. The direct transfer of the pathologic data elements to disparate systems is not only far more
efficient than current alternatives of manual abstraction or data mining, the results are far more accurate.
Again, the hospital can eliminate the costs associated with data abstraction. The pathologist or physician
receives far fewer inquiries to clarify the diagnosis.

Improved Efficiency
Systems that include synoptic reporting and structured data capture often can also improves billing and
coding efficiency and accuracy by automatically assigning codes at the point of decision. The current
process involves auto coding or manual assignment of codes by medical abstracters. Again, this is an
error prone and costly practice for the hospital that is eliminated. Many institutions, primarily teaching
hospitals, have eliminated medical transcription to save money. The task of data entry has fallen to
residents and staff pathologists. The younger, more computer literate pathologists are discovering that
they can actually save time completing their own reports. Once mastering a brief learning curve, the “once
and done” process that allows the pathologist to immediately view the report and sign the case out is a
tremendous time saver. The efficiencies gained by avoiding the redundant editing and case re-
examination process far outweigh any additional time involved in direct data entry. Ideally, applications
designed by pathologists who recognized that a physician will not be a slave to the computer are the best
solutions. The pathologist will only use the computer if it improves the quality of performance while not
sacrificing efficiency. The system has to improve the pathology work flow process or it will not be adopted
by most practitioners. System designs should be focused on ease and flexibility of use and minimizing the
effort to enter data. If this could not be accomplished, the benefits of synoptic reporting could not be
achieved. There are additional benefits to the clinician’s workflow provided synoptic reporting and data
capture systems. Applications need to deliver context sensitive, point of care diagnostic reference
materials which enhance the clinician’s memory, reduces the repetition of facts, and saves trips to the
bookshelf. Additionally, systems should prompt the user to complete all required data fields. Only the
relevant question fields, based on information already entered, are delivered to the pathologist, further
streamlining the workflow. By implementing a system as described above, very little physician software
training and fantastic improvements in physician productivity, can be achieved.

Single Step Sign Out

A single step sign out process is absolutely imperative to a physician data capture system. The major
advantage to the pathologist is the single step sign out process or what we previously referred
to as “once and done”. This feature alone will save the pathologist time; preliminary studies have shown
a minimum of a ten percent savings in editing and redundant slide handling. This is a hard dollar savings
when one recognizes that the pathologist time equates to money.

Subjective or “soft dollar” savings include:

• The avoidance of omissions; reports will be complete.

• The synoptic report will improve the communication with the surgical staff and will rapidly evolve
to be the standard of practice as younger surgeons and pathologists come out of residency.
• The accreditation process for cancer centers does not demand synoptic reporting but does
require that a surgical pathology report meet minimum requirements for the inclusion of standard
data elements.
• The reporting turn-around time will be reduced.
• Coding for billing and compliance can be automated in the workflow; audit trails are a natural by-
product.
• In a teaching environment the process is the perfect learning and monitoring tool.
• Direct data capture will improve the quality of data transferred to cancer registries, tissue banks,
and research databases.

Hard dollar savings that will be gained by others, usually the hospital, include:

• Reduced cost of transcription

• Reduction and eventual elimination of data abstraction to populate cancer registries, not to
mention the improvement in the quality of the data
• Improved reporting of critical clinical information
• Elimination of manual clinical coding such as SNOMED CT.

Conclusion

Implementation of effective synoptic reporting procedures and structured data capture systems are one of
the most important challenges facing the healthcare industry. Synoptic reporting ensures quick,
complete, and concise documentation of clinical findings. In Pathology, we have found synoptic reporting
decreases questions from clinicians and cancer registrars. It allows for accurate collection and
comparison of cancer data which directly impacts cancer screening and treatment protocols. Any report
that can consistently offer an interpreting clinician the same data information in the same format using
medically consistent terminology has intangible benefits. These benefits can be seen in areas outside of
pathology as well. Structured data capture, an extension of synoptic reporting, enables data to be
captured and stored as a set of discrete data elements. This allows for rapid and powerful queries, data
aggregation and analysis through predefined and ad hoc reports. This approach provides high quality,
fast analysis, compared to the rudimentary capabilities of text search on narrative text. Additionally, this
process is all done electronically which reduces errors and redundancy inherent in paper-based data
collection. The best approach combines knowledge delivery, decision assistance and electronic capture
of discrete data elements as a coherent process for decision makers. The process yields more informed
decisions, eliminates wasted resources, and makes information instantly sharable. For more information
on healthcare software solutions, medical technology, or creating structured data capture applications for
your own industry or business, visit mTuitive at www.mTuitive.com.