No resistance to standardizing reports

March 2006
Feature Story

Ed Finkel

As the tangible product of pathologists’ work, reports must provide clear and consistent information, all elements needed for decisionmaking, and information about the validity of the process—all in a format that enables easy retrieval and searching.

The quality of information in the report defines pathologists’ competence more than training, experience, and colleague interactions. Moreover, reports document services for purposes of billing, pay-for-performance initiatives, and guarding against malpractice—faced once every 12 years for an average $454,000 per claim.

M. Elizabeth H. Hammond, MD, chair of the CAP Education Committee, stressed these points at the start of a daylong course on pathology reporting, held in Chicago last fall, as reasons why the profession should work to standardize such reports. Much to her surprise, attendees agreed unanimously.

"I expected, when we had this session, that there was going to be a lot of pushback about the idea of standardizing pathology reports—that pathologists would say, ’No, this is a creative aspect of my work,’" says Dr. Hammond, director of the CAP ’05 course. "The people who chose to be there basically agreed, because of the seriousness of the problems we have, and the value that reporting has to show we are competent, and to mitigate our malpractice risk," that those factors outweighed their desire to be creative.

"That was something I didn’t expect," she adds. "We had a diverse crowd, those new to the practice as well as seasoned people. Regardless of who they are, they believed there was serious work that needed to be done, and they wanted the CAP to do it."

Dr. Hammond, a pathologist at Intermountain Healthcare in Salt Lake City, knows the lack of pushback was not just anecdotal, or attendees being polite, because the session made use of "Who Wants to be a Millionaire" technology to enable audience participation and feedback in anonymous fashion, to encourage candid responses.

"It’s a terrific way to do it. You get immediate input from a large number of people who have very differing views," says Jim Robb, MD, an Education Committee member and CAP governor. "You can reach consensus fairly quickly by taking a vote, rephrasing the question, and voting again, and getting some granularity to the discussion with quantitative numbers." This method could be used in other areas where consensus discussions are needed, he says.

Dr. Robb, who is medical director of Integrated Regional Laboratories for HCA’s East Florida division, says it’s important for pathologists to "unify around best practices."

"Pathologists produce information. If we can’t produce that clearly for physicians making treatment decisions, we’ve failed at our duties." By unifying around best practices, he says, pathologists will not only improve care and safety for patients but also help themselves by lessening the odds that claims of malpractice can be filed.

Those who participated in the course arranged according to priority the critical issues involved in standardizing pathology reports. The top six with the most votes:

• Listing the minimum elements required for each report type, including data for billing purposes.
• Better communicating the content of reports, including critical values.
• Reviewing report formats, including amendments, consults, and addenda.
• Developing synoptic content for report types in addition to those already developed for cancer.
• Clarifying ambiguous terms and uncertainty.
• Addressing information systems issues and challenges.

The desire for a list of minimum elements grew out of the protocols the CAP developed for cancer reporting, Dr. Hammond says. "Members have become so accustomed to the use of cancer reports that they want minimum elements defined for all report types," she says. "That’s a huge task, but we’re up to the task and we’ve got a plan to do it."

Communication with clinical colleagues ranked No. 2. Attendees said they want to define "what elements of communication are critical and how they should be communicated to our clinician colleagues," Dr. Hammond says. "And how electronic tracking can help with that."

Pathologists must apply lessons learned from clinical pathology reporting to anatomic pathology, Dr. Robb says. "A good example here is that we need to establish anatomic pathology critical values, and . . . we have to develop policies and procedures to notify the physicians of those critical values. It’s done more or less haphazardly everywhere. It needs to be looked at and best practices developed."

The attendees said a review of report formats is critical to clarity and patient safety. Group consensus was that recommendations for report formats should be general principles, not specific recommendations, including clinician input to ensure clarity. "We can define the principles required," Dr. Hammond says. "A bigger challenge will be to determine how we make sure those reports are done in such a way that they promote accurate interpretation and appropriate action by clinicians."

The latter challenge referred to findings presented at the CAP ’05 course by Education Committee member Richard Zarbo, MD, DMD, who evaluated the pathology practice at Henry Ford Health System, Detroit, over a period of three years.

"The most shocking feature of his results was that the most common form of error that was detected in his practice related to nondiagnostic information defects in pathology reports. That was not something I expected," Dr. Hammond says. What might she have expected? "Misidentification of samples—we sometimes misidentify specimens and therefore we misidentify results. He found the most serious problem was the pathology report, and that those reports really signaled the difficulties with the whole process."

Dr. Zarbo, who received a federal grant to conduct his research, says the top defect leading to the need for amended reports was "typos, or something not diagnostic," followed by misidentification, an erroneous interpretation, and, lastly, the preparation or handling of the specimen.

"At this point," Dr. Zarbo says, "there is no standard for looking at or classifying these defects. That was the most important information I imparted that afternoon-this suggested taxonomy for looking at these defects that related to the phases of the test cycle." He shared that information with the audience to enable them to adopt a similar classification of defects that might lead to amended reports. "Then I talked about strategies that would allow us to standardize the reporting of the amended reports or the defective reports."

As for synoptic content, attendees said structured elements should be defined for each report type with, again, a focus on principles rather than specific recommendations to allow for needed format flexibility.

"We need synoptic reporting not only for the malignant diseases but for as many of the non-malignant diseases as we can," such as liver and gastric biopsies, Dr. Robb says. "We have to have a unified way to report these to physicians."

To better define ambiguous terms, No. 5 on the list of priorities, attendees suggested developing a list of terms in use to explain the certainty of a diagnosis and ranking the terms from most to least certain. "There are a lot of terms we use in pathology to describe things" that lack a unified definition, Dr. Hammond says.

Though information systems issues ranked No. 6, the CAP has moved the quickest on that because solving IT problems will help lead to solutions for many of the others. "The next step with our IS issues is to get into a dialogue with vendors about how they can help us with that," Dr. Hammond says. "We defined the critical issues, so we know which ones we have to work on."

The leader of that effort, Robert Rainer, MD, member and former chair of the CAP’s Informatics Committee, compares his committee’s work to creating the "electronic scaffolding" within which content will be developed.

"Our committee is going to form the superstructure," he says. "We have to build the scaffolding, and then people have to build the inside." Two obstacles are getting the vendors to implement the standards and support them, he says. "It will be a financial commitment. It’s up to pathologists to ask their vendors to provide this."

Information systems issues have come to the forefront as pathology reporting systems have had to integrate with hospital systems, says Dr. Rainer, of Spartanburg (SC) Regional Medical Center. "There’s been a bit of a shift in that pathology reporting systems, in the past, have been stand-alone systems," he says. "With the rise of hospital systems, we’re feeding those systems."

That causes problems because the hospital systems do not necessarily recognize and translate the formatting from the pathology reporting systems, which leads to the loss of bold, underscoring, tabs, colors, and other graphic elements, Dr. Rainer says.

"What we’re trying to do on the Informatics Committee is push formatting that will go into the clinical document architecture," he says. "That will allow us to present our reports unscathed, where they’re not beaten up." Many pathologists believe clinicians see on the screen what pathologists send out. "My challenge to them is to go look at that and see if they’re [the clinicians] getting what pathologists think they’re getting. They’ll be rudely surprised."

Creating a unified architecture will allow the integrity of the report to be maintained. "We’re switching from a paper world to an electronic world, and that transition is not as smooth as people expect it to be," Dr. Rainer says. Another benefit: "Data is encapsulated in such a way that it can be extracted. It’s not just that the words are in there," he says. "You’re independent of a database. You can import these documents anywhere and search them."

The Informatics Committee is expected to report on its progress and vendors will participate in a panel at CAP ’06 this fall, Dr. Hammond says. The committees formed to address other issues will not present at CAP ’06 but will post updates on the CAP’s Web site as appropriate. Materials from the previous session, including presentations and supporting documents, are already posted. "Members will be able to see it in a continuous rather than an episodic way," she says.

The CAP is still forming work groups. All who would like to volunteer or who would like to provide input should do so at the designated spot on the CAP Web site. "People can look at those resources, see who the work group leaders are, and volunteer to help with those activities as they feel it’s appropriate," she says. (At www.cap.org, click on Reference Resources and Publications and then Pathology Reporting under Practice Resources.)

Meanwhile, within their own practices, pathologists should discuss the need for standardization—and perhaps sell those who are skeptical by using slightly different terminology, suggests Dr. Robb, who has done so in the 13 hospitals and 13 pathology groups of Integrated Regional Laboratories HCA’s East Florida division.

"Over six years we’ve unified everything we need to unify," he says. "What I don’t use is the word ’standardize.’ Physicians hate the word ’standardization.’ But they will unify. I have no trouble talking about unifying. You get your stakeholders involved, and then you agree, hopefully with some data. ’Standardize’ sounds like you’re going to be told what to do."