Clearing the air for electronic cancer checklists

One option is the solution the CAP has undertaken with mTuitive, whose eFRM is a full-service solution for maintaining structured reporting needs. “The CAP eFRM solution is inclusive of eCC, but provides more,” says Colin Murphy, mTuitive’s vice president of business development. He likes the analogy of income tax software. “If eCC is the IRS tax form, then eFRM is Turbo Tax. If you subscribe to eCC, you have access to the forms, but if you subscribe to eFRM, you have an easy-to-use, vetted solution that provides automatic updates to maintain compliance.” Murphy says the cost to maintain the checklists has led some AP LIS vendors, such as Sunquest (CoPath) and Meditech, to abandon their own solutions and integrate eFRM.

Voicebrook’s speech recognition solution for pathology reporting turns audio into text instantly, without transcription. “Customers typically want narrative reporting via speech recognition, text templates, and the eCC,” Voicebrook president Joe Desiderio says. “When pathologists encounter a positive finding, while still creating the report, they can say, ‘Insert cancer checklist,’ and it will do that.”

Implementation is simple and straightforward, Shedd says. “If a site already has VoiceOver, we just install a module on their workstation. It comes with eCC content ready to use, and it takes about 15 minutes to train users on the tool and the checklists.” The tool works with speech and with mouse and keyboard, if that’s the preferred workflow.

Voicebrook will release in July its latest eCC product as part of its new VoiceOver PRO Solution, which makes extensive use of structured data. This makes it possible for findings already dictated to be reused in the corresponding sections of the eCC report, Shedd says.

Epic integrates the eCC into its Beaker AP LIS. “Pathologists have access to eCC in line with their workflow, within pathology reports,” explains Melissa Hunter, Epic product manager. “They don’t have to launch another system or pull it up somewhere else. It’s all within their resulting screen. After they finish their report, they click a tab and the current report is placed on one side of the screen and the eCC forms are on the other.” A report can be reviewed while the forms are completed. “When it is pushed out, it is available to clinicians in both oncology and radiology—anyone who would want to see it,” Hunter says.

A significant aspect of the internal integration allows information entered into eCC forms to intersect with clinical cancer staging reports. “It auto-populates the AJCC forms because they are mapped to the eCC forms,” Hunter says. “When a clinician goes to an AJCC form for their clinical staging, they have immediate access to the information the pathologist entered in the CAP form, which not only reduces transcription errors but ensures that what the pathologist entered is what is being reported. This allows pathologists to provide clinicians with decision support to drive quality patient care.”

By comparison, Cerner CoPath­Plus has a native synoptic editor built into the program software. “It has a synoptic module inside,” says Dustin Greer, solution leader. “If a department is implementing synoptic reporting, we offer an ‘automated worksheet build tool,’ which allows eCC-licensed users to download CAP’s eCC XML files into their CoPathPlus system.”

The tool will then turn the XML file into worksheets. One advantage of using an automated worksheet build tool, Greer says, is that departments can download new XMLs and generate updated worksheets on the same day the CAP makes them available. There is no need to wait for a vendor to create new updated forms. Pathologists can select appropriate worksheets and associate more than one worksheet to a case. “The synoptic worksheets are easily filled out with point and click to answer questions,” Greer says. “It fills out the worksheet as you go, and at the end there is an option to validate it to make sure nothing was missed.”

Dr. Spencer says all vendor software has “completeness checkers” for use with the eCC, something she views as highly valuable. “There’s no more worrying and wondering if you missed required elements.”

Some vendors don’t support the eCC, or don’t support them well, and that has frustrated users, who inform the CAP of the problems. Says Dr. Berman: “Vendors say, ‘Our customers aren’t telling us this.’ So our message to pathologists is, ‘If your vendor is doing something you don’t like, please tell your vendor.’ They listen to their customers. And vendors work on volume, so the more pathologists who speak up, the quicker they get resolution.”

Cancer protocols are revised as staging and classification and other standards change. “The protocols are living documents that get updated, and not infrequently,” Dr. Spencer says. “People making their own report forms have to keep up to date with changes and have eight months from the time a protocol is released to be in compliance.”

In contrast, the eCC are automatically and immediately updated with new checklists, which are customarily provided to vendors and licensed users at the same time as the protocol release. But pathology departments sometimes insist on customizing the CAP-provided eCC report forms.

“Customizations come with a big maintenance burden to an organization and shouldn’t be taken lightly,” Hunter warns. “If you choose to customize, you will have to figure out who is responsible for making sure new forms that get released are maintained within those customizations.”

Desiderio recalls visiting one site in southern California that has a large pathology department. “They had one person who was responsible for making all the updates. He spent about a third of his time just trying to keep everything updated and pushed out to everyone using these reports in the organization. That’s a pretty significant resource spent in that manner,” he says.

Some vendors have attacked the problem head-on. Murphy says mTuitive has successfully met many pathology departments’ requests to build local modifications into eFRM algorithms. “When new updates are introduced from the CAP, mTuitive has a process to bring those modifications forward,” he says, “eliminating a massive burden and potential point of failure during a content upgrade for pathology departments.”

The worksheet tool in Cerner CoPathPlus also allows customization from site to site. Says Greer: “If users want to add questions or take some questions away that are not required by the CAP, and thus modify the downloaded content, they have the ability to do that. While they can build the worksheets from the ground up, most laboratories start with CAP requirements and go from there.”

CAP cancer protocols and eCC continue to evolve, not only to reflect changes in medical understanding but also to address the need for greater ease of use. “There has been pushback by those who feel synoptic reporting has gotten out of hand,” Dr. Spencer says. “The reports can get very long, and something important to a particular user could be sunk down in the various element-value pairs. People believe that defeats the whole purpose, to make it easy to find information.”

California has passed into law a requirement for electronic reporting of cancer diagnoses by pathologists starting in 2019. This has caused the California Department of Public Health, which must execute the new electronic reporting requirement, to reflect on and react to the length of the checklists and data elements and to vendor variability in checklist implementation.

“California pathologists have basically asked the CAP to minimize the number of required elements in reports,” Dr. Spencer says. “They said, ‘Is there something you can do about this?’ Of note, the CAP has already been doing something about it for quite a while but we haven’t been successful in getting this message out to people.”

This too-much-of-a-good-thing problem dates back to when CAP content experts first assembled lists of parameters they felt should be reported in any given case, Dr. Berman says. “The original protocol authors were not asked to restrict the parameters they were discussing to meet a certain level of evidence.”

In addition to the core elements in the eCC, which are required for accreditation, optional parameters add to the heft of the templates. “If you remove the optional elements, they are not particularly long,” Dr. Berman says. The optional parameters should not be indiscriminately stripped away, in his view, because they may be of clinical value. “It is important for each site to assess the need to report the optional elements,” he says.

Still, a streamlining of changes is afoot. “CAP recognizes it is critical to assess all of our protocols and make sure we give core element status to only those parameters that meet a specific level of evidence,” Dr. Berman says.

The Cancer Protocol Oversight Project Team, a group working to help coordinate efforts between the Cancer and PERT committees, is making title page improvements and standardizing templates across all tumor types, “so we can get into the habit of expressing things in similar ways,” Dr. Edgerton says. “It won’t require as much intense concentration.”

The order of data input will be standardized, as will the terminology and even the fonts used. “PERT and the CAP’s Cancer Committee work collegially,” Dr. Berman says, “which is wonderful. We have worked in a symbiotic way—one specializing in creating content, the other in modeling how best to get that content into use.”

Dr. Spencer’s team is providing vendors with guidance on outputting a report that pathologists will find professionally and aesthetically pleasing—concise, clear, aligned, and readable. Improved output makes it possible for reports to be more easily consumed. “It also encourages pathologists to take greater ownership of the process because the reports will meet their own high standards,” Dr. Berman says.

Dr. Edgerton hopes vendors, who implement eCC in different ways, will follow the lead toward standardization and work with the CAP to identify the best ways to release new eCC versions for easier assimilation. This will result in the least amount of effort needed for pathologists to keep up with the latest version, she says.

Users do want greater ease of use as electronic reporting moves to the forefront, as seen in California. The California law is “really pretty simple,” Dr. Edgerton says. “It says that data that is transmitted to the California Cancer Registry must be done electronically. They do not go into detail as to what the format of that data must be; however, it cannot be sent by fax, telephone, or mail.” The law, she adds, provides for a first step forward in committing to electronic data. “It may be a baby step, but California is leading the way. The word ‘electronic’ is finally being used.”

While barriers remain to eCC adoption, the most basic of which may be its cost, Dr. Berman urges pathologists to keep the focus on patient outcomes.

“Some pathologists likely think changes in reporting are making their lives harder,” he says. “But they must recognize that these efforts are better for clinicians, for registrars, for researchers, for patients, and for the field of pathology. When pathologists fully understand the big picture, they will be willing to put more data into this format, and it will get faster and easier for them to do so.”

Data are invaluable, he adds. “And the better we are at providing appropriate, actionable data to clinicians, patient registrars, and many other end users, the better the patient outcomes.”
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Valerie Neff Newitt is a writer in Audubon, Pa.