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How a synoptic reporting system improved specimen quality

March 2022—Medical professionals and, more importantly, patients at Virginia Commonwealth University Medical Center are benefitting from a synoptic reporting system that allows the pathology lab to assess the quality of all bone marrow specimens that it receives.

Key to the system’s value, says Alden Chesney, MD, associate professor and director of hematopathology at VCU Medical Center, is a feedback structure that allows those who perform bone marrow procedures, such as specially trained nurse practitioners and hematology and oncology fellows, to see specimen quality reports quickly, while the procedures are still fresh in their minds.

“What was happening previously is that the feedback on sample quality occurred after some period,” Dr. Chesney says. “We had quarterly bone marrow quality meetings with various stakeholders in the hospital.” This system provides information “more in the moment for them,” he adds. “They can remember whether this bone marrow was a difficult one or whether they thought they did a good biopsy.”

The synoptic reporting system uses a relational database that contains bone marrow specimen parameters and generates specimen quality reports as soon as pathologists finalize their evaluations, which is three to five days after the lab receives a specimen. The hospital’s electronic health record system automatically distributes the reports.

The timely responses have been so vital to improving bone marrow specimen quality that the pathology department is planning to build out and refine the feedback structure in future iterations of the database, Dr. Chesney says. This will be particularly advantageous, he explains, because the synoptic reporting system sends specimen quality reports directly to the practitioners who perform the procedures in some areas of the hospital while sending the reports to the departments where the specimens were procured in other areas of the institution. Upcoming modifications to the system will ensure that appropriate practitioners throughout VCU Medical Center receive specimen quality reports directly.

The hospital’s synoptic reporting system uses an Oracle database that was set up by the laboratory information systems team in 2017 and integrated into the Cerner Millennium EHR and lab information system that VCU Medical Center was using at that time. At the end of last year, the hospital switched to the Epic Beaker EHR and LIS, Dr. Chesney says, and the synoptic reporting system was moved to the new platform with only minor adjustments. “We inadvertently have had it on two different hospital information system platforms, so we know it can work on any of these EHR systems,” he adds.

The hospital is undertaking a stabilization period of approximately three months to observe the new EHR and LIS before any new technology projects begin, Dr. Chesney says. Consequently, he and his system codevelopers anticipate enhancing the feedback process to ensure direct delivery of reports to practitioners during the second quarter of this year, after the stabilization period ends.

Dr. Chesney and his colleagues developed the synoptic reporting system to standardize specimen quality across hospital departments in accordance with industry-recommended guidelines. Their efforts were validated by an internal quality initiative that found a direct link between specimen quality and patient care, he says.

Before implementing the system, the pathology department did not record bone marrow quality data in a manner that allowed pathologists to analyze the data systematically and identify areas for improvement, Dr. Chesney explains. Pathologists provided feedback in egregious cases, such as if someone performed a biopsy that didn’t contain any bone marrow, but the laboratory lacked a standardized system for identifying smaller issues and providing quick responses about specimen quality.

To address this shortcoming, the pathology team used guidelines from the International Society of Laboratory Hematology and College of American Pathologists to determine which specimen quality criteria to record in the synoptic reporting system database. Then, from August 2017 through December 2019, pathologists entered quality parameters on 3,189 adult bone marrow aspirates, 3,302 adult core biopsies, and 3,183 adult biopsy imprints into the database to determine the most prevalent issues affecting bone marrow aspirate quality. The data were extracted from the biopsy reports using Structured Query Language query and summarized in tabular form.

The bone marrow quality assurance grading parameters incorporated into the system address length of interpretable bone marrow, hemodilution, cell preservation, staining quality, number of spicules, aspiration artifact and other artifacts, decalcification, and total biopsy length. Pathologists and pathology residents record the numeric values for the mean and interpretable length of the bone marrow biopsy and rate other parameters as “inadequate/suboptimal/adequate” or as “moderate/severe, minimal/mild, none.” (Dr. Chesney and his colleagues published these and other details about the synoptic reporting system project in the Journal of Pathology Informatics [doi.org/10.4103/jpi.jpi_53_20].)

Pathologists record their assessments of the quality parameters for a specific specimen in the synoptic reporting system database at sign out, Dr. Chesney says. This is important for training pathology residents and fellows, he adds, because they are the first to review specimens before sign out.

“It has become a practical way of helping our trainees incorporate an understanding of quality into their practice,” he explains. “We teach them how to assess specimen quality, and they perform these quality assessments when they first look at the specimen.”

Supervising pathologists, who perform the final sign out of specimens, review each fellow’s initial quality assessments and provide feedback about discrepancies or omissions. This feedback is an additional training opportunity, Dr. Chesney says.

Since implementing the synoptic reporting system, the pathology lab has seen a noticeable improvement in the quality of bone marrow specimens submitted by the pediatric department and other specialty groups. Pediatrics “is especially important to us,” Dr. Chesney says, “because repeating an invasive procedure like a bone marrow biopsy is not something you want to contemplate on a child.”

Poor specimen quality often results simply from a lack of understanding about the specimen parameters that pathologists require, Dr. Chesney says. At VCU Medical Center, an initial analysis of synoptic reporting system data revealed issues with the quality of bone marrow specimens submitted by the hospital’s interventional radiologists. By digging deeper into the data, the pathology department determined why these issues were occurring.

“One reason was because they had not been getting feedback about where the best places might be to obtain the sample and what might be the best approaches to do this,” Dr. Chesney says. “That was an important finding from our early assessments that we could take back in an evidenced-based way to discuss with the team in interventional radiology.”

A critical step in using quality data reports to improve specimen quality is explaining the purpose of the project to the practitioners who procure the specimens, he notes. Hospitals looking to implement similar types of specimen quality databases need to first reassure stakeholders systemwide that feedback data is not punitive and will not be used against them professionally, Dr. Chesney emphasizes.