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Pathologists use two-pronged strategy to convey IOC results

September 2019—It’s a simple and nearly airtight communication strategy: Tell someone something verbally and then share the same message with them in writing to make sure they understood you. Following this logic, a group of surgical pathologists at the University of Minnesota Medical Center made an assumption that if their intraoperative consultation results were made available to surgeons in written form during surgery as documentation of verbal communication—either in person or via telephone—the frequency of communication errors would be reduced.

Morphing their logic into labor, the pathologists began working with University of Minnesota-Fairview Health Services information technology staff in 2016 to develop a solution that enabled them to send IOC results from their institution’s Sunquest CoPath lab information system to its Epic EHR system, allowing surgeons to view preliminary diagnoses in real time. The solution replaced the medical center’s practice of scanning handwritten intraoperative consultation diagnoses into the EHR—a process that took a minimum of three days—thereby also providing surgeons with the opportunity to review a well-documented IOC at the time of operative notes dictation.

Two years after implementation, an audit of the new system showed a significant reduction in the number of discrepancies between the pathologist’s intraoperative consultation results and the IOC results as documented by the surgeon in the operative notes.

Dr. Khalifa

“Every place in North America [with a standalone LIS] struggles with this type of miscommunication,” says Mahmoud A. Khalifa, MD, PhD, professor and director of anatomic pathology, Department of Laboratory Medicine and Pathology, at the University of Minnesota. “There is nothing that would inspire us to look into it until something goes wrong. Then you start to ask the question, ‘Are the surgeons hearing us correctly?’ Then when you start digging, you realize that we thought there was high fidelity between what we say and what they hear and document in their operative notes, but maybe that’s not the case.”

This issue affects only those laboratories with a standalone LIS, says Dr. Khalifa, who briefly discussed his institution’s IOC procedure in a 2019 Healthcare Information and Management Systems Society annual meeting presentation on postanalytic risk reduction in pathology results reporting. Labs using Epic’s Beaker integrated laboratory module can activate the feature that allows IOC results to immediately appear in the EHR, he notes. But “real-time crossing to the EHR [from a standalone LIS] is a truly revolutionary concept that, I suspect, most people never even dared to dream of.”

That said, Dr. Khalifa acknowledges that he does not know if all lab systems can create a similar IOC reporting solution. “But at least the components of the recipe are there,” he says, “and the pathologists can ask the IT people, ‘Can we do this? These guys did it with CoPath/Sunquest, [so] can you do it?’” Any hospital with a standalone LIS can benefit from this tool, he adds, regardless of whether it is an academic or community hospital. “Some of the other major academic centers have implemented their own homegrown solutions to address this type of miscommunication,” he notes.

At the University of Minnesota-Fairview Health Services, two pathology IT staff members worked for several months to create a procedure in CoPath that would allow the intraoperative consultation findings to appear as a preliminary diagnosis in the EHR, Dr. Khalifa says, adding that “we also needed hospital IT people to modify Epic to be able to receive this very strange system.” The first step was to create two new text fields: preliminary intraoperative diagnosis and preliminary interoperative comment. Then the developers added six templates containing all pertinent IOC data elements—diagnosis, comment, date ordered, date completed, date signed out, and pathologist’s signature.

The biggest challenge for the IT team, Dr. Khalifa explains, was embedding instructions to ensure that the IOC results appeared in the correct location relative to the final pathology report. “Our team found that the only way to have the IOC cross to the EHR was to put it in an addendum,” he says. “The rule for the EHR is that the most recent addendum appears at the top of the screen. We realized during testing that because it’s an addendum, the IOC was appearing before the final report. For patient safety, you don’t want the preliminary report to appear on top of the final report because we don’t want a hasty or rushing provider to read the first line and think they got the diagnosis and move on. So we had to make a modification to make sure that this particular IOC addendum does not appear on top.”

The procedure added a step to pathologists’ workflow, which generated mild resistance at first, notes Dr. Khalifa. “They were used to doing one thing: Pick up the phone, say the diagnosis, hang up, and move on. Now we’re asking them to call, then put the diagnosis in writing in the LIS and click ‘enter’ so it actually crosses to the EHR. They weren’t happy about it, but after a few months it becomes second nature, and now they’ve forgotten they did it any other way. On the other hand, surgeons were very excited about this, and the administration contributed funding to the project from their QA budget, so they were
on board.”

After two years, the pathologists analyzed 22 months of data to determine if surgeons were reading the IOC results in the EHR and, if so, when they were reading them. They also determined whether the process reduced the number of discrepancies between what the pathologist reported in the IOC and what the surgeon entered in the operative notes. Of 2,886 IOC orders, 68 percent had a documented review time while in preliminary status (before the final report was issued). Of those, 14 percent were reviewed in the first hour that they appeared in the EHR and 55 percent within the first 48 hours. “Our interpretation is that immediate reading of the IOC was because they really wanted to know what’s in them because it’s relevant to surgery,” says Dr. Khalifa. “The other peak, after 25 hours, probably was their attempt to correlate with the final report when they received it.”

The team also reviewed 150 cases from each of three years: the year preceding implementation of the new procedure and the first and second year after. For each case, the intraoperative consultations documented by the pathologist were compared with the operative notes dictated by the surgeon or surgical house staff. The team found 12 discrepancies pre-implementation. That number dropped to six in the first year post-implementation and seven in the second year. In the pre-implementation year, half of the discrepancies were attributed to “vague diagnosis” from the pathologist. In each of the next two years, only one such discrepancy appeared among the 150 cases.

“If I say something vague on the phone, chances are you will not hear it or understand it well,” says Dr. Khalifa. “If I say something vague but then write it so you can see it on the screen, that vagueness should be clarified. And that’s what we found—that type of discrepancy dropped from six to one. These five patients benefited from our system because the surgeon was able to dictate their operative notes exactly as we communicated.” —Jan Bowers

Schuyler House adds features to SchuyLab review module

Schuyler House has enhanced the review module of its SchuyLab laboratory information system to allow pathology labs to establish which individuals can review and release patient results on a per department basis.

The module also allows department supervisors or designated employees to see, but not approve, the results of tests performed by other areas, depending on how the laboratory has configured the security settings in its SchuyLab LIS. This view-only functionality is important because “a comprehensive view of all results will enhance the ability of a technologist to scan for unusual patterns,” Schuyler House reported.

The new module updates Schuyler House’s initial results review feature, which was geared toward consolidated laboratories and did not fully address the needs of laboratories that run their various departments autonomously, according to the company.