A Synoptic Reporting System for Bone Marrow Aspiration and Core Biopsy Specimens

Abstract

Context.—Advances in information technology have made electronic systems productive tools for pathology report generation. Structured data formats are recommended for better understanding of pathology reports by clinicians and for retrieval of pathology reports. Suitable formats need to be developed to include structured data elements for report generation in electronic systems. Objective.—To conform to the requirement of protocol-based reporting and to provide uniform and standardized data entry and retrieval, we developed a synoptic reporting system for generation of bone marrow cytology and histology reports for incorporation into our hospital information system. Design.—A combination of macro text, short preformatted templates of tabular data entry sheets, and canned files was developed using a text editor enabling protocol-based input. The system is flexible and has facility for appending free text entry. It also incorporates SNOMED coding and codes for teaching, research, and internal auditing. Results.—This synoptic reporting system is easy to use and adaptable. Features and advantages include pick-up text with defined choices, flexibility for appending free text, facility for data entry for protocol-based reports for research use, standardized and uniform format of reporting, comparable follow-up reports, minimized typographical and transcription errors, and saving on reporting time, thus helping shorten the turnaround time. Conclusions.—Simple structured pathology report templates are a powerful means for supporting uniformity in reporting as well as subsequent data viewing and extraction, particularly suitable to computerized reporting.

Toward a Platform for Structured Data Acquisition in Oncology: A Pilot Study on Prostate Cancer Screening

“…The survey results indicate that synoptic reporting improved data quality in terms of completeness, clarity, and consistency compared to narrative reporting. This is in line with previous studies and widely acknowledged in the diagnostic disciplines [10,16,32,33,35,36]. Several studies demonstrated increased completeness in synoptical reports across various cancer reports including the breast, colorectal, lung, and prostate [35,[37][38][39][40].…”

“…The usage of synoptic reporting reduced time for documentation of examination results compared to traditional narrative reporting, which is in line with previous studies [32]. Potential reasons include the reduced effort for text formatting [32, 33], correction of dictation errors (casus, numerus, and genus of word endings) [33], use of defaults (normal finding), automated calculations (prostate volume and tumor volumes in biopsies), proofreading for completeness, and consistency of the report [11, 13, 14]. The comparison of time savings between diagnostic departments showed greater time savings for radiology compared to pathology.…”

A Synoptic Reporting System to Monitor Bone Marrow Aspirate and Biopsy Quality

“…[ 12 13 ] Based on the CAP checklist, Murari and Pandey proposed synoptic reporting system for bone marrow specimens, in 2006, and a similar synoptic system for hematological and lymphoid neoplasms was devised by Mohanty et al . [ 14 15 ] Detailed guidelines for the application of the checklist in synoptic bone marrow reporting were subsequently published by the CAP Pathology and Laboratory Quality Center. [ 4 ] However, these guidelines do not specifically address the reporting of bone marrow quality parameters.…”

Artificial intelligence driven framework for the structurization of free-text diagnostic reports

“…Moreover, a system based on background information found in the standard protocol for marrow reports generates diagnostic and prognostic bone marrow aspiration and biopsy synoptic reports in macro text or template formats [43]. Yet, the abovementioned research is limited in transforming biomedical information in free-text format to a structurized, relational format.…”

“…However, the bulk of biomedically significant information is stored in free-text format without any predefined structure. This makes the computational analysis of data and their relationships across pathology reports a daunting task [43]. In addition to that, [38], [39], [42], [48], [60]- [66].…”