Ordo ab Chao: Framework for an Integrated Disease Report

Abstract

Context.-The volume of information that must be assimilated to appropriately manage patients with complex or chronic disease can make this task difficult because of the number of data points, their variable temporal availability, and the fact that they may reside in different systems or even institutions.Objective.-To outline a framework for building an integrated disease report (IDR) that takes advantage of the capabilities of electronic reporting to create a single, succinct, interpretative report comprising all disease pertinent data.Design.-Disease pertinent data of an IDR include pathology results, laboratory and radiology data, pathologic correlations, risk profiles, and therapeutic implications. We used cancer herein as a representative process for proposing what is, to our knowledge, the first example of standardized guidelines for such a report. The IDR was defined as a modular, dynamic, electronic summary of the most current state of a patient in regard to a particular illness such as lung cancer or diabetes, which includes all information relevant for patient management.Results.-We propose the following 11 core data concepts that an IDR should include: patient identification; patient demographics; disease, diagnosis, and prognosis; tumor board dispositions and decisions; graphic timeline; preresection workup and therapy; resection workup; interpretative comment summarizing pertinent findings; biobanking data; postresection workup; and disease and patient status at follow-up.Conclusions.-A well-executed IDR should improve patient care and efficiency for health care team members. It would demonstrate the added value of pathology interpretation and likely contribute to a reduction in errors and improved patient safety by decreasing the risk that important data will be overlooked. T he complexity of the data used to manage patients with chronic diseases such as cancer has grown during the past decades. Consequently, the task of the clinician has become increasingly difficult and time-consuming; for each patient, clinicians need multiple reports, which reach them in a discontinuous, often illogical, time frame. Furthermore, these reports must be monitored, reviewed, and integrated with other reports and results. What did the chest radiography show? What did the computed tomography show? Do those findings correlate? What did the positron emission tomography-computed tomography show? Did the pathology and radiology findings correlate? Did they correlate with the fine-needle aspiration, with the biopsy results, or with both? Is this pathology report finalized? Is this a preliminary report? Were the appropriate special studies performed to determine therapy? Is information still outstanding? When is it expected? What information is outstanding for clinical trial enrollment? When can we expect those data? Also see p. 159 and p. 160.At its worst, patient safety can be compromised, 1 or the delivery of care may be delayed because of the difficulty in retrieving all of the necessary data elements needed for treatm...

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