Challenges and Opportunities in the Adoption of College of American Pathologists Checklists in Electronic Format

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1 Challenges and Opportunities in the Adoption of College of American Pathologists Checklists in Electronic Format Perspectives and Experience of Reporting Pathology Protocols Project (RPP2) Participant Laboratories Lewis A. Hassell, MD; Anil V. Parwani, MD, PhD; Lawrence Weiss, MD; Michael A. Jones, MD; Jay Ye, MD, PhD N Context. The site-specific cancer checklists developed by the College of American Pathologists have the potential to improve the quality of data derived from pathology reports and incorporated into cancer registry databases and are now mandated report elements by various accrediting bodies. A pilot project, funded by the Centers for Disease Control National Project for Cancer Registries in 2004, brought 4 pathology services in 3 states, with differing baseline implementations of the checklists, the opportunity to partner with their state National Project for Cancer Registry and their laboratory information system vendors to evaluate the feasibility of using electronically encoded College of American Pathologists cancer checklists for melanoma and tumors of the breast and prostate. Objectives. To identify existing and potential barriers to adoption of electronically encoded checklists and to also identify unique benefits not associated with text-only uses of the checklists. Design. Participants mapped an implementation process from their current state to an electronic checklist capable state. For a sample of cases of melanoma, prostate, and breast cancers, the checklist elements were captured and transmitted to the registry using Health Level 7 (version 2.3.1). Process assessments with adoption of electronic checklists were conducted to assess pathologist Although the pathology report is crafted and primarily designed in the context of the physician-consultantpatient relationship, the consumers of this information Accepted for publication December 9, From the Department of Pathology, University of Oklahoma Health Science Center, Oklahoma City (Dr Hassell); Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Dr Parwani); Department of Pathology, City of Hope Medical Center, Duarte, California (Dr Weiss); Department of Pathology, Maine Medical Center, South Portland, Maine (Dr Jones); Department of Pathology, Dahl Chase Diagnostic Services, Eastern Maine Medical Center, Bangor, Maine (Dr Ye). The authors have no relevant financial interest in the products or companies described in this article. Presented in part at the annual meeting of the North American Association of Central Cancer Registries, San Diego, California, June 16, Reprints: Lewis A. Hassell, MD, Department of Pathology, Oklahoma University Health Science Center, 940 Stanton L. Young Blvd, BMSB 451, Oklahoma City, OK ( lewis-hassell@ouhsc.edu). effect and other potential barriers. An evaluation of the utility and usefulness of electronic checklists was performed after the project. Results. All 4 laboratories successfully performed the capture of individual data elements from the College of American Pathologists checklist into a discrete format suitable for electronic transmission. The effect on pathologist performance and laboratory workflow was neutral. Points of resistance were identified in the checklists and in individual users. Specific challenges in individual laboratories varied according to the personnel and the baseline system in use. Clinical responses to implemented changes were generally positive. Analysis of the postproject experiences of the laboratories showed expansion of use and additional utility in some, but not all, laboratories. Conclusions. Pathology laboratory adoption of the College of American Pathologists cancer checklists in an electronic format suited to direct transmission to cancer registries poses business case, information technology, and human resource challenges. Laboratory information system vendor readiness to upgrade systems to facilitate this process helps to reduce some of these challenges. Personalities and preferences in practices may yet pose barriers to widespread adoption. (Arch Pathol Lab Med. 2010;134: ) are clearly not limited to the primary parties in this triad. An important, but often forgotten, audience for the pathology report, when the case involves a cancer diagnosis, is the cancer registrar. Cancer registries face the perpetual challenge of providing timely, complete, and accurate cancer data for public health and other purposes. The changing demographic and economic challenges of doing this in today s environment create the need to use new tools and systems to fulfill the registry s charge with the limited resources available. The College of American Pathologists (CAP) protocols and checklists were created to improve the quality and uniformity of information in pathology reports, leading to improved patient care and management. 1 3 These protocols contain checklists as tools to ensure consistency as well as site-specific and cancer-specific staging and prognostic information and supporting references. The CAP cancer protocols and checklists provide new oppor Arch Pathol Lab Med Vol 134, August 2010 Challenges and Opportunities in Electronic Checklists Hassell et al

2 tunities to more easily integrate discrete data elements from structured pathology reports with highly standardized, but evolving, cancer registry software applications. 4,5 This is particularly true as more and more laboratory information system (LIS) vendors hardwire these checklists into their modules for anatomic pathology reporting, a process encouraged by the recently launched, published Electronic Cancer Checklists (ecc). 6 The Centers for Disease Control and Prevention and its National Program of Cancer Registries have taken the lead in examining such possibilities through a demonstration project titled Reporting Pathology Protocols Project for Breast and Prostate Cancers and Melanomas (RPP2). 7 A significant outcome of that project was a greater understanding of the utility of, and barriers to, adoption of electronic, searchable, data capture of checklist elements beyond what might be retrievable from text-only formatted reporting data. The CAP cancer checklists were originally designed as paper-based tools (generally in word processing software documents) for use in the pathology laboratory. 8 However, many laboratories and associated software vendors began to incorporate these elements into reports in a textbased, synoptic format, a change which was greatly accelerated by the accreditation requirements of the American College of Surgeons Commission on Cancer, which stipulated that cancer programs must include the essential CAP checklist data elements in the facility s pathology reports. The encoding in the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT), which took place in 2003, was a further critical step toward making the checklists more compatible with modern data processing and the highly computerized world of cancer registration. 9 These steps catapulted the reporting of pathology data beyond just the electronic medical record of the patient into the realm of electronic public health and epidemiology in a significant way. In opening the door for registries to provide more timely, complete, and accurate cancer information, these steps have also significantly enhanced the opportunity for improving the quality and utility of the pathology report database for traditional users and others. The RPP2 project sought to answer several questions. This article focuses on the experiences of participating laboratories and pathologists on the following 2 queries:. Will pathologists use the electronically encoded CAP cancer protocols and checklists as a routine part of their reporting responsibilities?. What challenges or barriers exist for cancer registries and pathology laboratories in implementing the CAP cancer protocols and checklists? Two additional questions whether CAP cancer checklists are more accurate than data derived from traditional text reports and whether implementation of these checklists results in more complete information in cancer registries were also dealt with by the project. These questions of primary interest to cancer registrars are dealt with in another article. 10 In this report, we analyze the experiences of laboratories involved in the RPP2 project in implementing of electronic checklists to reveal the actual and potential barriers to adoption of both the checklist format and electronic encoding of that data, and we consider some of the added benefits that follow the adoption of this method of reporting. MATERIALS AND METHODS Participating state registries were selected in 3 states based on their ability to obtain a suitable minimum number of cases of each of the 3 tumor types (breast, prostate, and melanoma) during 1 year and on their willingness to collaborate with the project and their ability to identify a laboratory partner (or partners) to participate. Because the configuration and practices of pathology laboratories and state and hospital registries and their respective software products differed among the project participants, the specific methods employed to answer the major questions were different, as detailed below. General project details are presented elsewhere. 11 Details of the electronic messaging issues are not considered here but will be reported subsequently (R. Moldwin et al unpublished data, 2010). Full details of the project are described in the Centers for Disease Control and Prevention report. 12 Query 1: Will Pathologists Use the CAP Cancer Protocols and Checklists as a Routine Part of Their Reporting Responsibilities? California. The participating California pathology laboratory, City of Hope Medical Center (Duarte, California), was not using synoptic reporting or the CAP checklists at the beginning of the project but was including pertinent information within a text-only format. Following implementation of synoptic checklists in April 2007, we assessed the use of, and response to, the electronic checklists. Completed breast, prostate, and melanoma reports were audited following implementation of the protocols to assess inclusion of the checklists. The CAP checklists were introduced as an appendage to the report. Pathologists were surveyed at 1 and 9 months after implementation of the change to assess reaction on several parameters, including ease of use, time required to use checklists, completeness of checklists, and feedback received from recipients of the new reports containing the data in synoptic format. Each survey question response was tallied, and totals for each category were compiled. To simplify analysis, responses of strongly agree and agree were combined and tabulated as agree; the responses for strongly disagree and disagree were similarly tabulated as disagree. Eight of 10 participating pathologists completed both surveys, for a response rate of 80%. Full text of the survey is presented in Appendix A. This survey was used only in California because the other sites had already adopted synoptic reporting in at least text format. Maine. Before the RPP2 project, the 2 participating pathology laboratories from Maine (Dahl Chase Diagnostic Services, Bangor [DCDS] and NorDx, Scarborough) routinely used the CAP checklists, in locally adapted text-based forms, as a part of their reporting responsibilities; hence, a portion of query 1 was already answered during a decade of use. Adoption of electronic versions of the checklists required implementation of new versions of the Impac PowerPath (IMPAC Medical Systems, Inc, Sunnyvale, California) LIS in use at the laboratories, and implementation of a virtual private network connection with the Maine Cancer Registry. A selected set of breast, prostate, and melanoma cases were piloted through both standard text and electronic synoptic processes, and the reports and process steps compared. Pathologist completion of the electronic checklist was also compared with routine dictation of the checklist in both formats. Continued use of, and any extension of use of, encoded checklists to other tumor sites was evaluated 18 months after completion of the project. Pennsylvania. To assess pathologists use of CAP checklists as a part of their reporting responsibilities, the University of Pittsburgh Medical Center (UPMC; Pittsburgh, Pennsylvania) collected computed compliance rates for pathologists using the respective pathology synoptic reports for the RPP2 specimen types. Data were exported directly from the CoPathPlus Anatomic Pathology Solution (North Kansas City, Missouri) LIS for eligible specimen types of cases accessioned between October 1, 2005, and December 31, The total number of Arch Pathol Lab Med Vol 134, August 2010 Challenges and Opportunities in Electronic Checklists Hassell et al 1153

3 Table 1. specimens was compared with those having completed synoptic reports to obtain a raw percentage of compliance. A pathologist also performed a manual review of a random sample of the first 100 eligible cases for the same period. In addition to compliance rates, findings from a previous survey of surgeons, oncologists, and tumor registrars in the UPMC network, as well as other hospital affiliations, informed the research question. The purpose of the survey was to assess the perception of medical professionals regarding different aspects of the synoptic pathology reports. The survey was distributed to 207 individuals, and 40 responded, resulting in a response rate close to 20%. Although a total of 17 items were included on the survey, the item most relevant to the study questions asked: What percentage of pathology reports are synoptic reports or includes a synoptic report? A summary of the baseline status for each pathology laboratory is presented in Table 1. Query 2: What Challenges and/or Barriers Exist for Cancer Registries and Pathology Laboratories in Implementing the CAP Cancer Protocols and Checklists? California. As noted above, we conducted 2 surveys that were distributed to pathologists at 1 and 9 months after adoption of the synoptic checklists. Ten staff pathologists were solicited for each survey, and 8 pathologists responded for each survey, yielding a response rate of 80%. Open-ended queries allowed solicitation of unforeseen obstacles and opportunities for improvement of the process and checklists in use. Maine. Feedback from participating Maine pathologists was gathered by individual interview with the champion at each site to assess the effect of using the electronic checklists as opposed to the text-based method in place before the study. Additionally, the adoption of electronic checklists for tumors beyond the initial scope of RPP2 and continuing use of the electronic checklists by others in the 2 participating laboratories was assessed 18 months after the conclusion of the project. Pennsylvania. Implicit conclusions about the barriers to adoption were drawn from the surveys of electronic checklist users and from the audits of checklist use for various specimen types. RESULTS California Survey results for the 2 surveys showed considerable resistance to adoption of the checklists among the California pathologists, with the proportion finding them more difficult to use than standard text reporting rising from 37.5% at 1 month to 50% at 9 months. Respondents were fairly evenly split on the question of whether the text or synoptic versions required less time, although by 9 months, 50% disagreed with the assertion that it took less time to complete the synoptic version than traditional text. Baseline Configuration of Participant Laboratories Project Site Baseline Reporting Model LIS Version Postadoption LIS Version No. of Pathologists PA-UPMC Synoptic Checklist added as a separate Cerner CoPath Plus Cerner CoPath Plus 50+ text portion of report ME-DCDS Synoptic Checklist included in text of PowerPath 8.0 PowerPath Diagnosis ME-NorDx Synoptic Checklist included in text of PowerPath 8.0 PowerPath Diagnosis CA-City of Hope Text only Cerner CoPath Plus Cerner CoPath Plus 10 Abbreviations: CA-City of Hope, City of Hope National Medical Center, Duarte, California; LIS, laboratory information system; ME-DCDS, Dahl Chase Diagnostic Services, Bangor, Maine; ME-NorDx, NorDx Laboratories, Scarborough, Maine; PA-UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Some of the resistance may have been related to missing elements in the synoptic checklists or to the seemingly cumbersome application of the structured electronic checklists to very complex situations occurring in a tertiary referral center. After 9 months of use, the proportion who felt that all the elements for a complete report were included in the checklists dropped from 50% to only 25%. The inflexibility of the checklist format, the absence of certain staging-modifier terms (ie, for adjuvant therapy or recurrences), and some limitations on histology choices were voiced concerns. Uncertainty as to how to handle multiple tumors in the same specimen was also a concern with the checklist format. Some expressed concern about the inclusion of seemingly meaningless elements, such as overall specimen size, in the checklists as well. Redundancy in the entry of synoptic data both in the text diagnosis and related fields and in the electronic checklist could also have been a source of resistance in addition to introducing the potential for error or ambiguity. By 9 months after implementation, 25% of pathology respondents had received favorable feedback from report recipients, and none had reported unfavorable feedback. The RPP2 study parameters stipulated the evaluation of sufficient numbers of each case type to facilitate evaluation of the accuracy and completeness of the queries noted above. In the California cases selected for study, 25% of the cases of breast tissue and 7% of the prostate tissue specimens did not include the synoptic checklists. In general terms, willingness to adopt the new method of reporting seemed to be correlated with 2 probably related, primary factors: age of the pathologist and facility with computer technology. Since completion of the project, City of Hope continues to use the checklists as reporting elements within their Cerner LIS, but only the 3 study sites are electronically encoded. Use of the encoded data has not expanded beyond the tumor registry. Pennsylvania Use of the checklists was variable, as depicted in Tables 2 and 3. These variations in use patterns appeared to be related to 2 factors: business rules or policies of the individual sections (often in response to clinician demand or preference) and individual pathologist preferences or experiences with the checklists. In the Pennsylvania portion of our study, several factors posed challenges and barriers to the implementation of the CAP checklist for pathology laboratories. These factors included incomplete data items listed in the CAP checklists for specific specimens and individual patholo Arch Pathol Lab Med Vol 134, August 2010 Challenges and Opportunities in Electronic Checklists Hassell et al

4 Table 2. Compliance Rates in Pennsylvania: Specimens Accessioned Into CoPathPlus a Synoptic Type Total Specimens, No. Specimens With Synoptic Reporting, No. Compliance Rate, % Breast resection Melanoma Prostate resection Prostate biopsy a 100% of specimens were accessioned into CoPathPlus; review, October 1, 2005, through December 31, gist resistance to use of checklists. Data entry from the pathologist or transcriptionist was not found to be a barrier (see Figure 1.) Checklist maintenance and evaluation are active processes at UPMC, with regular intervention from an active informatics division to facilitate the use of the checklists. Post-RPP2 study experience has shown a stable pattern of electronic checklist use, which now appears to be engrained in the culture of the pathology laboratory. electronic transmission to the cancer registry is continuing for the selected tumor types, with hopes of expanding to other tumors. The utility of the accompanying database, derived from electronic entry of the synoptic checklist, is beginning to expand beyond just transmission to the cancer registry. For example, the tumor/tissue bank is now able to readily obtain data files stripped of patientidentifier information, with accurate staging and other pertinent information, to accompany samples deposited into the bank. Maine Participants in the RPP2 project provided postimplementation feedback on the challenges and barriers experienced throughout the project. Of those pathologists participating in the project at DCDS (a specialized signout structure meant that a few pathologists evaluated skin and prostate cases), almost all completed the electronic checklists themselves, rather than dictating the results for a transcriptionist to enter. At NorDx, the proportion grew as time progressed, with 50% of the users finding it simpler to complete the checklist themselves. At both laboratories, the checklist data elements were included in the diagnosis field of the reports to exclude the need for, or inclination toward, redundancy. Data entry into the Electronic synoptic checklists was not a major obstacle but proved to be slightly more cumbersome than text editing because additional keystrokes were required to retrieve and attach the checklist into the report (see Figure 2). Following completion of the selected cases required for the RPP2 project, the experience of the 2 laboratories Table 3. Compliance Rate: Specimens Accessioned Into CoPathPlus Random, Manual Review of First 100 Cases a Synoptic Type Specimens With Synoptic Reporting (N = 100), No. Compliance Rate, % Breast resection Melanoma Prostate resection a Review, October 1, 2005, through December 31, regarding the electronically encoded checklists was different. At DCDS, because the project was done in a LIS test mode, the effort required to migrate all the different types of checklists in use in the laboratory to the live, LIS-based electronic checklist was seen as formidable and, perhaps, premature. Pilot testing with some cases in the live mode revealed problems in report formatting and data integrity. This dampened enthusiasm. Furthermore, because the cancer registry was not yet ready to receive reports in their live system, a key benefit of the transition was missing. As a result, the practice opted strategically to delay implementation until the information technology difficulties were resolved. Thus, text-based synoptic reporting, using the locally adapted text versions of the CAP checklists, is still the norm for virtually all reporting. The electronic checklist module of the version 9 PowerPath software is not in use. Although 1 of the champions of the effort has departed the practice, others have stepped forward to fill that role, and the RPP2 experience has prepared the practice to implement expanded, electronic checklist reporting when the circumstances are opportune. In contrast, at NorDx, the 3 pilot sites and their accompanying electronic checklists have been tailored to local use and are now the norm for reporting of these tumors. Work on additional tumor sites is ongoing, as resources allow, with the goal being to expand use of the electronic format to all of the commonly reported tumor sites. However, because this process is still labor-intensive, in the initial formatting, in the setup, and, to some degree, in the maintenance of these checklists, the implementation process appears to allow for the addition of only a few additional tumor sites each year. The champion for these efforts is still in place in this laboratory, and use of the electronically searchable database for quality assurance, credentialing, and other purposes appears to be viewed as a compelling business driver to further the efforts. The absence of a champion at DCDS may explain, in part, the recidivism there, as opposed to the extension of use at NorDx. A summary of the barriers and opportunities by site is presented in Table 4. COMMENT Since the first discussion of standardized checklists and synoptic reporting began in the late 1980s, the use of this means of reporting and communication has spread sporadically and somewhat haphazardly. The initiation of many of these discussions in the Association of Directors of Anatomic and Surgical Pathology meant that new trainees were often exposed to the concepts associated with standardized synoptic reporting. 13 A series of regulatory, accreditation, and technologic changes have continued to increase the proportion of cancer cases being reported in a synoptic format. 14 Laboratory information system software upgrades have recently attempted to facilitate the transition from all-text to database-encoded reporting for portions of the diagnostic information. 15,16 However, despite these favorable circumstances, the practice is still more variable than would be desired, and the further adoption of more advanced tools, such as electronically encoded reports, faces significant challenges. Our experiences in participating in the RPP2 project expose some of the potential benefits available to adopters of electronic synoptic reporting, as well as the challenges that will need to be overcome before adoption is universal. Arch Pathol Lab Med Vol 134, August 2010 Challenges and Opportunities in Electronic Checklists Hassell et al 1155

5 Figure 1. Sample data entry interface in use by Pennsylvania participants. Abbreviations: N/A, not applicable; NOS, not otherwise specified. In previously referred to published reports of other findings from RPP2, the ease of data acquisition into cancer registry software is enhanced with encoded checklists. 10,12 The clinical positive feedback reported in the California survey, and anecdotal reports from Maine (unpublished observations), are supportive of other studies documenting clinical benefits from the use of the synoptic formats. We were not able to demonstrate a specific clinical advantage to the use of electronically encoded checklist data because this was generally invisible to clinical report recipients. As is evident from the pushback encountered at City of Hope, UPMC, and Dahl Chase, the benefits of adoption of electronic synoptic checklists do not directly accrue to those required to perform the work of creating them and entering the data. The primary beneficiaries of the project were the cancer registries receiving the electronic data from the pathology laboratories. To the degree that adoption of a synoptic format (electronically encoded or not) was a new step, other recipients of pathology data may respond with enthusiasm to a logical, standardized, easily readable report in this format. But in the setting of established use of CAP cancer checklists or similar synoptic tools in a text-based format, the additional benefits of upgrading to electronically encoded checklists may not be compelling, particularly if the costs and benefits of that upgrade are asymmetric. This will probably continue to impede adoption, even in settings where the utility of a searchable database, such as academic centers, is viewed as mission-critical. The UPMC and NorDx experience in being able to transfer the capabilities acquired through this project to serve quality assurance and credentialing purposes and to support the research mission of a companion tissue bank are, therefore, important outcomes of this project. The project participants, while representing a varied cohort of private and academic practices, still do not totally represent the broad scope of pathology laboratories. The specimen numbers stipulated by the project proposal restricted the possibility that smaller practices could qualify as participants. Thus, the obstacles encountered may not fully represent those that could be unique to a different subset of practices or the advantages and opportunities that might be expected to accrue in such practices. The experience of the DCDS group in adoption and extension of the electronic checklists do, however, appear to represent somewhat the situation that might be expected in those settings. The study by Srigley et al 17 reporting on a multiyear project in Ontario, Canada, to enhance the completeness, 1156 Arch Pathol Lab Med Vol 134, August 2010 Challenges and Opportunities in Electronic Checklists Hassell et al

6 Figure 2. Sample data entry interface in use by Maine participants. Diamonds signify required elements; options on the right expand as the feature on the left is selected to allow data entry. accuracy, timeliness, and usability of cancer pathology reporting in that province illustrate some of the same principles documented in our study. At the start of their intervention, only 55% of cancer reports were in a synoptic format. None of those using a synoptic format were doing so at the highest potential level (encoded in SNOMED CT and in the International Classification for Diseases in Oncology system with searchable database elements.) With the use of various incentives, including contingent funding to the hospitals engaged in these quality improvement endeavors, the adoption of synoptic reporting formats increased to 94% for all sites combined by the Table 4. Summary of Barriers and Opportunities With Adoption of Electronically Encoded College of American Pathologists Checklists for Breast, Prostate, and Melanoma Project Site Baseline Reporting Model Barriers Opportunities Realized PA-UPMC ME-DCDS ME-NorDx Synoptic checklist added as a separate text portion of report Synoptic checklist included in text of diagnosis Synoptic checklist included in text of diagnosis Service and individual preferences or business rules IT customization time; familiarity with text method; flexibility of text methods IT costs of customization CA-City of Hope Text only Age of pathologist; redundant entry of data for checklist; flexibility of text for complex cases Quality monitoring; transmission of pathology data to tissue bank; research Transmission to cancer registry in test mode only Quality metric reporting by provider; tissue banking; transmission to hospital cancer registry Clinician approval Abbreviations: CA-City of Hope, City of Hope National Medical Center, Duarte, California; IT, information technology; ME-DCDS, Dahl Chase Diagnostic Services, Bangor, Maine; ME-NorDx, NorDx Laboratories, Scarborough, Maine; PA-UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Arch Pathol Lab Med Vol 134, August 2010 Challenges and Opportunities in Electronic Checklists Hassell et al 1157

7 end of their study period. 17 Pathologists are responsive to the extensive evidence that synoptic reporting offers more consistently complete reporting, reduces the need for callback inquiries in search of missing information, and results in improved clinician satisfaction with a more easily and fully comprehended report, but generating the motivation for change requires a catalyst or added incentive, at times, to overcome the rigidity of age, technophobia, or inertia. We believe that broader use of the CAP checklists and comparable synoptic tools should be further encouraged and that effective incentives to catalyze this change can come from several fronts. First, it is evident from our experience and that of Srigley et al 17 that organizations such as National Program of Cancer Registries and Cancer Care Ontario can play an important leadership role in bringing the stakeholders to the discussion and finding tools and resources to better balance the costs and benefits between entities. Adoption in the pathologist s workstation is contingent on the ease of use, which can be quite different to users at different levels of comfort with mouse and keyboard versus microscope and dictation device. Laboratory information system vendors, and other interested vendors involved in the process, need to spend resources on the interface as well as on the code to capture and store the data. Standard setting and credentialing organizations, such as the Joint Commission on Accreditation of Healthcare Organizations, the American College of Surgeons Commission on Cancer, and CAP, need to continue to raise the bar regarding adoption and compliance with these tools, both from a quality and from a patient safety standpoint. The latter argument is also something that hospital administrators, payers, and other purse-string stakeholders should recognize and support with the currency of change. Just as the unevenly distributed costs and benefits of electronic health records have been addressed through stimulus programs, grant programs and incentives to adopt electronic checklists should be made available by those with capacity and a view of the larger issues involved. Laboratories anticipating adoption of electronic checklists should consider our experiences and recognize the obstacles to be encountered on several fronts. The workflow and reporting format should be designed to reduce duplicate data entry of synoptic information. Careful assessment of personnel and their affinity for computer tools should be done so that appropriate training and support can be made in advance of resistance. Evaluation of the user interface and data entry process should also be considered to foster adoption. Discussion and policy to deal with challenging complex cases should be undertaken to confront the barrier of switching from highly flexible text reporting to rigidly defined, relatively fixed electronic checklist templates. Additionally, the information technology demands in maintaining, updating, and using encoded checklists should be considered and included in budgeting. Clearly, identifying expected advantages to be gained through the process and selecting champions to shepherd users through the process of adoption should also be done to help retain focus on this desirable goal. Funding for the RPP2 project was provided as subcontracts to participant sites by the Centers for Disease Control and Prevention, through SAIC prime contract , which managed the project. References 1. Bostwick DG, Grignon DJ, Hammond ME, et al. Prognostic factors in prostate cancer: College of American Pathologists Consensus Statement Arch Pathol Lab Med. 2000;124(7): Dworak O. Synoptic surgical pathology reporting. Hum Pathol. 1992;23(8): Hammond ME, Compton CC, for the Cancer Committee of the College of American Pathologists. Protocols for the examination of tumors of diverse sites: introduction. Arch Pathol Lab Med. 2000;124(1): College of American Pathologists. Cancer protocols and checklists Web site. Fportlets%2FcontentViewer%2Fshow&_windowLabel5cntvwrPtlt&cntvwrPtlt%7 BactionForm.contentReference%7D5committees%2Fcancer%2Fcancer_protocols %2Fprotocols_index.html&_state5maximized&_pageLabel5cntvwr. Accessed September 30, Rosai J; for The Department of Pathology, Memorial Sloan-Kettering Cancer Center. Standardized reporting of surgical pathology diagnoses for the major tumor types: a proposal. Am J Clin Pathol. 1993;100(3): College of American Pathologists. About CAP electronic cancer checklists (CAP ecc) Web site. cntvwrptlt_actionoverride5%2fportlets%2fcontentviewer%2fshow&_window Label5cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D5snomed% 2Fabout_ecc.html&_state5maximized&_pageLabel5cntvwr. Accessed October 5, Centers for Disease Control, National Program on Cancer Registries. Reporting pathology protocols Web site. Accessed September 30, Nochomovitz LE. Application of synoptic reports. Arch Pathol Lab Med. 1998;122(6): Van Berkum MM. SNOMED CT encoded Cancer Protocols. AMIA Annu Symp Proc. 2003; Hassell LA Aldinger W, Moody C, et al. Electronic capture and communication of synoptic cancer data elements from pathology reports: results of the Reporting Pathology Protocols 2 (RPP2) project. J Registry Mgmt. In press. 11. Parwani A, Jones M, Hassell LA et al. Reporting pathology protocols for cancers of the breast, prostate, and melanomas (RPP2): utility of computer database capture, encoding and transmission of synoptic data elements. Cancer Inform. In press. 12. RPP2 Project Team Members. Report on the Reporting Pathology Protocols for Cancers of the Breast and Prostate, and Melanomas. Atlanta, GA: the Department of Health and Human Services, the Centers for Disease Control and Prevention, and the National Center for Chronic Disease Prevention and Health Promotion; Association of Directors of Anatomic and Surgical Pathology. Standardization of the surgical pathology report. Am J Surg Pathol. 1992;16(1): Commission on Cancer, American College of Surgeons. Cancer program and data standards: cancer program standards 2009 revised edition. facs.org/cancer/coc/standards.html. Accessed May 29, Cerner Corporation. Cerner launches Cerner Millennium PathNet synoptic reporting [press release]. Available at: Releases.asp?id5257&cid5229. Accessed May 29, Murdock E; for IMPAC Medical Systems, Inc. Impac Software introduces PowerPath version 9.0 [press release]. Available at: company/pressroom/ind_prs/lpr html. Accessed May 29, Srigley JR, McGowan T, Maclean A, et al. Standardized synoptic cancer pathology reporting: a population-based approach. J Surg Oncol, 2009;99(8): Rigby K, Brown SR, Lakin G, et al. The use of a proforma improves colorectal cancer pathology reporting. Ann R Coll Surg Engl. 1999;81(6): Yunker WK, Matthews W, Dort JC. Making the most of your pathology: standardized histopathology reporting in head and neck cancer. J Otolaryngol Head Neck Surg. 2008;37(1): Karim RZ, van den Berg KS, Colman MH, et al. The advantage of using a synoptic pathology report format for cutaneous melanoma. Histopathology. 2008;52(2): Arch Pathol Lab Med Vol 134, August 2010 Challenges and Opportunities in Electronic Checklists Hassell et al

8 APPENDIX A City of Hope Pathologist Satisfaction Survey Synoptic Pathology Reports Please circle your response or fill in the blanks for the following statements. 1. The synoptic pathology report is easier to complete than a standard text pathology report. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 2. It takes less time to complete a synoptic pathology report than it does to complete a text pathology report. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 3. It takes less time to complete a text pathology report than it does to complete a synoptic pathology report. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 4. All of the data elements necessary to generate a complete pathology report are contained in the synoptic report form. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE 5. Data elements that are missing from the synoptic report form are Please list: 6. If you could change one thing regarding the synoptic pathology report format, it would be: 7. Please rate the feedback you have received from synoptic pathology report recipients. FAVORABLE NO FEEDBACK UNFAVORABLE 8. Additional Comments: Arch Pathol Lab Med Vol 134, August 2010 Challenges and Opportunities in Electronic Checklists Hassell et al 1159