As the need for improved research and measurable methods of care increases, more organizations are starting to require specific standards be used in capturing medical information. Gone are the days where hastily scribbled notes or dashed together dictations are acceptable — there's simply too much useful information in these reports to let it vanish down an obsolete rabbit hole. In pathology, adhering to standardized structures allows researchers and physicians to better understand efficacy of treatments, how certain ailments are affecting the population (or a particular demographic), and improves the ease with which physicians can read/comprehend the results. In order to improve overall data reporting and retention, many organizations have encouraged (and required) using synoptic reporting for pathology. Recently it was announced that The Joint Commission would be joining that growing number of organizations and, starting July 1, 2014, would require labs to use synoptic reporting in order to be accredited.
Founded in 1951, The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. They join with other local, national, and system wide organizations in requiring pathologists to report their findings in a synoptic manner in order to ensure adherence to best practices of data capture and efficiency in the workflow of sending out results. We first heard that this was going to happen a few weeks ago from a number of prospective customers, so we felt it was important to go straight to the source and asked The Joint Commission about it. They replied:
Joint Commission Standard QSA,13.04.01 EP 10 will be effective July 1, 2014. This Element of Performance requires the use of synoptic format in reports of cancer pathology. The footnote to that Element of Performance includes the following reference: Additional information can be found in Cancer Program Standards 2012: Ensuring Patient-Centered Care by the Commission on Cancer of the American College of Surgeons at http://www.facs.org/cancer/coc/programstandards2012.pdf.
We then followed up to ask if this was for programs/facilities (like the Commission on Cancer's requirement is) or if it was just targeting labs accredited by The Joint Commission. They replied that "this standard appears in the Comprehensive Accreditation Manual for Laboratory and Point of Care Testing (CAMLAB) and applies only to laboratories accredited by The Joint Commission Laboratory Accreditation Program."
So the answer is "Yes" this will be a requirement for all labs seeking accreditation from Joint Commission and the requirement begins July 1, 2014. The standard that Joint Commission is referencing, the Commission on Cancer's Cancer Program Standards 2012, is about ensuring accuracy, efficiency, and best practices for all levels and departments involved in administering care to cancer patients. But the page of significance for laboratories and pathologists can be found here, where it is defined that "90% of eligible pathology reports that include a cancer diagnosis will contain the required data elements outlined on the currently applicable surgical case summary checklist of the [College of American Pathologists] publication, Reporting on Cancer Specimens."
We've previously discussed the advantages of using College of American Pathologists' electronic Cancer Checklists (CAP eCC), not just for meeting requirements but also for ensuring that the most important information is captured in a standardized format with a unified language. By using these checklists, pathologists are not just meeting the requirements of Commission on Cancer (and now The Joint Commission), but are also adhering to the constantly updated sections and data points that have been deemed important to track. CAP has made it even easier to maintain compliance with these standards by partnering with us to create the CAP electronic Forms and Reporting Module (eFRM), a synoptic reporting tool that ensures users automatically have the most up-to-date versions of every eCC while creating synoptic reports that meet requirements and make it easier for physicians to understand the pathologic findings.
The adoption of synoptic reporting — specifically the CAP eCCs — as a standard of care continues to grow. Health care organizations, professional societies, even nations are requiring that best practices are adopted not just in administering care, but also in documenting it. By highlighting the vital parts of the cancer findings, these synoptic reports are helping to ensure complete reporting (without missing a field or data point) and strengthening future research by adopting a unified lexicon (using the same words to describe or define the same thing, as opposed to relying on data extractors to understand synonyms). The Joint Commission's decision to require synoptic reporting for pathology lab accreditation on July 1, 2014 reflects this growing agreement and hopefully signals to other specialties how important such standards of reporting can be when administering care.