An electronic version of standardized cancer protocols, as well as checklists embedded within the Snomed Clinical Terminology, are now available from the American College of Pathologists, based in Northfield, Ill.
The American College of Surgeons Commission on Cancer (ACoS CoC), which accredits cancer treatment centers, has mandated use of the data elements listed in the CAP cancer checklists in surgical pathology reports on cancer specimens. The mandate will become effective as of Jan. 1.
Dovetailing with this electronic effort, CAP has been urging pathologists to adopt synoptic, or structured, pathology reports rather than traditional narrative reports, according to John Madden, M.D., assistant professor of pathology at Duke University Medical Center. Madden also serves as a member of the Snomed International Editorial Board, which develops and updates Snomed CT.
Paper or PDF-based electronic versions of the protocols and their accompanying checklists have been under development since 1999, Madden says.
With the advent of an electronic version of the protocols and Snomed-coded checklists, physicians and IT people at treatment centers should be able to automate electronic patient records with pathologists' lab reports, Madden says.
"The checklists themselves provide a standard content model for what needs to be in a cancer report," Madden says. "That information will be provided in a standard format and terminology. It will provide assurance to a physician he's going to get a comprehensive report."
Switching to the protocols and coded checklists "is also going to help out tumor registries and cancer epidemiologists in the long run. The tumor registrars will be able to pull this information much more easily than in an old-fashioned narrative report."
The new tool will be available from CAP for a "nominal fee," Madden says.