Standardized Reporting, Encoding and Computerization of Cancer Pathology Reports

The information collected in pathology cancer reports represents a critical data source for central cancer registries. Traditionally, these reports have been largely free text reports. But in recent years, Centers for Disease Control and Prevention, National Program of Cancer Registries (NPCR) has provided funds through a cooperative agreement with the College of American Pathologists (CAP) to help develop a standards based format of structured, site-specific, electronic SNOMED CT-encoded cancer checklists. The CAP Pathology Electronic Reporting Taskforce's (PERT) mission is to advance electronic implementation of the CAP Cancer Checklists using innovative health information technology.  Part of this mission is to collaborate with the North American Association of Central Cancer Registries (NAACCR) to facilitate cancer registries' receipt and use of the information stored in these checklists. PERT activities include:

¨        Create computational forms and software to facilitate implementation of cancer checklists using XML schemas and move towards a standard format for Laboratory Information System (LIS) integration and implementation.

¨        Review and submit recommendations for electronic reporting of SNOMED CT encoded checklists to ensure interoperability with international standards and professional organizations through mappings to the NAACCR data layout used by registries.

¨        Develop graphical user interface (GUI) prototypes or specifications to create an improved data entry layout for pathologists.

Standardized reporting of critical data and integration within health information technology systems can improve quality of patient care, our understanding of cancer epidemiology and investigate comparative effectiveness measures. The activities of this CAP/NPCR collaboration illustrate how structured reporting can be used for cancer surveillance, scalable to other public health case reporting, and provide a sustainable model for use across a wide reach of public health practices. It provides a model for development of structured reporting templates, electronic formats for capturing and transmitting data captured in structured reports, and use of standards for interoperability.