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Good Quality Pathology
David Driman MBChB FRCPC
CCO Regional Pathology Lead, LHIN 2
South West Surgical Oncology Quality Symposium May 2014
and its Impact on Surgical Oncology
What CCO’s Pathology
Program Does
Outline
1. synoptic reporting
2. pathology turn-around-times
3. guideline development
4. tissue pathways
5. biomarker implementation and funding
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• synoptic reporting
• pathology turn-around-times
• guideline development
• tissue pathways
• biomarker implementation and funding
Early 2000s - CCO’s Goal: Electronic pathology reporting in synoptic format
13.5 million people
420 pathologists
116 acute care hospitals
100,000 + cancer
pathology reports
12 lab vendors / software packages
1 central agency
CCO
Milestones in Checklist Reporting
2004-2007
• transition: narrative synoptic-like reporting
• engagement strategy: roadshows, manual chart audits and feedback
• hospital working group established
2008-2010
•engage hospitals to implement synoptic reporting e-Tools
•CCO modified CAP eCC checklist solution based on 2005 checklist standard
• implementation of synoptic reporting e-Tools for 5 common cancer resection reports
2010-present
•expanded synoptic reporting to 63 mandated disease sites
•update pathology reporting standards to align with :
•2010 CAP content standard and TNM7
•Update to HL7 2.5.1
•NAACCR and Canada Health Infoway (CHI) data messaging standards
5
Pathology drives quality and performance indicators; enhanced data and information required
An 8-year initiative engaging physicians, administrators, IT, vendors and provincial, national, and international partners
Ontario: 1st jurisdiction anywhere to structure and standardize pathology reporting in eHRs across virtually all hospitals
Province-wide transformation to standardize cancer
pathology reports based on common standards achieved
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Cancer Pathology Reporting Level
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Narrative
No CAP content
Narrative
CAP content
Level 2+ synoptic-like structured
format
Level 3+ electronic
reporting tools
using drop down menus
Level 4+ standardized
reporting
language
Level 5+ common data and messaging
standards with C-
Keys, SNOMED CT or others
Data Format Single text field Discrete data fields
Abstraction of quality indicators
Manual Semi-automated Automated
%age Ontario
Hospitals
2004-5 5% 40% 50% 5% 0% 0%
2006-7 0% 5% 70% 25% 0% 0%
2008-9 0% 0% 65% 17% 18% 0%
2009-10 0% 0% 2% 20% 78% 0%
2011-14 0% 0% 3% 0% 0% >90%
Data Source: CCO Pathology Information Management System (PIMS) and ePath All hospital s included 119 acute care hospitals that provide cancer treatment in Ontario, Canada
Synoptic Pathology Reporting Rate
2008 – 2014
7
Synoptic Pathology Reporting
Completeness Rate 2008 to 2014
8
No other jurisdiction of this size anywhere in the world can
demonstrate this quality of completeness of cancer pathology reporting.
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Checklist Reporting Vendors and Hospitals
Report Completeness per Vendor
Not just this:
• discrete data fields electronic data mining
• automatic calculation of key indicators reports back to Pathologist, Surgeon Leads
• regular reporting on completeness of reports = key enabler to achieve high standard of completeness and fosters culture of quality improvement
• physician-level reporting
But this:
Prostatectomy Margin Rates
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Provincial target is set at 25%
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Prostatectomy Margin Rates
Colorectal Cancer ≥12 lymph nodes sampled
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Colorectal Cancer ≥12 lymph nodes sampled
• synoptic reporting
• pathology turn-around-time
• guideline development
• tissue pathways
• biomarker implementation and funding
Pathology Turn-Around-Time
• pathological assessment of cancer specimens = critical component of patient journey
• first phase: percentage of final CRC resection reports received by CCO within 14
calendar days from date of surgery (target = 90%)
• as of April 1, 2014: measured for all cancer sites (target = 85%)
• identify resource gaps use as a critical driver to bridge resource gaps
(as in other programs, such as surgery, radiation and systemic therapy)
• hospitals expected to explain reasons for variance >2% close performance
gaps – with the support of the region and CCO
2013/2014 Quarter 4 – Turnaround Time
Colorectal Cancer
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2013/2014 Quarter 4 – Turnaround Time
All Disease Sites
2013/2014 Quarter 4 – Turnaround Time
Breast Cancer
• synoptic reporting
• pathology turn-around-times
• guideline development
• tissue pathways
• biomarker implementation and funding
Guideline Development 23
Secondary Review Guideline to assess the value of secondary pathology review of samples across cancer sites
Bladder Cancer Guideline to optimize of the pathological assessment of patients with muscle-invasive bladder
cancer
Prior Guidelines • Optimization of Surgical and Pathological Quality Performance in Radical Surgery for Colon and Rectal Cancer: Margins
and Lymph Nodes (April 2008) • Guideline for Optimization of Surgical and Pathological Quality Performance in Radical Prostatectomy in Prostate
Cancer Management (September 2008) • Guideline on Hormone Receptor Testing in Breast Cancer (April 2011)
• synoptic reporting
• pathology turn-around-times
• guideline development
• tissue pathways
• biomarker implementation and funding
Majority of patients
diagnosed in late stages of
disease
Increasing number of target
therapies available for treatment requiring
molecular testing
Ensure sufficient tissue is resected
to support diagnosis and
ancillary testing
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Lung Cancer Tissue Pathway
Goal
optimize handling of lung cancer specimens – to
support diagnosis, molecular testing and treatment planning for
patients
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Joint project between the Pathology and Laboratory Medicine Committee and the Molecular Oncology Advisory Committee
Surgery
Pathology & Lab
Medicine
Medical Oncology
• synoptic reporting
• pathology turn-around-times
• guideline development
• tissue pathways
• biomarker implementation and
funding
Biomarkers in Cancer
• CCO currently funds and oversees the following molecular tests on behalf of the Ministry of Health and Long-Term Care
• Breast - HER2
• Gastric - HER2
• Colorectal cancer - KRAS
• Melanoma - BRAF
• NSCLC - ALK
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• decreased implementation time
• streamlined process for implementing and funding tests
• development of a robust QA/test exchange process to monitor and ensure quality
In Summary
1. 8-year change to synoptic reporting with >90% completeness and use of indicators to enhance quality
2. monitoring of pathology turn-around-time with continued improvements
3. guideline development
4. tissue pathways e.g. lung cancer
5. processes for biomarker implementation and funding
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