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Displaying Pathology Consultants' Names and Opinions in Surgical Pathology Reports

Posted Sep 07 2010 12:00am

This is a guest blog note by Dr. Alexis Carter , Director of Pathology Informatics at Emory University School of Medicine. She discusses some of the pitfalls of the AP-LIS documentation of the names of pathologists who serve as consultants on a surgical pathology case.

At Emory, we are currently in the process of upgrading our old AP-LIS to CoPathPlus .  During this upgrade, a number of issues have arisen that need to be resolved. Sometimes a new system can address new tasks, replacing previous manual/paper solutions. Sometimes the old system was able to perform tasks that the new system cannot. Sometimes neither system can deliver an acceptable solution. 

One of the problems that we are struggling with falls into this last category. Pathologists frequently show surgical pathology cases to one another within their own group.  Such cases can usually be described as one of three types: the informal (“drive-by” or "hallway") consult, the partial case consult, and the total case consult.  All of these three scenarios create challenges about how the various consulting pathologists' names are displayed in the final pathology report and even whether the consultants name are shown at all.

At most hospitals where I have practiced, either manual records, electronic records, or a combination of the two, are maintained in order to document which cases were shown to other pathologists in the group as well as the consulting pathologists' opinions. The paper record provided the advantage of allowing the consulting pathologists to affix his or her signature to the hardcopy report and also to document exactly which slides they reviewed as well as their opinions.

Such a system provided some reassurance to me as a consulting pathologist. When and if I was asked to re-review the case at a later time, I could easily recognize my handwriting, signature, and style of writing.  The disadvantage of such a system, obviously, is that retrieval of paper reports is cumbersome. This problem is compounded when the reason for searching for a paper report is some disagreement about the case or, worse, some legal action. In such a setting, the task becomes especially harrowing, particularly if the paper report in question cannot be found.

By way of contrast, AP-LISs are very efficient in terms of report retrieval. However, most of them lack the ability to provide the necessary reassurances that I, as a consulting pathologist, did indeed review the case in question and render a diagnosis, or opinion, that is stated in the report.  If there are no manual paper copies of the consult and no " 21 CFR Part 11-Compliant Electronic Signature " supplied by me, anyone could have entered my name in the report as a consulting pathologist. This is problematic if I never saw the case but also if I had been shown only a few selected slides without having been presented with all of the details about it.

Wouldn’t it be better to have an AP-LIS reporting system that enables a pathologist to document exactly which slides he/she reviewed and then affix an electronic signature to that segment of the report?  Once the case is signed out, such a system could automatically append this consulting pathologists' names to the final report, detailing which portion of the case her or she reviewed. This would avoid the need for the primary pathologist on the case to remember to add this information in the comment section or elsewhere. Moreover, the consulting pathologist would be assured that he/she had reviewed the case, either fully or partially. This assumes, of course, that the consultants' access codes into the system have not been compromised. 

Requests for consultations on a particular case could also be placed in electronic queues. If the AP-LIS allowed the generation of notes from the primary pathologist requesting an opinion from an internal or external consultant, specifics about a particularly challenging slide could be provided. Unfortunately, such a “consultation nirvana” does not seem to exist in our current, or even in future AP-LISs.

We are now entering into a era in pathology in which integration of digital imaging and exchange of healthcare data occurs across individual group practices. hospital systems, states, and even countries. We need to develop a system of accurate and secure AP-LIS-based surgical pathology consultations. One of the biggest challenges when sending digital whole-slide-images (WSIs) to consultants at another facility is not just a description about how the images were acquired and delivered but also how the returning opinions will be communicated, reported and tracked. This is important for both the requesting and receiving institutions.  Clearly, this requires coordination across a number of organizations with attention to the exchange of healthcare data. It occurs to me, however, that our first job is to work out the specific details of consultation within our own pathology groups.
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