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

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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

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Synoptic Pathology Reporting

Completeness Rate 2008 to 2014

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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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