scholarly journals Utilization of 2D Barcode Technology to Create Surgical Pathology Reports

2021 ◽  
Vol 156 (Supplement_1) ◽  
pp. S116-S116
Author(s):  
Z Qu ◽  
E Qu ◽  
J Huang ◽  
M A Micale ◽  
E Li
Keyword(s):  
Speech Recognition ◽  
Data Entry ◽  
Small Sample ◽  
Data Matrix ◽  
Pathology Report ◽  
Diagnostic Data ◽  
Specimen Type ◽  
2D Barcode ◽  
On Line ◽  
Pathology Reports

Abstract Introduction/Objective After professional transcription service is eliminated, pathologists inevitably undertake the task of diagnostic data entry into pathology repot by adapting a variety of methods such as speech recognition, manual typing, and pre-texted command. Errors and inefficiency in reporting remain common problems, especially for information with unusual syntax such as genotype or nucleotide sequences. To overcome these shortcomings, we introduce here a novel application of a well-established technology as a complementary method, namely 2- dimensional (2D) barcode symbology. Methods/Case Report Commonly used diagnostic wordings of pathology reports including specimen type, surgical procedure, diagnosis, and test results are collated and organized by organ (specimen type) and by their frequency of usage/occurrence. Next, 2D data matrix barcodes are created for these diagnostic wordings using a on-line tool (www.free-barcode-generator.net/datamatrix/). The 2D barcodes along with their text are displayed on the computer screen (or printed out as a booklet). A 2D barcode scanner (Symbol LS2208, Motorola) was used to retrieve the text information from the barcodes and transfer into the pathology report. To assess the efficacy of this barcode method, we evaluated the time of data entry into reports for 117 routine cases using an on-line stopwatch and compared with those by other data entry methods. Results (if a Case Study enter NA) Unlike manual typing or speech recognition, the barcode method did not introduce typographic or phonosemantic errors since the method simply transferred pre-texted and proof-read text content to report. It was also faster than manual typing or speech recognition, and its speed was comparable to that of the pre-text method integrated in LIS but did not require human memorization of innumerable text commands to retrieve desired diagnosis wordings. Conclusion Our preliminary results demonstrated that the diagnostic data entry time was reduced from 28.5% by other methods to 22.1% by the barcode method although due to the small sample size, statistical analysis was not conclusive.

A Synoptic Reporting System for Bone Marrow Aspiration and Core Biopsy Specimens

2006 ◽  
Vol 130 (12) ◽  
pp. 1825-1829 ◽  
Author(s):  
Manjula Murari ◽  
Rakesh Pandey
Keyword(s):  
Bone Marrow ◽  
Reporting System ◽  
Data Entry ◽  
Structured Data ◽  
Pathology Report ◽  
Free Text ◽  
Electronic Systems ◽  
Report Generation ◽  
Pathology Reports ◽  
Synoptic Reporting

Abstract Context.—Advances in information technology have made electronic systems productive tools for pathology report generation. Structured data formats are recommended for better understanding of pathology reports by clinicians and for retrieval of pathology reports. Suitable formats need to be developed to include structured data elements for report generation in electronic systems. Objective.—To conform to the requirement of protocol-based reporting and to provide uniform and standardized data entry and retrieval, we developed a synoptic reporting system for generation of bone marrow cytology and histology reports for incorporation into our hospital information system. Design.—A combination of macro text, short preformatted templates of tabular data entry sheets, and canned files was developed using a text editor enabling protocol-based input. The system is flexible and has facility for appending free text entry. It also incorporates SNOMED coding and codes for teaching, research, and internal auditing. Results.—This synoptic reporting system is easy to use and adaptable. Features and advantages include pick-up text with defined choices, flexibility for appending free text, facility for data entry for protocol-based reports for research use, standardized and uniform format of reporting, comparable follow-up reports, minimized typographical and transcription errors, and saving on reporting time, thus helping shorten the turnaround time. Conclusions.—Simple structured pathology report templates are a powerful means for supporting uniformity in reporting as well as subsequent data viewing and extraction, particularly suitable to computerized reporting.

Timeliness of breast tissue pathology reports: Quality thresholds for breast centers.

2011 ◽  
Vol 29 (27_suppl) ◽  
pp. 204-204
Author(s):  
C. S. Kaufman ◽  
L. D. Shockney ◽  
J. Landercasper ◽  
B. Rabinowitz ◽  
J. B. Askew ◽  
...  
Keyword(s):  
Data Entry ◽  
Geographic Location ◽  
Threshold Level ◽  
Mean Value ◽  
Pathology Report ◽  
Surgical Biopsy ◽  
National Quality ◽  
Breast Centers ◽  
Pathology Reports ◽  
Quality Threshold

204 Background: The National Quality Measures for Breast Centers (NQMBC) was started in 2005 to provide quality metrics for breast centers. Each center enters confidential aggregate results to questions regarding the process of breast care. Each data entry can be immediately compared with all other centers. We reviewed data regarding the timeliness of pathology reports after tissue sampling to look for variation among different types of breast centers. Methods: We reviewed the following measures: 1) Time between needle/core biopsy and availability of pathology report; 2) Time between surgical biopsy and availability of pathology report; and 3) Time between initial cancer surgery and availability of pathology report. We looked for variation in results according to structural differences of breast centers. Results: There were 391 center entries reviewing over 21,000 patient encounters between 2005 and 2011. Results included percentiles at 10, 25, 50, 75, and 90 and mean value. Overall, pathology reports for needle biopsy were available much sooner (mean 1.4 days) than any surgical biopsy or excision (2.1, 2.4 days). Results were not altered according to demographic characteristics (type of center, cancer volume, financial structure, size of city and geographic location). Conclusions: The timeliness of pathology reporting of breast specimens is very consistent throughout the participating NQMBC centers, regardless of type and size of breast center. In view of the consistency of those results, a threshold level of care (10th percentile) may be identified above which all centers should be expected to perform. This minimum level of performance is called the quality threshold. Centers that do not perform above this quality threshold should be ready to explain why their performance falls below this level. Centers who surpass this quality threshold should strive for a quality goal (50th percentile). We expect that by setting both the quality threshold and the quality goal for each measurement, we will have ongoing encouragement for achievable improvement for each measure.

scholarly journals Implementing Structured Clinical Templates at a Single Tertiary Hospital: Survey Study

10.2196/13836 ◽  
2020 ◽  
Vol 8 (4) ◽  
pp. e13836
Author(s):  
Ji Eun Hwang ◽  
Byung Ook Seoung ◽  
Sang-Oh Lee ◽  
Soo-Yong Shin
Keyword(s):  
Data Extraction ◽  
Vital Signs ◽  
Data Entry ◽  
Tertiary Hospital ◽  
Survey Study ◽  
Pathology Report ◽  
Free Text ◽  
Log Data ◽  
Pathology Reports ◽  
Time Required

Background Electronic health record (EHR) systems have been widely adopted in hospitals. However, since current EHRs mainly focus on lowering the number of paper documents used, they have suffered from poor search function and reusability capabilities. To overcome these drawbacks, structured clinical templates have been proposed; however, they are not widely used owing to the inconvenience of data entry. Objective This study aims to verify the usability of structured templates by comparing data entry times. Methods A Korean tertiary hospital has implemented structured clinical templates with the modeling of clinical contents for the last 6 years. As a result, 1238 clinical content models (ie, body measurements, vital signs, and allergies) have been developed and 492 models for 13 clinical templates, including pathology reports, were applied to EHRs for clinical practice. Then, to verify the usability of the structured templates, data entry times from free-texts and four structured pathology report templates were compared using 4391 entries from structured data entry (SDE) log data and 4265 entries from free-text log data. In addition, a paper-based survey and a focus group interview were conducted with 23 participants from three different groups, including EHR developers, pathology transcriptionists, and clinical data extraction team members. Results Based on the analysis of time required for data entry, in most cases, beginner users of the structured clinical templates required at most 70.18% more time for data entry. However, as users became accustomed to the templates, they were able to enter data more quickly than via free-text entry: at least 1 minute and 23 seconds (16.8%) up to 5 minutes and 42 seconds (27.6%). Interestingly, well-designed thyroid cancer pathology reports required 14.54% less data entry time from the beginning of the SDE implementation. In the interviews and survey, we confirmed that most of the interviewees agreed on the need for structured templates. However, they were skeptical about structuring all the items included in the templates. Conclusions The increase in initial elapsed time led users to hold a negative opinion of SDE, despite its benefits. To overcome these obstacles, it is necessary to structure the clinical templates for optimum use. In addition, user experience in terms of ease of data entry must be considered as an essential aspect in the development of structured clinical templates.

scholarly journals Implementing Structured Clinical Templates at a Single Tertiary Hospital: Survey Study (Preprint)

2019 ◽  
Author(s):  
Ji Eun Hwang ◽  
Byung Ook Seoung ◽  
Sang-Oh Lee ◽  
Soo-Yong Shin
Keyword(s):  
Data Extraction ◽  
Vital Signs ◽  
Data Entry ◽  
Tertiary Hospital ◽  
Survey Study ◽  
Pathology Report ◽  
Free Text ◽  
Log Data ◽  
Pathology Reports ◽  
Time Required

BACKGROUND Electronic health record (EHR) systems have been widely adopted in hospitals. However, since current EHRs mainly focus on lowering the number of paper documents used, they have suffered from poor search function and reusability capabilities. To overcome these drawbacks, structured clinical templates have been proposed; however, they are not widely used owing to the inconvenience of data entry. OBJECTIVE This study aims to verify the usability of structured templates by comparing data entry times. METHODS A Korean tertiary hospital has implemented structured clinical templates with the modeling of clinical contents for the last 6 years. As a result, 1238 clinical content models (ie, body measurements, vital signs, and allergies) have been developed and 492 models for 13 clinical templates, including pathology reports, were applied to EHRs for clinical practice. Then, to verify the usability of the structured templates, data entry times from free-texts and four structured pathology report templates were compared using 4391 entries from structured data entry (SDE) log data and 4265 entries from free-text log data. In addition, a paper-based survey and a focus group interview were conducted with 23 participants from three different groups, including EHR developers, pathology transcriptionists, and clinical data extraction team members. RESULTS Based on the analysis of time required for data entry, in most cases, beginner users of the structured clinical templates required at most 70.18% more time for data entry. However, as users became accustomed to the templates, they were able to enter data more quickly than via free-text entry: at least 1 minute and 23 seconds (16.8%) up to 5 minutes and 42 seconds (27.6%). Interestingly, well-designed thyroid cancer pathology reports required 14.54% less data entry time from the beginning of the SDE implementation. In the interviews and survey, we confirmed that most of the interviewees agreed on the need for structured templates. However, they were skeptical about structuring all the items included in the templates. CONCLUSIONS The increase in initial elapsed time led users to hold a negative opinion of SDE, despite its benefits. To overcome these obstacles, it is necessary to structure the clinical templates for optimum use. In addition, user experience in terms of ease of data entry must be considered as an essential aspect in the development of structured clinical templates.

A Retrieval System for a Library of Pathology Reports, Slides and Kodachromes

1972 ◽  
Vol 11 (03) ◽  
pp. 152-162 ◽  
Author(s):  
P. GAYNON ◽  
R. L. WONG
Keyword(s):  
Medical Records ◽  
Operative Procedure ◽  
Clinical Findings ◽  
Free Text ◽  
X Ray ◽  
Inverted File ◽  
Natural Language Parsing ◽  
On Line ◽  
Pathology Reports ◽  
Frequency Counts

With the objective of providing easier access to pathology specimens, slides and kodachromes with linkage to x-ray and the remainder of the patient’s medical records, an automated natural language parsing routine, based on dictionary look-up, was written for Surgical Pathology document-pairs, each consisting of a Request for Examination (authored by clinicians) and its corresponding report (authored by pathologists). These documents were input to the system in free-text English without manual editing or coding.Two types of indices were prepared. The first was an »inverted« file, available for on-line retrieval, for display of the content of the document-pairs, frequency counts of cases or listing of cases in table format. Retrievable items are patient’s and specimen’s identification data, date of operation, name of clinician and pathologist, etc. The English content of the operative procedure, clinical findings and pathologic diagnoses can be retrieved through logical combination of key words. The second type of index was a catalog. Three catalog files — »operation«, »clinical«, and »pathology« — were prepared by alphabetization of lines formed by the rotation of phrases, headed by keywords. These keywords were automatically selected and standardized by the parsing routine and the phrases were extracted from each sentence of each input document. Over 2,500 document-pairs have been entered and are currently being utilized for purpose of medical education.

ILIS--An integrated laboratory information system. I. Biochemistry and hematology.

1982 ◽  
Vol 28 (2) ◽  
pp. 271-276 ◽  
Author(s):  
S U Deshpande
Keyword(s):  
Medical Records ◽  
Data Entry ◽  
Large Data ◽  
Work Load ◽  
Processing Unit ◽  
Patient Identification ◽  
Central Processing ◽  
Cathode Ray Tubes ◽  
Clinical Laboratories ◽  
On Line

Abstract IBM System 34 (central processing unit, 128 kilobytes; fixed disks, 128.4 megabytes) with seven cathode-ray tubes has been used by our clinical laboratories for the last 30 months. All data-entry programs are in a conversational mode, for on-line corrections of possible errors in patient identification and results. Daily reports are removed from the medical records after temporary and permanent cumulative weekly reports are received, which keep a three-month track of the results. The main advantages of the system are: (a) the increasing laboratory work load can be handled with the same staff; (b) the volume of the medical record files on the patients is decreased; (c) an easily retrievable large data base of results is formed for research purposes; (d) faster billing; and (e) the computer system is run without engaging any additional staff.

Selected Aspects of Ocular Toxicity Studies With a Focus on High-Quality Pathology Reports: A Pathology/Toxicology Consultant’s Perspective

2020 ◽  
pp. 019262332094671
Author(s):  
Brian Short
Keyword(s):  
Species Selection ◽  
Toxicity Study ◽  
Pathology Report ◽  
Ocular Toxicity ◽  
High Quality ◽  
Contract Research Organization ◽  
Toxicity Studies ◽  
Fit For Purpose ◽  
Pathology Reports ◽  
Study Designs

Ocular toxicity studies are the bedrock of nonclinical ocular drug and drug–device development, and there has been an evolution in experience, technologies, and challenges to address that ensures safe clinical trials and marketing authorization. The expectations of a well-designed ocular toxicity study and the generation of a coherent, integrative ocular toxicology report and subreports are high, and this article provides a pathology/toxicology consultant’s perspective on achieving that goal. The first objective is to cover selected aspects of study designs for ocular toxicity studies including considerations for contract research organization selection, minipig species selection, unilateral versus bilateral dosing, and in-life parameters based on fit-for-purpose study objectives. The main objective is a focus on a high-quality ocular pathology report that includes ocular histology procedures to meet regulatory expectations and a report narrative and tables that correlate microscopic findings with key ophthalmic findings and presents a clear interpretation of test article-, vehicle-, and procedure-related ocular and extraocular findings with identification of adversity and a pathology peer review. The last objective covers considerations for a high-quality ophthalmology report, which in concert with a high-quality pathology report, will pave the way for a best quality toxicology report for an ocular toxicity study.

The Design and Evaluation of a Speech Interface for Generation of Air Tasking Orders

2000 ◽  
Vol 44 (22) ◽  
pp. 750-753 ◽  
Author(s):  
David T. Williamson ◽  
Timothy P. Barry
Keyword(s):  
Speech Recognition ◽  
Planning Process ◽  
Data Entry ◽  
Command And Control ◽  
Error Rates ◽  
Subject Matter Experts ◽  
Speech Interface ◽  
System Selection ◽  
And Control ◽  
Operations Center

This paper discusses the design, implementation, and evaluation of a prototype speech recognition interface to the Theater Air Planning (TAP) module of Theater Battle Management Core Systems (TBMCS). This effort was in support of a Kenney Battlelab Initiative proposal submitted to the Command and Control Battlelab at Hurlburt Field, FL to assess the operational benefits of speech recognition for data entry applications in a Joint Air Operations Center environment. Several factors contributing to the design of the “TAPTalk” speech interface included interviews with subject matter experts, speech system selection, grammar development, and integration into TAP, which required only minor modification of existing software. Results from the two week operational assessment with sixteen subjects from the Command and Control Training and Innovation Group, numbered Air Forces, Navy, and Marine Corp indicated that the Theater Air Planning process could be accomplished significantly faster with no increase in error rates. Subjectively, the sixteen planners unanimously agreed that the TAPTalk speech interface was a valuable addition to TAP and would recommend its inclusion in a future upgrade. Recommendations for further improving the TAPTalk system are discussed.

Improving the Quality of Surgical Pathology Reports for Breast Cancer: A Centralized Audit With Feedback

2008 ◽  
Vol 132 (9) ◽  
pp. 1428-1431
Author(s):  
Ronald Onerheim ◽  
Pierre Racette ◽  
André Jacques ◽  
Robert Gagnon
Keyword(s):  
Breast Cancer ◽  
Resection Margin ◽  
Lymphatic Invasion ◽  
Surgical Pathology ◽  
Breast Cancer Surgery ◽  
Pathology Report ◽  
Good Communication ◽  
Quality Of Reports ◽  
Pathology Reports

Abstract Context.—Good communication of pathologic characteristics of a malignancy is crucial to therapy choices and accurate prognostication. The information must be easily retrieved from a surgical pathology report. Objectives.—To evaluate, first in 1999, the quality of surgical pathology reports for segmental breast resections for cancer in Quebec hospitals. Subsequently, to reevaluate, in 2003, the same indicators to determine if the first surveillance, with feedback, was associated with an improvement in the quality of the reports. Design.—All Quebec hospitals performing the preset number of 20 or more segmental breast resections for cancer in 1999 and 2003 participated. A committee of pathologists, after review of the literature, chose 7 diagnostic elements deemed vital to a surgical pathology report for conservative breast cancer surgery. Medical archivists in each institution were instructed on how to retrieve the data. The main outcome measure was the presence or absence of the diagnostic information clearly presented on the surgical pathology report. Results.—Fifty-one hospitals participated in 1999 and 50 in 2003. Overall, conformity improved from 85.0% in 1999 for the first evaluation to 92.5% in 2003 for the second evaluation (P < .001). Six of the 7 indicators showed an improvement in the level of conformity between the first and second evaluations. Conformity was weakest for recording the distance between the tumor and the resection margin (68.2%) and vascular/lymphatic invasion (61.4%) in 1999. Conclusions.—Surveillance of quality of surgical pathology reports, with feedback, is significantly associated with an improvement in the quality of reports.

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