Amended Surgical Pathology Reports: Where Are They Going?
Amended Surgical Pathology Reports: Where Are They Going?
Objectives. Amended reports (AmRs) need to follow patients to treating physicians, to avoid erroneous management based on the original diagnosis. This study was undertaken to determine if AmRs followed the patient appropriately.
Methods. AmRs with diagnostic changes and discrepancies between ordering and treating physicians were tracked. Chart reviews, electronic medical report (EMR) reviews, and interviews were conducted to establish receipt of the AmR by the correct physician.
Results. Seven of 60 AmRs had discrepancies between the ordering and treating physicians, all with malignant diagnoses. The AmR was present in the treating physician's chart in only one case. Ordering physicians indicated that AmRs were not forwarded to treating physicians when corrected results arrived after patient referral, under the assumption that the new physician was automatically forwarded pathology updates. No harm was documented in any of our cases. In one case with a significant amendment, the correct information was entered in the patient chart based on a tumor board discussion. A review of two electronic health record systems uncovered significant shortcomings in each delivery system.
Conclusions. AmRs fail to follow the patient's chain of referrals to the correct care provider, and EMR systems lack the functionality to address this failure and alert clinical teams of amendments.
Upwards of 27 million surgical pathology reports communicate critical tissue evaluation results to treating physicians in the United States annually. In a small number of cases, these reports have errors, and a corrected (amended) report is issued at a later date. The amended report (AmR) needs to follow the patient through a potentially rapid chain of referrals to a physician actively caring for the patient, to avoid erroneous management based on the original report Figure 1. This is particularly challenging because the procedure–report generation loop has closed and an erroneous report is in circulation. We conducted this study to determine how often AmRs did not reach the correct treating physician, and the role of the electronic medical record (EMR) in addressing this issue.
(Enlarge Image)
Figure 1.
Chart showing the flow of information among the ordering physician, pathologist, and the current treating physician, in transforming a tissue specimen from a patient to an actionable surgical pathology report. IR, interventional radiologist; dotted line, optional referral.
Abstract and Introduction
Abstract
Objectives. Amended reports (AmRs) need to follow patients to treating physicians, to avoid erroneous management based on the original diagnosis. This study was undertaken to determine if AmRs followed the patient appropriately.
Methods. AmRs with diagnostic changes and discrepancies between ordering and treating physicians were tracked. Chart reviews, electronic medical report (EMR) reviews, and interviews were conducted to establish receipt of the AmR by the correct physician.
Results. Seven of 60 AmRs had discrepancies between the ordering and treating physicians, all with malignant diagnoses. The AmR was present in the treating physician's chart in only one case. Ordering physicians indicated that AmRs were not forwarded to treating physicians when corrected results arrived after patient referral, under the assumption that the new physician was automatically forwarded pathology updates. No harm was documented in any of our cases. In one case with a significant amendment, the correct information was entered in the patient chart based on a tumor board discussion. A review of two electronic health record systems uncovered significant shortcomings in each delivery system.
Conclusions. AmRs fail to follow the patient's chain of referrals to the correct care provider, and EMR systems lack the functionality to address this failure and alert clinical teams of amendments.
Introduction
Upwards of 27 million surgical pathology reports communicate critical tissue evaluation results to treating physicians in the United States annually. In a small number of cases, these reports have errors, and a corrected (amended) report is issued at a later date. The amended report (AmR) needs to follow the patient through a potentially rapid chain of referrals to a physician actively caring for the patient, to avoid erroneous management based on the original report Figure 1. This is particularly challenging because the procedure–report generation loop has closed and an erroneous report is in circulation. We conducted this study to determine how often AmRs did not reach the correct treating physician, and the role of the electronic medical record (EMR) in addressing this issue.
(Enlarge Image)
Figure 1.
Chart showing the flow of information among the ordering physician, pathologist, and the current treating physician, in transforming a tissue specimen from a patient to an actionable surgical pathology report. IR, interventional radiologist; dotted line, optional referral.
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