# Implementation Approaches

Three approaches for cancer synoptic data recording are described in this section: paper-based forms, distributed electronic forms, and a centralized reporting platform. Each of these approaches has benefits and drawbacks, which are described below. In addition, the emerging Fast Healthcare Interoperability Resources (FHIR) model is an elegant hybrid of central registry reporting and electronic health system integration. Although FHIR implementations for cancer synoptic reporting are in pilot phases only, the approach is also described.

## Paper-based Approach

Structured, synoptic cancer reporting can be realized using a paper-based system. Multiple organizations release paper-based forms for cancer synoptic reporting.

Pathologists can manually record their observations using these *pro forma* templates. This approach does provide structure and enhances the completeness of data records. However, it does not directly render cancer pathology data into computable form. That can only happen with a transcription or abstraction of the paper form into an electronic system that is encoded using SNOMED CT.

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The limitations of this approach are readily apparent. Yet, in an environment where electronic health record systems are not readily available, this approach to pathology cancer reporting can be effective for completeness of reports for immediate use by clinical care teams, and these forms can be used by public health authorities to populate central cancer registries for surveillance and disease management efforts.

## Distributed Approach: Electronic Health Record and Laboratory Information System Integration

This approach requires that publishers of cancer pathology data sets render their protocols (pro forma templates) into a format that can be ingested and used by EHR and LIS software platforms. The EHR/LIS vendor software then use these electronic representations to create an electronic version of the paper form for the user to complete as part of their usual reporting workflow.

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**Benefits of this approach:**

* Structured, encoded cancer pathology reporting is fully integrated into usual pathology documentation/reporting workflows
* Centralized management and distribution of curated content
* Ability to customize workflow within institutional EHR/LIS
* Data can be incorporated into the EHR/LIS data structure for clinical decision support, analytics, and electronic reporting to public health registries

**Limitations of this approach:**

* Relies on a standard interoperability framework
* The approach relies on software vendors to implement content in accordance with the publisher's intent
* The approach relies on software vendors to incorporate encoded pathology cancer data into EHR/LIS data models
* Variation in implementation quality and capability

**Example**

In the United States, the College of American Pathologists (CAP) developed a process to render their published reporting protocols into a XML documents that electronic health records (EHR) and Laboratory Information System (LIS) vendors. This approach was unique to the US and Canada for many years. It is now expanding into other parts of the world through middleware vendors that customize cancer pathology datasets for incorporation into EHR/LIS workflows. It is the longest-standing electronic method of capturing cancer pathology reports in a computable fashion at the time of report generation.

## Centralized Approach: Central Web Portal

In this approach, pathologists interact with a centralized application rendering the specific reporting form. Upon completion of the form, the data is fully encoded and stored within the central cancer registry. A PDF or other electronic form of the report is sent back to that pathologist for incorporation into the patient's medical record.

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**Benefits of this approach:**

* Central management of cancer pathology reporting data sets
* Immediate incorporation into the registry
* Sophisticated user interface logic is easily incorporated into the user interface to optimize workflow efficiency, ensuring only the required data elements are presented for pathologist recording.
* Possible to integrate workflow with EHR/LIS as done by PALGA

**Limitations of this approach:**

* Requires "leaving" EHR/LIS to complete the report. Can be additional work for the pathologist
* Documentation/ entry of data is required in both the EHR and the central web portal
* External report may be returned only as a PDF or other non-computable form
* Computable data not available for local clinical decision support or analysis

**Example**

This approach is used in the Netherlands by PALGA and is emulated in other nations, which use a centralized web portal for cancer pathology reporting. Here, pathologists navigate to a web portal managed by national cancer registries.

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