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Synoptic Reporting for Surgical Oncology Procedures Implemented at UHN

The Canadian Partnership Against Caner (CPAC) is leading an important initiative to develop and implement synoptic reporting for cancer procedures across Canada. Synoptic reporting involves collecting and displaying data from a patient exam in a uniform way, where important factors are laid out in a list of options rather than described by a physician’s narrative. Consistent standards ensure that important clinical features from the procedure are captured in the report correctly and completely, and also make it easier for researchers to use anonymous data to improve evidence-based medicine.

UHN’s Dr. Barry Rosen led the Ontario implementation with Techna Project Manager Erika Rodrigues, and the team recently reached an important milestone. Templates for breast, endometrial, and prostate cancer procedures—as well as a surgical oncology discharge summary—have been developed and implemented at UHN, and will be rolled out for use nationally. The templates were developed by an expert panel of users, with representation from across Canada. As of April 2014, 24 surgeons have used the breast, endometrial and prostate cancer procedure templates to document a total of 236 procedure notes. The surgical oncology discharge summary template is being evaluated with the Head & Neck group at UHN and will soon be expanded to other areas of the hospital.

Each template is developed in a technology-agnostic way so that they can be implemented seamlessly into any hospital’s electronic medical record. At UHN, the templates have been implemented on the eNotes platform, developed by Techna’s Health Informatics Research team.

The UHN team will continue to work with CPAC and Canada Health Infoway to develop synoptic reporting tools for other cancer procedures and sites, and help other provincial teams work towards a national implementation.

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Canadian Partnership Against Cancer and provincial implementation teams