CAP Electronic Cancer Checklists
(CAP eCC) Overview
An International Implementation of SNOMED CT®
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Outline
¾ Structured Reporting
¾ The CAP Cancer checklists
¾ Moving from paper form to application
¾ XML & the Cancer Checklists
¾ Demo of the example XHTML implementation
¾ Adoption
¾ Putting collected Pathology information to use
Structured Reporting
A systematic process for the creation and management of
clinical documentation
Standardized content
Consistent placement/sequence of information
Processible content
All clinically significant information is semantically encoded
Clinical decision/diagnostic support systems (CDSS)
System interoperability
Supports a robust electronic analysis process
Narrative Æ Structured Reports
Traditional Narrative Report
Stored, managed and utilized as a document
Synoptic Report
A summary (synopsis) of the findings included in the narrative
Generally accepted & standardized content
Synoptic/Summary Section augments a traditional Narrative Report
Structured Report
Expands the concept of the synoptic report
All clinically important information is coded
Limited narrative, only where needed for clarification
Narrative information augments a Structured Report
Some Functional Aspects of Structured Reports
Collection (templates or checklists)
CAP Cancer Checklists
Transport (interoperability)
HL7 2.X
Clinical Document Architecture (HL7)
Emerging Anatomical Pathology sub-standard
Continuity of Care Record (ASTM Æ HL7)
Semantic Web
Data Management
OLTP (transaction processing)
OLAP (analytical processing)
Semantic Web
Presentation
Synoptic/Summary Section of Pathology/Clinical Reports
Analysis
Clinical Decision Support Systems
Public Health
Research
CAP Cancer Checklists
What are they?
Guidelines to aid the pathologist in collecting the
essential data elements needed in the pathology report
for each tissue/procedure type
Created in printable format by CAP Cancer Committee
The CAP eCC is the electronic fo