Improving Discrete Data Capture in Synoptic Reports With Optional Free-Text Modifiers.

Abstract

Upfront, discrete data capture in synoptic reporting fails when pathologists choose a response not associated with discrete data. We sought to determine the factors associated with this event. The results of all "Other" entries in four common tumor sites in synoptic reports were reviewed. "Other" entries occurred in 329 of 13,421 questions (2.5%). In 306 of these 329 questions (93.0%), the pathologist appeared to choose this response because they wished to add additional information to an already existing response that was associated with discrete data capture. As a result, the addition of a free-text modifiers to existing responses would allow pathologist to add this additional information while still selecting a response associated with discrete data capture, significantly improving the total discrete data capture (13,092 of 13,421 questions [97.5%] v 13,398 of 13,421 questions [99.8%]; P < .001). The addition of free-text modifiers to structured responses in synoptic reports could significantly improve the discrete data capture rate.