Challenges Facing Aultman Hospital

Dr. Ravichandran notes several pain points that limited Aultman’s anatomic pathology laboratory. 

No Access to a Shared Library of Templates:

Aultman’s sole pathologists' assistant had been using the hospital-provided Dragon dictation and created his own templates. The pathologists would cover for the PA when he took his annual six-to-eight weeks of paid time off each year. Says Dr. Ravichandran: “When we covered the gross room for our PA, we were not comfortable using Dragon. First, the templates he created were saved under his own personal profile in Cerner. The Dragon templates you create there are not easily shareable. The setup there was not conducive for pathologists using voice recognition. So, when our PA was not here, we ended up doing gross work using Olympus Dictation -- an old-fashioned digital dictation station which is networked to the transcriptionists and they had to type long and elaborate gross descriptions.” 

Transcription Bottlenecks:

All of Aultman’s pathologists were using the Olympus Dictation system and the transcriptionists were typing the reports. When Dr. Ravichandran started at Aultman, there were three transcriptionists. Two of those transcriptionists only worked three days a week.

“In addition to the main campus, we cover frozen sections and a couple other facilities. We have to pick up slides from outside facilities, and during operating room coverage for frozen sections or endobronchial procedures (which require a pathologist in the operating room) the timing is not in our control and they call anytime they need us,” Dr. Ravichandran states. “We have to go cover, then come back and resume our work. It puts us behind in finishing our slides."

"Typically, our slides start to come from 8:00 AM to 1:00 PM, and the slides that come late to us are often complex cancer resection cases, which we end up reviewing and composing our reports at the very end of the day. Sometimes the transcriptionists had to stay beyond 8:00 PM, well past their regular shift, to type the reports so we could get them ready for signout the next morning. It wasn't a good situation.”

Lack of Standard Procedure:

Dr. Ravichandran noticed that all three pathologists were doing their cancer synoptic reports in three completely different ways.

One pathologist had a binder of documents containing the commonly used cancer synoptic protocols printed off the College of American Pathologists (CAP) website. Says Dr. Ravichandran: “That binder was not being frequently updated. The secretaries didn't have the time to ensure that it was updated, and we weren't getting a notice from CAP notifying us to update or make changes. It was hard for a small institution like us to know when changes are made to the template.”

Another pathologist was checking the CAP website whenever a cancer case crossed their desk. They would log on to the CAP website and pull the most current template and read it off the screen into the dictation system. This meant that they were having to go through the entire template manually, reading off every detail word-for-word, including all of the template's sentences, questions, and answers. This made the dictation files for cancer cases very long and tiring for the transcriptionists to complete.

The third pathologist had their own approach. They tried to complete the cancer cases from memory. “In their mind , this pathologist knew what the standard order of the standard questions in the CAP checklists were,” says Dr. Ravichandran. “But there are a lot of items which are now essential, and sometimes the pathologist missed those. So this led to a situation in the latter half of 2021, where approximately 10 percent of our cancer synoptic reports were asked to be corrected for errors.” 

Report Errors:

In the case of the pathologist who was recreating the CAP protocols from memory, the errors were discovered during the hospital’s cancer center certification  inspection by the American College of Surgeons.

“When the inspectors were reviewing the reports for completeness and compliance with the cancer center accreditation requirements, they found that some reports were missing two essential data elements," Dr. Ravichandran says. "We had to correct them, and it takes a lot of time to go back to each case and correct those reports.”

"These core data elements were mandatory for purposes of accreditation, and the pathologist thought it was unnecessary to put in that data element because it didn't apply to the case. But they did not realize that from the cancer center's standpoint, it was a completely essential element."

Transcription Errors:

There were transcription errors as well, both because of dictation mistakes and transcriptionist errors.

“There was no instant way to know that you got something wrong,” Dr. Ravichandran recalls. “The next day when you look at it or late in the evening when you look at it, it's not always easy to catch those mistakes.”