Cimic Adela, Mironova Maria, Karakash Scarlett, Sirintrapun Sahussapont Joseph
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA.
Department of Medicine, Capital Health System, Trenton, NJ, USA.
J Pathol Inform. 2020 Aug 21;11:25. doi: 10.4103/jpi.jpi_24_20. eCollection 2020.
Accurate pathologic assessment in placental pathology is mostly dependent on a complete clinical history provided by a clinical team. However, often, the necessary clinical information is lacking, and electronic order sets (EOSs), if implemented correctly, create an opportunity for entering consistent and accurate clinical data. In this viewpoint piece, we describe a framework for synoptic EOS in placental pathology. We outline the necessary data and create optional clinical data that get entered as a dropdown menu of free text. While EOSs are the best way to approach and diagnose placenta and other nonneoplastic pathologic specimens, the barriers for implementation include paper requisitions and a cultural mindset resistance. The aspiration for our synoptic EOS is to become an effective tool for communication between proceduralists and pathologists for proper diagnosis of placental specimens. Through our EOS, the appropriate and complete clinical context is conveyed from the clinical teams to the pathologist. The pathologist can easily and rapidly extract the necessary information to render an accurate and precise diagnosis. The captured data likewise become a valuable research resource.
胎盘病理学中的准确病理评估大多依赖于临床团队提供的完整临床病史。然而，通常缺乏必要的临床信息，而电子医嘱集（EOSs）如果实施得当，可为输入一致且准确的临床数据创造机会。在这篇观点文章中，我们描述了胎盘病理学中概要性EOS的框架。我们概述了必要的数据并创建了可选临床数据，这些数据以自由文本下拉菜单的形式输入。虽然EOSs是处理和诊断胎盘及其他非肿瘤性病理标本的最佳方式，但实施的障碍包括纸质申请单和文化观念上的抵触。我们概要性EOS的目标是成为临床医生和病理学家之间进行沟通的有效工具，以正确诊断胎盘标本。通过我们的EOS，适当且完整的临床背景从临床团队传递给病理学家。病理学家可以轻松快速地提取必要信息以做出准确精确的诊断。所采集的数据同样成为宝贵的研究资源。
