title: Reflex test reminders in required cancer synoptic templates decrease order entry error: An analysis of mismatch repair immunohistochemical orders to screen for Lynch syndrome.
abstract: BACKGROUND
  Endometrial carcinoma (EC) is the most common extracolonic malignant neoplasm associated with Lynch syndrome (LS). LS is caused by autosomal dominant germline mutations in DNA mismatch repair (MMR) genes. Screening for LS in EC is often evaluated by loss of immunohistochemical (IHC) expression of DNA MMR enzymes MLH1, MSH2, MSH6, and PMS2 (MMR IHC). In July 2013, our clinicians asked that we screen all EC in patients ≤60 for loss of MMR IHC expression. Despite this policy, several cases were not screened or screening was delayed. We implemented an informatics-based approach to ensure that all women who met criteria would have timely screening.
  
  
  METHODS
  Reports are created in PowerPath (Sunquest Information Systems, Tucson, AZ) with custom synoptic templates. We implemented an algorithm on March 6, 2014 requiring pathologists to address MMR IHC in patients ≤60 with EC before sign out (S/O). Pathologists must answer these questions: is patient ≤60 (yes/no), if yes, follow-up questions (IHC done previously, ordered with addendum to follow, results included in report, N/A, or not ordered), if not ordered, one must explain. We analyzed cases from July 18, 2013 to August 31, 2016 preimplementation (PreImp) and postimplementation (PostImp) that met criteria. Data analysis was performed using the standard data package included with GraphPad Prism®7.00 (GraphPad Software, Inc., La Jolla, CA, USA).
  
  
  RESULTS
  There were 147 patients who met criteria (29 PreImp and 118 PostImp). IHC was ordered in a more complete and timely fashion PostImp than PreImp. PreImp, 4/29 (13.8%) cases did not get any IHC, but PostImp, only 4/118 (3.39%) were missed (P= 0.0448). Of cases with IHC ordered, 60.0% (15/25) were ordered before or at S/O PreImp versus 91.2% (104/114) PostImp (P= 0.0004). Relative to day of S/O, the mean days of order delay were longer and more variable PreImp versus PostImp (12.9 ± 40.7 vs. -0.660 ± 1.15;P= 0.0227), with the average being before S/O PostImp.
  
  
  CONCLUSIONS
  This algorithm ensures MMR IHC ordering in women ≤60 with EC and can be applied to similar scenarios. Ancillary tests for management are increasing, especially genetic and molecular-based methods. The burden of managing orders and results remains with the pathologist and relying on human intervention alone is ineffective. Ordering IHC before or at S/O prevents oversight and the additional work of retrospective ordering and reporting.
authors.affiliation: Department of Pathology, University of Washington, Seattle, WA, USA.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Kilgore
authors.affiliation: Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA.
authors.forename: Carrie A
authors.initials: CA
authors.lastname: McIlwain
authors.affiliation: Department of Pathology, University of Washington, Seattle, WA, USA.
authors.forename: Rodney A
authors.initials: RA
authors.lastname: Schmidt
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Washington, Seattle, WA, USA.
authors.forename: Barbara M
authors.initials: BM
authors.lastname: Norquist
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Washington, Seattle, WA, USA.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Swisher
authors.affiliation: Department of Pathology, University of Washington, Seattle, WA, USA.
authors.forename: Rochelle L
authors.initials: RL
authors.lastname: Garcia
authors.affiliation: Department of Pathology, University of Washington, Seattle, WA, USA.
authors.forename: Mara H
authors.initials: MH
authors.lastname: Rendi
keywords: Algorithm; Lynch syndrome; endometrial carcinoma; hard stop; mismatch repair enzymes; order entry error; synoptic templates