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Standardized Structured Reporting (SSR) in Pathology

Welcome to part one of Standardized Structured Reporting (SSR) in Pathology written by guest blogger Dr. Snehal Sonawane. What is SSR and why does it matter to you? You are in luck because part one dives into just that! Dr. Sonawane shares her knowledge and perspective on SSR and what it means in today’s era of precision medicine.

The Pathologist Behind the Pen

Snehal Sonawane, MBBS, MD, FASCP, is a staff pathologist at South Bend Medical Foundation, in South Bend, IN, and serves as a Laboratory director for three laboratories in Indiana. After graduation from medical school, Dr. Sonawane undertook a post-graduate training program in Pathology and Laboratory Medicine and received a Diplomate from the National Board in Pathology from the Government Medical College in India. On completion, she went on to work as research scholar at the Translational Neurobiology Laboratory, University of Illinois at Chicago, College of Medicine. Subsequently, she completed Anatomic and Clinical pathology residency training at the University of Illinois College of Medicine in Chicago followed by a fellowship in Surgical/GI pathology at Loyola University Medical Center, near Chicago. She is the recipient of a Scholarly Activity award for her dedication to research during residency training. Excitingly, she is an American Society for Clinical Pathology (ASCP) 40 Under Forty Honoree.

"Pathology is the study of disease. It is the bridge between science and medicine,” (1). Pathology is the medical discipline that provides diagnostic information to patients and clinicians. It impacts nearly all aspects of patient care, from diagnosing cancer to managing chronic diseases through accurate laboratory testing (2). The pathologist utilizes gross, microscopic examination skills and ancillary testing to aid in the diagnosis and patient management and thus plays a pivotal role in laboratory diagnosis, prognosis, and management of the diseases. The pathology report generated by the pathologist is usually considered a definitive diagnosis and becomes a part of patients' medical records.

SSR Explained

An unstructured report is a narrative form of reporting system without any subsections or headers; in contrast to the structured, the report has various levels of structures depending on subsections, a granularity of the reporting, machine readability, and ease of interoperability. A structured report document is a clinical report whose content is structured at one or more levels of detail.

Level 1: It is the simplest form of reporting format in which human beings may identify a within a free text or narrative report, sections but not readable by computers. This format allows for free text to facilitate the transfer of unstructured reports.

Level 2: The semi-structured report and sometimes also called itemized reporting. It consists of textual information structured in sections identified with "Observation identifiers."

Level 3: The structured report consists of structured observations usually based on templates and uses a standardized language. Template identifiers and version identify the templates. It contains information such as organ involvement, body system, tumor size, location, histological characteristics, information regarding the stage and grade of the tumor, etc. This level of structured reporting facilitates the retrieval of information and is accompanied by standard codes and allows machine readability (3). Ellis and Srigley have divided the structured data into six levels as (4). Level 1: Narrative report (no defined content), Level 2: Narrative report with standardized content (e.g., by using a checklist for dictation), Level 3: Synoptic report – adds a specific format, but not necessarily any underlying software implementation, Level 4: Synoptic report with electronic reporting tools, Level 5: Standardized structured report with underlying database structure, Level 6: Standardized structured report with binding terminology to facilitate data exchange.

Why SSR?

In today's era of precision medicine, patients records are typically stored, transmitted, and used as a free text document in various electronic health record systems and called as reports or notes. But as we dive deep into the ocean of information, data, bioinformatics, and precision medicine, there is an unmet need for complex data management, aggregation, and processing tasks. To achieve these goals, unstructured reports in the form of free text are a poor starting point. It precludes the ability to automate processes for data sharing and its use for clinical and research purposes, for example, clinical decision-making tools, rapid templating, quality management, and reducing error. The field of pathology is no exception to the current trend and need for collection and sharing of the data in healthcare. Due to the current shift in reimbursement models to value-based methods, pathology laboratories move towards standardization in reporting systems. For data-driven applications, the data resulting from individual test results, diagnostic reports must be represented in a discrete and granular format that is computer-readable and can be used for effective data sharing and dissemination for clinical and non-clinical use. It can be achieved by structured/ synoptic or templated reporting, also called standardized structured reporting.

Different laboratories globally in various studies have demonstrated that standardized data collection improves patient care and allows to provide feedback on quality to healthcare. The standardized data can be utilized to develop and monitor the performance indicators that can add value by assisting and managing public health. SSR also facilitates data mapping, data mining, patient safety and allows easy data sharing. SSR in radiology has already shown to have various benefits such as reduced error, more completeness of the reports, increase in interobserver and interobserver agreement, and increase in the quality of reports. It also has been shown that it promotes evidence-based medicine by integrating clinical and radiologic information.

Current efforts of SSR in Pathology

In the 1970's it was first recognized that there is a need for best management practice guidelines for pathology reporting in anatomic pathology. During those times, pathology reports were handwritten, often narrative, and had no structure. This kind of reporting system resulted in underreporting or missing critical elements. To provide better patient care, the American College of Radiology and College of American Pathologists (CAP) came together to tackle this issue. Later in 1980's CAP, a cancer committee was formed that conducted various studies to establish standardized guidelines. This work ultimately led to the publication of the first set of standardized protocols for reporting cancer. Later, CAP decided that reporting of the CAP cancer protocols is required for the laboratory accreditation (5). CAP has followed a detailed roadmap for the development of the CAP protocols checklist from level 1 (free text, narrative style report) to level 3 (structured reports) and finally moving towards level 6 (structured reports which follow data exchange standards). The CAP cancer protocols are currently available in implementable computer formats that can be directly used in EHR, LIS, or middleware.

College of American Pathologists (CAP), the Royal College of Pathology (United Kingdom), the Royal College of Pathology Australasia, the European Task Force for Structured Reporting, the American Society of Clinical Pathologists, the Canadian Association of Pathologists, the Italian Society of Pathological Anatomy and Cytology (SIAPEC) and French Society of Pathology (SFP) have come together to establish an International Collaboration on Cancer Reporting (ICCR) (6). It aims to develop cancer datasets that can be used across various countries and reduce the global burden of cancer checklist development, publishing, and its maintenance. ICCR's goal is to support the countries with these data sets that are unable to make their own. This effort will have several benefits, including developing a single international standard that is well defined, evidence-based, and comparable. It will also reduce the reduplication of the data sets and improve interoperability will help to advance international benchmarking in cancer management.

In part two Dr. Sonawane talks pros and cons and barriers and facilitators of SSR and touches upon implementation considerations moving forward. Is there a topic you are particularly knowledgeable about? We are looking for experts in all specialties to be guest bloggers. What will you write about? If it matters to you as a pathologist, then it matters to us and we want to share it with the larger pathology and medical community through our blog. Just email Kristin at and let’s chat.

Built on the vision of better patient outcomes, Instapath was founded in 2017 by engineers and scientists to enable patients to immediately know their cancer diagnosis. Our team made it our mission to develop fast and easy digital pathology technology so diagnosis can be made in minutes instead of days. To learn more about Instapath and our technology, visit www.instapathbio.comor contact us at





4. Ellis DW, Srigley J. Does standardized structured reporting contribute to quality in diagnostic pathology? The importance of evidence-based datasets. Virchows Arch. 2016 Jan;468(1):51–9.

5. Vanda F. Torous, Ross W. Simpson, Jyoti P. Balani, Alexander S. Baras, Michael A. Berman, George G. Birdsong, Giovanna A. Giannico, Gladwell P. Paner, Jason R. Pettus, Zack Sessions, S. Joseph Sirintrapun, John R. Srigley, and Samantha Spencer, College of American Pathologists Cancer Protocols: From Optimizing Cancer Patient Care to Facilitating Interoperable Reporting and Downstream Data Use; JCO Clinical Cancer Informatics 2021:5, 47-55


7. Lankshear S, Srigley J, McGowan T, Yurcan M, Sawka C. Standardized synoptic cancer pathology reports - so what and who cares? A population-based satisfaction survey of 970 pathologists, surgeons, and oncologists. Arch Pathol Lab Med. 2013 Nov;137(11):1599–602.

8. Torous VF, Simpson RW, Balani JP, Baras AS, Berman MA, Birdsong GG, Giannico GA, Paner GP, Pettus JR, Sessions Z, Sirintrapun SJ, Srigley JR, Spencer S. College of American Pathologists Cancer Protocols: From Optimizing Cancer Patient Care to Facilitating Interoperable Reporting and Downstream Data Use. JCO Clin Cancer Inform. 2021 Jan;5:47-55. DOI: 10.1200/CCI.20.00104. PMID: 33439728.

9. Swillens JEM, Sluijter CE, Overbeek LIH, Nagtegaal ID, Hermens RPMG. Identification of barriers and facilitators in nationwide implementation of standardized structured reporting in pathology: a mixed-method study. Virchows Arch. 2019 Nov;475(5):551-561. DOI: 10.1007/s00428-019-02609-6.

10. Hewer E. The Oncologist's Guide to Synoptic Reporting: A Primer. Oncology. 2020;98(6):396-402. DOI: 10.1159/000500884. Epub 2019 Jun 7. PMID: 3117726

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