Objectives: To assess the overall impact of access to the electronic medical record (EMR) on anatomic pathology performance.
Methods: We reviewed the results of all use of the EMR by 1 pathologist over an 18-month period.
Results: Of the 10,107 cases (913 cytology and 9,194 surgical pathology) reviewed, the EMR (excluding anatomic pathology records) was accessed in 222 (2.2% of all cases, 6.5% of all cytology cases, and 1.8% of all surgical pathology cases). The EMR was used to evaluate a critical value in 20 (9.0%) cases and make a more specific diagnosis in 77 (34.7%) cases, a less specific diagnosis in 4 (1.8%) cases, and a systemic rather than localized diagnosis in 4 (1.8%) cases. The percentage of cases in which the physician was contacted decreased from 7.3% for the prior 18 months to 6.7%, but this change was not significant (P = .13). Twelve cases were subsequently sent for interinstitutional consultation, and no disagreements were identified.
Conclusions: The EMR was accessed in 2.2% of all surgical pathology and cytology cases and affected the diagnosis in 48% of these cases.
Keywords: Accuracy; Anatomic pathology; Consultation; Continuous quality improvement; Diagnosis; Electronic medical record; Quality assurance; Second opinion; Sensitivity; Surgical pathology.