Integrated pathology reporting, indexing, and retrieval system using natural language diagnoses.

Pathology computer systems are making increasing use of natural language diagnoses. The Johns Hopkins Medical Institutions integrated pathology reporting system, a commercial product with extensive, locally added enhancements, covers all information management functions within autopsy and surgical pathology divisions and has on-line linkages to clinical laboratory reports and the medical library's Mini-MEDLINE system. All diagnoses are written in natural language, using a word processor and spelling checker. A security system with personal passwords and different levels of access for different staff members allows reports to be signed out with an electronic signature. The system produces financial reports, overdue case reports, and Boolean searches of the database. Our experience with 128,790 consecutively entered pathology reports suggests that the greater precision of natural language diagnoses makes them the most suitable vehicle for follow-up, retrieval, and systems development functions in pathology.