Berman J J, Moore G W
Department of Pathology, Baltimore Veterans' Administration Medical Center, MD 21201-1524, USA.
Mod Pathol. 1996 Sep;9(9):944-50.
Pathology departments have invested considerable energy, sometimes extending over several decades, toward coding their anatomic pathology reports. As a result of these labors, there is now a vast amount of electronically coded data from surgical pathology reports, holding a wealth of information relevant to virtually every recognized pathologic entity. The original intent of the Systematized Nomenclature of Medicine (SNOMED) was to prepare population-based disease data from pathology reports, but no such studies have emerged in the medical literature. This is due in part to the nonuniform, idiosyncratic, and incomplete manner in which most SNOMED databases are constructed. Automatic (computer-driven) coding provides uniformity and completeness of SNOMED databases and offers the possibility of customized recoding for an entire collection of reports using any nomenclature and any set of coding algorithms. In prior investigations, we described a computer program that SNOMED-codes surgical pathology reports, and we provided an analysis of a large surgical pathology SNOMED database. In this report, we describe the importance of coded surgical pathology databases for research, teaching, hospital administration, and public health, and we explain the functional differences between coded databases and free-text collections of surgical pathology data. Surgical pathology departments and vendors of laboratory information systems can ensure that surgical report files can be automatically coded or recoded with any chosen nomenclature by adhering to simple guidelines.
病理科投入了大量精力，有时长达数十年，用于对其解剖病理报告进行编码。经过这些努力，现在有大量来自外科病理报告的电子编码数据，包含了与几乎每一个公认的病理实体相关的丰富信息。医学系统命名法（SNOMED）的最初目的是从病理报告中整理基于人群的疾病数据，但医学文献中尚未出现此类研究。部分原因在于大多数SNOMED数据库的构建方式不统一、独特且不完整。自动（计算机驱动）编码可提供SNOMED数据库的一致性和完整性，并为使用任何命名法和任何编码算法的整个报告集进行定制重新编码提供了可能性。在之前的研究中，我们描述了一个对外科病理报告进行SNOMED编码的计算机程序，并对一个大型外科病理SNOMED数据库进行了分析。在本报告中，我们描述了编码外科病理数据库在研究、教学、医院管理和公共卫生方面的重要性，并解释了编码数据库与外科病理数据自由文本集之间的功能差异。外科病理科和实验室信息系统供应商可以通过遵循简单的指导方针，确保手术报告文件能够使用任何选定的命名法进行自动编码或重新编码。
