Prospects of Snomed CT to support workflow in surgical pathology
Surgical pathology is the art to extract information from tissue specimens taken from patients and to present it as reports to guide clinical management and therapy. Surgical pathology workflow involves steps of macroscopic and microscopic analyses supplemented by ancillary immunohistochemical and molecular studies obtaining data on the protein and genetic level, respectively. These steps build on clinical information provided with the specimen (order entry) and on one another.
Synoptic reports have been implemented especially for tumour specimens (by ICCR, CAP and RCPath) to harmonize and structure the information provided. Binding their terminology to Snomed CT greatly supports statistical analyses and cancer registries in their work on a population level.
Currently, specimens and diagnostic information are processed by laboratory technicians and pathologists without substantial professional support by laboratory information systems on the way to diagnosis and report. Data often need to b copied.
Applying Snomed CT in order entry and primary documentation allow to build subsequent steps based on evidence and access decision support directly.
Examples will be discussed how to build abstract rules to support the laboratory workup and the selection of ancillary studies and apply them if the use of Snomed CT is extended from the synoptic report to previous steps of the workflow.
To support workflow, the computation of attribute relationships and postcoordination may play a decisive role.