LETTER TO EDITOR
Year : 2009 | Volume
: 52 | Issue : 3 | Page : 450--451
Structuring data in anatomic pathology reports
Joy J Mammen, Mark J Tuthill
Division of Pathology Informatics, Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit Michigan, USA
Joy J Mammen
Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan- 482 02
|How to cite this article:|
Mammen JJ, Tuthill MJ. Structuring data in anatomic pathology reports.Indian J Pathol Microbiol 2009;52:450-451
|How to cite this URL:|
Mammen JJ, Tuthill MJ. Structuring data in anatomic pathology reports. Indian J Pathol Microbiol [serial online] 2009 [cited 2021 Jun 12 ];52:450-451
Available from: https://www.ijpmonline.org/text.asp?2009/52/3/450/55030
The anatomic pathology report has traditionally been considered the gold standard in diagnostic medicine upon which further management of the patient is based. Besides demographic and identification details, the traditional pathology report includes a brief description of the gross specimen, the summary of sections studied, detailed microscopic description and the final diagnosis. Where merited, a diagnostic comment would provide additional information or important findings. Historically, the report emphasized tumor type and nodal involvement. With newer diagnostic modalities becoming available and treatment also being affected by several other morphologic features, expectations of users have also changed. 
The management of cancer now calls upon the coordinated efforts of a team comprising the physician, surgeon, pathologist, radiologist, oncologist, besides others. The pathology report is transforming into more than a one-way communication from the pathologist to the physician. It has become a data-rich entity at the core of the multidisciplinary management of the patient as well as research. Failure to address or erroneously overlooking key entities while reporting cancer specimens, lead to delay in the care of patients and increased expenditure. Besides direct healthcare delivery being affected, genomics, cancer bio-informatics, tumor registries and bio-specimen repositories demand discrete high-quality data which is utilized by medical, diagnostic and pharmaceutical researchers. The availability of such data can also impact informed policymaking and allocation of funding for healthcare interventions. Further, with the changing financial scene in the country and the increasing presence of third party payers, the demand for objective quality parameters will soon be upon us.
In countries such as the United States of America, pathology reports have changed form and structure over the last two to three decades. In 1992, the Association of Directors of Anatomic and Surgical Pathology (ADASP) provided consensus lists of elements that need to be addressed with regard to cancer specimens.  The College of American Pathologists (CAP) and the American Joint Committee for Cancer Staging (AJCC) have also endorsed the effort to create standardized tumor checklists for use in anatomic pathology reports. The checklists are populated into the report by the pathologist at the bench and therefore produce accurate, complete and reliable data. Quality assurance surveys by the CAP have demonstrated that usage of these lists prevent missing vital information in cancer reports.  Traditionally, these checklists have been included in free text format. Recently, providers of laboratory software have become cognizant of the value of structured data in the reports and now there are several applications available to incorporate the structured data into cancer reports.  This facilitates data management, retrieval and communication between systems while maintaining security.
In India, although computerization is changing the practice of laboratory medicine, its influence in the anatomic pathology domain has largely been to provide electronic word processing and storage of reports. A few advanced centers have laboratory management systems.  Data retrieval for research, statistics or regulatory purposes still often relies on paper reports or using natural language searches or text-based searches of stored reports. This can lead to loss of data due to inherent flaws in free text-based data capture and natural language search strategies. Besides, transcribing, normalizing and cleaning the data is also very labor-intensive.
In view of these factors, it is now time for our pathologists to consider providing such standardized, structured data in their reports to provide best in class service to our patients.
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