An evaluation of automatic coding of surgical pathology reports

Abstract

Many histopathologists find that a system of coding and indexing the salient details of their reports provides a useful method for reviewing past material. The SNOP (College of American Pathologists, 1965) is a comprehensive and sophisticated system which can be used for reviewing past material, for teaching and for research. It provides separate sets of 4 digit codes to describe 4 aspects of the specimen, namely Topography, Morphology, Etiology, and Function (T, M, E, F). These codes can be used as the basis of an indexing system for copies of reports, slides, photographs, and museum specimens, both for card files and for computer based systems. Moreover the rapidity of computers will allow the daily search of files to review previous diagnoses in patients with material currently under examination. In England, several centers are now establishing computer based files of surgical pathology diagnoses. One of the difficulties of preparing data for entry into the computer file is that of recording the appropriate code. Looking up phrases in a code book is tedious, time consuming, and prone to error. Therefore an attempt was made to produce a system in which encoding follows automatically from an English summary typed on the report. The use of an English summary obviates the need for manual look up of the codes and the data may be prepared for entry to the computer system as a byproduct of normal office routines. This paper reports an evaluation of Pratt's computer system of automatic encoding of histopathology phrases and personal experience with a simpler pilot system based on the ICL 1900 Series computers which are used by most Regional Health Authorities in the United Kingdom.