A reference model based interface terminology for generic observations in Anatomic Pathology Structured Reports

BACKGROUND: Current terminology systems for structured reporting in pathology are more or less focused on tumor pathology. They have not been compiled in a systematic approach, therefore they gather terms of very different granularity. Generic models for terminology development could help in establishing reference terminologies for all fields of anatomic pathology. The core principle of those models is the ontological structure of native speaking terminology. By analyzing the PathLex interface a generic terminology model will be derived. METHODS: For each element template of PathLex its possible generic nature and its value set was analyzed, looking for the uniqueness or multiplicity of the values in the value sets. The generic terms were mapped to SNOMED-CT terms using "ArtDecor". RESULTS: The 488 PathLex element templates for Anatomic Pathology (AP) observations can be reduced to 53 generic templates, leaving out only 17 templates very specific for organ and/or disease. Among those 53 templates 28 are describing UICC-TNM staging, ICD-O-classification, and grading. Further 15 templates describe the results from marker investigations. Almost all of the terms, used in those templates could be mapped to SNOMED CT. All of the generic elements have their "organ specific" counterparts by assigning them to one of 20 organs and invasive or noninvasive cancer, respectively. Studying the structure of generic and specific terms it becomes obvious that any AP observation - occurs always in a context - consists of three basic elements (target of observation, property of observation, additional qualifiers, added by value sets for coded data). CONCLUSIONS: If a machine-readable terminology is aimed to preserve all the information of native speaking, then two principal solutions exist: - ystematic consideration of all the aspects mentioned above in each single term - ocusing on the generic elements of terms and combining this with the structure of communication, reflecting the non-obvious elements of the terminology. The fastest way for establishing an interface terminology is the first approach, which lists all of the terms needed for e.g. a checklist in a comprehensive manner (precoordination). However, if the list of terms and problems increases, or new requirements have to be met, considerable difficulties may arise in keeping the terminology consistent and complete. The second, postcoordination approach offers some advantages. It does not have limitations in the organ- or disease specificity, and it keeps the number of terms limited, making them more easily to survey.