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Changes to the MLA Handbook, 7th Edition

Pathology Accessioning and Retrieval System Icd-o 2 & 3 Automatic Coding

Pathology Accessioning and Retrieval System (PARS)

By encoding Automatic ICD-O 2 & 3

A Microcomputer - based System for Anatomic Pathology Featuring Automated ICD-O Coding and Multiple Administrative Functions.

I.R.IRAN National Cancer Registration Program Software.

Saed Harsini, :M.D.,Rokhsareh Yadegar, M.D., Mehrdad Mohamadi, B.S.

The numerical coding systems for oncology diagnoses, such as the ICD-O (International Classification of Disease for Oncology) classification, while of tremendous benefit for correlation and comparison of data, require considerable knowledge for application. When no medical personnel select these codes, the error rate of numerical coding is considerable. An obvious solution would be automatic coding by computer, thereby eliminating transcription or selection errors. The pathology department must also concern itself with the preparation of accurate final surgical pathology reports, with numerous possible revisions and retyping. This becomes a very intensive labor, involving business office-type function amenable to computerized word-processing.

More recently, a few systems have been described (PARSEC, CAPER, POLAR, PARIS, etc) that could be employed in the routine processing of pathologic specimens, while also enabling manipulation of large amounts of patient data for demographic, billing, clerical and even epidemiological purposes. Computerized encoding of final diagnoses has also been achieved, primarily utilizing the SNOP and SNOMED (Systematized Nomenclature of Medicine) lexicons. These usually involve the manual entry of the SNOP or SNOMED codes, or both, for subsequent computer retrieval. We describe a comprehensive system for anatomic pathology utilizing a microcomputer in the routine accessing, monitoring, encoding, and storage of acquired data from surgical pathology.

PARS and its principle function are described below and summarized in

Table 1

Table 1: Basic System Routines of the PARS program

Data entry, processing & quality control section:

A - Entering and modification of sample information:

Input of patient demographic data and relative pathology report if required. Demographic data including:

Patient medical registration number Pathology registration number Hospital code number

Date specimen received

Date specimen signed out First name

Last name

Father's name

Age (Year & Month) Sex

Place of birth (Province & District) Place of live in past ten year Physician

Address

Telephone number

Major medical insurance

B- Report editor:

Storage, retrieval, and editing of English-language gross and microscopic description and diagnoses.

Automatic assignment of final diagnoses English text phrase to corresponding four-digit topographic and six-digit morphologic ICD-O code.

Print corrected gross and microscopic description for verification by responsible pathologist.

C- IARC* check program link:

Preparing store data according to data input format and running IARC check program and present the result of check process.

Report & Search section-

Various statistics report based on morphology and topography categories and powerful search facility in different item of data entry form such as:

Patient medical registration number Pathology registration number Hospital code number

Patient name

Specimen type

Sex

Physician

Date specimen received Date specimen signed out

Utility programs

Reverse English code page to Farsi Re indexing

Definition of:

User type

Type of Insurance support Report type (Farsi or English)

Station or unit information (such as address & etc)

Making report disk (For use of National Cancer Registry Service)

Yearly storage

Recalled of storage data

Results:

The programs are designed primarily to replace the manual, error-prone functions that are involve in the accessioning, entry, coding, and retrieval of surgical specimen information.

Initially, the patient demographic data is interactively entered into system. This data includes patient medical registration number, name, date of birth, sex, palace of birth & palace of patient live in past ten years, address, telephone, physician and insurance support of patient.

Linked to the entry of administrative data is an English-text gross specimen description. A text editor enters the dictated gross pathologic description. After editorial changes are made to the gross and microscopic description, and pathologist makes a final histopathologic diagnoses, the system automatic assignment of final diagnoses English text phrase to corresponding four-digit topographic and six-digit morphologic ICD-O code. If an exact match of the morphologic and topographic is not found, a list of possible alternatives is presented to cover variation in spelling or syntax. A complete data search, including morphologic & topographic of ICD-O code to final diaznoses. takes less than one seconds.

Discussion

This microcomputer - based system able to automatic assignment of final diagnoses English (and other languages) text phrase to corresponding four-digit topographic and six-digit morphologic ICD-O code. It is designed to be used in histopathology departments by secretaries and technicians who have no formal training in ICD-O coding. Theses data base file have also been designed for the specific requirements of National Cancer Registry Program, although relatively simple alteration in data file set-up will adapt the system to any other situation. Finally, PARS in conjunction with a microcomputer is a low-cost, dedicated, and interactive approach to the computerization of anatomic pathology.

This software is authorized as standard pathology reporting system by Ministry of Health and Medical Education of IRAN and distributed to all

of pathology laboratory especially for data collection in national cancer registry program.

References:

1- Aller RD, Robboy SJ, Poitras nv, Altshuler BS, Cameron M, Prior MC, Miao S, Barnett GO: Computer-Assisted Pathology' Encoding and Reporting System (CAPER), Am J Clin Pathol 68:715-720, ! 977,

2- Ashworth CT, Mcf.onnel TH, Nielson C, Ashworth RD, Sanford .1: A Computerized word-processing and data system for histology in private medical laboratories. Am J Chn Patho! 71:275-262, 1979.

3- Codling B'V, Macartney Jc. Curran RC: An online Computer svstem for histopathology reporting J Clin Pathol 30: 1119-1123 1977.

4- Davey P'V, Vaughan KD: Computer-Assisted diagnostic surgical Pathology reporting, Am J Clin Pathol 78:337-341, 1982,

5- Foster EA, Stein A, Liberman D, Cooper C, Wolf HJ: A Computer-Assisted surgical Pathology System.Am J Clin Pathol 78:328-336, 1982.

6- Foulis PR, Norbut AM, Mendelow H, Kessler GF: Pathology Accessioning and Retreival system with Encoding by Computer(PARSEC),Am J Clin Pathol 73:748¬753, 1980

7- Macdonald RA, Pechet GS, Lovenbury P: Surgical Pathology Report by Portable Microcomputer.Arch Pathol Lab Med 106:666-669.

8- Allen PV, Angus BV: Computer-output microfilm 111 anatomic pathology laboratory. Am J Clin Pathol 69:537-543, 1978

9- International Classification of Disease for Onchology, Second edition. Geneva, World Health Organization, 1990,

10- SEER program code manual. Bethesda, MD, National Cancer Institute, 1989 (NTH Publication No. 89-1999)

11- Jensen, O. M. et al. Cancer Registration: principles and methods, Lyon, International Agency for Research on Cancer, 1989 nARC Scientific Publications No, 95),

12- Skeet R. G. Manual and computerized cancer registries: International Agency for Research on Cancer, 1989 (lARC Scientific Publications No. 95).

13- Jon S. Morrow, Information systems in surgical pathology: Ackerman s Surgical Pathology, Seventh edition, l'v10SBY Publication 1989,

14- Aller RD, ElevitchFR (eds): Clinics in laboratory medicine. Symposium on computers in the clinical laboratory. Philadelphia, 1983, W. B. Saunders

About the Author

Dr. Saed Harsini