Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial

Objective

To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety.

Design

From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating ‘eJournals’ that enabled rapid updating of medication lists during subsequent clinical visits.

Measurements

A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies.

Results

Among 121 046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04).

Conclusions

When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider''s medical record.

Trial registration number

This study was registered at ClinicalTrials.gov ({"type":"clinical-trial","attrs":{"text":"NCT00251875","term_id":"NCT00251875"}}NCT00251875).     

Research and applications: The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals

Background

Effective clinical communication is critical to providing high-quality patient care. Hospitals have used different types of interventions to improve communication between care teams, but there have been few studies of their effectiveness.

Objectives

To describe the effects of different communication interventions and their problems.

Design

Prospective observational case study using a mixed methods approach of quantitative and qualitative methods.

Setting

General internal medicine (GIM) inpatient wards at five tertiary care academic teaching hospitals.

Participants

Clinicians consisting of residents, attending physicians, nurses, and allied health (AH) staff working on the GIM wards.

Methods

Ethnographic methods and interviews with clinical staff (doctors, nurses, medical students, and AH professionals) were conducted over a 16-month period from 2009 to 2010.

Results

We identified four categories that described the intended and unintended consequences of communication interventions: impacts on senders, receivers, interprofessional collaboration, and the use of informal communication processes. The use of alphanumeric pagers, smartphones, and web-based communication systems had positive effects for senders and receivers, but unintended consequences were seen with all interventions in all four categories.

Conclusions

Interventions that aimed to improve clinical communications solved some but not all problems, and unintended effects were seen with all systems.     

The SMART Platform: early experience enabling substitutable applications for electronic health records

Objective

The Substitutable Medical Applications, Reusable Technologies (SMART) Platforms project seeks to develop a health information technology platform with substitutable applications (apps) constructed around core services. The authors believe this is a promising approach to driving down healthcare costs, supporting standards evolution, accommodating differences in care workflow, fostering competition in the market, and accelerating innovation.

Materials and methods

The Office of the National Coordinator for Health Information Technology, through the Strategic Health IT Advanced Research Projects (SHARP) Program, funds the project. The SMART team has focused on enabling the property of substitutability through an app programming interface leveraging web standards, presenting predictable data payloads, and abstracting away many details of enterprise health information technology systems. Containers—health information technology systems, such as electronic health records (EHR), personally controlled health records, and health information exchanges that use the SMART app programming interface or a portion of it—marshal data sources and present data simply, reliably, and consistently to apps.

Results

The SMART team has completed the first phase of the project (a) defining an app programming interface, (b) developing containers, and (c) producing a set of charter apps that showcase the system capabilities. A focal point of this phase was the SMART Apps Challenge, publicized by the White House, using http://www.challenge.gov website, and generating 15 app submissions with diverse functionality.

Conclusion

Key strategic decisions must be made about the most effective market for further disseminating SMART: existing market-leading EHR vendors, new entrants into the EHR market, or other stakeholders such as health information exchanges.     

Research and applications: Resident physicians as human information systems: sources yet seekers

Objective

To characterize question types that residents received on overnight shifts and what information sources were used to answer them.

Materials and Methods

Across 30 overnight shifts, questions asked of on-call senior residents, question askers’ roles, and residents’ responses were documented. External sources were noted.

Results

158 of 397 questions (39.8%) related to the plan of care, 53 (13.4%) to medical knowledge, 48 (12.1%) to taskwork knowledge, and 44 (11.1%) to the current condition of patients. For 351 (88.4%) questions residents provided specific, direct answers or visited the patient. For 16 of these, residents modeled or completed the task. For 216 questions, residents used previous knowledge or their own clinical judgment. Residents solicited external information sources for 118 questions and only a single source for 77 (65.3%) of them. For the 118, most questions concerned either the plan of care or the patient''s current condition and were asked by interns and nurses (those with direct patient care responsibilities).

Discussion

Resident physicians serve as an information system and they often specifically answer the question using previous knowledge or their own clinical judgment, suggesting that askers are contacting an appropriately knowledgeable person. However, they do need to access patient information such as the plan of care. They also serve an educator role and answer many knowledge-related questions.

Conclusions

As synchronous verbal communications continue to be important pathways for information flow, informaticians need to consider the relationship between such communications and workflow in the development of healthcare support tools.     

Improving completeness of electronic problem lists through clinical decision support: a randomized, controlled trial

Background

Accurate clinical problem lists are critical for patient care, clinical decision support, population reporting, quality improvement, and research. However, problem lists are often incomplete or out of date.

Objective

To determine whether a clinical alerting system, which uses inference rules to notify providers of undocumented problems, improves problem list documentation.

Study Design and Methods

Inference rules for 17 conditions were constructed and an electronic health record-based intervention was evaluated to improve problem documentation. A cluster randomized trial was conducted of 11 participating clinics affiliated with a large academic medical center, totaling 28 primary care clinical areas, with 14 receiving the intervention and 14 as controls. The intervention was a clinical alert directed to the provider that suggested adding a problem to the electronic problem list based on inference rules. The primary outcome measure was acceptance of the alert. The number of study problems added in each arm as a pre-specified secondary outcome was also assessed. Data were collected during 6-month pre-intervention (11/2009–5/2010) and intervention (5/2010–11/2010) periods.

Results

17 043 alerts were presented, of which 41.1% were accepted. In the intervention arm, providers documented significantly more study problems (adjusted OR=3.4, p<0.001), with an absolute difference of 6277 additional problems. In the intervention group, 70.4% of all study problems were added via the problem list alerts. Significant increases in problem notation were observed for 13 of 17 conditions.

Conclusion

Problem inference alerts significantly increase notation of important patient problems in primary care, which in turn has the potential to facilitate quality improvement.

Trial Registration

ClinicalTrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT01105923","term_id":"NCT01105923"}}NCT01105923.     

Personal health records and hypertension control: a randomized trial

Purpose

To examine the impact of a personal health record (PHR) in patients with hypertension measured by changes in biological outcomes, patient empowerment, patient perception of quality of care, and use of medical services.

Methods

A cluster-randomized effectiveness trial with PHR and no PHR groups was conducted in two ambulatory clinics. 453 of 1686 (26.4%) patients approached were included in the analyses. A PHR tethered to the patient''s electronic medical record (EMR) was the primary intervention and included security measures, patient control of access, limited transmission of EMR data, blood pressure (BP) tracking, and appointment assistance. BP was the main outcome measure. Patient empowerment was assessed using the Patient Activation Measure and Patient Empowerment Scale. Quality of care was assessed using the Clinician and Group Assessment Score (CAHPS) and the Patient Assessment of Chronic Illness Care. Frequency of use of medical services was self-reported.

Results

No impact of the PHR was observed on BP, patient activation, patient perceived quality, or medical utilization in the intention-to-treat analysis. Sub-analysis of intervention patients self-identified as active PHR users (25.7% of those with available information) showed a 5.25-point reduction in diastolic BP. Younger age, self-reported computer skills, and more positive provider communication ratings were associated with frequency of PHR use.

Conclusions

Few patients provided with a PHR actually used the PHR with any frequency. Thus simply providing a PHR may have limited impact on patient BP, empowerment, satisfaction with care, or use of health services without additional education or clinical intervention designed to increase PHR use.

Clinical trial registration number

http://ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT01317537","term_id":"NCT01317537"}}NCT01317537.     

Research and applications: Combining structured and unstructured data to identify a cohort of ICU patients who received dialysis

Objective

To develop a generalizable method for identifying patient cohorts from electronic health record (EHR) data—in this case, patients having dialysis—that uses simple information retrieval (IR) tools.

Methods

We used the coded data and clinical notes from the 24 506 adult patients in the Multiparameter Intelligent Monitoring in Intensive Care database to identify patients who had dialysis. We used SQL queries to search the procedure, diagnosis, and coded nursing observations tables based on ICD-9 and local codes. We used a domain-specific search engine to find clinical notes containing terms related to dialysis. We manually validated the available records for a 10% random sample of patients who potentially had dialysis and a random sample of 200 patients who were not identified as having dialysis based on any of the sources.

Results

We identified 1844 patients that potentially had dialysis: 1481 from the three coded sources and 1624 from the clinical notes. Precision for identifying dialysis patients based on available data was estimated to be 78.4% (95% CI 71.9% to 84.2%) and recall was 100% (95% CI 86% to 100%).

Conclusions

Combining structured EHR data with information from clinical notes using simple queries increases the utility of both types of data for cohort identification. Patients identified by more than one source are more likely to meet the inclusion criteria; however, including patients found in any of the sources increases recall. This method is attractive because it is available to researchers with access to EHR data and off-the-shelf IR tools.     

Research and applications: A question of trust: user-centered design requirements for an informatics intervention to promote the sexual health of African-American youth

Objective

We investigated the user requirements of African-American youth (aged 14–24 years) to inform the design of a culturally appropriate, network-based informatics intervention for the prevention of HIV and other sexually transmitted infections (STI).

Materials and Methods

We conducted 10 focus groups with 75 African-American youth from a city with high HIV/STI prevalence. Data analyses involved coding using qualitative content analysis procedures and memo writing.

Results

Unexpectedly, the majority of participants’ design recommendations concerned trust. Youth expressed distrust towards people and groups, which was amplified within the context of information technology-mediated interactions about HIV/STI. Participants expressed distrust in the reliability of condoms and the accuracy of HIV tests. They questioned the benevolence of many institutions, and some rejected authoritative HIV/STI information. Therefore, reputational information, including rumor, influenced HIV/STI-related decision making. Participants’ design requirements also focused on trust-related concerns. Accordingly, we developed a novel trust-centered design framework to guide intervention design.

Discussion

Current approaches to online trust for health informatics do not consider group-level trusting patterns. Yet, trust was the central intervention-relevant issue among African-American youth, suggesting an important focus for culturally informed design. Our design framework incorporates: intervention objectives (eg, network embeddedness, participation); functional specifications (eg, decision support, collective action, credible question and answer services); and interaction design (eg, member control, offline network linkages, optional anonymity).

Conclusions

Trust is a critical focus for HIV/STI informatics interventions for young African Americans. Our design framework offers practical, culturally relevant, and systematic guidance to designers to reach this underserved group better.     

Research and applications: Assisted annotation of medical free text using RapTAT

Objective

To determine whether assisted annotation using interactive training can reduce the time required to annotate a clinical document corpus without introducing bias.

Materials and methods

A tool, RapTAT, was designed to assist annotation by iteratively pre-annotating probable phrases of interest within a document, presenting the annotations to a reviewer for correction, and then using the corrected annotations for further machine learning-based training before pre-annotating subsequent documents. Annotators reviewed 404 clinical notes either manually or using RapTAT assistance for concepts related to quality of care during heart failure treatment. Notes were divided into 20 batches of 19–21 documents for iterative annotation and training.

Results

The number of correct RapTAT pre-annotations increased significantly and annotation time per batch decreased by ∼50% over the course of annotation. Annotation rate increased from batch to batch for assisted but not manual reviewers. Pre-annotation F-measure increased from 0.5 to 0.6 to >0.80 (relative to both assisted reviewer and reference annotations) over the first three batches and more slowly thereafter. Overall inter-annotator agreement was significantly higher between RapTAT-assisted reviewers (0.89) than between manual reviewers (0.85).

Discussion

The tool reduced workload by decreasing the number of annotations needing to be added and helping reviewers to annotate at an increased rate. Agreement between the pre-annotations and reference standard, and agreement between the pre-annotations and assisted annotations, were similar throughout the annotation process, which suggests that pre-annotation did not introduce bias.

Conclusions

Pre-annotations generated by a tool capable of interactive training can reduce the time required to create an annotated document corpus by up to 50%.     

Methodologic Issues in Health Informatics Trials: The Complexities of Complex Interventions

Objective

All electronic health (e-health) interventions require validation as health information technologies, ideally in randomized controlled trial settings. However, as with other types of complex interventions involving various active components and multiple targets, health informatics trials often experience problems of design, methodology, or analysis that can influence the results and acceptance of the research. Our objective was to review selected key methodologic issues in conducting and reporting randomized controlled trials in health informatics, provide examples from a recent study, and present practical recommendations.

Design

For illustration, we use the COMPETE III study, a large randomized controlled clinical trial investigating the impact of a shared decision-support system on the quality of vascular disease management in Ontario, Canada.

Results

We describe a set of methodologic, logistic, and statistical issues that should be considered when planning and implementing trials of complex e-health interventions, and provide practical recommendations for health informatics trialists.

Conclusions

Our recommendations emphasize validity and pragmatic considerations and would be useful for health informaticians conducting or evaluating e-health studies.     

Research and applications: An information-gain approach to detecting three-way epistatic interactions in genetic association studies

Background

Epistasis has been historically used to describe the phenomenon that the effect of a given gene on a phenotype can be dependent on one or more other genes, and is an essential element for understanding the association between genetic and phenotypic variations. Quantifying epistasis of orders higher than two is very challenging due to both the computational complexity of enumerating all possible combinations in genome-wide data and the lack of efficient and effective methodologies.

Objectives

In this study, we propose a fast, non-parametric, and model-free measure for three-way epistasis.

Methods

Such a measure is based on information gain, and is able to separate all lower order effects from pure three-way epistasis.

Results

Our method was verified on synthetic data and applied to real data from a candidate-gene study of tuberculosis in a West African population. In the tuberculosis data, we found a statistically significant pure three-way epistatic interaction effect that was stronger than any lower-order associations.

Conclusion

Our study provides a methodological basis for detecting and characterizing high-order gene-gene interactions in genetic association studies.     

caGrid 1.0: An Enterprise Grid Infrastructure for Biomedical Research

Objective

To develop software infrastructure that will provide support for discovery, characterization, integrated access, and management of diverse and disparate collections of information sources, analysis methods, and applications in biomedical research.

Design

An enterprise Grid software infrastructure, called caGrid version 1.0 (caGrid 1.0), has been developed as the core Grid architecture of the NCI-sponsored cancer Biomedical Informatics Grid (caBIG^™) program. It is designed to support a wide range of use cases in basic, translational, and clinical research, including 1) discovery, 2) integrated and large-scale data analysis, and 3) coordinated study.

Measurements

The caGrid is built as a Grid software infrastructure and leverages Grid computing technologies and the Web Services Resource Framework standards. It provides a set of core services, toolkits for the development and deployment of new community provided services, and application programming interfaces for building client applications.

Results

The caGrid 1.0 was released to the caBIG community in December 2006. It is built on open source components and caGrid source code is publicly and freely available under a liberal open source license. The core software, associated tools, and documentation can be downloaded from the following URL: https://cabig.nci.nih.gov/workspaces/Architecture/caGrid.

Conclusions

While caGrid 1.0 is designed to address use cases in cancer research, the requirements associated with discovery, analysis and integration of large scale data, and coordinated studies are common in other biomedical fields. In this respect, caGrid 1.0 is the realization of a framework that can benefit the entire biomedical community.     

Research and applications: Automatic glaucoma diagnosis through medical imaging informatics

Background

Computer-aided diagnosis for screening utilizes computer-based analytical methodologies to process patient information. Glaucoma is the leading irreversible cause of blindness. Due to the lack of an effective and standard screening practice, more than 50% of the cases are undiagnosed, which prevents the early treatment of the disease.

Objective

To design an automatic glaucoma diagnosis architecture automatic glaucoma diagnosis through medical imaging informatics (AGLAIA-MII) that combines patient personal data, medical retinal fundus image, and patient''s genome information for screening.

Materials and methods

2258 cases from a population study were used to evaluate the screening software. These cases were attributed with patient personal data, retinal images and quality controlled genome data. Utilizing the multiple kernel learning-based classifier, AGLAIA-MII, combined patient personal data, major image features, and important genome single nucleotide polymorphism (SNP) features.

Results and discussion

Receiver operating characteristic curves were plotted to compare AGLAIA-MII''s performance with classifiers using patient personal data, images, and genome SNP separately. AGLAIA-MII was able to achieve an area under curve value of 0.866, better than 0.551, 0.722 and 0.810 by the individual personal data, image and genome information components, respectively. AGLAIA-MII also demonstrated a substantial improvement over the current glaucoma screening approach based on intraocular pressure.

Conclusions

AGLAIA-MII demonstrates for the first time the capability of integrating patients’ personal data, medical retinal image and genome information for automatic glaucoma diagnosis and screening in a large dataset from a population study. It paves the way for a holistic approach for automatic objective glaucoma diagnosis and screening.     

The effectiveness of a new generation of computerized drug alerts in reducing the risk of injury from drug side effects: a cluster randomized trial

Context

Computerized drug alerts for psychotropic drugs are expected to reduce fall-related injuries in older adults. However, physicians over-ride most alerts because they believe the benefit of the drugs exceeds the risk.

Objective

To determine whether computerized prescribing decision support with patient-specific risk estimates would increase physician response to psychotropic drug alerts and reduce injury risk in older people.

Design

Cluster randomized controlled trial of 81 family physicians and 5628 of their patients aged 65 and older who were prescribed psychotropic medication.

Intervention

Intervention physicians received information about patient-specific risk of injury computed at the time of each visit using statistical models of non-modifiable risk factors and psychotropic drug doses. Risk thermometers presented changes in absolute and relative risk with each change in drug treatment. Control physicians received commercial drug alerts.

Main outcome measures

Injury risk at the end of follow-up based on psychotropic drug doses and non-modifiable risk factors. Electronic health records and provincial insurance administrative data were used to measure outcomes.

Results

Mean patient age was 75.2 years. Baseline risk of injury was 3.94 per 100 patients per year. Intermediate-acting benzodiazepines (56.2%) were the most common psychotropic drug. Intervention physicians reviewed therapy in 83.3% of visits and modified therapy in 24.6%. The intervention reduced the risk of injury by 1.7 injuries per 1000 patients (95% CI 0.2/1000 to 3.2/1000; p=0.02). The effect of the intervention was greater for patients with higher baseline risks of injury (p<0.03).

Conclusion

Patient-specific risk estimates provide an effective method of reducing the risk of injury for high-risk older people.

Trial registration number

clinicaltrials.gov Identifier: NCT00818285.     

Development and Implementation of a Clinician Reporting System for Advanced Stage Cancer: Initial Lessons Learned

Objective

Innovative approaches can strengthen patient-caregiver-clinician information exchange and more effectively address the physical and psychosocial challenges of advanced disease. This study reports initial findings from implementation of the Clinician Report (CR)—a patient and caregiver status report tool accessible by the oncology clinic team.

Design

The CR tracks and communicates essential information from cancer patients and caregivers to the oncology team. The CR conveys patient symptoms, emotional strain, and key concerns.

Measurements

Authors used a model developed to explain acceptance, implementation, and sustainability of Interactive Health Communication Systems (IHCS) to evaluate implementation of the new CR system. The study carried out qualitative analyses of interviews with clinicians regarding their experience utilizing the Clinician Report.

Results

Primary CR benefits included enhancement of patients'' clinic visit experiences, greater caregiver involvement, and facilitation of earlier interventions. Challenges included CR functional issues, users'' desire for greater depth of information, user privacy concerns, and limited patient use. These findings are discussed using parameters of the implementation model. Limitations of this study include its small clinician sample size, which represented only a portion of existing organizational settings in which CR systems might be implemented.

Conclusion

Though in its early implementation stages, the CR demonstrates the potential to positively impact care delivery in the cancer clinic setting, particularly by facilitating earlier interventions and improving patient-caregiver-clinician communication both during and between clinic visits.     

HealthMap: Global Infectious Disease Monitoring through Automated Classification and Visualization of Internet Media Reports

Objective

Unstructured electronic information sources, such as news reports, are proving to be valuable inputs for public health surveillance. However, staying abreast of current disease outbreaks requires scouring a continually growing number of disparate news sources and alert services, resulting in information overload. Our objective is to address this challenge through the HealthMap.org Web application, an automated system for querying, filtering, integrating and visualizing unstructured reports on disease outbreaks.

Design

This report describes the design principles, software architecture and implementation of HealthMap and discusses key challenges and future plans.

Measurements

We describe the process by which HealthMap collects and integrates outbreak data from a variety of sources, including news media (e.g., Google News), expert-curated accounts (e.g., ProMED Mail), and validated official alerts. Through the use of text processing algorithms, the system classifies alerts by location and disease and then overlays them on an interactive geographic map. We measure the accuracy of the classification algorithms based on the level of human curation necessary to correct misclassifications, and examine geographic coverage.

Results

As part of the evaluation of the system, we analyzed 778 reports with HealthMap, representing 87 disease categories and 89 countries. The automated classifier performed with 84% accuracy, demonstrating significant usefulness in managing the large volume of information processed by the system. Accuracy for ProMED alerts is 91% compared to Google News reports at 81%, as ProMED messages follow a more regular structure.

Conclusion

HealthMap is a useful free and open resource employing text-processing algorithms to identify important disease outbreak information through a user-friendly interface.     

Impact of iron supplementation on schistosomiasis control in Zambian school children in a highly endemic area

Aim

To study impact of once weekly iron supplementation on praziquantel cure rate, Schistosoma haematobium reinfection, and haematological parameters in pupils aged between 9 and 15 years of age in Nchelenge district, Zambia.

Methods

Pupils in the intervention group received once weekly dose of ferrous sulphate at 200mg while those in the control received once weekly vitamin C at 100mg for up to 9 months. Both study groups received a single dose of praziquantel at baseline.

Results

S haematobium reinfection intensity was significantly lower in boys in the intervention group than in boys in the control group at 6 months (P<0.001) and 9 months (P<0.001) of supplementation. Significantly lower S haematobium reinfection intensity was found in girls in the intervention group than in girls in the control group only at 6 months of supplementation (P=0.018). Boys in the intervention group were 42% (Adjusted Risk Ratio =0.58, 95% confidence interval 0.39, 0.86) less likely to be reinfected with S haematobium than in the control group at 6 months follow up.

Conclusion

Once weekly iron supplementation can decrease S haematobium reinfection after 6 months and should be incorporated into school based schistosomiasis control programs in highly endemic areas.

Clinical trials.gov identifier

{"type":"clinical-trial","attrs":{"text":"NCT 00276224","term_id":"NCT00276224"}}NCT 00276224, sponsored by DBL-Institute for Health Research and Development, Denmark.     

A personally controlled electronic health record for Australia

Objective

On July 1, 2012 Australia launched a personally controlled electronic health record (PCEHR) designed around the needs of consumers. Using a distributed model and leveraging key component national eHealth infrastructure, the PCEHR is designed to enable sharing of any health information about a patient with them and any other health practitioner involved in their care to whom the patient allows access. This paper discusses the consumer-facing part of the program.

Method

Design of the system was through stakeholder consultation and the development of detailed requirements, followed by clinical design assurance.

Results

Patients are able to access any posted information through a web-accessible ‘consumer portal.’ Within the portal they are able to assert access controls on all or part of their record. The portal includes areas for consumers to record their own personal information.

Discussion

The PCEHR has the potential to transform the ability of patients to actively engage in their own healthcare, and to enable the emerging partnership model of health and healthcare in medicine. The ability to access health information traditionally kept within the closed walls of institutions also raises challenges for the profession, both in the language clinicians choose and the ethical issues raised by the changed roles and responsibilities.

Conclusions

The PCEHR is aimed at connecting all participants and their interventions, and is intended to become a system-wide activity.     

Research and applications: Semantic analysis of SNOMED CT for a post-coordinated database of histopathology findings

Objective

This research investigated the use of SNOMED CT to represent diagnostic tissue morphologies and notable tissue architectures typically found within a pathologist''s microscopic examination report to identify gaps in expressivity of SNOMED CT for use in anatomic pathology.

Methods

24 breast biopsy cases were reviewed by two board certified surgical pathologists who independently described the diagnostically important tissue architectures and diagnostic morphologies observed by microscopic examination. In addition, diagnostic comments and details were extracted from the original diagnostic pathology report. 95 unique clinical statements were extracted from 13 malignant and 11 benign breast needle biopsy cases.

Results

75% of the inventoried diagnostic terms and statements could be represented by valid SNOMED CT expressions. The expressions included one pre-coordinated expression and 73 post-coordinated expressions. No valid SNOMED CT expressions could be identified or developed to unambiguously assert the meaning of 21 statements (ie, 25% of inventoried clinical statements). Evaluation of the findings indicated that SNOMED CT lacked sufficient definitional expressions or the SNOMED CT concept model prohibited use of certain defined concepts needed to describe the numerous, diagnostically important tissue architectures and morphologic changes found within a surgical pathology microscopic examination.

Conclusions

Because information gathered during microscopic histopathology examination provides the basis of pathology diagnoses, additional concept definitions for tissue morphometries and modifications to the SNOMED CT concept model are needed and suggested to represent detailed histopathologic findings in computable fashion for purposes of patient information exchange and research.

Trial registration number

UNMC Institutional Review Board ID# 342-11-EP.