Methods Of Data Retrieval

INSTITUTIONAL AUTOSPY RECORDS The files containing autopsy documents tend to become quite voluminous. Traditionally, cases are numbered consecutively and filed by year. If no further provisions are made, information retrieval is possible only by manually searching each individual record. This may be quite acceptable if autopsy records are kept only for legal reasons and otherwise are used only in rare family studies. In these instances, only names, clinic number, and other essential identifiers must be kept in a master file. However, for scientific studies based on diagnoses or findings, more elaborate filing and retrieval systems are needed.

PLANNING OF DATA PROCESSING For all practical purposes, data processing has become a computer-based activity. With this in mind, a decision must be made as to the expected use of the autopsy data-processing system. These expectations must be reconciled with the investments they would require in terms of time, personnel, hardware, software, computer time, and related issues. Experience shows that this is rarely done in a realistic manner. Typically, a powerful computerized system has been purchased and a paramedical operator is available who has been trained to run the system, but the physicians who must make the decisions of what should be encoded and how, fall more and more behind with this work, sometimes until the endeavor must be pronounced dead. Only experienced record librarians can achieve satisfactory results without the aid of physicians with expertise in coding.

Typically, autopsy pathologists, surgical pathologists, cytol-ogists, and often, clinical pathologists want or need to use the same database. This usually requires an integrated data-processing system within the medical center, often with linkage to satellite centers or other institutions. Unfortunately, the costs of such large systems are enormous, system breakdowns possible, and issues of privacy protection difficult to solve. Application of such systems (14-16) has not been studied widely.

How elaborate the autopsy data-processing system will be depends on whether all or only a portion of relevant autopsy data should be retrievable. Most general pathologists are principally interested in: 1) a basic documentation of major pathologic findings and 2) data that can be used for workload recording and other administrative functions. The system should also contain information about photographs and other material germane to the specific question.

CODING MANUALS Only few major coding manuals currently are in general use.

1. International Classification of Diseases, Fifth Edition (ICDx9xCM) (9). This classification is required for billing purposes and many other tasks. Unfortunately, it is based on the concept that each condition should have one number; such a monoaxial system is of very limited scientific value if one compares it with SNOMED (see below). Also, disease designations are often obsolete. The international classification of tumors (ICD-O) is part of the ICD (International Classification of Diseases for Oncology) but of greater scientific usefulness because tumors are more suitable for this type of classification.

2. SNOMED International (17). The volumes contain eleven modules (topography; morphology; function; living organisms; chemicals, drugs and biologic products; physical agents, forces, and activities; occupation and social context; procedures; and general linkage modifiers). The codes from the International Classification of Diseases (ICD-9-CM) are included also. The tumor codes in SNOMED International are the same as in ICD-O. Systematized nomenclature of medicine (SNOMED) coding can be done manually or in an automated fashion; it appears that automated coding yields almost the same results as manual coding (18).

3. Physicians' Current Procedural Terminology. This is an important supplemental tool for the encoding of autopsy documents (10).

SNOMED International is available from the American College of Pathologists in Chicago, IL. The other coding manuals, together with CD-ROM versions, teaching material, and related publications can be purchased from several companies such as Medicode, Inc., 5225 Wiley Post Way, Suite 500, Salt Lake City, UT 84116-2889 and PMIC 4727 Wilshire Boulevard, Los Angeles, CA 90010.

Some computer programs provide codes automatically if a diagnosis is entered. In addition, natural language could be stored and retrieved without the use of codes. However, much confusion may arise if these capabilities are applied indiscriminately because of our often undisciplined use of medical terminology. Thus, the same term often is used for different conditions or one condition may have different names. Worse yet, diagnoses often are entirely descriptive ("swollen kidneys") and the proper diagnostic term ("acute renal allograft rejection") is not mentioned at all. In any event, encoded diagnoses should be reviewed by a physician knowledgeable in this field. Because this is rarely possible, it is probably best if the paramedical personnel charged with these duties encodes only familiar diagnoses, avoids the encoding of minutiae, and obtains consultations in doubtful cases.

It should be noted that encoding of well-defined diagnoses is valuable not just for data retrieval but also for ongoing clinical communication because the need to code enforces uniformity in the use of diagnostic designations, and exposes or even prevents the use of ambiguous language. This allows institutions to maintain an up-to-date terminology in all fields and, at the same time, prevent the use of obsolete names. Unfortunately, this added benefit of coding is seldom appreciated. Because it is unrealistic to expect detailed knowledge of the changing terminologies in all fields of pathology, coding manuals and computer programs are needed that suggest current names whenever an obsolete term is typed into the system.

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