An integrated information and management system for anatomic pathology

We report a user-developed computer system for anatomic pathology that integrates archival, word-processing, and managerial functions. The programs are written in MUMPS, and the word processor is a MUMPS-based commercial package. The diagnoses are coded via Snomed. Functions include case accession, billing, histology laboratory orders, surgical pathology report preparation, case retrieval, identification of late reports, and monthly reports on billing and on histology laboratory usage. For the preparation of surgical pathology reports, thye system software sets the word processor parameters and accessions text, while the word processor programs edit and print the text. Prior diagnoses in our files are automatically incorported into the text of the report. Standardized ('canned') text can be used for gross specimen descriptions. Automatic coding is effected when the operator selects the appropriate diagnosis from an on-line user-definable dictionary, although diagnoses can also be entered as plain text and coded later. All retrievals are performed in real time; a search can be done by patient name or by combinations of Snomed codes, age, sex, etc. The system has been well-received by pathologists and support personnel alike and has had a favorable effect on the recruitment of personnel.