A system has been established to collect medical data and produce reports, logs, and retrieval files. On-line data entry programs allow for entry of both fixed-length and free-text data through remote terminals. This data is then collected to allow retrieval based on its natural language contents. The system is currently implemented for surgical pathology and cytology applications.
1. Introduction
A system has been designed and implemented to improve the efficiency of medical data management in a pathology department. This project, named the Pathology On-Line Logging and Reporting System (POLARS), is a component of an ongoing effort designed to construct a retrieval system for a pathology library of educational resources based on clinical histories, autopsy reports, and surgical pathology reports (I). The total system, when in full operation, will integrate the service, education, and research functions of the department of pathology in a university hospital. This project's potential rests on its capability to integrate and utilize various narrative data sources. Surgical pathology reports and their corresponding requests for tissue examination occupy an important position in a patient's medical record. Surgical pathology reports are used as a progress note in the patient's chart providing a tissue diagnosis, and as a document to verify the removal of the patient's tissue, organ, or a foreign body. The accompanying request for tissue examination, authored by the clinician, provides a concise source of background information including the operation performed and a summary of the patient's illness. This information can be collected to monitor the activities of the clinical departments as well as the pathology department itself. Such information also provides a meaningful context for the study of the specimens, slides, kodachromes, and photographs that are preserved for their teaching and research purposes.