Modelling breast cancer pathology reports using SNOMED CT and openEHR

Abstract: With a longer-living population and an increase in cancer incidence the health care’s workload has increased over the past decade. The treatment process of a cancer patient is dependant on clinical information collected and communicated from the pathology department. With a standardised and structured pathology report the information communicated can become easier to interpret and will fa- cilitate the search for important parameters. This master thesis aims to develop a template prototype to replace four static free-text templates used in the area of breast cancer pathology at the pathology department at Region Östergötland. The end product was intends to store docu- mented information in a structured manner through structured data, in order to obtain semantic interoperability. Semantic interoperability means that different systems are able to communicate with each other in such a way that the information is handled and interpreted equally by the systems. By using certain standards such as openEHR archetypes and SNOMED CT concepts, the data becomes uniform and unambiguous. When that is achieved, information can be sent more easily between systems such as patient health data if an individual moves between different cities where the hos- pitals have different medical records systems. The result of the master thesis is a single template that incorporates all the parts from the four static templates currently used at Region Östergötland. To avoid a large and cumbersome template for the end-user the template is built with con- ditions that changed the appearance of the template while it is being filled in, making it dynamic.