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The MII Pathology Report represents a significant advancement in structured pathology reporting, addressing the challenges of converting freetext into structured data. This initiative, a collaboration between the German Medical Informatics Initiative's pathology module and the Federation of German Pathologists (Bund Deutscher Pathologen), has developed a generalized structure based on HL7 FHIR standards and IHE Anatomic Structural Pathology Report 2.0. This structure serves as both a foundational data model and a blueprint for document-based workflow artifacts essential in modern medicine.
The most recent version of the MII Pathology Report is the 2025 edition, with the 2026 version currently in development. This ongoing evolution demonstrates the commitment to continually improving and updating the reporting structure to meet the changing needs of pathology and medical informatics.
While the MII Pathology Report provides a robust structure, true interoperability requires semantic annotation of pathological findings. SNOMED-CT and LOINC are identified as the most suitable terminologies for this purpose. However, the scarcity of individuals with expertise in both pathology and code systems poses a challenge for post-annotation efforts.
To address these challenges, Synoptic Reporting has emerged as a promising solution. This approach structures the reporting process from the outset by employing a questionnaire-based methodology. The International Collaboration on Cancer Reporting (ICCR) has played a crucial role in this area by:
Building on the ICCR forms, the SNOMED Synoptic Cancer Reporting Group is actively working on annotating these questionnaires. This effort aims to bridge the gap between structured reporting and semantic interoperability.
The implementation of structured and semantically annotated pathology reports offers several advantages:
By addressing the challenges of freetext conversion and semantic annotation, the MII Pathology Report and associated initiatives are paving the way for more efficient, accurate, and interoperable pathology reporting in modern healthcare systems.