How to store Pathological examination result in CDM

I believe that pathology procedures belong in the Procedure domain. And the OMOP vocabulary mostly agrees with me. For example, if you look in the OMOP vocabulary, SNOMED code 39228008 ‘Surgical pathology procedure’ is in the ‘Procedure’ domain.

http://athena.ohdsi.org/search-terms/terms/4213297

I have worked with pathology data within OMOP. This is how I believe that pathology data should be represented in OMOP:

  • The pathology procedure belongs in the ‘PROCEDURE_OCCURRENCE’ table.
  • The pathology report that records the pathology findings of the pathology procedure belongs in the ‘NOTE’ table.
  • The pathology report in the ‘NOTE’ table should be related to the pathology procedure in the ‘PROCEDURE_OCCURRENCE’ table via the note_event_id/note_event_field_concept_id (or via FACT_RELATIONSHIP in CDM 5.X).
  • The pathology findings (like anatomic site, histology, grade, staging and lymphatic invasion, etc.) belong in the ‘MEASUREMENT’ domain/table.
  • The pathology findings in the ‘MEASUREMENT’ domain/table should related to the pathology procedure in the ‘PROCEDURE_OCCURRENCE’ table via ‘FACT_RELATIONSHIP’.

I have an open ticket related to this here:

The upshot of my ticket is that I believe pathology procedure concepts should be uniformly moved into the ‘Procedure’ domain and that the definition of a procedure should be modified as follows:

“The PROCEDURE_OCCURRENCE table contains records of activities or processes ordered by, or carried out by, a healthcare provider on the patient, OR A SPECIMEN EXTRACTED FROM THE PATIENT, to have a diagnostic or therapeutic purpose. Procedures are present in various data sources in different forms with varying levels of standardization.”

One current issue is that pathology procedure concepts are scattered accross multiple domains:

SNOMED Code SNOMED URL OHDSI URL Name Domain
108259003 SNOMED International Browser Athena Autopsy pathology procedure AND/OR service Procedure
127801007 SNOMED International Browser Athena Body fluid analysis Measurement
26086007 SNOMED International Browser Athena Bone marrow laboratory procedure (procedure) Measurement
73735000 SNOMED International Browser Athena Cytogenetic procedure Procedure
77485009 SNOMED International Browser Athena Cytopathology procedure or service Procedure
15719007 SNOMED International Browser Athena Fine needle aspirate with routine interpretation and report Measurement
64444005 SNOMED International Browser Athena Flow cytometry Procedure
426329006 SNOMED International Browser Athena Fluorescence in situ hybridization Procedure
33468001 SNOMED International Browser Athena Hematology procedure Measurement
4192879 SNOMED International Browser Athena Hematopathology Observation
108262000 SNOMED International Browser Athena Molecular biology method Procedure
116148004 SNOMED International Browser Athena Molecular genetics procedure Procedure
59000001 SNOMED International Browser Athena Surgical pathology consultation and report on referred slides prepared elsewhere Observation
39228008 SNOMED International Browser Athena Surgical pathology procedure Procedure