Standardized Pathology Assessment Template Design

Information system design and implementation require generally accepted norms, principles, and standards. Lately, the challenge for achieving a high degree of general acceptance has increased with the presence of formal governance structures. Compliance with norms for information system development depends on the shared recognition of regulations and standards. The research problem in this study concerns standards and their role in the development of a pathology laboratory information system. In this paper, in the theoretical background section, the authors present regulations, standards, and disease classification, which are necessary for planning the pathology laboratory information system. Next, in the template design project section, the authors focus on development of a new, ontology-based, and standard-oriented approach for elaboration of a standardized template of the pathological assessment of histopathology material. Authors use the World Health Organization (WHO) ICD-11 classification to elaborate on that template, which permits the precise coding of diagnoses and medical procedures. The main findings concern the proposed ontology-based document template, which can further be used in the Laboratory Information Management System (LIMS), and as such can be considered a pattern for the development of other LIMS documents. In conclusion, the authors emphasized the standardized method application for designing and implementing medical documents. This original contribution concerns the assessment template design based on existing ontologies ICD-10 and ICD-11.