Confidence

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Submitted by: Victor Brodsky	Revision date: 11/19/2009
Submitted date: 11/19/2009	Change request ID: <<Change Request ID>>

Issue

A diagnosis within the Anatomic Pathology report (such as a diagnosis of "cancer") is often provided in free text along with a phrase noting the confidence of the responsible pathologist, which expresses whether the provided diagnosis is the only possibility given the observed laboratory data. When the diagnosis is coded to a strict diagnosis code from some structured vocabulary, the carefully worded confidence (or lack thereof) is ignored, and the Cancer Registries (and others retrieving the information) end up with very different reports being indistinguishable from each other since they all have the same code. Here is an example of a value set for confidence: Confidence Value Set example.

Recommendation

Introduce codeConfidence="text-value-here" attribute to be placed next to the code="" tag. Alternatively a separate code="ConfidenceLevelValue" tag should have a way to tie it precisely to the very specific other code="" tag in the same CDA document instance that contains the diagnosis, making sure that the code expressing the confidence is unambiguously and directly tied to the specific code containing the diagnosis.

Rationale

We can argue about the necessity to eliminate the need for this, about how wonderful it would be if all pathologists would agree on everything in their textbooks, and how great it would be if various evidence would always 100% support a given diagnosis, however this is simply not the case in real life. As a simple but real example several crucial immunohistological stains of tumor tissue may support several diagnostic possibilities (stain A and B being positive usually means diagnosis #1 is correct, while stain C being positive usually means diagnosis #2 is correct according to an authoritative textbook; however for the case at hand, all three are positive.) In the case of this example the pathologists has no choice but to hate coded synoptic reporting which does not allow for the flexibility to accurately describe a real world specimen in front of him. The quality of gathered data while retrieving such reports suffers as well. This example situation is one of many types out there and happens multiple times a week for every surgical pathologist.

As you can see from the example of the Confidence Value Set, each pathologist may have their own preferred value set for expressing confidence, reiterating the need for the recipient to see the entire value set used by a pathologist in order to determine the scale. This in turn emphasizes the need for the pathologist to be able able to reference a local server within the CDA document instance that is able to respond to a query asking for the value set of "Confidence" , which is proposed in the Vocabulary Authority Reference CDA R3 formal proposal.

Resolution

May 4, 2010 SDWG: Can use act.uncertaintyCode, actRelationship.uncertaintyCode, PPD, and/or UVP to represent uncertainty (depending on the exact use case). No action needed here, as all these constructs will be available in CDA R3.