Anatomic Pathology Structured Report: Difference between revisions

Latest revision as of 17:17, 1 November 2019

This profile is part of the Pathology and Laboratory Medicine (PaLM) domain, which merged the former AP and LAB domains since 2016, January 4th.

Summary

This APSR 2.0 IHE content profile specifies a unique digital document template for an anatomic pathology structured report (APSR) to be shared or exchanged between pathology laboratories and other care providers and institutions. This content profile describes how to exchange a digital anatomic pathology report in a human-readable format, which may include images. In addition it also contains findings and observations in a machine-readable structured format to facilitate the integration of individual observations and interpretations into the database of a consumer system, which will enable the application of automated reasoning on this content. The digital document template uses the HL7 Clinical Document Architecture standard (CDA R2).

Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons covering all aspects of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology. This information can be used for patient care, clinical research and epidemiology.

The document template includes a header conveying the contextual metadata of the report, and a structured body organized in sections. Each section contains a narrative content for the human reader and may also contain a number of entries (in red on the figure below) carrying the corresponding structured data intended to be integrated in the database of consuming applications.

Benefits

Standardizing and computerizing anatomic pathology reports is necessary to improve the quality of reporting and to facilitate the exchange and reuse of the content of these reports.

Details

The CDA document templated by APSR 2.0 is meant to be shared or exchanged by leveraging the document sharing profiles built by the IT Infrastructure domain of IHE.

The Clinical Information Section assembles the information delivered by the clinician who ordered to the pathology laboratory the diagnostic study that is documented in this report. The other sections report the activities, investigations and findings conducted by the laboratory. The only mandatory section in the report is the Diagnostic Conclusion Section, which conveys the conclusion of the pathology study both in human-readable format and in machine-processable format.

The optional Procedure Steps Section tracks all the activities of collection and preparation of specimens, and conveys the hierarchy of specimens from part to block, dice, ... to stained slide.

The structured data of most sections of the report is provided using the common template Problem Organizer Entry. An instance of this Entry assembles all the observations and related specimens, which investigate one problem identified in the study. e.g. "in situ carcinoma". Within the Organizer structure, the first observation describes the particular problem represented by this instance of Problem Organizer Entry.

The Update Information Organizer Entry is used only when a new revision of the report is shared, in replacement of a previous version. In this case this entry indicates the level of clinical significance of the update and lists the sections that have revised content.

Systems Affected

Laboratory Information Systems (LIS) are usually the systems that produce anatomic pathology structured reports.
HIS, CIS, EHR, EMR systems are the application that consume the reports.
Other systems used by researchers or by public health institutions are potential consumers of these reports.

Actors & Transactions:

Specification

Profile Status: Trial Implementation

Documents: http://pubswiki.ihe.net/index.php/APSR20

Underlying Standards:

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-Page in construction
+{| style="color: blue;"
+| '''This profile is part of the Pathology and Laboratory Medicine (PaLM) domain, which merged the former AP and LAB domains since 2016, January 4th.'''
+|}
 __TOC__
 ==Summary==
-''<Describe the profile in about a paragraph using user-oriented language.  Focus on what it accomplishes for a user (i.e. the Use Cases).  Don't get into how it works, leave that to the Details section.>''
+This APSR 2.0 IHE content profile specifies a unique digital document template for an anatomic pathology structured report (APSR) to be shared or exchanged between pathology laboratories and other care providers and institutions.  This content profile describes how to exchange a digital anatomic pathology report in a human-readable format, which may include images. In addition it also contains findings and observations in a machine-readable structured format to facilitate the integration of individual observations and interpretations into the database of a consumer system, which will enable the application of automated reasoning on this content. The digital document template uses the HL7 Clinical Document Architecture standard (CDA R2).
-''<Insert a simple graphic that, at a glance, visually summarizes what the profile is about.  Do not use an actor/transaction diagram here.  Show your graphic to someone for 5 seconds (literally) and ask them what it's about.  If what they say hits the main points in your summary paragraph, you have succeeded.  E.g. a graphic of a hospital, a clinic, and a lab with patient records moving between them.  .>''
+Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons covering all aspects of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology. This information can be used for patient care, clinical research and epidemiology.
-''<See [[Help:Contents#Tips_.26_Tricks| Help - Tips and Tricks]] for details on inserting an image/graphic.>''
+The document template includes a  header conveying the contextual metadata of the report, and a structured body organized in sections. Each section contains a narrative content for the human reader and may also contain a number of entries (in red on the figure below) carrying the corresponding structured data intended to be integrated in the database of consuming applications.
+[[Image:apsr2layout.png]]
 ==Benefits==
-''<List the key benefits the profile provides (e.g. error reduction, increased throughput) and how they come about (e.g. SWF reduces patient errors due to mistyped demographics at the modality by transfering demographics electronically from the Order Filler).  Consider using a bullet list for readability.  If possible, identify benefits that help users and vendors make the business case for the profile.>''
+Standardizing and computerizing anatomic pathology reports is necessary to improve the quality of reporting and to facilitate the exchange and reuse of the content of these reports.
 ==Details==
-''<A few paragraphs, if appropriate, providing more details (mostly in user-speak, not tech-speak) on what the profile does and how it works.>''
+The CDA document templated by APSR 2.0 is meant to be shared or exchanged by leveraging the document sharing profiles built by the IT Infrastructure domain of IHE.
+The Clinical Information Section assembles the information delivered by the clinician who ordered to the pathology laboratory the diagnostic study that is documented in this report. The other sections report the activities, investigations and findings conducted by the laboratory. The only mandatory section in the report is the Diagnostic Conclusion Section, which conveys the conclusion of the pathology study both in human-readable format and in machine-processable format.
+The optional Procedure Steps Section tracks all the activities of collection and preparation of specimens, and conveys the hierarchy of specimens from part to block, dice, ... to stained slide.
+The structured data of most sections of the report is provided using the common template Problem Organizer Entry. An instance of this Entry assembles all the observations and related specimens, which investigate one problem identified in the study. e.g. "in situ carcinoma". Within the Organizer structure, the first observation describes the particular problem represented by this instance of Problem Organizer Entry.
-''<If the user might be familiar with the mechanisms used by the profile, you can mention them here.  E.g. Evidence Documents is based on DICOM Structured Report (SR) Templates.>''
+The Update Information Organizer Entry is used only when a new revision of the report is shared, in replacement of a previous version. In this case this entry indicates the level of clinical significance of the update and lists the sections that have revised content.
-''<If the user might have an appreciation for the problems addressed in the profile, you can mention them here, but keep it short.  E.g. Mapping HL7 Order fields to DICOM Modality Worklist attributes can be inconsistent in the marketplace, so Scheduled Workflow provides vendors with more detailed instructions.>''
 ==Systems Affected==
-''<List (in user terms) the types of systems they might expect to have implemented actors from this profile, e.g. RIS, PACS, HIS, CAD Workstation, etc. and for each, how it would participate.>''
-* ''PACS systems may store, manage, and/or display Evidence Documents.''
+* Laboratory Information Systems (LIS) are usually the systems that produce anatomic pathology structured reports.
-* ''Display systems may query, retrieve and display Evidence Documents.''
+* HIS, CIS, EHR, EMR systems are the application that consume the reports.
-* ''Reporting workstations may retrieve, process and include details from Evidence Documents in reports
+* Other systems used by researchers or by public health institutions are potential consumers of these reports.
 '''Actors & Transactions:'''
+[[Image:xd-lab_actor_transaction.JPG]]
-''<Insert an actor-transaction diagram, and or list of Content Definitions>''
 ==Specification==
-'''Profile Status:''' [[Comments| Final Text]]
+'''Profile Status:''' [[Comments| Trial Implementation]]
-''<Replace "Final Text" with "Trial Implementation" or "Public Comment" as appropriate.>''
 '''Documents:'''
+http://pubswiki.ihe.net/index.php/APSR20
-''<Provide direct links to the specific volumes or supplements, and list the volume sections relevant to this profile.  This is a simple inventory of official normative and informative text.  If you would like to provide a reading guide or walkthrough of what is in each of the different sections for implementers or users, do that in the Profile FAQ or the Profile Implementation Page linked below.  If the profile uses transactions from multiple Tech. Frameworks, repeat the structure below.>''
-[http://www.ihe.net/Technical_Framework/index.cfm#radiology IHE Radiology Technical Framework:]
-:* [http://www.ihe.net/Technical_Framework/upload/ihe_tf_rev8.pdf Vol. 1] - Section 5 (SWF Profile)
-:* [http://www.ihe.net/Technical_Framework/upload/ihe_tf_rev8-2.pdf Vol. 2] - Sections 4.8 to 4.10, 4.14 to 4.19, and 4.23
-:* [http://www.ihe.net/Technical_Framework/upload/ihe_tf_rev8-3.pdf Vol. 3] - Appendix E
 '''Underlying Standards:'''
+:* [http://www.hl7.org HL7 CDA R2]
-''<list all the standards on which the profile is based; if possible with links to sources>''
+:* [http://snomed.info/sct SNOMED CT]
-:* [http://dicom.nema.org DICOM]
+:* [http://loinc.org LOINC]
-:* [http://www.hl7.org HL7]
+:* [http://unitsofmeasure.org UCUM]
-:* ...
 ==See Also==
-''<The following sections can be left out if there is nothing to point to.  This is just to show where such information can go.>''
+This page is based on the [[Profile Template]]
+[[Category:Profiles]]
+[[Category:PaLM Profile]]
+[[Category:CDA]]
+[[Category:DocShare]]