Difference between revisions of "Anatomic Pathology Structured Reports"
Line 34: | Line 34: | ||
==3. Key Use Case== | ==3. Key Use Case== | ||
− | + | Activity diagrams and strucured reporting will be defined for the use cases already available in the IHE Anatomic Pathology TF | |
− | + | 1 USE CASE 1: SURGICAL PATHOLOGY – OPERATIVE SPECIMEN | |
− | + | 1.2 Use case 1.2: Surgical pathology - more than one specimen per container | |
− | + | 1.3 Use case 1.3: Surgical pathology – two requested procedure per order | |
+ | 2 USE CASE 2: SURGICAL PATHOLOGY – BIOPSIES | ||
+ | 2.2 Use case 2.2: Biopsies – more than one specimen per container | ||
+ | 3 USE CASE 3: CYTOLOGY | ||
+ | 3.2 Use case 3.2: Cytology – more than one specimen per container | ||
+ | 5 USE CASE 5: TISSUE MICRO ARRAY (MORE THAN ONE SPECIMEN FROM MORE THAN ONE PATIENT PER CONTAINER) (UNDER CONSTRUCTION) | ||
==4. Standards & Systems== | ==4. Standards & Systems== |
Revision as of 19:45, 1 October 2008
1. Proposed Workitem: <initial working name for profile/whitepaper/etc>
- Proposal Editor: Thomas Schrader, CHristel Daniel
- Editor: Thomas Schrader?
- Domain: Anatomic Pathology
2. The Problem
The transaction relatied to the reporting worflow (PAT3-Order Results Management) of the IHE Anatomic Pathologyt Technical Framework is mainly dedicated to storage and sharing of free text anatomic pathology reports.
There are many initiatives in different countries and/or within standardization bodies (HL7, CEN)aiming at proposing standard structured architecture for anatomic pathology reports.
- CEN TC 251 WI 130.1.1:2003 : A histology report may be divided into sections describing the: macroscopic appearance, microscopic features and the conclusion of the service provider based on these findings. Each of these sections may consist of free-text, measurements (e.g. size, weight etc.) and code values representing the findings.Different healthcare parties may be responsible for different parts of a report. Furthermore, overall responsibility for reviewing and signing-off the reports may rest with yet another supervisory healthcare party.
- CAP Cancer Protocoles and checklists (US)
- INCa (France)
- Royal College (UK), etc)
Generally speaking, according to “evidence-based pathology”, only features that are reproducible and relevant – with a demonstrated diagnostic or prognostic signification – should be reported in description and corresponding evidence available”.
The obective of this white paper is to collect, analyze and summarize these different initiative in order to discuss the available technical solution to store and share strucred reports in anatomic pathology and to choose the most appropriate one.
Will be especially considered the following issues and barriers :
- Medical consensus is not easy to achieve at regional/national/international level about important features that should e reported as well as the vocabulary and/or code system to use.
- Standard information models (templates) are not available.
- "International" code systems are mainly available in English and ther content coverage with regards to the cotent of anatomic pathology reports has not been formally evaluated
- Structured report can be built from different sources(APIS, post processing station ("evidence" creation), etc)
Confidentiality issues are out of the scope of this white paper
A crucial issue is to identify a technical solution to handle templates of structured reports including findings and their evidences. It should be possible to link each observation or finding to the specimen source (part(s) (Box ID) for macroscopic findings, tissue item (Slide ID) for microscopic findings)). Moreover it must be possible to link each observation or finding to the image(s) or region of interest of image(s) acquired from the specimen source. Complex diagnostic structured reports include numeric quantitative measurement, images or graphs, image annotation and links between image (and/or evidence) information and textual information.
3. Key Use Case
Activity diagrams and strucured reporting will be defined for the use cases already available in the IHE Anatomic Pathology TF 1 USE CASE 1: SURGICAL PATHOLOGY – OPERATIVE SPECIMEN 1.2 Use case 1.2: Surgical pathology - more than one specimen per container 1.3 Use case 1.3: Surgical pathology – two requested procedure per order 2 USE CASE 2: SURGICAL PATHOLOGY – BIOPSIES 2.2 Use case 2.2: Biopsies – more than one specimen per container 3 USE CASE 3: CYTOLOGY 3.2 Use case 3.2: Cytology – more than one specimen per container 5 USE CASE 5: TISSUE MICRO ARRAY (MORE THAN ONE SPECIMEN FROM MORE THAN ONE PATIENT PER CONTAINER) (UNDER CONSTRUCTION)
4. Standards & Systems
<List existing systems that are/could be involved in the problem/solution.>
<If known, list standards which might be relevant to the solution>
5. Discussion
<Include additional discussion or consider a few details which might be useful for the detailed proposal>
- <Why IHE would be a good venue to solve the problem and what you think IHE should do to solve it.>
- <What might the IHE technical approach be? Existing Actors? New Transactions? Additional Profiles?>
- <What are some of the risks or open issues to be addressed?>
<This is the brief proposal. Try to keep it to 1 or at most 2 pages>