Anatomic Pathology Structured Reports

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.

Confidentiality issues are out of the scope of this white paper

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
  • 1.1: Surgical pathology – one specimen per container
  • 1.2: Surgical pathology - more than one specimen per container
  • 1.3: Surgical pathology – two requested procedure per order
• 2 USE CASE 2: SURGICAL PATHOLOGY – BIOPSIES
  • 2.1: Biopsies – one specimen per container
  • 2.2: Biopsies – more than one specimen per container
• 3 USE CASE 3: CYTOLOGY
  • 3.1: Cytology – one specimen per container
  • 3.2: Cytology – more than one specimen per container
• 4 USE CASE 4 : AUTOPSY
• 5 USE CASE 5: TISSUE MICRO ARRAY (MORE THAN ONE SPECIMEN FROM MORE THAN ONE PATIENT PER CONTAINER) (UNDER CONSTRUCTION)

4. Standards & Systems

• XDS - CDA
• cf LAB domain
• HL7 v3 : Domaines Laboraory, Specimen, Observation

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>