Anatomic Pathology Structured Orders

1. Proposed Workitem: Anatomic Pathology Structured Orders

• Editor: Wendy Scharber (wendy@registrywidgets.com)- Sandy Jones (sft1@cdc.gov )

Date: September 17, 2010 Version: 1.0 Domain: Anatomic Pathology, Canadian Partnership Against Cancer (CPAC), National Program of Cancer Registries, North American Association of Central Cancer Registries (NAACCR).

2. The Problem

Currently, there is no guidance on the information that should be included on a surgical requisition/test order form when a specimen is submitted to an anatomic pathology laboratory for evaluation and diagnosis. The lack of guidance means that it is not unusual for clinical diagnosis and other information to be missing on pathology requisition forms. Pathologists may not be able to render a complete or even an accurate diagnosis because important clinical information has not been provided. Cancer registrars require the many of the same information as the pathologists in order to have a comprehensive record of patient’s cancer. Registrars spend a large amount of time and effort to get this information from physicians and surgeons.

3. Key Use Case

1. Specimen is obtained from the patient.

2. Physician creates a pathology test order that includes clinical and other information that has been demonstrated to be useful for complete and accurate results.

3.Test Ordering System transmit information to the anatomic pathology laboratory.

4. Standards & Systems

• HL7 2.x
• DICOM

5. Discussion

Using best practice guidelines that have been developed by the anatomic pathology community in Canada (New Brunswick and Ontario), the United States, and in France, the authors/editors will work with pathologists to develop a content module supplement. The first version will be limited to data elements necessary for lung, breast, prostate and lung cancers.

Note 1: The information will be transmitted using the OBX segment within an HL7 2.x message. Use of the NTE segment for patient information is inappropriate.

Note 2: Creation of this Content Module will require a change to PAT-2:
Lines 1220 – 1223:
OBR-13 Relevant Clinical information (ST), not supported.
Transaction PAT-1 uses OBX segment to carry relevant clinical information, or a NTE segment below the OBR for more comment orientated information.
Would be changed to:
OBR-13 Relevant Clinical information (ST), Required if Available. Harry: I think this should be "optional", since some systems use it; not sure what "if available" means
Transaction PAT-1 uses OBX segment to carry relevant clinical information. or a NTE segment below the OBR for more comment orientated information.

Note 3: Addition of OBX referencing persistent externally accessible data relevant to the order. This may include references to a CDA patient summary, or to a peri-operative DICOM imaging study (X-ray, ultrasound, or photographic) as documentation of the source and condition of the specimen, especially for biopsy under imaging guidance.