Anatomic Pathology Reporting

1. Anatomic Pathology Reporting Challenge • Reporting methods over HL7 transactions vary significantly by vendor • Result Segment(s) -- OBXs • Note Segment(s) -- NTEs • Comments within a Note Segment (NTE-3) • Combination of above • Limitations of standards • Complex formatting capability does not exist in HL7 2.x or HL7 3.x • No real support for graphics or complex tables

2. Anatomic Pathology Reporting Recommendation • Reports use result segment (OBX) • PDF supported for full report and/or each section • CDA supported for structured data for specific purposes (e.g. Cancer Reporting) • Use one result segment (OBX) for each PDF and/or CDA • Use LOINC code to define the report or section • All standard data types supported in OBX-5 for reports or part of reports: • that do not use PDF or CDA • Individual section header (if desired/required) • Individual coded information • Should avoid use of one OBX per line of report (use formatted text); may want to define additional guidance on how multiple OBXs related (e.g. for sections of the report or as additional structured information) (e.g. group based on observation ID in OBX-3 or OBX-4) • NTE supported but “results” should be only in the OBX • Scope of “guidance” – Surgical Pathology, Cytology, Autopsy, and other complex reports