Electronic Pathology Reports and the Use of HL7 Messaging Workbench

1. Electronic Pathology Reports and the Use of HL7 Messaging Workbench 2008 NAACCR Conference Ken Gerlach, MPH, CTR CDC-National Program of Cancer Registries June 10, 2008

2. Outline • Overview - NAACCR Pathology Tools • HL7 Introduction • Need for Conformance Testing • HL7 Messaging Workbench (MWB) • Overview – High Level • Usages • Advantages

5. NAACCR Volume V • NAACCR Pathology Data Work Group • Electronic Transmission of Reports from Pathology Laboratories to Cancer Registries • Chapter 6 in Volume II, Version 9.1 – Published March 2001 • Version 2.0 release - November 2005 • Version 2.1 release - December 2007 • Next Step -- HL7 Version 2.5.1

6. Two Standard Formats • Pipe-Delimited Format • Less sophisticated (less technically challenging) • Retained for legacy e-path reporting systems • Health Level Seven (HL7) • http://www.hl7.org/ • Flexible and robust protocol widely utilized for electronic data transmissions by medical facilities and pathology Laboratories

8. Health Level Seven (HL7) • Volunteer, not for profit organization • International community • American National Standards Institute (ANSI) • Widely used in US hospital information systems • HL7 refers to standards • Transmission of data between systems

9. High degree variability - HL7 implementations Optionality and other degrees of freedom “If you’ve seen one HL7 message, you’ve seen…one HL7 message.” Variability Impact Custom-modifications for each laboratory Ongoing maintenance cost for these many slightly different formats We Have a Standard, but?

10. MSH|^~\&|HLS|HITECK PATH LAB-ATLANTA^3D9328409^CLIA||STJ|20031124122230||ORU^R01|200311241222300023|P|2.3.1|||||||||2.0 <CR> PID|1||97 810430^^^^PI^HITECK PATH LAB-ATLANTA &3D9328409&CLIA~00466144^^^^PT^ST JOSEPH’S&3932&CMA~3270686987^^^^PN^US HEALTHCARE||SAMPLE30^ALLAN||19530621|M|||112 BROAD STREET^APT 10^ATLANTA^GA^30301^ <CR> PV1|1||||||ATTENDINGID^ATTENDINGDR^MANAGING|REFERRINGID^REFERRER^FOLLOWUP^^^DR| <CR> ORC|RE||||||||||||||||||||ATLANTA CANCER SPECIALISTS|STREET ADDRESS 1^SUITE #^ATLANTA^GA^30303<CR> OBR|1||97810430|11529-5^SURGICAL PATH REPORT^LN^^PATHOLOGY REPORT^L|||20030922|||EMLOYEEID^PHLEBOTOMIST^PAMELA|||||164341^SURGEON^HANNAH^^^DR||||||||||F||||||||109772&PATHOLOGIST&QUINCY<CR> OBX|1|TX|22637-3^FINAL DIAGNOSIS^LN^^DIAGNOSIS^L|1|LEFT INGUINAL LYMPH NODE - GRANULOMATOUS LYMPHADENITIS||||||F<CR> OBX|2|TX|22637-3^FINAL DIAGNOSIS^LN^^DIAGNOSIS^L|1|/ljm <CR> OBX|3|TX|^^^^Clinical History^L|2|? lymphoma Quick Section||||||F<CR> OBX|4|TX|22633-2^Nature of Specimen^NS^^Tissue Submitted^L|3|Left inguinal node||||||F<CR> OBX|5|TX|22634-0^Gross Pathology^LN^^Gross Pathology^L|4|The specimen is received fresh labelled lymph node. The specimen consists of two nodes 2.3 and 2.2. cm each. The cut surface is bulky tan to pink in colour and fleshy.||||||F<CR> OBX|6|TX|22634-0^Gross Pathology^LN^^Gross Pathology^L|4|QP/jlm||||||F<CR> OBX|7|TX|11529-5^SURGICAL PATH^LN^^Microscopic^L|5|Sections of left inguinal lymph node demonstrated an encapsulated node which is largely replaced by epithelioid granulomata without necrosis. Special stains do not reveal the presence of organisms. The background lymphocytes are both B and T lymphocytes and include macrophages and occasional neutrophils and plasma cells. Reed-Sternberg cells are not demonstrated.||||||F<CR> OBX|8|TX|22639-9^Supplemental Reports/Addendum^LN^^Supplements/Addenda^L|6| Material was requested by Dr. D. Consult, Saint Joseph’s Hospital for review. ||||||C<CR> OBX|9|TX|22639-9^Supplemental Reports/Addendum^LN^^Supplements/Addenda^L|6|A report from Dr. C. Darwin was received.||||||C<CR> OBX|10|TX|22639-9^Supplemental Reports/Addendum^LN^^Supplements/Addenda^L|6|DIAGNOSIS: Consistent with peripheral T-cell lymphoma with epithelioid histocytes (Lennert's lymphoma), see description and comment - lymph node, left inguinal (biopsy from November 24, 1997). (See attached report). /HMB||||||C<CR> OBX|11|TX|22639-9^Supplemental Reports/Addendum^LN^^Supplements/Addenda^L|6|Tissue was submitted for lymph node protocol. A report from Dr. B. Study, Sunnybrook Health Science Center was received.||||||C<CR> OBX|12|TX|^^^^Supplements/Addenda^L|7|DIAGNOSIS: (See attached report). LYMPH NODE; INGUINAL REGION, BIOPSY. NON-NECROTIZING GRANULOMATOUS LYMPHADENITIS. /hmb||||||C<CR> OBX|13|SN|21612-7^Reported PatientAge^LN^^Pat_age^L|1|^050|Y||||||F<CR>

11. HL7 Messaging Workbench (MWB) • Conformance Testing Software • Tool for standardizing HL7 Version 2.x messages • Tool allows messages to be validated against the developed profile • Can handle precise, explicit, specifications • Publicly available through the HL7 website • Under HL7 Conformance SIG • Developed by Peter Rontey of the VA

12. MS Word software Opens & Reads A file Minutes Start new file Messaging Workbench software Opens & Reads A profile NAACCR Volume V Start new profile Terms and Concepts

13. Use in US & internationally Key tool measuring & enforcing conformance - HL7 Version 2 Integrates with the HL7 Profile Registry MWB - generates profiles in a standard form MWB - can read published standard profiles MWB Usage

15. Message Structure Conformance Rules HL7 Message Segments

16. Individual Message Fields Individual Message Fields Implementation Notes And Definition Table

18. Test File Import

20. Easy to Find Data in the Test Message Using Parse Tree

21. Validation result

22. MWB Advantages • All laboratories and registries have access to the same profile (specifications) • Software eliminates variability - due to interpretation of text guidance • Messages may be machine-tested for conformance to specification • Explicit identification of differences from the standard eases implementation issues • Eases task of reading HL7 messages during testing and debugging • Standard form for publishing specifications

23. Final Thoughts • Cancer Abstracts vs. Pathology Reports • Tradition of Electronic Cancer Abstract Submissions - ~1988 • E-Pathology Reports - New • Work in Progress • Primary Use – Patient Care • Secondary Use - Public Health, QC, etc. • Flexible • MWB – A tool for senders and receivers

24. For More Information • Tutorials – Pete Rontey at Veteran’s Administration (monthly and web-cast) • Introductory • Advanced • HL7 Meetings (www.hl7.org) • In person training • NAACCR Standards Web-site • NAACCR web tutorial – August 21, 2008?

25. Ken Gerlach kgerlach@cdc.gov Thank you Acknowledgements: Ted Klein, Klein Consulting Sanjeev Baral, Northrop Grumman The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention."

26. Ken Gerlach kgerlach@cdc.gov Thank you Acknowledgements: Ted Klein, Klein Consulting Sanjeev Baral, Northrop Grumman The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention