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Anatomic Pathology Reporting

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

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Anatomic Pathology Reporting

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  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 • Scope of recommended guidance – Surgical Pathology, Cytology, Autopsy, and other complex reports • Reports use observation segment (OBX) and notes segment (NTE) as defined below. • A full report, a discrete section of a full report, or a result shall be transmitted as a single observation segment (OBX) • PDF supported for full report and/or each section • CDA supported for full report of structured data for specific purposes (e.g. Cancer Reporting) • All allowed data types supported in OBX-5 • For plain text results of line breaks must be indicated with text formatting commands within an FT data type • Use one observation segment (OBX) for each PDF and/or CDA • Use LOINC code to define the report or section • Relationship or order between OBX’s is pending the sequencing discussion • NTE supported for additional information about the results in the OBX

  3. Testing limits • Define test size/limit for PDF, CDA, etc • Based on data type?

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