PathologiebefundundKrebsregister

Synergiennutzen,mehrdennje

GunterHaroske,DresdenTobiasHartz,Hannover

27.10.2016

IHE PaLM TF rev. 7.0 2016

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IHE PaLM Suppl. APSR 2.0Aims

• Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons.

• Information for • patient care, • clinical research • epidemiology.

• improve the quality of reporting • facilitate the exchange and reuse of the content of these reports.

• digital anatomic pathology report• human-readable format• may include images• contains findings and observations in a machine-readable format, to facilitate the integration of these into

the database of a consumer system, and to enable the application of automated reasoning to this content.

• Scope• all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well

as cytopathology.

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IHE APSR 2.0

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- 1DocumentModule

- 6SectionModules

- 2primäreEntryModules(ProblemOrganizer,SpecimenProcedureSteps)

- 14ChildElementModules

darunterneu:

- XSpecimenIdentified

(gemeinsammitXD-LAB)

- UICC/AJCCTNM

- ICD-O-3TypingandGrading

- AssessmentScalesforScoringSystems

(APconstrainseinerCDAObservation)27.10.2016

Contentmodules

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Struktur(i)

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Struktur(ii)

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Valuesets

27.10.20169

27.10.2016

IHE PaLM Suppl. Anatomic Pathology Reporting to Public Health (ARPH)

• TransactionPAT-10

• Usecase3.1.2„Sendingnarrativeorsemi-structuredorstructuredreports“

• Usecase3.1.5„SendingthewholeAPreportoronlyasubsetofrelevantitems“This

alternativeonlyoccurswhenpathologistsareusinglevel2orlevel3APreporttemplates

toproducestructuredorsemi-structuredreports.

• CommonMessageSegments(HL7v2.7)ausIHE-PATTFAPW

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27.10.2016

Was nun?

• nutzenwirdasIHE-Profil!• AblaufundVariantenderMeldungausdemPat-LIS

• Usecase3.1.2„Sendingnarrativeorsemi-structuredorstructuredreports“

• Usecase3.1.5„SendingthewholeAPreportoronlyasubsetofrelevantitems“This

alternativeonlyoccurswhenpathologistsareusinglevel2orlevel3APreporttemplates

toproducestructuredorsemi-structuredreports.

• CommonMessageSegments(HL7v2.7)ausIHE-PATTFAPW

• nutzenwirdieCDA-Entwicklungen?

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