Typing, Grading, Staging - The Ultimate Goals Of Pathology Reports Modelled In HL7V3/CDA
Clinicians want pathologists to provide their reports fast, understandable, and useable for clinical decision making. Reports without a concise diagnostic conclusion in terms of typing, grading and staging of a disease are of low value. Therefore Anatomic Pathology Structured Reports (APSR) should have those keystones also reflected.
Instead to define very long lists with specific TNM-formulas, grading values, and tumor classifications information models have been developed which allow a flexible use in the diagnostic reporting approach and a compact programming.
Exemplarily for any diagnostic conclusion a model for TNM- as well as ICD-O-classification of malignant tumors for HL7 reporting to cancer registries in Germany was modified and completed with codes and value sets by means of Art-Decor. Additionally, an assessment score model was developed applicable for a wide variety of grading systems used in neoplastic as well as non-neoplastic diseases. ART-DECOR is a toolkit allowing for maintaining information models designated to data exchange facilitating communication standards.
An information model for TNM as well as ICD-O-classification of malignant tumors for reporting to cancer registries in Germany supporting the required data set was developed and filled with appropriate codes and value sets by means of ART-DECOR. The IHE APSR Trial implementation with its templates and value sets was mirrored in ART-DECOR and completed by templates for TNM-, ICD-O-3 and Assessment-Scores, based on the German HL7 Oncology Reporting requirements. A model based approach for structured reporting of complex problems is the preferred approach instead of exhaustive lists of permutated single values.
The developed templates are to be used as entries in the Diagnostic Conclusion section of IHE APSR allowing for a structured data exchange so that automatic clinical decision support is maximized.
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