TY - GEN
T1 - HL7 CDA implementation guide for structured anatomic pathology reports methodology and tools
AU - Kussaibi, Haitham
AU - MacAry, François
AU - Kennedy, Mary
AU - Booker, David
AU - Brodsky, Victor
AU - Schrader, Thomas
AU - Garcia-Rojo, Marcial
AU - Daniel, Christel
PY - 2010
Y1 - 2010
N2 - Anatomic pathology reports (APR) provide diagnostic and prognostic information crucial to patient care, clinical research and epidemiology. Currently, it is difficult to collect and exchange APR data between different healthcare organizations at an international level. Objective: IHE and HL7 anatomic pathology joint efforts aim at providing a methodology and tools to define an international HL7 "Clinical Document Architecture" (CDA) implementation guide for APRs and especially in the domain of cancer. Methods: A four-step methodology is employed, consisting of comparing existing clinical model of APRs originating from different countries; deriving consensus-based clinical models (Delphi technique); providing the corresponding HL7 CDA implementation guide ("CDA templates") and validating these templates. Results: International experts defined HL7 CDA implementation guides for breast and colon cancer APRs within an IHE content profile. CDA templates include required data elements, as well as optional ones, that can be further specified as required in national extensions. Conclusion: This study demonstrates that it is possible to define an international HL7 CDA implementation guide for cancer APRs. Further efforts are needed to provide CDA templates for approximately 60 other cancer APRs dedicated to different organs, diagnoses, and procedures as well as for APRs of non neoplastic pathologies. The methodology is not confined to APRs and could be applied to clinical documents of any type.
AB - Anatomic pathology reports (APR) provide diagnostic and prognostic information crucial to patient care, clinical research and epidemiology. Currently, it is difficult to collect and exchange APR data between different healthcare organizations at an international level. Objective: IHE and HL7 anatomic pathology joint efforts aim at providing a methodology and tools to define an international HL7 "Clinical Document Architecture" (CDA) implementation guide for APRs and especially in the domain of cancer. Methods: A four-step methodology is employed, consisting of comparing existing clinical model of APRs originating from different countries; deriving consensus-based clinical models (Delphi technique); providing the corresponding HL7 CDA implementation guide ("CDA templates") and validating these templates. Results: International experts defined HL7 CDA implementation guides for breast and colon cancer APRs within an IHE content profile. CDA templates include required data elements, as well as optional ones, that can be further specified as required in national extensions. Conclusion: This study demonstrates that it is possible to define an international HL7 CDA implementation guide for cancer APRs. Further efforts are needed to provide CDA templates for approximately 60 other cancer APRs dedicated to different organs, diagnoses, and procedures as well as for APRs of non neoplastic pathologies. The methodology is not confined to APRs and could be applied to clinical documents of any type.
KW - Anatomic pathology reports
KW - CDA
KW - Cancer checklists
KW - Delphi method
KW - HL7
KW - IHE
KW - Structured data entry
KW - Structured reports
KW - Synoptic reports
UR - http://www.scopus.com/inward/record.url?scp=78649514164&partnerID=8YFLogxK
U2 - 10.3233/978-1-60750-588-4-289
DO - 10.3233/978-1-60750-588-4-289
M3 - Conference contribution
C2 - 20841695
AN - SCOPUS:78649514164
SN - 9781607505877
T3 - Studies in Health Technology and Informatics
SP - 289
EP - 293
BT - Medinfo 2010 - Proceedings of the 13th World Congress on Medical Informatics
PB - IOS Press
T2 - 13th World Congress on Medical and Health Informatics, Medinfo 2010
Y2 - 12 September 2010 through 15 September 2010
ER -