Anatomic Pathology CDA Project Discription

Document (Project) description

The goal of this project is to provide a CDA representation for the anatomic pathology report. The anatomic pathology report is a complex clinical document that describes, amongst other things, gross, microscope and other laboratory findings on one or more clinical specimens.

The CDA Pathology Report, as envisioned, will contain three main “layers” each related through participations and act relationships. An example of a similar approach is the SPL CDA. The CDA Pathology Report will use the following “layers”:

• The first layer is the “Document” layer. The Document layer is taken directly from the basic CDS model. It is used to describe the creation, lifecycle and structure of the document (for authors, status, sections, etc.
• The second layer is the “Specimen” layer. The Specimen layer is taken directly from the Specimen model being developed and balloted by the Laboratory SIG. It describes the specimens which are the subjects of the report and the relationships between the specimens.
• The third layer is the “Observation” layer. The observation layer will be modeled closely from the standard HL7 OBX structures. The Observation layer will support free text, as well as structured and coded data. In this phase of the project, we will not specify specific vocabularies or data elements for describing observations, but we will expect that all coded data will be combined with sufficient metadata for the user to identify the coding system used.

An important capability of the Anatomic Pathology CDA will be the ability for observations or specimens to be linked to there relevant documents. For example, observations could be linked to procedures in a laboratory manual or specimen linked to an image. This capacity is intrinsic to the Document, Specimen and OBX models used in creating the Anatomic Pathology CDA

Project need

Anatomic Pathology reports are complex clinical documents that relate the patient’s clinical condition, one or specimens which are the subject(s) of the report, and a wide range of observations in both free text or structured data. For many years, anatomic pathology reports have been transmitted through standard HL7 V 2.x Laboratory interfaces. This has resulted in data being sent in large text blobs. As pathology reports become more complex, with structured data, images, etc. This is becoming increasingly less tenable. The CDA is a better structure for representing and transmitting the complex data and relationship in an anatomic pathology report.