Pathology Report-abstracts Request Use Case (Linda Mook)

The PALGA foundation runs the nationwide network and registry of histo- and cytopathology in the Netherlands. The system will be connected to the AORTA infrastructure and National Switch Board (LSP)

This use-case describes the foreseen retrieval of abstracts of pathology reports by pathologists when they open a new pathology case and need to review the history on previous pathology cases for the same patient. Abstracts of all pathology-reports in the Netherlands should be available for retrieval.

Use-case

When a specimen is received at the pathology lab a new ‘pathology case’ is created. The performing lab should request all the historic pathology report abstracts for this patient. The pathologist/secretary/assistant sends a query with the national patient ID to the national information broker. The information broker sends the query through to those labs that have registered historic cases for this particular patient. The labs respond to the broker by sending the available abstracts to the broker. The abstracts consist of the following data-elements:

• Patient ID (fielded data)
• Reportnumber (fielded data)
• Lab-mnemonic(fielded data)
• Lab ID (fielded data)
• Type of report (codes for cytology, cervix screening, histology, autopsy)
• PA-number (fielded data, probably id for pathologist)
• Date of receiving specimen (fielded data)
• Clinical information (free text with the question from the healthcareprovider that send in the sample)
• Macroscopic description (perhaps coded, need to check)
• Microscopic description (perhaps coded, need to check)
• Conclusion (multiple sections of 2 fields below allowed)
  • Diagnosis_code (PALGA codes in line with SNOMED)
  • Diagnosis text (text description with chosen code)
• Type autopsy (coded)
• Date of death (fielded data)

When the pathologist has approved the pathology report on the case, the report is signed and the new abstract is registered at the national switchboard index-file.

This abstract can be retrieved when other pathology specimens are ever processed for this patient.