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Specifying a Pathology Structured Report with HL7® FHIR®

An approach towards standardization

A. Essenwanger, G. Haroske, T. Hoelter, A. Bartschke, S. Thun

Berlin

16.06.22

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Medical Informatics Initiative �Structured Pathology Report

Specifying a Pathology Structured Report with HL7® FHIR®

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To the repository

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IHE Pathology and Laboratory Medicine (PaLM) �Anatomic Pathology Structured Report (APSR)

Specifying a Pathology Structured Report with HL7® FHIR®

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What is FHIR®?�

Specifying a Pathology Structured Report with HL7® FHIR®

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Fast

Healthcare

Interoperability

Resources

Set of XML/JSON health data resources + REST API

FHIR Interoperability Paradigms

  • REST – lightweight, leverage web stack
  • Documents – long-term persistence
  • Messages – request/response
  • Services – other SOA-based interfaces

PLUS: Storage & Analysis

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What is FHIR®?�

Specifying a Pathology Structured Report with HL7® FHIR®

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What is FHIR®?�

Specifying a Pathology Structured Report with HL7® FHIR®

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FHIR resource

“container” of information that represent something in the real world

Link between resources

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Pathology Report on FHIR® �

Specifying a Pathology Structured Report with HL7® FHIR®

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To the repository

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Pathology Report on FHIR®

Microscopic observation

�Histologic type: DUCTAL.�Nottingham combined histologic grade: 1 of 3.�Tubule formation score: 2. �Nuclear pleomorphism score: 2.�Mitotic rate score: 1.

Specifying a Pathology Structured Report with HL7® FHIR®

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"hasMember": [

    {

      "reference": "Observation/histologic-type"

    },

{

"reference": "Observation/nottingham-histologic-grade„

},

{

      "reference": "Observation/tubule-formation-score"

    },

{

      "reference": "Observation/nuclear-pleomorphism-score"

    },

{

      "reference": "Observation/mitotic-rate-score"

    },

  ],

  "specimen": {

    "reference": "Specimen/right-breast"

  }

Microscopic Grouper

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Pathology Report on FHIR®

Microscopic observation

�Histologic type: DUCTAL.�Nottingham combined histologic grade: 1 of 3.�Tubule formation score: 2. �Nuclear pleomorphism score: 2.�Mitotic rate score: 1.

Specifying a Pathology Structured Report with HL7® FHIR®

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"code": {

"coding": [

{

"code": "44638-5",

"system": "http://loinc.org",

"display": "Histologic type in Breast tumor"

}

]

},

"valueCodeableConcept": {

"coding": [

{

"code": "82711006",

"system": "http://snomed.info/sct",

"display": "Infiltrating duct carcinoma (morphologic abnormality)"

}

]

},

Microscopic Pathology Finding

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Does structured mean better?

Specifying a Pathology Structured Report with HL7® FHIR®

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Andrea Essenwanger

Research Fellow for Medical Informatics

Berlin Institute of Health at Charité

(BIH@Charité)