Introduction

Foreword

This is a supplement to the IHE Pathology and Laboratory Medicine Technical Framework V9.0. Each supplement undergoes a process of public comment and trial implementation before being incorporated into the volumes of the Technical Frameworks.

This supplement was published on September 28, 2018 for Trial Implementation and may be available for testing at subsequent IHE Connectathons. The supplement may be amended based on the results of testing. Following successful testing it will be incorporated into the PaLM Technical Framework. Comments are invited and may be submitted at http://www.ihe.net/PaLM_Public_Comments.

This supplement describes changes to the existing technical framework documents.

“Boxed” instructions like the sample below indicate to the Volume Editor how to integrate the relevant section(s) into the relevant Technical Framework volume.

Replace Section X.X by the following:

Where the amendment adds text, make the added text bold underline. Where the amendment removes text, make the removed text bold strikethrough. When entire new sections are added, introduce with editor’s instructions to “add new text” or similar, which for readability are not bolded or underlined.

General information about IHE can be found at https://www.ihe.net.

Information about the IHE Pathology and Laboratory Medicine domain can be found at https://www.ihe.net/ihe_domains/.

Information about the structure of IHE Technical Frameworks and Supplements can be found at https://www.ihe.net/about_ihe/ihe_process/ and https://www.ihe.net/resources/profiles/.

The current version of the IHE Technical Framework can be found at https://www.ihe.net/resources/technical_frameworks/.

Acknowledgements

The following authors mainly contributed to this document:

• Francois Macary, PHAST, Paris
• Dr. Gunter Haroske, Federal Association of German Pathologists, Berlin
• Dr. Frank Oemig, Deutsche Telekom Healthcare Solutions GmbH, Bonn
• Dr. Riki Merrick, APHL, San Francisco
• Dr. Raj Dash, Duke University, Durham

They also acknowledge the contributions of Dr. Kai U. Heitmann, who managed the cooperation between PaLM and ART-DECOR. It was the very first time that a complete IHE Technical Framework document was developed by means of the ART-DECOR tools and Media Wiki.

Introduction to this Supplement

This supplement complements Volume 1 of the PaLM Technical Framework with the description of the Anatomic Pathology Structured Report (APSR) content profile, and Volume 3 with the structured artifacts - content modules, bindings and value sets - which specify this profile technically.

The PDF format of this specification is automatically generated from the online version, which is available to all readers on the pubswiki.ihe.net platform where it is maintained.

The structured artifacts, which represent the most part of Volume 3 content, are produced and maintained on the ART-DECOR(R) tool and platform, where they are also freely accessible to all readers. This structured part of the specification is automatically transcluded into the pubswiki.ihe.net APSR specification. Then the PDF format is generated.

Although the PDF format captures the entire specification, interested parties are most likely to prefer browsing and reading through the APSR specification directly on the two aforementioned online platforms.

Open Issues and Questions

None

Closed Issues

APSR-07 – Representing the hierarchy of specimens in an entry: This APSR supplement enables to represent the hierarchy of specimens at the CDA® level 3. The operations on specimen and production of child specimens are tracked in the “Procedure Steps” section, which has a level 3 entry.

APSR-10 – Observation related to multiple specimens: For example tumor staging may require combining data from multiple specimens (e.g., a breast excision with positive margins followed by a re-excision with clear margins – in this case the tumor size may be a composite of measurements from both specimens. Another example is staging of ovarian carcinomas with multiple biopsies of pelvis, peritoneum, nodes, omentum, etc.). To accommodate these use cases, each problem organizer as well as each observation may reference any number of specimens using the <specimen> child element. Each of these references may point to a detailed description of the specimen, in the "procedure steps" section.

APSR-11 – Derivative specimens: Specimens derived from primary specimens for ancillary studies, which may be sent to a reference lab or done in another part of the same institution, are included in the scope of this profile. The results produced on a derived specimen are attached to this specimen in the report.