Standardisation of pathology terminology: how e-health records should work

Abstract

Attempts to progress e-health in pathology in Australia have been hindered by a lack of standardisation in key requesting and reporting parameters, such as request codes, test panels, test names, units and reference intervals. Leverage off electronic health records (e.g., development and use of decision support systems) is difficult without agreement in these areas. The Royal College of Pathologists of Australasia (RCPA) led ‘Pathology Units and Terminology Standardisation’ (PUTS) project is showing leadership in these areas by bringing together pathologists, scientists and IT professionals to make recommendations on best practice. Working groups have been established to review request codes, recommended units, and reporting codes for seven pathology disciplines. Each group will also consider the terminology most applicable to that discipline (e.g., SNOMED-CT, LOINC, both, or possibly other) and where necessary highlight tests for which results should not be combined across pathology providers. Work on the ambitious Personally Controlled Electronic Health record program continues, with initial operation scheduled for mid 2012. Although participation will not initially be mandatory for patients or providers, Pathology reporting will be included. The pathology industry needs to be actively engaged in this rapidly changing landscape for optimal outcomes.