IHE PaLM TF Suppl. APSR 2.0
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Dieses Dokument gibt wieder:
Draft for Public Comment / Implementierungsleitfaden "Pathologiebefund auf der Basis von CDA R2" IHE PaLM TF Suppl. APSR 2.0 (09). Die Teilmaterialien gehören der Kategorie cdapath an. |
IHE International
| Version: | 09 |
| Datum: | 2017 |
| Status: | Draft |
| Verfahren: | {{{Verfahren}}} |
| Realm: |
Charlottenstr. 42
10117 Berlin
| Abstimmungsdokument | |||
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| Version | Datum | Status | Realm |
| 09 | 2016 |  Entwurf |
 Deutschland
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noch kein download verfügbar | ||
| Kontributoren | ||
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Agfa HealthCare GmbH | Bonn |
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Vivantes Netzwerk für Gesundheit | Berlin |
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Städtisches Klinikum Dresden Friedrichstadt | Dresden |
Document information
Dieses Material ist Teil des Leitfadens Implementierungsleitfaden.
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Impressum
For the Anatomic Pathology Structured Report Version 2.0 (APSR 2.0), an IHE Project, the existing German "Leitfaden Pathologiebefund" has been modified to an IHE Technical Framework document, starting from the IHE reference text APSR, Trial Implementation, to be linked with Art-Decor for the specification of value sets, terminologies, and templates according HL7/CDA.
Dieser Leitfaden wird von einer Arbeitsgruppe des Interoperabilitätsforum in Kooperation mit dem Berufsverband der Pathologen erstellt. Er basiert auf dem Leitfaden "Arztbrief 2014", der parallel hierzu durch eine Arbeitsgruppe des Interoperabilitätsforums erstellt wird.
Dieses Material ist Teil des Leitfadens Implementierungsleitfaden.
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Contact
- IHE PaLM, palm@ihe.net
- Prof.Dr. Gunter Haroske, BVDP, Berlin, haroske@icloud.com
- Francois Macary, PHAST, Paris, francois.macary@phast.fr
- Dr. Frank Oemig, Deutsche Telekom Healthcare Solutions GmbH, Bonn, Frank.Oemig@t-systems.de
- Dr. Kai-Uwe Heitmann, hl7@kheitmann.de
Dieses Material ist Teil des Leitfadens Implementierungsleitfaden.
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Authors and copyrights, terms of use
Copyright permissions
This document has been developed by Agfa HealthCare GbmH, Bonn, in cooperation with the HL7 user group Germany e.V. The claims for use or publication are not restricted.
The content of this specification is public.
It should be noted that parts of this document are based on the reconciliation package 2 of May 17, 2009 and the HL7 version 3 normative edition 2008, for which © Health Level Seven, Inc. applies. For further information see http://www.hl7.de/ and http://www.hl7.org/.
The extension or rejection of the specification, in whole or in part, shall be notified in writing to the board of the user group and to the editors / authors.
All HL7 specifications, adapted and published to national circumstances, can be used in any type of application software without license and usage fees.
Health Level Seven, Inc. has granted permission to the IHE to reproduce tables from the HL7 standard. The HL7 tables in this document are copyrighted by Health Level Seven, Inc. All rights reserved. Material drawn from these documents is credited where used.
Disclaimer
Although this publication has been compiled with the utmost care, neither HL7 Deutschland e.V. nor the companies involved in the creation can assume any liability for direct or indirect damage that could arise through the content of this specification. {DocumentPart}
Authors
- 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
with contributions by
- Dr. Christel Daniel, Paris (CD)
- Prof. Dr. Thomas Schrader, Berlin/Brandenburg (TS)
- Dr. Kai-Uwe Heitmann, Köln (KH)
- Dr. Jochen Thümmler, Agfa HealthCare GmbH, früher bei Vivantes Netzwerk für Gesundheit, Berlin, (JT)
- Prof. Dr. Stefan Sabutsch, ELGA, Wien, (SS)
- Ivonne Riedel, Agfa HealthCare GmbH, Bonn, (IR)
Dieses Material ist Teil des Leitfadens Implementierungsleitfaden.
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Foreword
This is a supplement to the IHE Pathology and Laboratory Medicine Technical Framework V8.0. 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 27, 2017 for Public Comment, with a comment period extending to mid-November. The current content is the Trial Implementation version, which has taken in consideration the comments received.
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: http://www.ihe.net.
Information about the IHE Pathology and Laboratory Medicine domain can be found at: http://ihe.net/IHE_Domains.
Information about the structure of IHE Technical Frameworks and Supplements can be found at: http://ihe.net/IHE_Process and http://ihe.net/Profiles.
The current version of the IHE Technical Framework (if applicable) can be found at: http://ihe.net/Technical_Frameworks.
Comments may be submitted on IHE Technical Framework templates any time at http://ihe.net/ihetemplates.cfm. Please enter comments/issues as soon as they are found. Do not wait until a future review cycle is announced.
Acknowledgements
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 have to 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 TF document could be developed by means of the ART-DECOR tools and a media wiki.
Inhaltsverzeichnis
Introduction to this Supplement
This supplement complements volume 1 of the PaLM technical framework with the description of the APSR 2.0 content profile, and volume 3 with the bindings, content modules and value sets, which specify this profile.
Open Issues and Questions
None yet
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.
