title: HL7 CDA implementation guide for structured anatomic pathology reports methodology and tools.
abstract: Anatomic pathology reports (APR) provide diagnostic and prognostic information crucial to patient care, clinical research and epidemiology. Currently, it is difficult to collect and exchange APR data between different healthcare organizations at an international level.
  
  
  OBJECTIVE
  IHE and HL7 anatomic pathology joint efforts aim at providing a methodology and tools to define an international HL7 "Clinical Document Architecture" (CDA) implementation guide for APRs and especially in the domain of cancer.
  
  
  METHODS
  A four-step methodology is employed, consisting of comparing existing clinical model of APRs originating from different countries; deriving consensus-based clinical models (Delphi technique); providing the corresponding HL7 CDA implementation guide ("CDA templates") and validating these templates.
  
  
  RESULTS
  International experts defined HL7 CDA implementation guides for breast and colon cancer APRs within an IHE content profile. CDA templates include required data elements, as well as optional ones, that can be further specified as required in national extensions.
  
  
  CONCLUSIONS
  This study demonstrates that it is possible to define an international HL7 CDA implementation guide for cancer APRs. Further efforts are needed to provide CDA templates for approximately 60 other cancer APRs dedicated to different organs, diagnoses, and procedures as well as for APRs of non neoplastic pathologies. The methodology is not confined to APRs and could be applied to clinical documents of any type.
authors.affiliation: INSERM, UMR_S 872, Eq. 20, Paris, F-75006 France. h.kussaibi@gmail.com
authors.forename: Haitham
authors.initials: H
authors.lastname: Kussaibi
authors.forename: François
authors.initials: F
authors.lastname: Macary
authors.forename: Mary
authors.initials: M
authors.lastname: Kennedy
authors.forename: David
authors.initials: D
authors.lastname: Booker
authors.forename: Victor
authors.initials: V
authors.lastname: Brodsky
authors.forename: Thomas
authors.initials: T
authors.lastname: Schrader
authors.forename: Marcial
authors.initials: M
authors.lastname: Garcia-Rojo
authors.forename: Christel
authors.initials: C
authors.lastname: Daniel
mesh_terms: D004282:Documentation / Q000592:standards*; D005568:Forms and Records Control / Q000592:standards*; D005602:France; D006751:Hospital Information Systems / Q000592:standards*; D010338:Pathology, Clinical / Q000592:standards*; D017410:Practice Guidelines as Topic; D012984:Software / Q000592:standards*