Pathology Terminology and Information Standardisation Projects

In 2011, The National Pathology Terminology and Information Standardisation Plan was developed to standardise pathology terminology leading to limited terminology reference sets with guidelines for their use and a standard for units of measure to minimise the risks from variation in practice. Standardised pathology information structures and terminologies allow for improvement in the recording, decision support, communication and analysis of pathology data to enhance overall healthcare for the individual, the population, and the healthcare system for its practitioners and payers. The ability to provide semantic interoperability between computers enables assurance of fidelity of communication while reducing the risks associated with laboratory variation, transcription errors and misinterpretation of data due to ambiguity of terminology.

With funding provided by the Commonwealth’s Quality Use of Pathology Program and expertise volunteered by a range of pathologists, scientists, informatics specialists, and terminology analysts, the RCPA has led a series of pathology terminology standardisation projects to drive the use of semantic interoperability. A synopsis of each Project’s major outcomes is listed below:

PUTS Project 2011-2013:
  • endorsed adopting SNOMED CT for test requesting; LOINC for results reporting (HL7v2 OBX-3); and UCUM for the representation of units of measure.
  • established guidelines for the use of standardised terminology and units covering each pathology discipline.
  • developed constrained sets of the most common terms, corresponding codes and units of measure for pathology requesting and reporting.

PITUS 2014 Project:
  • implemented proof of concept for standardised pathology requesting terminology used in chronic disease management into General Practice software.
  • developed guidelines for report rendering addressing cumulative reports, abnormal indicators, and demographics.
  • commenced developing guidelines necessary for electronic transmission of pathology reports to Australian registries.

PITUS 2015-2016 Project:
  • finalised guidelines for safe atomic reporting to Australian registries, including Personally Controlled Electronic Health Record (PCEHR).
  • developed an HL7 Implementation Guide to allow for safe communication of atomic reporting of pathology results to external computer systems.
  • developed and trialled a quality assurance protocol in consultation with RCPAQAP for use by accrediting bodies to assist with SPIA compliance. 
  • developed an information model and associated terminology for genetic test requesting.
  • identified chemical pathology tests to safely combine on a cumulative pathology report. 

PITUS 2018-2020 Project:
  • completed an audit and evaluation of the level RCPA SPIA adoption for pathology reporting in laboratory practice.
  • transformed the 2017 published RCPA SPIA terminology reference sets into FHIRR Resources.
  • developed information models for RCPA SPRC protocols: Carcinoma of the ovary, Fallopian tube and primary peritoneal site; Endometrial cancer; Cervical cancer; Polypectomy and local resections of the colorectum.
  • developed best practice guidelines for grouping selected pathology tests on a report focussed on highlighting or flagging clinically significant results in a report.
  • completed a trial for a new IEQA program to assess structured Colorectal cancer reporting against RCPA Colorectal cancer information models.
  • completed scoping requirements for a computer tool to manage the authoring and maintenance of the RCPA SPIA terminology reference sets and information models.

PI Pilot 2022-2024 Project:
  • identified the five most requested tests and panels for a SPIA Adoption Pilot
  • identified two laboratories with different degrees of current SPIA Guideline implementation and readiness to participate in the Pilot.
  • draft pre-implementation and post-implementation reports on SPIA compliance for the approved tests and panels for each Pilot site.
  • identify barriers to SPIA Guideline adoption.

SPIA Terminology Reference Sets & Information Models

The RCPA Standardised Pathology Informatics in Australia (SPIA) Guidelines and associated information models and terminology reference sets

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Frequently Asked Questions relating to RCPA Standardised Pathology Informatics in Australia

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