Informatics standards for better and safer
pathology reporting and requesting
Legg, M (Michael Legg & Associates ); Moore, D (The Royal College of Pathologists of Australasia)
Abstract
The Royal College of Pathologists of Australasia, with the support of the Department of Health, have been
leading a program to standardise pathology information, terminology and units for safety and quality since
April 2012.
Figure 1: ECRI Institute’s Top 10 Safety Concerns for 20142
Pre and post-laboratory phases of the pathology process are known to be where most errors occur in
pathology1 and from recent incident analysis we also know that these errors are among the top ten causes of
patient harm2 (Figure 1). The Pathology Information, Terminology and Units Standardisation (PITUS)
project is developing pathology informatics standards aimed at safer improved pathology requesting and
reporting, facilitating their uptake and developing means to test conformance and compliance by pathology
practices and their customers (Figure 2).
PITUS has previously produced standardised pathology terminology reference sets for requesting and
reporting in Australia. This includes Australian preferred terms which are now College Policy. Likewise,
standardised units for most tests performed in Australia have been determined and are now policy. The
Australian Pathology Units and Terminology - Standards and Guidelines v24 is also the vehicle for publishing
the work of the AACB working parties on adult normalised reference intervals for 11 analytes and for 9
paediatric ones.
Work was also undertaken on the safe rendering of pathology results including developing standards around
cumulative reporting and the safe combination of results from different laboratories.
The next phase of the PITUS project will continue the work on interoperability between systems for both
requesting and reporting pathology. As before with the support and direct participation of the many
stakeholders including, patients, other clinicians, pathologists, scientists and informaticians it will also
develop methods to encourage and test compliance and continue with the development of information
models, terminology and safety advice for requestors, report recipients and laboratories.
Figure 2: Why standardise ?3
After standardisation
Point to point communications between players in pathology requesting
and reporting. Red lines are requests. Blue lines are reports.
Information flows between players in pathology requesting and reporting
after standardisation.
Acknowledgements
The Royal College of Pathologists of Australasia would like to acknowledge the Department of Health for providing the funding for the PITUS-15-16 project.
This project would not be possible without the continued collective efforts of many key stakeholders with deep knowledge of their disciplines and work places.
References
1. Khoury M, Burnett L, Mackay MA. Error rates in Australian chemical pathology laboratories. Med J Aust 1996; 165:128–30.
2. Lerner, J, et al. ECRI Institute’s Top 10 Patient safety concerns for Healthcare organisations. https://www.ecri.org/components/HRC/Pages/RMRep0414_Focus.aspx?tab=2
3. Michael Legg. Standardisation of test requesting and reporting for the electronic health record. Clinica Chimica Acta 2014; 432: 148–156
4. The Royal College of Pathologists of Australasia (RCPA), Australian Pathology Units and Terminology – Standards and Guidelines v2.2 (2015)
Australian Pathology Units and Terminology—Standards and Guidelines
To download the latest version, go to
http://www.rcpa.edu.au/Library/Practising-Pathology/PTIS/APUTS-Downloads
For more information
Contact Donna Moore (PITUS-15-16 Project Officer) donnam@rcpa.edu.au
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