[Document standards for pathology reports in digital medicine]. / Dokumentenstandards für Pathologiebefundberichte in einer digitalisierten Medizin.

Pathology reports are important clinical documents for the diagnosis, treatment, and follow-up of often severe diseases. They are subject to a series of formal and substantive requirements that are anchored in several jurisdictions, which also apply to the digital form of these records. Only a few of the currently used digital document formats meet these requirements and are at the same time interoperable, regardless of the computer platforms used. Practically, they are only partially used in pathology laboratories, practice management, and hospital information systems. The consistent use of these standard formats for pathological findings reports provided a clear digital added value for both pathologists and clinicians as well as their patients.

Semantic interoperability adheres to proper models and code systems. A detailed examination of different approaches for score systems.

OBJECTIVES: Achieving semantic interoperability requires not only the use of communication standards like HL7 with its underlying models and specifications, but also to constrain those models to instances including permitted attributes, data types, values and code systems. Even the application of both strategies may lead to different modeling approaches and therefore incompatible results, however. METHODS: This paper analyzes the different ways to create a model exemplified at score and assessment systems. RESULTS: The different approaches have advantages and disadvantages. The presented results allow for transmitting the same basic information facilitating HL7 v2.x and V3 in a way reducing implementation efforts. CONCLUSIONS: Establishing a generic approach to communicate the details of score systems driven by an appropriate set of codes is the best solution for implementers.