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**National Program of Cancer Registries --Modeling Electronic Reporting
Project (NPCR‑MERP)**

**ePath Pilot Project Phase 1: Implementing Electronic Pathology
Laboratory Reporting from a National Laboratory to State Central Cancer
Registries**

**Phase 1 Final Report**

Contents

Executive Summary [3](#__RefHeading___Toc182725526)

Overview [5](#overview)

Problem Statement [5](#problem-statement)

Purpose [5](#purpose)

Objectives [5](#objectives)

Advantages of a Pilot Project [6](#advantages-of-a-pilot-project)

Project Scope [6](#project-scope)

Project Tasks [7](#project-tasks)

Methods [8](#methods)

Laboratory and Central Registry Participation
[8](#laboratory-and-central-registry-participation)

Central Registry Participation [8](#central-registry-participation)

Use of PHINMS [9](#use-of-phinms)

Development of an HL7 message parser
[9](#development-of-an-hl7-message-parser)

Results [10](#results)

Results and Conclusions - Specific Pilot Project Activities
[11](#results-and-conclusions---specific-pilot-project-activities)

Issues needing further evaluation
[14](#issues-needing-further-evaluation)

Future Plans [15](#future-plans)

In Summary [16](#in-summary)

Annotated Glossary of Electronic Pathology Components
[17](#annotated-glossary-of-electronic-pathology-components)

Appendix A: Description of an HL7 Message
[18](#appendix-a-description-of-an-hl7-message)

Message Segments [18](#message-segments)

Field Components [18](#field-components)

Appendix B: Message Development Issues for LabCorp
[20](#appendix-b-message-development-issues-for-labcorp)

Appendix C: Mapping of LabCorp Local Test Codes to LOINC
[21](#appendix-c-mapping-of-labcorp-local-test-codes-to-loinc)

Appendix D: HL7 Mapper Plus Program Version 1.0.1
[26](#appendix-d-hl7-mapper-plus-program-version-1.0.1)

Introduction [26](#introduction)

Pathlab Database [26](#pathlab-database)

## Executive Summary

Anatomical pathology laboratory reports, one of the most valuable data
sources for cancer registry surveillance, have traditionally been
reported in a paper format. Because a manual review process is time
consuming, inefficient, and costly, it would benefit state cancer
registries to receive pathology reports securely in a standard
electronic format with minimal need for customized technology.

The National Program of Cancer Registries---Modeling Electronic
Reporting Project (NPCR‑MERP) conducted an electronic pathology (ePath)
pilot project to test the implementation of cancer data reporting
standards.

Goals of the ePath pilot project were to

1.  Implement consistent electronic pathology reporting from a national
    laboratory to participating state central cancer registries.

2.  Provide guidance to state cancer registries and pathology
    laboratories for implementing electronic pathology reporting in
    their respective environments.

3.  Offer new and improved capabilities for using pathology reports as a
    cancer information source.

Advantages of this project are to create a single reporting process
using existing technological infrastructure and standards, and to
provide a unified voice for consistent communication between
stakeholders. Successful implementation and lessons learned from this
project will build momentum for adopting across the spectrum of
pathology laboratories and state cancer registries.

The NPCR-MERP ePath pilot project focused on the:

-   Creation of a Health Level 7 (HL7)[^1] message conforming to the
    North American Association of Central Cancer Registries, Inc.
    (NAACCR) Standards for Cancer Registries, Volume V, Pathology
    Laboratory Electronic Reporting, Version 2.0 and the business rules
    defined in the NAACCR ePath Reporting Guidelines.

-   Use of PHIN Messaging System (PHINMS) standard transmission
    architecture and software because of its cross-platform capability
    and established use in reporting communicable diseases.

-   Adoption or development of software for processing HL7 messages at
    the registry.

LabCorp, which participates in PHINMS communicable disease reporting,
agreed to join the ePath Pilot Project, as did 20 state program
registries with the ability and willingness to use PHINMS.

The ePath pilot project delivered on all of the following goals:

1.  **Implement consistent electronic pathology reporting from a
    national laboratory to participating state central cancer
    registries.**

    -   The pilot group implemented a straightforward data flow as
        recommended in the NAACCR Electronic Pathology Reporting
        Guidelines.

    -   Use of the NAACCR standards allowed LabCorp to create an HL7
        message for each pathology report generated in its laboratory in
        a timely manner with minimal input from the NPCR‑MERP team.

    -   PHINMS proved an accurate means of securely transmitting HL7
        messages from the laboratory to the participating states.

2.  **Provide guidance to state cancer registries and pathology
    laboratories for implementing electronic pathology reporting in
    their respective environments.**

    -   The PHINMS Deployment Team worked with participating states to
        set up the technical infrastructure needed to receive electronic
        messages.

    -   The New York Cancer Registry developed a comprehensive plan for
        managing implementation of electronic pathology reporting in
        their state.

    -   The NPCR-MERP Team developed a lessons learned document for
        PHINMS and state use in future installations.

3.  **Offer new and improved capabilities for using pathology reports as
    a cancer information source.**

    -   HL7 Mapper Plus is an effective tool for retrieving HL7 messages
        from a server, validating and parsing the messages, and
        identifying relevant reports based on a list of search terms.
        NPCR provided funding for developing this tool. HL7 Mapper Plus
        is customizable and free to users.

Based on implementation experience, the ePath pilot group also
recommended the following changes to standards for reporting cancer
registry data:

-   The pilot group recommended changes to two areas of the NAACCR HL7
    Standard, which the NAACCR Pathology Data Workgroup evaluated and
    accepted

-   Comparison of the standard Logical Observations Identifiers, Names,
    Codes (LOINC) with pathology laboratory (local) codes identified a
    need for LOINC codes specific to anatomic pathology results.
    Adopting new standard codes will enable laboratories to send the
    LOINC code in addition to its local code.

Issues that require additional evaluation include the following:

-   Availability of demographic data sufficient to perform linkage with
    registry data.

-   Accurate identification of a report as a cancer case.

-   Use of electronic pathology reports in the registry.

NPCR‑MERP is continuing the ePath Pilot Project into a second phase to
--

-   Transport the process/product to other national laboratories.

-   Extend HL7 Mapper Plus functionality to include processing of
    pathology reports.

-   Begin a dialogue with the College of American Pathologists to create
    a flag indicating whether a pathology report represents a reportable
    condition.

-   Document requirements for accurate processing of electronic
    pathology reports and actively work with organizations to implement
    them.

The work performed, knowledge shared, and results gained from the
NCPR-MERP ePath pilot project highlight substantial opportunities to
improve methods of providing, receiving, and processing pathology data
for central cancer registries.

## Overview

Anatomical pathology laboratory reports are one of the most valuable
data sources for cancer registry surveillance. Approximately 95% of
cancer cases reported to the Centers for Disease Control and
Prevention's (CDC) National Program of Cancer Registry (NPCR) and the
National Cancer Institute's (NCI) Surveillance, Epidemiology, and End
Results Program (SEER) are microscopically confirmed.[^2] Traditionally,
if a cancer registry receives pathology reports they are usually in a
paper format. The Certified Tumor Registrars (CTRs) review paper forms
to identify cancer cases. This manual process is very time consuming.
With the advancements of computer technology and the movement towards an
electronic medical record, it would be beneficial for the cancer
registry to receive pathology reports securely in a standard electronic
format.

### Problem Statement

The information collected and included in the pathology laboratory
reports represents a critical data source for state cancer registries.
Currently, states lack the resources either to obtain and process paper
pathology reports or to implement their own electronic pathology
reporting systems. The need to retrieve data from the pathology report
in a more efficient and timely fashion is driving the development of an
automated electronic process for accessing and utilizing pathology
reports to identify cancer cases.

### Purpose

The National Program of Cancer Registries---Modeling Electronic
Reporting Project (NPCR‑MERP) proposed a pilot project to test the
implementation of transmitting electronic anatomical pathology reports
from a national laboratory to state central cancer registries. This
pilot project will implement electronic pathology reporting using the
approved standard in the North American Association of Central Cancer
Registries, Inc. (NAACCR) Standards for Cancer Registries, Volume V,
Pathology Laboratory Electronic Reporting, Version 2.0 and the business
rules defined in the draft NAACCR ePath Reporting Guidelines (at
[www.naaccr.org).\*]() Links to non-Federal organizations are provided
solely as a service to our users. This link does not constitute an
endorsement of this organization by CDC or the Federal Government, and
none should be inferred. The CDC is not responsible for the content of
the individual organization Web pages found at this link.

### Objectives

The NPCR‑MERP ePath pilot project has the potential to move the cancer
registry community forward in using consistent standards for electronic
pathology reporting that can improve the completeness, timeliness, and
quality of cancer registry data.

#### Goals

The following goals will help in directing the project:

-   Implement consistent electronic pathology reporting from a national
    laboratory to participating state central cancer registries.

-   Provide guidance to state cancer registries and pathology
    laboratories for implementing electronic pathology reporting in
    their respective environments.

-   Offer new and improved capabilities for using pathology reports as a
    cancer information source.

Specific goals include the following:

-   Test and document the implementation of electronic pathology
    reporting from a national laboratory to state central cancer
    registries.

-   Identify and/or develop software needed to implement electronic
    successful pathology reporting.

-   Provide guidance to state central cancer registries and pathology
    laboratories on the requirements for implementing electronic
    pathology reporting.

-   Integrate and/or reference the NAACCR ePath Transmission
    Guidelines[^3] into the model under development by NPCR's Modeling
    Electronic Reporting Project (NCPR-MERP).

### Advantages of a Pilot Project

Several advantages validate the decision to perform a pilot project:

-   Develop, test, and implement a single process that will meet the
    needs of the participating states; the laboratory will not have to
    accommodate individual state nuances which would overburden it.

-   Provide "one voice" to communicate with the laboratory to ensure
    that a consistent message is maintained.

-   Build momentum to work with other national labs on implementing
    ePath reporting to cancer registries.

-   Evaluate and implement the Public Health Information
    Network/National Electronic Disease Surveillance System (PHIN/NEDSS)
    architecture and tools to allow laboratories and registries to make
    better use of existing resources.

### Project Scope

The project focuses on the following:

-   Creating a Health Level 7 (HL7)[^4] message conforming to --

-   NAACCR standard for electronic pathology reporting using HL7
    messages.

-   NAACCR electronic pathology transmission guidelines.

-   Using PHIN Messaging System (PHINMS) standard transmission
    architecture and software because of its cross-platform capability
    and established use in reporting communicable diseases.

-   Adopting or developing software for processing HL7 messages at the
    registry.

### Project Tasks

The following tasks are defined to meet project objectives:

-   Test business rules defined in the NAACCR ePath Reporting
    Guidelines.

-   Develop and test an HL7 message that is consistent with NAACCR
    Standards Volume V, Pathology Laboratory Electronic Reporting,
    Version 2.0.

-   Review and analyze data transmitted in an HL7 format from LabCorp to
    ensure it will meet cancer registry data requirements.

-   Document issues relating to the NAACCR Standards Volume V, Pathology
    Laboratory Electronic Reporting, Version 2.0, and the ePath Business
    Rules and provide feedback to NAACCR with any modifications and/or
    enhancements that may be needed.

-   Test the existing PHINMS data transmission software for the secure
    transmission of messages.

-   Identify and test existing data translation and parsing software
    that will convert data from an HL7 format to the standard NAACCR
    file format for ePath. This should include the mapping tools that
    Minnesota and Pennsylvania developed, as well as the NEDSS Program
    Area Module (PAM) Platform software.

-   Identify an HL7 parser tool that is cost effective, easy-to-use,
    flexible, and interoperable with all state systems.

## Methods

### Laboratory and Central Registry Participation 

CDC PHIN has established a working relationship with LabCorp, Quest
Diagnostics, and Mayo Medical Laboratories, with LabCorp submitting HL7
messages for communicable diseases to approximately 25 state health
departments. NPCR‑MERP identified LabCorp as a national laboratory
willing to participate in the ePath Pilot Project.

### Central Registry Participation

NPCR‑MERP solicited program registries to obtain project commitment. The
ability and willingness to use PHINMS were required.

Twenty states joined the ePath pilot project: Alabama, Arizona,
California, Colorado, Florida, Georgia, Maryland, Michigan, Missouri,
Nevada, New Hampshire, New Jersey, New York, North Carolina, Ohio,
Oklahoma, Pennsylvania, Tennessee, Texas, and Virginia.

Figure 1 depicts the states participating in the ePath Pilot Project.

Figure 1: Participating States

### Use of PHINMS

#### The ePath Pilot Project selected PHINMS as the transmission technology. PHINMS runs on virtually all major operating system platforms and is already used by many states for communicable disease reporting. 

The CDC NPCR‑MERP collaborated with the CDC PHIN staff to identify the
infrastructure in place for electronic laboratory reporting of
communicable diseases. NPCR‑MERP compiled information about the existing
system infrastructure of each participating state and helped states
develop a list of requirements and timelines for installing and
implementing the PHINMS infrastructure (hardware and software).[^5]

Participating states worked directly with the PHIN technical support
staff to fulfill the requirements before and during implementation.
Monthly conference calls were held with LabCorp, participating state
health departments and central registries, NPCR‑MERP, and CDC-PHIN to
discuss progress, evaluate results, and develop solutions for issues.

### Development of an HL7 message parser

NPCR‑MERP evaluated the mapper tools developed by the Pennsylvania
Cancer Registry and the Minnesota Cancer Surveillance System to evaluate
current capabilities and features of existing systems. NPCR funded
development of HL7 Mapper Plus software to fit in with the existing
suite of cancer registry software products available from NPCR.

Refer to Appendix C: Mapping of LabCorp Local Test Codes to LOINC on
page [22](#appendix-c-mapping-of-labcorp-local-test-codes-to-loinc) and
Appendix D: HL7 Mapper Plus Program Version 1.0.1 on page
[27](#appendix-d-hl7-mapper-plus-program-version-1.0.1).

## Results

NPCR‑MERP implemented a straightforward data flow for the ePath Pilot
Project similar to that recommended in the NAACCR Electronic Pathology
Reporting Guidelines. LabCorp created an HL7 message for each pathology
report generated in its laboratory. The messages were grouped into an
HL7 batch message and transferred from LabCorp to the state health
department or central cancer registry using PHINMS. HL7 Mapper Plus
retrieved the batch message, parsed it into individual messages and data
element components and subcomponents and loaded the elements into a
Microsoft Sequel (MS SQL) Server or Oracle database. HL7 Mapper Plus
evaluated each message and highlighted relevant cancer terms and negated
cancer terms. Figure 2 depicts the data flow.

![](media/image3.wmf)

Figure 2: Message Flow

### Results and Conclusions - Specific Pilot Project Activities

#### HL7 Message Creation

The NPCR‑MERP team and the LabCorp representative reviewed the HL7
message specifications described in the NAACCR Standards Volume V,
Version 2.0, and the NAACCR Guidelines for Electronic Pathology
reporting to identify issues relating to the format, content or process
of creating an HL7 ePath data message. Within the NAACCR Standards
Volume V, only minimal clarification of data to be reported between the
cancer registry community and LabCorp were needed. An example was the
clarification of what data was expected to be placed in the Ordering
Facility (ORC-21) and Ordering Provider (ORC-12, OBR-16) data elements.
Comparing the definitions for these two data elements allowed the data
to be accurately placed in the message. The NAACCR Guidelines were
easily understood and applied by LabCorp with no requests for revision.

Issues relating to HL7 message specifications were resolved in a variety
of ways. Out of 106 "Required" and "Required if Available" data
elements, 7 deviations from the standard were implemented. In most
instances, deviation from the NAACCR HL7 Standard was due to LabCorp's
database design or because data items weren't available. For example,
LabCorp does not collect pathologist ID in a discrete data field and
therefore could not populate the appropriate HL7 data element. In some
instances, the NAACCR Pathology Data Workgroup was contacted to provide
additional information and rationale regarding the requirements. A
complete list of deviations and resolutions can be found in Appendix B:
Message Development Issues for LabCorp on page
[21](#appendix-b-message-development-issues-for-labcorp)*.*

Two areas resulted in a change to the NAACCR HL7 Standard:

The first change is reflected in the instructions for completing a data
element whose requirement is R\* - Required if available. The original
version of the standards stated the following:

> **"R\* = Required when available; if never available, leave as empty.
> When data are available, but missing on this instance, use default
> values as specified in this document."**
>
> At LabCorp's request, the NAACCR Pathology Data Workgroup evaluated
> and approved a revision to delete the last sentence from the
> instruction as it was labor-intensive without providing much benefit.
> R\* data elements that are not present for a particular report may be
> left empty, regardless of whether the data element is ever populated.

The second change corrected an oversight in not requiring collection of
the name of the Ordering Provider, even though their address is
required.[^6] Instructions have been added to clarify the requirement
status of Ordering Provider and Ordering Facility.

The pilot project found that LabCorp uses local codes instead of the
standard Laboratory Observation Identifiers Names and Codes (LOINC)
coding system for laboratory tests and results in the OBX-3 component
because equally specific LOINC codes were not available. Submission of
local codes as the only laboratory test code in OBX-3 is not acceptable
as it would require registries to independently create mappings for each
laboratory's specific codes. The extensive number of laboratories and
the volume of local codes being used preclude development and
maintenance of multiple maps.

The ePath pilot project workgroup worked with LabCorp to map the local
codes to LOINC codes, using more general LOINC codes when no specific
code was available. Both the mapped LOINC code and the LabCorp local
codes are reported in OBX-3. Refer to Appendix C: Mapping of LabCorp
Local Test Codes to LOINC on page
[22](#appendix-c-mapping-of-labcorp-local-test-codes-to-loinc).
NPCR‑MERP is working with three national laboratories to request that
more specific LOINC codes be created for anatomic pathology results.

#### ePath Implementation Standards 

The NAACCR standards for transmitting HL7 messages and the guidelines
for electronic pathology reporting provide comprehensive and accurate
instructions for preparing a standardized electronic pathology
report.[^7] Using the NAACCR standards allowed an HL7 message to be
created in a very timely manner with minimal input and instructions from
the NPCR‑MERP technical team. The NAACCR Pathology Data Workgroup
provided active support by responding to questions and agreeing to
revisions in two situations. While deviations from the standard did
occur, they were due to factors outside the influence of NPCR‑MERP and
NAACCR.

The NPCR‑MERP technical team should continue using these documents and
provide feedback to NAACCR during its future electronic pathology
reporting implementation projects to assist in keeping the standards
complete and insync with laboratory practices.

#### PHINMS Implementation

PHINMS proved to be an accurate means of securely transmitting HL7
messages from the laboratory to the participating states. Implementing
PHINMS proved to be very complex, requiring extensive staff resources
from both PHINMS staff and the participating states. The NPCR‑MERP
technical team presented PHINMS as a freely available method for
transmitting messages; however, there were costs for implementing
PHINMS. Costs incurred seem to reflect availability of hardware and
significant information technology (IT) support to perform the
implementation.

The New York Cancer Registry developed a comprehensive plan for managing
implementation of electronic pathology reporting in their state. The
features of this plan include the following:

-   An instruction manual tailored to their specific requirements.

-   A web page for PHINMS information that contained links to pertinent
    information (e.g., Overview of Architecture and Function, General
    Executive Summary, Installation and Configuration Instructions, How
    to Guide, and others).

-   An IT staff member who served as the subject matter expert in the
    PHINMS software and could answer installation questions from
    laboratories.

Open-source software is used to support the PHINMS. Additionally,
Internet Information Services (IIS), also standard software was used to
provide the front-end security.

The PHINMS deployment team provided technical assistance for each cancer
registry and was highly committed to getting a configuration implemented
and in production. When a registry had difficulties, the deployment team
was able to troubleshoot the complexities of this System by remotely
accessing the registry's physical PHINMS server or by using the
registry's WebEx function.

Selecting the appropriate PHINMS documentation was the most common and
frustrating challenge identified during the pilot project. Labor to
review and select documentation and follow the complex process through
to implementation was significant for all registries. Concise
documentation to determine requirements was not available, so that ePath
Pilot Project participants could not match their IT environment to the
PHINMS implementation plan documentation manuals.

The complexity, cost, and process of implementing PHINMS within the
registry's IT environment were directly dependent on whether PHINMS was
already in place, was in the implementation phase, or needed to be
initiated. Maryland and Pennsylvania withdrew from the pilot project
because they were not prepared to implement a PHINMS environment within
the pilot project timeline.

Documentation on assessing adequacy of existing infrastructure was not
available; registries proceeded with implementation and later discovered
that additional hardware and software would be needed.

Currently there is no automated acknowledgement that a message has been
received from the transmitting laboratory. This is a problem in that if
there is downtime on either the sender's or the receiver's server, there
might be files that are assumed to have been transmitted that never
reach the receiver. A mechanism to monitor logs and/or provide feedback
on the status of the transmission is needed.

The pilot project selected PHINMS version 2.6 for testing. Service packs
and newer versions of PHINMS became available during the pilot project,
some of which corrected problems registries were having during
implementation. However, the new features in PHINMS 2.7 and 2.7 SP1 were
functional upgrades, not bug fixes for PHINMS 2.6.

-   The PHINMS deployment team indicated that PHINMS requires a
    stand-alone server. A configuration of three servers was recommended
    to house PHINMS in the demilitarized zone (DMZ) and in a separate
    secured environment, and to store the database. [^8] The new servers
    required new ports, new static IP numbers, new entries into the
    Domain Name System (DNS) tables, and a new opening in the firewall.

-   Some states had difficulty with their internal IT/network
    departments in determining the cost of sharing PHINMS hardware and
    maintenance. While costs will be specific to each installation,
    registries should fully evaluate whether they will need to
    contribute financial resources to the maintenance and IT support of
    the existing PHINMS environment at their institution/department.

The NPCR-MERP technical team will develop and forward to the CDC PHINMS
Management staff a document comprising specific details on
implementation provided by the participating states. Based partially on
the difficulties experienced by registries in the ePath Pilot Project,
PHINMS is making changes that should improve the implementation process.

Future cancer registry implementations of PHINMS should include a
full-cost assessment prior to starting the implementation, a
standardized installation model and a more seamless method of handling
authentication certificates.

#### Software for processing HL7 messages at the registry

NPCR‑MERP developed HL7 Mapper Plus as a comprehensive ePath message
extraction and parsing software package to process the HL7 files
received from the Laboratory. It does the following:

-   Polls the PHINMS receiver queue to identify new incoming files;

```{=html}
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```
-   Reads an HL7 message batch file and breaks each message down into
    its segments;

-   Extracts all the data elements that have corresponding NAACCR item
    numbers and names assigned in the NAACCR Standards Volume V, Version
    2.0;

-   Scans the English text data elements (OBX-5) for occurrence of
    cancer terms.[^9]

    **Note:** Depending on the user's preference, messages with no
    cancer terms are either discarded or marked and saved to the
    database.

HL7 Mapper Plus is an effective tool for retrieving HL7 messages from a
server, validating and parsing the messages, and identifying relevant
reports based on a list of search terms. HL7 Mapper Plus successfully
performs all of the tasks identified during the project plan, is
customizable, and is freely available for use by registries.

Full documentation of HL7 Mapper Plus can be found in Appendix D: HL7
Mapper Plus Program Version 1.0.1 on page
[27](#appendix-d-hl7-mapper-plus-program-version-1.0.1). HL7 Mapper Plus
can be downloaded from <http://www.cdc.gov/cancer/npcr/tools/>.

Based on input from the work group, the product is undergoing further
development to do the following:

-   Enhance specificity in text mining.

-   Provide a user interface for translating the pathology report into
    ICD-O-3 topography and morphology codes.

-   Export messages to a standard layout format for loading reports to
    the central registry database.

-   Monitor the work queue automatically.

### Issues needing further evaluation 

#### Availability of demographic data sufficient to perform linkage with registry data

Pathology report data is of limited use if registries cannot perform
patient linkage accurately. Most registries require a combination of
patient's name, social security number, birth date, sex, and sometimes
address in order to determine whether the pathology report matches a
case already in the database. Without these fields, limited or no
linkage will be possible. The lack of ordering provider (physician or
facility) information beyond that of the provider name limits the
ability to follow back to the provider to obtain full cancer data. Many
states (due to volume of pathology reports) do not have the resources
necessary to follow back to the ordering provider (if available) to get
the necessary linkage data items and key them into a computer system.

#### Accurate identification of a report as a cancer case

Currently, registries rely on a variety of text mining methods to
determine whether the pathology report has a relevant cancer diagnosis.
All require registrar review to eliminate false positive reports.

A possible solution is to add a report flag, completed by the
pathologist, to indicate that the record represents a reportable
condition.

#### Use of electronic pathology reports in the registry

Two general methods currently exist for using electronic pathology
reports. The first method matches the electronic pathology reports to
the main database records to identify missing cancer cases. This
information is sent back to the facility or provider for reporting the
case through a routine process. The second method loads the reportable
pathology reports into the main database and is processed similarly to
other types of reports.

Evaluation of these methods as it relates to the NPCR‑MERP vision should
be considered.

### Future Plans

NPCR‑MERP is continuing the ePath Pilot Project into a second phase.
Plans for Phase II include the following activities:

-   Transport the process/product to other national laboratories.

-   Work with national laboratories and LOINC to create standard codes
    for anatomic pathology.

-   Extend HL7 Mapper Plus functionality to include processing of
    pathology reports.

-   Explore and document options for importing electronic reports into
    central cancer registry systems.

-   Begin a dialogue with the College of American Pathologists to
    initiate a reportability flag for all pathology reports, indicating
    whether the pathology report represents a reportable condition.

-   Document requirements for accurate processing of electronic
    pathology reports and actively work with organizations to implement
    them.

> As an example, the NPCR‑MERP final report would state that Social
> Security Number and date of birth are requirements for implementing
> electronic pathology reporting; it would have to note that this goes
> beyond the NAACCR requirements. The NPCR-MERP technical team would
> need to start working actively with pathology associations and
> laboratories to get their buy-in and participation for providing
> required data elements on the specimen request form.

-   Evaluate Orion Rhapsody to identify functions that can be shifted
    from HL7 Mapper Plus to the state integration broker software (such
    as retrieving and parsing HL7 Messages).

### In Summary

The work performed, knowledge shared, and results gained from the
NCPR-MERP ePath pilot project highlight substantial opportunities to
improve methods of providing, receiving, and processing pathology data
for central cancer registries. The ePath Pilot Project demonstrated the
NAACCR standards can be successfully implemented in a national
laboratory that is required to report to multiple registries. It also
demonstrated that PHINMS, the transfer tool developed for use by the
communicable disease program, can be implemented as effectively in the
cancer registration program. Additionally, a software tool for
processing the HL7 message from a laboratory was developed and released
for use by registries.

## Annotated Glossary of Electronic Pathology Components

+-------------+-------------------+-------------------+---------------+
| Component   | Definition        | Options           | Comments      |
+=============+===================+===================+===============+
| **IMPL      | Methods, steps    | **NAACCR**        | [ww           |
| EMENT-ATION | and rules for     |                   | w.naaccr.org] |
| G           | implementing an   | **E-Path          | (http://www.n |
| UIDELINES** | electronic        | Guidelines**      | aaccr.org/)\* |
|             | pathology         |                   |               |
|             | reporting         |                   |               |
|             | (E-Path) System.  |                   |               |
+-------------+-------------------+-------------------+---------------+
| **MESSAGE** | Format in which   | NAACCR **HL7**    | Recommended   |
|             | data is recorded. | Standard          | format for    |
|             |                   |                   | submitting    |
|             |                   |                   | data.         |
+-------------+-------------------+-------------------+---------------+
|             |                   | NAACCR **ASCII**  | Alternate     |
|             |                   | Standard          | format for    |
|             |                   |                   | submitting    |
|             |                   |                   | data.         |
+-------------+-------------------+-------------------+---------------+
| *           | Transfer message  | **PHINMS**        | Open source   |
| *SUBMISSION | between           |                   | software to   |
| PROCESS**   | laboratory and    |                   | securely      |
|             | registry.         |                   | transfer any  |
|             |                   |                   | type of file  |
|             |                   |                   | from one      |
|             |                   |                   | entity to     |
|             |                   |                   | another.      |
+-------------+-------------------+-------------------+---------------+
| **PARSER**  | A software        | **NPCR Mapper     | Open source   |
|             | application that  | Plus**            | software to   |
|             | interprets an HL7 |                   | map the HL7   |
|             | batch message,    |                   | message to    |
|             | separating it     |                   | the NAACCR    |
|             | into individual   |                   | ASCII file    |
|             | messages and      |                   | format so     |
|             | discrete data     |                   | that the      |
|             | elements, which   |                   | records can   |
|             | then may be       |                   | be inserted   |
|             | translated,       |                   | into a        |
|             | stored in a       |                   | database.     |
|             | database and/or   |                   |               |
|             | further           |                   |               |
|             | processed.        |                   |               |
+-------------+-------------------+-------------------+---------------+
|             |                   | **Registry        | Registries    |
|             |                   | Specific**        | may choose to |
|             |                   |                   | use their own |
|             |                   |                   | existing      |
|             |                   |                   | method of     |
|             |                   |                   | processing    |
|             |                   |                   | the HL7 file  |
|             |                   |                   | so that the   |
|             |                   |                   | records can   |
|             |                   |                   | be inserted   |
|             |                   |                   | into a        |
|             |                   |                   | database.     |
+-------------+-------------------+-------------------+---------------+
| **CASE      | Identifies which  | **NAACCR**        |               |
| IDENT       | reports relate to | **Search Term     |               |
| IFICATION** | cancer.           | List**            |               |
+-------------+-------------------+-------------------+---------------+
|             |                   | **SNOMED CT       |               |
|             |                   | Codes**: 80000 -- |               |
|             |                   | 99999             |               |
+-------------+-------------------+-------------------+---------------+
|             |                   | **SEER ICD-O-3    |               |
|             |                   | Selection         |               |
|             |                   | Criteria**        |               |
+-------------+-------------------+-------------------+---------------+
|             |                   | **Others:**       | Registries    |
|             |                   |                   | may choose to |
|             |                   | ICD-9,            | use their own |
|             |                   | ICD-10**,**       | methods/tools |
|             |                   | ICD-O-3,          | for           |
|             |                   | Pathologist       | identifying   |
|             |                   | indicator.        | reports that  |
|             |                   |                   | relate to     |
|             |                   | Registry specific | cancer.       |
+-------------+-------------------+-------------------+---------------+

## Appendix A: Description of an HL7 Message

### Message Segments

The NAACCR *Standards for Cancer Registries Volume V. Pathology
Laboratory Electronic Reporting, Version 2.0* establishes the HL7
**"Observation Report-Uninitiated (ORU)"** message as the standard for
submitting pathology reports electronically. Each ORU message consists
of[^10]:

-   **a Message Header** (**MSH) segment**, which describes information
    about the file,

-   **a Patient Identifier (PID) segment,** which describes patient
    characteristics/demographic information;

-   **one or more Common Order (ORC) segments,**[^11] describing the
    characteristics of the test order;

-   **one or more Observation Request (OBR) segments**, providing
    information about the results;

-   **one or more Observation/Results (OBX)** **segments**, the results
    of the test.

### Field Components

OBR/ORC segments are reported in pairs, with each pair having one or
more OBX results segments. Each segment consists of several fields; a
field may be simple (only one component) or complex (multiple
components).

A simple data type contains only one value.

> Example: PID-6: Date/Time of Birth\
> Only one data value is reported in this field: the patient's birth
> date/time.\
> E.g. \|19370408\| is reported for a patient whose birthday is April 8,
> 1937.

A complex data type field is divided into components; components, in
turn, may be further divided into sub-components if they are of complex
data type themselves.

> Example: PID-11 Patient Address is a complex field. Included in the
> one field is the --

-   Street Address

-   Other Designation

-   City

-   State or Province

-   ZIP or Postal Code

-   Country

-   Address Type

-   Other geographic Designation

-   County/Parish Code

-   Census Tract

-   Address Representation Code

> E.g., \|1245 Peachtree Avenue\^Apt
> 4C\^Atlanta\^Georgia\^30341\^USA\^M\^\^DeKalb \^\^A\|

Refer to NAACCR *Standards for Cancer Registries* *Volume V. Pathology
Laboratory Electronic Reporting, Version 2.0* for a complete description
of the concepts and requirements for reporting pathology reports using
HL7.

[http://www.naaccr.org/filesystem/pdf/Standards%20Volume%20V%20Final%20PDF%201-24-06.pdf](http://www.naaccr.org/filesystem/pdf/Standards Volume V Final PDF 1-24-06.pdf)\*

## Appendix B: Message Development Issues for LabCorp

+-------+-----------------+--------------------+----------------------+
| HL7   | Data Element    | Problem            | Resolution           |
| Se    |                 |                    |                      |
| gment |                 |                    |                      |
+=======+=================+====================+======================+
| PID   | 3: Patient ID   | Not always         | Will report when     |
|       |                 | received from      | available.           |
|       |                 | ordering client.   |                      |
+-------+-----------------+--------------------+----------------------+
| PV1   | All data        | Existing HL7       | Segment not          |
|       | elements        | message that       | submitted.           |
|       |                 | LabCorp is using   |                      |
|       |                 | as a template does |                      |
|       |                 | not include this   |                      |
|       |                 | segment.           |                      |
+-------+-----------------+--------------------+----------------------+
| ORC   | 12: Ordering    | Not available for  | LabCorp to report    |
|       | Provider        | this field.        | data in ORC-21 and   |
|       |                 |                    | ORC-22.[^12]         |
|       |                 |                    |                      |
|       |                 |                    | NAACCR changed       |
|       |                 |                    | requirement to       |
|       |                 |                    | required (R\*).      |
+-------+-----------------+--------------------+----------------------+
|       | 24: Ordering    | Physician name     | Reported in ORC-21   |
|       | Physician[^13]  | available only     | and ORC-22 when      |
|       |                 | when client is an  | available.           |
|       |                 | individual         |                      |
|       |                 | physician          |                      |
|       |                 | practice.          |                      |
+-------+-----------------+--------------------+----------------------+
| OBR   | 16: Ordering    | Physician name     | Reported in ORC-21   |
|       | Physician       | available only     | and ORC-22 when      |
|       |                 | when client is an  | available.           |
|       |                 | individual         |                      |
|       |                 | physician          |                      |
|       |                 | practice.          |                      |
+-------+-----------------+--------------------+----------------------+
|       | 32: Pathologist | Not maintained in  | Will be provided     |
|       | Name            | a discrete field   | with in OBX-5 text.  |
|       |                 | in the database.   |                      |
|       |                 |                    | LabCorp recommended  |
|       |                 |                    | requirement status   |
|       |                 |                    | be changed to        |
|       |                 |                    | required (R\*).      |
+-------+-----------------+--------------------+----------------------+
| OBX   | 3: Observation  | LOINC codes not    | LOINC codes will be  |
|       | Identifier      | always available;  | reported when        |
|       |                 | some codes are     | available.           |
|       |                 | local codes.       |                      |
|       |                 |                    | A list of LabCorp's  |
|       |                 |                    | local codes and      |
|       |                 |                    | definitions will be  |
|       |                 |                    | provided.            |
+-------+-----------------+--------------------+----------------------+

## Appendix C: Mapping of LabCorp Local Test Codes to LOINC

  ----------- ------------ ---------------- --------- ------------ ---------- ----------------- --------------
  **LabCorp                                                                                     
  Test Panel                                                                                    
  500918:                                                                                       
  Pathology                                                                                     
  Report**                                                                                      

  **LabCorp   **LabCorp    **LabCorp Full   **LOINC   **Status**   **NAACCR   **NAACCR Data     **Comments**
  Specific    Specific     English Name**   code**                 Data Item  Item Name**       
  Results     Result                                               \#**                         
  Code**      Code +                                                                            
              Abbrev**                                                                          

  500920      500920 -     Material         22633-2   Mapped       7420       Nature of          
              MATER        Submitted                                          Specimen          

  500943      500943 -     Clinician        22637-3   Mapped       7360                         LabCorp will
              CICD-9       provided ICD-9:                                                      provide local
                                                                                                code and text
                                                                                                description to
                                                                                                identify
                                                                                                clinician vs.
                                                                                                pathologist
                                                                                                result ICD9-CM
                                                                                                code.

  500921      500921 --    Pre-operative    22636-5   Mapped       7410       Path-Clinical     
              PREOP        diagnosis:                                         History           

  500922      500922 --    Post-operative             Mapped       none                          
              POSTOP       diagnosis:                                                           

  500923      500923 --    Clinical         22636-5   Mapped       7410       Path\--Clinical   
              CLHIST       history:                                           History           

  500937      500937 - OR  O/R consult:                            none                          
              CON                                                                               

  500934      500934 --    Frozen section                          none                          
              FROSEC       diagnosis:                                                           

  500924      500924 -     Amended report:                                                      No data being
              AMEN RP                                                                           reported in
                                                                                                this field.

  500942      500942 - P   Preliminary                             none                          
              DIAG         diagnosis:                                                           

  500927      500927 - F   Diagnosis:       22637-3   Mapped       7450       Path\--Final       
              DIAG                                                            Diagnosis         

  500928      500928 --    Comment:         22638-1   Mapped       7460       Path\--Comment     
              CMNT                                                            Section           

  500925      500925 --    Addendum:        35265-8   Mapped       7470       Path\--Suppl       
              ADDEND                                                          Reports           

  500938      500938 --    Diagnosis                               N/A                          Internal
              DIAG         provided by:                                                         code - will
                                                                                                not appear in
                                                                                                client
                                                                                                pathology
                                                                                                reports.
  ----------- ------------ ---------------- --------- ------------ ---------- ----------------- --------------

  ----------- ------------ ---------------------------------- --------- ------------ ---------- ---------------- --------------
  **LabCorp   **LabCorp    **LabCorp Full English Name**      **LOINC   **Status**   **NAACCR   **NAACCR Data    **Comments**
  Specific    Specific                                        code**                 Data Item  Item Name**      
  Results     Result                                                                 \#**                        
  Code**      Code +                                                                                             
              Abbrev**                                                                                           

  500929      500929 --    Electronically signed:             19139-5   Mapped       7260,      Pathologist Last 
              SIGNED                                                                 7270,      Name,            
                                                                                     7290, 7280 Pathologist      
                                                                                                First Name,      
                                                                                                Pathologist      
                                                                                                Middle Name,     
                                                                                                Pathologist Name 
                                                                                                Suffic           

  500930      500930 --    Gross description:                 22634-0   Mapped       7430       Path\--Gross      
              GROSSD                                                                            Pathology        

  500931      500931 --    Microscopic:                       22635-7   Mapped       7440       Path\-- Micro     
              MICROD                                                                            Pathology        

  500932      500932 --    Previous material submitted:                                                          No data being
              PREVIO                                                                                             reported in
                                                                                                                 this field.

  500935      500935 - SP  Special procedure:                                        none                         
              PRO                                                                                                

  500933      500933 --    Transcriptionist:                                         none                         
              TRANS                                                                                              

  500936      500936 --    Report reviewed by:                                       none                         
              REPREV                                                                                             

  191144      191144 - QA  QA comment:                                               N/A                         Internal
              COM                                                                                                code - will
                                                                                                                 not appear in
                                                                                                                 client
                                                                                                                 pathology
                                                                                                                 reports.

  500940      500940 -     Pathologist Provided ICD-9:        22637-3   Mapped       7360       Path\--ICD-CM    LabCorp will
              PICD-9                                                                            Code             provide local
                                                                                                                 code and text
                                                                                                                 description to
                                                                                                                 identify
                                                                                                                 clinician vs.
                                                                                                                 pathologist
                                                                                                                 result ICD9-CM
                                                                                                                 code.

  500941      500941 --    CPT                                49560-6   Mapped       7380       Path\--CPT Codes Need to strip
              CPT                                                                                                last digit off
                                                                                                                 CPT Code.

  **LabCorp                                                                                                      
  Test Panel                                                                                                     
  191189: Gyn                                                                                                    
  Report**                                                                                                       

  **LabCorp   **LabCorp    **LabCorp Full English Name**      **LOINC   ** **        **NAACCR   **NAACCR Data    **Comments**
  Specific    Specific                                        code**                 Data Item  Item Name**      
  LOINC**     LOINC +                                                                \#**                        
              Abbrev**                                                                                           

  ** **       ** **        ** **                              ** **     ** **        ** **      ** **            ** **

  191121      191121 --    Test ordered:                                             none                         
              ORDER                                                                                              

  191158      191158 --    \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*                            none                         
              ASTERI                                                                                             

  191108      191108 --    DIAGNOSIS:                         22637-3   Mapped       7450       Path\--Final      
              DIAGN                                                                             Diagnosis        

  191111      191111 --    Recommendation:                    22638-1   Mapped       7460       Path\--Comment    
              RECOMM                                                                            Section          

  191109      191109 --    Specimen adequacy:                                        none                         
              ADEQ                                                                                               

  191159      191159 --    \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*                          none                         
              ASTERI                                                                                             

  191154      191154 --    Source:                            22633-2   Mapped       7420       Nature of         
              SOURCE                                                                            Specimen         

  191160      191160 -     Clinician provided ICD9:           22637-3   Mapped                                   LabCorp will
              CICD-9                                                                                             provide local
                                                                                                                 code and text
                                                                                                                 description to
                                                                                                                 identify
                                                                                                                 clinician vs.
                                                                                                                 pathologist
                                                                                                                 result ICD9-CM
                                                                                                                 code.
  ----------- ------------ ---------------------------------- --------- ------------ ---------- ---------------- --------------

  ------------ ------------ ---------------------------------------- --------- ------------ ---------- ----------------- --------------
  **LabCorp    **LabCorp    **LabCorp Full English Name**            **LOINC   **Status**   **NAACCR   **NAACCR Data     **Comments**
  Specific     Specific                                              code**                 Data Item  Item Name**       
  Results      Result                                                                       \#**                         
  Code**       Code +                                                                                                    
               Abbrev**                                                                                                  

  191107       191107 --    Clinical history:                        22636-5   Mapped       7410       Path\--Clinical    
               CLHIST                                                                                  History           

  191124       191124 --    Amended report:                                                                              No data
               AMEND                                                                                                     reported in
                                                                                                                         this field.

  191110       191110 --    Additional comment:                      22638-1   Mapped       7460       Path\--Comment     
               COMM                                                                                    Section           

  191125       191125 --    Addendum:                                35265-8   Mapped       7470       Path\--Suppl       
               ADDEND                                                                                  Reports           

  191123       191123 -- MI Maturation index:                                               none                          

  191112       191112 --    Performed by:                                                   none                          
               PERFOR                                                                                                    

  191128       191128 - QC  QC reviewed by:                                                 none                          
               REV                                                                                                       

  191145       191145 --    Diagnosis provided by:                                          N/A                          Internal
               DXPROV                                                                                                    code - will
                                                                                                                         not appear in
                                                                                                                         client
                                                                                                                         pathology
                                                                                                                         reports.

  191113       191113 --    Electronically signed by:                19139-5   Mapped       7260,      Pathologist Last  
               SIGNED                                                                       7270,      Name, Pathologist 
                                                                                            7290, 7280 First Name,       
                                                                                                       Pathologist       
                                                                                                       Middle Name,      
                                                                                                       Pathologist Name  
                                                                                                       Suffic            

  191139       191139 - SP  Special procedure:                                              none                          
               PRO                                                                                                       

  191129       191129 --    Cytology history:                                               none                          
               CYHIST                                                                                                    

  191144       191144 --    QA comment:                                                     N/A                          Internal
               COMM                                                                                                      code - will
                                                                                                                         not appear in
                                                                                                                         client
                                                                                                                         pathology
                                                                                                                         reports.

  019018       019018 --    . (management reporting bucket)                                 N/A                          Internal
               COMM                                                                                                      code - will
                                                                                                                         not appear in
                                                                                                                         client
                                                                                                                         pathology
                                                                                                                         reports.

  191157       191157 -     Pathologist provided ICD9:               22637-3   Mapped       7360       Path\--ICD-CM     LabCorp will
               PICD-9                                                                                  Code              provide local
                                                                                                                         code and text
                                                                                                                         description to
                                                                                                                         identify
                                                                                                                         clinician vs.
                                                                                                                         pathologist
                                                                                                                         result ICD9-CM
                                                                                                                         code.

  **LabCorp                                                                                                              
  Test Panel                                                                                                             
  191114: Fine                                                                                                           
  Needle                                                                                                                 
  Aspirate**                                                                                                             

  **LabCorp    **LabCorp    **LabCorp Full English Name**            **LOINC   ** **        **NAACCR   **NAACCR Data     **Comments**
  Specific     LOINC +                                               code**                 Data Item  Item Name**       
  LOINC**      Abbrev**                                                                     \#**                         

  191131       191131 --    Specimen type:                           22633-2   Mapped       7420       Nature of          
               SPECTY                                                                                  Specimen          

  191153       191153 --    Source:                                  22633-2   Mapped       7420       Nature of          
               SOURCE                                                                                  Specimen          

  191160       191160 -     Clinician provided ICD9:                 22637-3   Mapped                                    LabCorp will
               CICD-9                                                                                                    provide local
                                                                                                                         code and text
                                                                                                                         description to
                                                                                                                         identify
                                                                                                                         clinician vs.
                                                                                                                         pathologist
                                                                                                                         result ICD9-CM
                                                                                                                         code.

  191158       191158 --    \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*                          none                          
               ASTERI                                                                                                    

  191136       191136 --    DIAGNOSIS:                               22637-3   Mapped       7450       Path\--Final       
               DIAG                                                                                    Diagnosis         
  ------------ ------------ ---------------------------------------- --------- ------------ ---------- ----------------- --------------

  ----------- ------------ ---------------------------------------- --------- ------------ ---------- ----------------- --------------
  **LabCorp   **LabCorp    **LabCorp Full English Name**            **LOINC   **Status**   **NAACCR   **NAACCR Data     **Comments**
  Specific    Specific                                              code**                 Data Item  Item Name**       
  Results     Result                                                                       \#**                         
  Code**      Code +                                                                                                    
              Abbrev**                                                                                                  

  191165      191165 --    Recommendation:                          22638-1   Mapped       7460       Path\--Comment     
              RECOMM                                                                                  Section           

  191142      191142 --    Comment:                                 22638-1   Mapped       7460       Path\--Comment     
              COMM                                                                                    Section           

  119159      119159 --    \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*                          none                          
              ASTERI                                                                                                    

  191157      191157 -     Pathologist provided ICD9:               22637-3   Mapped       7360       Path\--ICD-CM     LabCorp will
              PICD-9                                                                                  Code              provide local
                                                                                                                        code and text
                                                                                                                        description to
                                                                                                                        identify
                                                                                                                        clinician vs.
                                                                                                                        pathologist
                                                                                                                        result ICD9-CM
                                                                                                                        code.

  191132      191132 --    Clinical history:                        22636-5   Mapped       7410       Path\--Clinical    
              CLHIST                                                                                  History           

  191134      191134 --    Amended report:                                                                              No data
              AMEND                                                                                                     reported in
                                                                                                                        this field.

  191135      191135 --    Addendum:                                35265-8   Mapped       7470       Path\--Suppl       
              ADDEND                                                                                  Reports           

  191150      191150 --    Diagnosis provided by:                                          N/A                          Internal
              DXPROV                                                                                                    code - will
                                                                                                                        not appear in
                                                                                                                        client
                                                                                                                        pathology
                                                                                                                        reports.

  191137      191137 --    Signed out by:                                                  7260,      Pathologist Last  
              SIGNED                                                                       7270,      Name, Pathologist 
                                                                                           7290, 7280 First Name,       
                                                                                                      Pathologist       
                                                                                                      Middle Name,      
                                                                                                      Pathologist Name  
                                                                                                      Suffic            

  191138      191138 --    Performed by:                                                   none                          
              PERFOR                                                                                                    

  191133      191133 --    Gross description:                       22634-0   Mapped       7430       Path\--Gross       
              GROSS                                                                                   Pathology         

  191168      191168 --    Microscopic description:                 22635-7   Mapped       7440       Path\-- Micro      
              MICRO                                                                                   Pathology         

  191143      191143 - SP  Special procedure:                                              none                          
              PRO                                                                                                       

  191144      191144 - QA  QA comment:                                                     N/A                          Internal
              COM                                                                                                       code - will
                                                                                                                        not appear in
                                                                                                                        client
                                                                                                                        pathology
                                                                                                                        reports.

  019018      019018 --    . (management reporting bucket)                                 N/A                          Internal
              COMM                                                                                                      code - will
                                                                                                                        not appear in
                                                                                                                        client
                                                                                                                        pathology
                                                                                                                        reports.

  **LabCorp                                                                                                             
  Test Panel                                                                                                            
  191106                                                                                                                
  Non-GYN                                                                                                               
  Report**                                                                                                              

  **LabCorp   **LabCorp    **LabCorp Full English Name**            **LOINC   ** **        **NAACCR   **NAACCR Data     **Comments**
  Specific    LOINC +                                               code**                 Data Item  Item Name**       
  LOINC**     Abbrev**                                                                     \#**                         

  ** **       ** **        ** **                                    ** **     ** **        ** **      ** **             ** **

  191115      191115 --    Specimen type:                           22633-2   Mapped       7420       Nature of          
              SPECTY                                                                                  Specimen          

  191152      191152 --    Source                                   22633-2   Mapped       7420       Nature of          
              SOURCE                                                                                  Specimen          

  **LabCorp   **LabCorp    **LabCorp Full English Name**            **LOINC   **Status**   **NAACCR   **NAACCR Data     **Comments**
  Specific    Specific                                              code**                 Data Item  Item Name**       
  Results     Result                                                                       \#**                         
  Code**      Code +                                                                                                    
              Abbrev**                                                                                                  

  191160      191160 -     Clincian provided ICD9:                  22637-3   Mapped       7360                         LabCorp will
              CICD-9                                                                                                    provide local
                                                                                                                        code and text
                                                                                                                        description to
                                                                                                                        identify
                                                                                                                        clinician vs.
                                                                                                                        pathologist
                                                                                                                        result ICD9-CM
                                                                                                                        code.

  191158      191158 --    \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*                          none                          
              ASTERI                                                                                                    

  191118      191118 --    DIAGNOSIS:                               22637-3   Mapped       7450       Path\--Final       
              DIAGN                                                                                   Diagnosis         

  191165      191165 --    Recommendation:                          22638-1   Mapped       7460       Path\--Comment     
              RECOMM                                                                                  Section           

  191140      191140 --    Comment:                                 22638-1   Mapped       7460       Path\--Comment     
              COMM                                                                                    Section           

  191159      191159 --    \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*                          none                          
              ASTERI                                                                                                    

  191157      191157 -     Pathologist provided ICD9:               22637-3   Mapped       7360       Path\--ICD-CM     LabCorp will
              PICD-9                                                                                  Code              provide local
                                                                                                                        code and text
                                                                                                                        description to
                                                                                                                        identify
                                                                                                                        clinician vs.
                                                                                                                        pathologist
                                                                                                                        result ICD9-CM
                                                                                                                        code.

  191117      191117 --    Clinical history:                        22636-5   Mapped       7410       Path\--Clinical    
              CLHIST                                                                                  History           

  191126      191126 --    Amended report:                                                                              No data
              AMEND                                                                                                     reported in
                                                                                                                        this field.

  191127      191127 --    Addendum:                                35265-8   Mapped       7470       Path\--Suppl       
              ADDEND                                                                                  Reports           

  191147      191147 --    Diagnosis provided by:                                          N/A                          Internal
              DXPROV                                                                                                    code - will
                                                                                                                        not appear in
                                                                                                                        client
                                                                                                                        pathology
                                                                                                                        reports.

  191119      191119 --    Signed out by:                                                  7260,      Pathologist Last  Pathologist
              SIGNED                                                                       7270,      Name, Pathologist Name.
                                                                                           7290, 7280 First Name,       
                                                                                                      Pathologist       
                                                                                                      Middle Name,      
                                                                                                      Pathologist Name  
                                                                                                      Suffic            

  191120      191120 --    Performed by:                                                   none                          
              PERFOR                                                                                                    

  191116      191116 --    Gross description:                       22634-0   Mapped       7430       Path\--Gross       
              GROSS                                                                                   Pathology         

  191156      191156 --    Microscopic description:                 22635-7   Mapped       7440       Path\-- Micro      
              MICROS                                                                                  Pathology         

  191141      191141 - SP  Special procedure:                                              none                          
              PRO                                                                                                       

  191144      191144 - QA  QA comment:                                                     N/A                          Internal
              COM                                                                                                       code - will
                                                                                                                        not appear in
                                                                                                                        client
                                                                                                                        pathology
                                                                                                                        reports.

  019018      019018 -     . (management reporting bucket)                                 N/A                          Internal
              COMM                                                                                                      code - will
                                                                                                                        not appear in
                                                                                                                        client
                                                                                                                        pathology
                                                                                                                        reports.
  ----------- ------------ ---------------------------------------- --------- ------------ ---------- ----------------- --------------

## Appendix D: HL7 Mapper Plus Program Version 1.0.1

### Introduction

The HL7 Mapper Plus program reads Health Level 7 (HL7) Message batch
files, parses messages, and stores various HL7 data elements as discrete
field values into tables in the Pathlab database. In a typical setting,
the PHIN Messaging System (PHINMS) sends HL7 batch files from a
laboratory to a cancer registry or some other agency working on a cancer
registry's behalf.

The HL7 Mapper Plus program is installed on a workstation at a cancer
registry and polls the worker queue of the PHINMS receiver for any new
incoming files. When a new file arrives in the queue, the application
identifies and processes the file, and then returns to waiting mode for
the arrival of a new file. HL7 Mapper Plus can also be used in an
interactive mode where the user can manually select a file to parse and
import into the Pathlab database.

During import, depending upon user settings in Configuration, the
software checks messages for any cancer terms contained in the OBX-5
texts of the messages, and highlights the terms in a rich-text formatted
report that are available for user review after the import is complete.

### Pathlab Database

HL7 Mapper Plus imports HL7 batch files, parses the messages, and stores
HL7 data elements of interest to tables in the Pathlab database. A
mapping table, called datamap, contains the mapping definition of HL7
data elements to fields within tables (refer to Local Customization
section below to see how individual states can use this table to select
additional data items for storage).

There are seven data tables, MSH, PV1, PID, ORC, OBR, OBX, and
OBXCOMBINEDTEXT, the first six of which correspond to the six segments
of the ORU\^01 message. HL7 components and subcomponents can be
individually stored in the registry database. The hierarchical
relationships among segments are maintained in the database.

To simplify processing and use of data, in addition to the OBX table
which stores data elements of individual OBX segments as separate
records, the text field (OBX-5) of all OBX segments that belong to (are
children of) an OBR segment are combined and inserted as one row in the
OBXCOMBINEDTEXT table. This table has eight fields to store text of the
OBX segments. Depending on the LOINC code that exists in the OBX-3
field, the text of OBX-5 is stored in one of these eight text fields. If
OBX-5 texts from multiple OBX segments are mapped to one field they are
concatenated.

The actual messages in the HL7 format are stored in the HL7Messages
table.

[^1]: HL7 Version 2.3.1 is used for this pilot project.

[^2]: Menck H, Deapen D, Phillips J, Tucker T. Central Cancer
    Registries: Design, Management and Use, Second Edition. Dubuque, IA:
    Kendall/Hunt Publishing Company, 2007.

[^3]: NAACCR Electronic Pathology Reporting Guidelines, 2006:
    http://www.naaccr.org/index.asp?Col_SectionKey=7&Col_ContentID=122

[^4]: HL7 Version 2.3.1 is used for this pilot project.

[^5]: Detailed description of PHINMS can be found at
    <http://www.cdc.gov/phin/software-solutions/phinms/>

[^6]: In HL7 2.3.1 these data elements are located in the Common Order
    Segment (ORC). ORC-12 -- Ordering Provider; and ORC-24 -- Ordering
    Provider Address.

[^7]: North American Association of Central Cancer Registries, Inc.
    (NAACCR) Standards for Cancer Registries, Volume V, Pathology
    Laboratory Electronic Reporting, Version 2.0; NAACCR Electronic
    Pathology Reporting Guidelines, 2006:
    <http://www.naaccr.org/index.asp?Col_SectionKey=7&Col_ContentID=122>\*.

    NAACCR Electronic Pathology Reporting Guidelines; Dec, 2006

[^8]: If the organization does not have a DMZ, only two servers are
    required: one for the PHINMS software, and one for MS-SQL.

[^9]: Pathology report English text is located in the Observation/Result
    Segment (OBX), specifically OBX-5.

[^10]: The ORU message has other segments available; however, they are
    optional for NAACCR electronic pathology reports and not discussed
    here.

[^11]: ORC segment is optional in the NAACCR HL7 message; however,
    LabCorp provides this segment in its HL7 message to cancer
    registries.

[^12]: ORC-21 carries ordering facility name (medical facility where
    specimen was obtained), facility's local number or AHA identifier,
    or other national identifier, and should be placed in the third
    component \<ID number (NM)\> ORC-22 carries ordering facility
    address

[^13]: ORC-24 carries ordering provider address (name in ORC-12)---the
    address of the care provider requesting the order