Requirements for Information Communication (2007 Edition)

Scope

Page last updated: 14 January 2008

This document covers the communication of pathology information between pathology requesters, consumers and laboratories. It emphasises the role of the laboratory and defines the boundary of responsibility of the laboratory and its processes.

Throughout this document, practices considered desirable to improve safety, security and privacy, consistent with best practice, have been identified within guidelines and commentary. However, a laboratory may be limited in its ability to influence requesting doctors to implement desirable practices.

Laboratory responsibilities are confined to activities within the laboratory and where there is interaction with external bodies, as described in Figure 1.

Figure 1 Laboratory messaging in context


Figure 1 : Flowchart "Laboratory messaging in context"
The laboratory is responsible for acting when:
  • a request and specimen is collected from a requester or delivered to the laboratory
  • a request is received from a requester via a consumer (e.g. presentation of patient with request form at collection centre)
  • an enquiry is received from a third party
  • a request is received for additional testing on an existing sample.
The laboratory is considered to have fulfilled its responsibility when:
  • for routine reports, a result has been sent and a transport acknowledgment has been received (delivery of result by electronic means only)
  • for urgent reports, a result has been sent and there has been clinical acknowledgment, or clinical application acknowledgment. That is, it is certain the requesting practitioner or proxy has received it (any mode of communication)
  • for ‘amended final report’, if there is variation in the result that is clinically significant, the laboratory has treated the amended final report as an urgent report.
An electronic request which is yet to become a referral is outside the scope of this document.

Several methods of pathology communication can be identified for requests, reports, and interlaboratory and intralaboratory communication, including:
  • physical delivery of paper documents, with manual data entry
  • telephoning
  • faxing, with manual data entry
  • short messaging service (SMS) text messaging
  • electronic file transfer on physical media
  • remote access to the pathology system by direct dial-in or web access
  • electronic messaging using standard protocols
  • access via a third-party data repository (e.g. cancer registries).
To facilitate the secure and private transmission of pathology requests and reports, laboratories must be able to ensure the confidentiality, integrity (including authenticity) and availability (collectively known as information security) of messages received and sent. This includes recording, storing and, where required, archiving messages. Each method introduces its own particular risks. Addressing these risks requires attention to information security risk management. Australian Standards AS/ISO17799 Information Security Management and HB174 Information Security Management Implementation Guide for the Health Sector provide guidance on this.

In ensuring risks are well managed, systems managers should pay particular attention to:
  • manual data entry of request form information
  • address (destination) requirements for transmitted information
  • authentication where remote access is granted
  • appropriate security during transmission and receipt.
Unique request numbers generated by requesting systems provide the most reliable method of correlating requests and reports, especially when identifying information does not match or reports do not match requests.

AS4700.2 Implementation of Health Level Seven1 recommends a method for correlating requests, specimens, results, add-on tests, and reflex tests.

AS5017 Health Care Client Identification provides guidance on patient identification and data matching.

1 AS4700.2 Implementation of Health Level Seven (HL7), version 2.3.1 part 2: Pathology requests and results section 5.6, HL7 encoding of pathology orders and reports.