1.0 Introduction

The purpose of this document is to define the vocabulary for either message-based or document-based laboratory results reporting. The goals supported by this terminology Component specification are stated in the AHIC Electronic Health Records (EHR) Laboratory Results Reporting Use Case:

Deploy standardized, widely available, secure solutions for accessing laboratory results and interpretations in a patient-centric manner for clinical care by authorized parties

Provide the following functionality for laboratory results reporting and notification, and is applicable to many types of laboratory tests, including but not limited to: clinical chemistry, hematology, serology and microbiology

The Use Case notes that there are obstacles to achieving the stated goals. In particular, the following obstacle is delineated:

Lack of harmonization among data interoperability standards including vocabulary, laboratory and other messaging standards

This Lab Result Terminology Component is the result of a considered assessment of the terminologies available and the current practices in electronic laboratory results reporting for the purpose of moving forward in the harmonization of those terminologies. Without standard terminologies, interoperability is severely limited. This specification describes the vocabularies needed to implement the communication of an electronic standards-based laboratory result. A guiding principle for these selections was to follow the Consolidated Heath Informatics (CHI) Initiative standards selections as appropriate. The following sections describe the selected terminologies, the events that are supported by those standards and the reason for their selection. Also described are the organizations that maintain the standards and where to obtain more information.

This Component specification is part of a series of documents to establish Interoperability Standards for laboratory results reporting.

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2009 ANSI. This material may be copied without permission from ANSI only if and to the extent that the text is not altered in any fashion and ANSIs copyright is clearly noted.