Coding for pathology tests - strengths and weaknesses

Laboratory professionals will increasingly find themselves called upon to assist with the coding of pathology test requests and reported results in the era of the e-Health Record (EHR). EHR users from outside pathology, including patients and clinicians, will expect seamless integration of pathology services, and question variations in test nomenclature, units, reference intervals, and interpretive comments. Scientists and pathologists will need to be ready to work with colleagues outside their traditional scientific disciplines, along with IT and terminology experts, to resolve illogical historical variations, highlight differences that might endanger patient safety, and help lay the foundations for evolving e-health systems that enhance healthcare without eroding the interpretive value of pathology reports from different laboratories. An overview of medical terminologies and Australasian eHealth harmonisation programs is also provided.