Standardisation of test requesting and reporting for the electronic health record

• Review of standardisation for pathology test requesting and reporting interoperability
• Interoperability is two parties, either human or machine, able to exchange information with preserved shared meaning.
• This is needed to make healthcare safer, more efficient and more effective.
• It is dependent on consensus.
• Much has been done, but much remains to be done.

This paper is a review of the standardisation required to achieve interoperability for pathology test requesting and reporting. Interoperability is the ability of two parties, either human or machine, to exchange data or information in a manner that preserves shared meaning. This is needed to make healthcare safer, more efficient and more effective. Interoperability requires standardisation around: transmission of data; identification policies; information structures; common terminology; common understanding; and behavioural agreement. It is dependent on consensus. Each of these aspects is considered from the perspective of pathology requesting and reporting concluding that while much has been done, much remains to be done.