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HL7 CDA and DICOM SR Diagnostic Imaging Reports

HL7 CDA and DICOM SR Diagnostic Imaging Reports. Helmut Koenig, MD SIEMENS AG – Healthcare Sector Co-Chairman DICOM WG20 / HL7 Imaging Integration WG. HL7 CDA and DICOM SR Diagnostic Imaging Reports. Introduction Motivation

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HL7 CDA and DICOM SR Diagnostic Imaging Reports

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  1. HL7 CDA and DICOM SR Diagnostic Imaging Reports Helmut Koenig, MD SIEMENS AG – Healthcare SectorCo-Chairman DICOM WG20 / HL7 Imaging Integration WG

  2. HL7 CDA and DICOM SR Diagnostic Imaging Reports • Introduction • Motivation • Comparison of Structured Document Standards: DICOM SR vs. HL7 CDA Rel.2 • Facilitation of Document Exchange between Imaging and Information Systems • Use Cases / Scenarios • Scope of SR Transformation Guide / CDA Implementation Guides • Conclusions • Strategies for Document Exchange DICOM International Conference & Seminar

  3. Introduction (1) • Structured Documents: • Provide the basis for extended search capabilities through: • Defined document structure and contents (e.g. through XML elements and attributes) • Use of terminologies (contolled vocabulary, defined semantics of concepts) • Individual and inter-individual evaluation of: • Outcome of imaging studies / procedures • Diagnoses… CDA Snippet: <observation classCode="DGIMG" moodCode="EVN"> <id root= “SOP Instance UID” /> <code code="SOP Class UID " codeSystem="1.2.840.10008.2.6.1“ codeSystemName="DCMUID" displayName="Computed Radiography Image Storage“/> … <effectiveTime value="20060823223232"/> </observation> DICOM International Conference & Seminar

  4. Introduction (2) • Goal: Leverage Communication of Document-Based Imaging Results for Coordination of Clinical Tasks • Multiple Specialties in Intra- and Cross-Institutional Settings • Provision of Relevant Images, Image-Based Quantitative Measurements and Interpretation Results for Planning Diagnostic and Therapeutic Activities • DICOM WG20 created a set of harmonized Structured Document Standards • DICOM Supplement 135 „SR Diagnostic Imaging Report Transformation Guide” which will be included in the new DICOM part 20 “Transformation of DICOM to and from HL7 Standards” • HL7 CDA Diagnostic Imaging Report (DIR) Implementation Guide (focus: diagnostic imaging procedures) • HL7 CDA Procedure Note Implementation Guide (focus: image-guided interventions) DICOM International Conference & Seminar

  5. Comparison DICOM SR / HL7 CDA R2 • Structure of DICOM SR and HL7 CDA R2: • Analysis of SR Basic Diagnostic Imaging Report (Template 2000): • Essential Metadata, Document Structure, SR Imaging Service Data and Context Information can be represented and mapped to CDA R2. Not only as narrative text, but as structured document content. • Minimal Context Information on Subject (Patient/Fetus), Observer (Person/Device) and Procedure has been identified DICOM SR HL7 CDA R2 DICOM International Conference & Seminar

  6. Comparison DICOM SR / HL7 CDA R2 DICOM International Conference & Seminar

  7. Reporting Workflow: Terms & Definitions • Evidence Document • Uninterpreted Information (Primarily Managed and Used Inside the Imaging Department) • Non-Image Information such as Measurements, CAD Results • Used in the Process of Creating a Radiological Diagnostic Report • Radiological Diagnostic Report • Interpreted Information, Primary Output of the Radiology Department • “Evidence Documents may be used either as additional evidence for the reporting physician or in some cases for selected items in the Evidence Document to be included in the diagnostic report.” • Clinical Document • May contain Results and Diagnoses from various Clinical Specialties • Radiological Diagnostic Report may be included in the Clinical Document DICOM International Conference & Seminar

  8. Reporting Workflow: Use Cases / Scenarios CDA = Clinical Document Architecture DIR = Diagnostic Imaging Report KOS = Key Object Selection SR = Structured Reporting DICOM International Conference & Seminar

  9. Original CDA R2 RMIM • Document Header • Related Acts: Encounter, Order, Parent • Document… • - Participations: PatientRole, Author… • Document Body • Section with Narrative Text • Structured Section Entries • External References Section DICOM International Conference & Seminar

  10. CDA Document Key Elements <ClinicalDocument> ... <!--HEADER (PARTICIPATIONS, RELATED ACTS)--> <structuredBody> <section> <text></text> <!--NARRATIVE BLOCK--> </section> <section> <text>...</text> <entry> <!--STRUCTURED ENTRIES--> <observation>…</observation> </entry> </section> </structuredBody> </ClinicalDocument> DICOM International Conference & Seminar

  11. Sample CDA Diagnosting Imaging Report (1) DICOM International Conference & Seminar

  12. Sample CDA Diagnosting Imaging Report (2) DICOM International Conference & Seminar

  13. Constrained CDA Model for Imaging Reports • Clinical Document Header • Relevant Participations (author, legal authenticator…) • Relevant document related acts (parent document, order, service event…) • Subject (record target/patient) and observer context (author) • Structured Body • Sections as top-level structure within structured body • Special DICOM object catalog section (information on all DICOM objects referenced within the document) • Section text (narrative block) contains attested content of the document • Relevant Clinical Statement Entries: “Observation” (Text and Code), “Procedure” and “Act” (part of procedure context) • entryRelationship Types used: “component”, “reason”, “subject”, “support” • WADO references to relevant DICOM objects (i.e. images) DICOM International Conference & Seminar

  14. Numeric Measurements and Image References • CDA R2 Structured Representation DICOM International Conference & Seminar

  15. Conclusions • Represention of Essential SR Imaging Service Data and Context Information in CDA R2 is Possible • Document and Observation Context • Preservation of Structural Information, i.e. for Measurements based on Image Data and their Interpretation • Reuse of Identified Patterns for Other Document Types • Mapping Supports Communication of Structured Imaging Results and Diagnoses to HL7 Speaking Information Systems • Next Steps: • Work on RSNA CDA Report Templates in Cooperation with DICOM WG8 DICOM International Conference & Seminar

  16. Acknowledgments • Contributions to Documents and Sample Materials: • L. Alschuler, R. Geimer, F. Behlen, PhD: CDA Diagnostic Imaging Report (DIR) Implementation Guide • D. Donker, PhD: CDA Sample Document + XSL Stylesheet • David S. Channin, MD: Basis for SR Sample Document, Sample Images • B. Dolin, MD and Members of HL7 Structured Documents WG: Guidance on CDA Standard and Term Info Patterns DICOM International Conference & Seminar

  17. References http://medical.NEMA.org/ http://www.HL7.org/ http://www.IHE.net/ Thank you for your attention ! DICOM International Conference & Seminar

  18. Backup Slides DICOM International Conference & Seminar

  19. Glossary Acronyms: CDA = Clinical Document Architecture DIR = Diagnostic Imaging Report GSPS = Grayscale Softcopy Presentation State KOS = Key Object Selection RMIM = Refined Message Information Model (HL7 Version 3) SOP = Service Object Pair SR = Structured Reporting WADO = Web Access to DICOM Persistent Object (DICOM Part 18) Terms & Definitions: • Evidence Document • Uninterpreted Information (Primarily Managed and Used Inside the Imaging Department) • Non-Image Information such as Measurements, CAD Results • Used in the Process of Creating a Radiological Diagnostic Report • Radiological Diagnostic Report • Interpreted Information, Primary Output of the Radiology Department • “Evidence Documents may be used either as additional evidence for the reporting physician or in some cases for selected items in the Evidence Document to be included in the diagnostic report.” • Clinical Document • May contain results and diagnoses from various clinical specialties • Radiological Diagnostic Report may be included in the Clinical Document DICOM International Conference & Seminar

  20. Clinical Summary Report Clinical Clinical Patient Medical History / Relevant Document Document Prior Documents HL7 Message 2b) Imaging Report Import (Transcoded for Inclusion into CDA Clinical Summary Report) * * Specialized Image Data Order Diagnostics/ Post - Processing Interventions Derived Image Obser - Image Data vations Data * 1a) Evidence Doc Export (for CDA Imaging Report) SR - > CDA Rel.2 Transcoding Evidence Document 2a) SR Imaging Report Export (for CDA Clinical Summary Report) CCOW Access Interpretation * Convey relevant information of clinical document Observations Conclusions Diagnoses On one or more imaging procedures 1b) Evidence Doc Import (Transcoded for Inclusion into CDA Imaging Report) , HL7 CDA Imaging Report DICOM SR DICOM Reporting Strategy DICOM International Conference & Seminar

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