RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR...

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Transcript of RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR...

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RSNA 2007 Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM WG 8 Structured Reporting HL7 Structured Documents TC DICOM WG 20 / HL7 Imaging Integration SIG IHE Cross-Domain Reporting Task Force Slide 2 2 Disclosure Harry Solomon Employee, GE Healthcare Slide 3 3 Acknowledgements Fred Behlen, co-author of a previous version of this presentation Fred Behlen, Bob Dolin, Liora Alschuler, Calvin Beebe co- chairs of HL7 Structured Documents Technical Committee, and authors of presentations on CDA used in this talk Dave Clunie former co-chair of DICOM Standards Committee, and author of the definitive book on DICOM Structured Reporting Kevin ODonnell IHE Reporting Task Force Slide 4 4 Objectives Understand the key elements for effective radiology reporting, and issues with electronic reporting Understand the HL7 CDA (Clinical Document Architecture) and its use cases Understand DICOM SR (Structured Reporting) and its use cases Understand reporting workflows, the use of DICOM SR and HL7 CDA in those workflows, and the importance of the IHE (Integrating the Healthcare Enterprise) effort Slide 5 5 Key Elements of Radiology Reporting Slide 6 6 Paper or Electronic Reports Accurately convey the findings to the referring physician Reflect the competence of the radiologist Timely communication for patient care Archived in the patient medical record Legal record of imaging exam Radiologist signature Support secondary uses Charge capture and billing Teaching and research Clinical data registries, clinical trials Process improvement Produced making best use of radiologists time Typical busy radiologist at Northwestern Memorial Hospital Slide 7 7 Benefits and challenges of Electronic Reports (1) Accuracy +Drive for quality improvement with quantitative data, CAD and other measurements +Possible major benefit with attached key images and graphical analysis (picture = 1000 words) Will systems support graphical reports? Timely communication +Probable improvement Archived in the patient medical record Where is the electronic medical record? (distributed, multiple copies) Slide 8 8 Benefits and challenges of Electronic Reports (2) Legal record What is a valid electronic signature? Is an exact visual reproduction required, or only exact semantic content? Secondary uses +Huge potential improvement, especially with structured and coded data Use of radiologists time Potential negative impact with transition from traditional dictation workflow Radiologist pays the cost for improvements downstream Slide 9 9 This is Process Re-engineering! Transition to electronic reports is hard New systems New architectures New policies and procedures Organizationally disjunct costs/benefits Minimize the risk and the effort A standards-based approach Incremental evolution from current workflow Leverage the work of IHE (Integrating the Healthcare Enterprise) Slide 10 10 HL7 Clinical Document Architecture Overview HL7 is a Standards Development Organization whose domain is clinical and administrative data Slide 11 11 HL7 Clinical Document Architecture The scope of the CDA is the standardization of clinical documents for exchange. A clinical document is a record of observations and other services with the following characteristics: Persistence Stewardship Potential for authentication Wholeness Human readability A CDA document is a defined and complete information object that can exist outside of a message, and can include text, images, sounds, and other multimedia content. Slide 12 12 Clinical Document Characteristics Persistence Documents exist over time and can be used in many contexts Stewardship Documents must be managed, shared by the steward Potential for authentication Intended use as medico-legal documentation Wholeness Document includes its relevant context Human readability Essential for human authentication Slide 13 13 CDA Use Cases Diagnostic and therapeutic procedure reports Encounter / discharge summaries Patient history & physical Referrals Claims attachments Consistent format for all clinical documents Slide 14 14 Key Aspects of the CDA CDA documents are encoded in Extensible Markup Language (XML) CDA documents derive their meaning from the HL7 v3 Reference Information Model (RIM ) and use HL7 v3 Data Types A CDA document consists of a header and a body Header is consistent across all clinical documents - identifies and classifies the document, provides information on patient, provider, encounter, and authentication Body contains narrative text / multimedia content (level 1), optionally augmented by coded equivalents (levels 2 & 3) Slide 15 15 CDA Standard Release 1 (2000) Standalone standard Based on early draft v3 RIM Level 1 narrative and multimedia Release 2 (2005) Incorporated into HL7 v3 Standard (Normative Edition) Level 2 structured narrative and multimedia, plus Level 3 coded statements Implementation Guides HL7 Care Record Summary (CRS) ASTM/HL7 Continuity of Care Document (CCD) IHE Patient Care Coordination Templates Slide 16 16 CDA Release 2 Information Model HeaderBody Participants Sections/ Headings Clinical Statements/ Coded Entries Extl RefsContext Doc ID &Type Start Here Slide 17 17 CDA Structured Body Structured Body Section Text Section Text Section Text Section Text Section Text Section Text Entry Coded statement Entry Coded statement Entry Coded statement Arrows are Act Relationships Has component, Derived from, etc. Entries are coded clinical statements Observation, Procedure, Substance administration, etc. Slide 18 18 Sample CDA Slide 19 19 Narrative and Coded Info CDA structured body requires human-readable Narrative Block, all that is needed to reproduce the legally attested clinical content CDA allows optional machine-readable coded Entries, which drive automated processes Narrative may be flagged as derived from Entries Textual rendering of coded entries content, and contains no clinical content not derived from the entries General method for coding clinical statements is a hard, unsolved problem CDA allows incremental improvement to amount of coded data without breaking the model Slide 20 20 Narrative and Coded Entry Example Slide 21 21 CDA Non-XML Body Alternative to XML Structured Body Standard CDA header wraps existing document Any MIME type Especially PDF (IHE Scanned Document Profile) Slide 22 22 CDA Implementation Guides Published by HL7 Care Record Summary encounter notes, discharge summary Continuity of Care Document transfer of care (harmonized with ASTM Continuity of Care Record) Published by IHE Patient Care Coordination Emergency Department Referral Pre-procedure History and Physical Scanned Documents Personal Health Record Extract Basic Patient Privacy Consents Antepartum Summary Emergency Department Encounter Summary Slide 23 23 DICOM Structured Reporting Overview DICOM is a Standards Development Organization whose domain is biomedical imaging Slide 24 24 DICOM Structured Reporting The scope of DICOM SR is the standardization of documents in the imaging environment. SR documents record observations made for an imaging-based diagnostic or interventional procedure, particularly those that describe or reference images, waveforms, or specific regions of interest. Slide 25 25 SR Use Cases Radiology reports with robust image / ROI references Measurements/analyses made on images Computer-aided detection results Notes about images (QC, flag for specific use, quick reads) Procedure logs for imaging-based therapeutic procedures Image exchange manifests Slide 26 26 Use Case Common Features Structured Lists and hierarchies Numeric measurements, coded values Automatically extractable for database, data mining Relationships between items Hierarchical, or arbitrary reference Power of rich semantic expression References to images, waveforms, other objects Collected in DICOM environment Explicit contextual information Unambiguous documentation of meaning Slide 27 27 DICOM SR and the Five Clinical Document Characteristics The five characteristics: Persistence: SR objects are persistent Stewardship: SR objects are managed and can identify their steward Potential for authentication: SR has digital signature capability Wholeness: SR objects include their relevant context Human readability: DICOM requires SR objects to be rendered completely and unambiguously, but this needs a conformant application SR emphasizes coded semantic content (especially in relation to images), while CDA emphasizes human readable text through simple XML style sheets Slide 28 28 Key Aspects of DICOM SR SR documents are encoded using DICOM standard data elements and leverage DICOM network services (storage, query/retrieve) SR uses DICOM Patient/Study/Series information model (header), plus hierarchical tree of Content Items Extensive mandatory use of coded content Allows use of vocabulary/codes from non-DICOM sources Templates define content constraints for specific types of documents / reports Slide 29 29 SR Content Item Tree Root Content Item Document Title Content Item Arrows are parent-child relationships Contains, Has properties, Inferred from, etc. Content Items are units of meaning Text, Numeric, Code, Image, Spatial coordinates, etc. Content Item Slide 30 30 DICOM SR Example Slide 31 31 DICOM SR Object Classes Basic Text - Narrative text with image references Enhanced and Comprehensive - Text, coded content, numeric measurements, spatial and temporal ROI references CAD - Automated analysis results (mammo, chest, colon) Key Object Selection (KO) - Flags one or more images Purpose (for referring physician, for surgery ) and textual note Used for key image notes and image manifests (in IHE profiles) Procedure Log - For extended duration procedures (e.g., cath) Radiation Dose Report - Projection X-ray; CT Slide 32 32 DICOM Encapsulated Document Complementary to DICOM Structured