Download - RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Page 1: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

RSNA 2007 – Course 039

Electronic Reports:

HL7 CDA (Clinical Document Architecture)

and DICOM SR (Structured Reporting)

Harry SolomonGE Healthcare

DICOM WG 8 Structured Reporting

HL7 Structured Documents TC

DICOM WG 20 / HL7 Imaging Integration SIG

IHE Cross-Domain Reporting Task Force

Page 2: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Disclosure• Harry Solomon

– Employee, GE Healthcare

Page 3: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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 O’Donnell – IHE Reporting Task Force

Page 4: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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

Page 5: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Key Elements ofRadiology Reporting

Page 6: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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 radiologist’s time

Typical busy radiologist at

Northwestern Memorial Hospital

Page 7: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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)

Page 8: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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 radiologist’s time– Potential negative impact with transition from traditional

dictation workflow– Radiologist pays the cost for improvements downstream

Page 9: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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)

Page 10: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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HL7 Clinical Document

ArchitectureOverview

HL7 is a Standards Development Organization

whose domain is clinical and administrative data

Page 11: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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.

Page 12: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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

Page 13: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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CDA Use Cases• Diagnostic and therapeutic procedure reports

• Encounter / discharge summaries

• Patient history & physical

• Referrals

• Claims attachments

• Consistent format for all clinical documents

Page 14: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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)

Page 15: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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

Page 16: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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CDA Release 2 Information Model

Header Body

ParticipantsSections/Headings

Clinical Statements/Coded Entries

ExtlRefsContext

Doc ID&Type

StartHere

Page 17: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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.

Page 18: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Sample CDA

Page 19: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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

Page 20: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Narrative and Coded Entry

Example

Page 21: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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CDA Non-XML Body• Alternative to XML Structured Body

• Standard CDA header “wraps” existing document

• Any MIME type– Especially PDF (IHE Scanned Document Profile)

Page 22: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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

Page 23: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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DICOM Structured ReportingOverview

DICOM is a Standards Development Organization

whose domain is biomedical imaging

Page 24: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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.

Page 25: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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

Page 26: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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

Page 27: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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DICOM SR and the FiveClinical 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

Page 28: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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

Page 29: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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SR Content Item Tree

Root Content Item

Document Title

Content Item Content Item Content Item

Content Item Content Item 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

Content Item Content Item

Page 30: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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DICOM SR Example

Page 31: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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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

Page 32: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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DICOM Encapsulated Document• Complementary to DICOM Structured Reporting

• Standard DICOM header “wraps” existing document– Allows use of DICOM infrastructure – object exchange,

archive (PACS), query/retrieve

• Only specific document types allowed– PDF– CDA

Page 33: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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PDF (Adobe®

Portable Document Format)• Neither CDA nor SR guarantee exact visual reproduction

of a displayed document, which may be a legal requirement in some locales

• PDF allows exact visual reproduction, and display software is readily available

• Role for PDF as a presentation-ready equivalent rendering of a coded document

• Both CDA and DICOM support wrapping PDF with their standard header, so a presentation-ready PDF can be managed in the same environment with cross-links to the original coded document– Also supports legacy documents scanned into PDF

Page 34: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Radiology ReportingWorkflows

Page 35: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Reporting Starts Before the Radiologist Sees the Study

• Reason for exam (from order)• Technical aspects of procedure

– Protocol– Exam notes from tech

• Post-processing results– Measurement and analysis applications (e.g., vascular,

obstetric, cardiac) by tech– Computer Aided Detection results

• These need to get to the radiologist and integrated into the report– Produced on modality or imaging workstation

Page 36: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Reporting Integration (1)• Review study evidence

– Order and relevant clinical information– Images and relevant priors– Tech notes and post-processing results

• Radiologist interpretation – on imaging workstation– Annotation (virtual grease pencil)– Key image selection– Measurement and analysis applications by radiologist

• Radiologist findings reporting – on a different system?– Structured data entry (forms-based)– Dictation + transcription

Where’s Waldo going to prepare his report?

Page 37: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Reporting Integration (2)• Report assembly

– Findings and selected evidence/interpretation results

• Radiologist signature– Auditable action, or digital encryption-based

• Report communication– To referring physician– To “secondary” users (billing!)

• Report archive– And subsequent access

Page 38: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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The DICOM Solution?• DICOM was supposed to take care of all this, and has

(almost) all the requisite features and network services

• DICOM SR has found vital uses in key subspecialty areas that produce structured data in the examination or post-processing

– Leveraging the DICOM infrastructure is easy and desirable

– Results managed with other study evidence

• But the end recipients of radiology reports, referring physicians, commonly use systems without DICOM capabilities (imaging or SR)

Page 39: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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“Evidence” and “Reports”• Evidence Documents

– Includes measurements, procedure logs, CAD results, etc., created in the imaging context, and together with images are interpreted by a radiologist to produce a report

– The radiologist may quote or copy parts of Evidence Documents into the report, but doing so is part of the interpretation process at his discretion

– Appropriate to be stored in PACS as DICOM SR objects, with same (legal/distribution) status as images

• Reports – Become part of the patient’s medical record, with

potentially wide distribution– Ideal match to HL7 CDA, but sometimes SR is appropriate

Page 40: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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DICOM-HL7 Synergy (1)• SR and CDA developed simultaneously

• DICOM and HL7 working groups recognized the need to work together

• DICOM SR and HL7 CDA are congruent in key areas– Document persistence

– Document identification, versioning and type code

– Document’s relation to the patient and to the authoring physicians

• SR strength in robust image-related semantic content; CDA strength in human readable narrative report

• DICOM WG10 (Strategic Advisory) suggested composing radiology reports directly in CDA format when appropriate

Page 41: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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DICOM-HL7 Synergy (2)• References to CDA documents from within DICOM

objects, and vice versa• Include CDA documents on DICOM removable disks

– As native CDA files, or encapsulated in a DICOM file– Indexed in DICOMDIR for integration with DICOM applications

• PDF rendering of SR can be wrapped in a CDA document

• Transcoding between SR and CDA feasible for limited subset of reports

• CDA Implementation Guide for Diagnostic Reporting in development

Page 42: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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The Role of IHE• Industry-wide effort to “make it work”

• Real world use cases drive standards-based approach to integration– Practical evolution from current architectures

• Venue for testing implementations and interoperability

• Reporting is a high priority task for Radiology Domain

• Your participation is welcome!

Page 43: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Reporting Profiles• Documented workflow profiles

– IHE Evidence Documents Profile– IHE Key Image Notes Profile– DICOM Part 17 Dictation-Based Reporting with Image

References [Supplement 101]

• Ongoing work in IHE Reporting Task Force and Radiology Technical Committee– Revise IHE Simple Image and Numeric Report Profile,

consolidate with Post-processing and Reporting Workflow Profiles

– Align with Retrieve Information for Display and Cross-Enterprise Document Sharing Profiles

Page 44: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

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Usercontrol

Diagnostic reporting

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

Image Viewing Application

Reporting Application

PACSArchive

Information System

Diagnosticreport

Report

ImageSources

Orders,Prior

Reports

DiagnosticImages

Viewingsettings

Page 45: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

45

Reportwith imagereferences &annotation

Usercontrol

Reporting with annotation(use case - desired)

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

Image Viewing Application

Reporting Application

PACSArchive

Information System

Diagnosticreport

ImageSources

DiagnosticImages

Imagereferences

& annotation

Viewingsettings

Orders,Prior

Reports

Page 46: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

46

Usercontrol

Reporting with annotation(what’s available)

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

Image Viewing Application

Reporting Application

PACSArchive

Information System

Diagnosticreport

Report

ImageSources

DiagnosticImages

Viewing settings,image references& annotation

Imagereferences

& annotation

Orders,Prior

Reports

Page 47: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

47

Diagnosticreport

Integrated solutionImage Viewing &

Reporting Application

Integrated PACS &Information System

ImageSources

Orders,Diagnostic images

& Prior reports

Viewing settings,Reports, imagereferences & annotation

Imagereferences

& annotation

******************************************************************************** UNIVERSITY OF CHICAGO HOSPITALS RADIOLOGY CONSULTATION342 02/05/96BHIS #: 1234567 INPATIENT 201-23-90Hematology / Oncology CHANDLER, CAROLYNMitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIAClinical data: Biliary tube check. Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed& Int -- Exam #47 on 02/05/96

FINDINGS: As above. IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumorgrowth.

Simon A. Templar, MD / Richard Nixon, MD (R19) Signed 02/9/96 at 8:48 AM3

******************************************************************************** UNIVERSITY OF CHICAGO HOSPITALS RADIOLOGY CONSULTATION342 02/05/96BHIS #: 1234567 INPATIENT 201-23-90Hematology / Oncology CHANDLER, CAROLYNMitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIAClinical data: Biliary tube check. Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed& Int -- Exam #47 on 02/05/96

FINDINGS: As above. IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumorgrowth.

Simon A. Templar, MD / Richard Nixon, MD (R19) Signed 02/9/96 at 8:48 AM3

Usercontrol

Page 48: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

48

Usercontrol

Loosely integrated reporting

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

Image Viewing Application

Reporting Application

PACSArchive

Information System

Diagnosticreport

Report

ImageSources

DiagnosticImages

Viewing settings,image references& annotation

Imagereferences

& annotation

Image references& annotation

Image retrieval

Orders,Prior

Reports

Report w/ image ref & annot

Page 49: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

Transcribednarrative

Verification

Imageselection

Annotation

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

********************************************************************************

UNIVERSITY OF CHICAGO HOSPITALS

RADIOLOGY CONSULTATION

342 02/05/96

BHIS #: 1234567 INPATIENT 201-23-90

Hematology / Oncology CHANDLER, CAROLYN

Mitchell-6NE 49 FEMALE

Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA

Clinical data: Biliary tube check.

Carl M. Gompers, MD

Change Perc Biliary Drainage Cath Proced -- Exam #46 on 01/08/96

COMPARISON: 07/23/95 and 06/27/95

FINDINGS: After the procedure was explained to the patient and informed

& Int -- Exam #47 on 02/05/96

FINDINGS: As above.

IMPRESSION:

Successful biliary tube change, and findings consistent with interval tumor

growth.

Simon A. Templar, MD / Richard Nixon, MD (R19)

Signed 02/9/96 at 8:48 AM

3

Image Viewing Application Reporting Application

Image Archive(DICOM SCP)

Reporting SystemValidation Functions

Dictatedreport

DICOMKO object“For Report”

DICOM Query/Retrieve for all KO objects matching Accession Number

WADOServer

Reporting Integration Functions

CDAReport

WADO URI references toImages with GSPSs (JPEG rendering)

DICOMGSPS object (annotations)

DICOMEncapsulated CDA object

Page 50: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

50

Other Use Cases to be Profiled• All the basic elements are standardized and ready to be

fit into integrated reporting workflows– Need consensus approaches to specific use cases (IHE)

• Quantitative measurement intensive reporting with DICOM SR inputs

– Mammo with CAD input, Obstetric with sonographer measurements, Cardiac with functional assessments

– DICOM SR as primary report with PDF wrapped in CDA as distributed version?

• Selected key measurements imported into report (loosely coupled architecture)

– Similar to Key Image / Annotation workflow– Possible push model of key measurements to RIS?

Page 51: RSNA 2007 – Course 039 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) Harry Solomon GE Healthcare DICOM.

51

Conclusions• CDA now viewed as a primary format for diagnostic

imaging reports– Definition of CDA DI report to be done in 2008 by a

balloted HL7 Implementation Guide – Method is extensible to reports with more structure

• DICOM SR will see continued and expanding use for Evidence Documents created in the imaging setting– IHE Evidence Documents Integration Profile

• Evolutionary workflows utilizing both standards in coordination are being profiled by IHE – Does not require tight integration of imaging and

reporting workstations