Imaging Diagnostic Report (Phase II) - Proposal

1. Proposed Workitem: Imaging Diagnostic Report – Phase II

• Proposal Contributors: Kevin O’Donnell, Tarik Alkasab, Ignacio Jauregui, Ana Kostadinovska, Bas van den Heuvel
• Workitem Editor: Kevin O’Donnell
• Domain: Radiology

Summary

Imaging Diagnostic Report (IDR) left detailed encoding of the Findings section Out Of Scope for Phase I. Addressing that would support more complete coding of report data, a variety of automation functions for radiologists, and better clinical databasing. Also, work is needed to harmonize the IDR IG and the HL7 Europe Imaging Report IG motivated by EHDS.

The Findings work will primarily leverage the hierarchical Observation resource and Radelement/CDE work on finding "sets". The harmonization work will be primarily based on the two FHIR Implementation Guides (IGs) for IDR and the HL7 Europe activity.

An updated IDR Profile IG will be produced with revisions and more detail on Findings. A European National/Regional Extension may result for details that remain after convergence work. possible.

HL7 EU Imaging project members have expressed interest in harmonization. RSNA RadElement participants will be involved in review and possibly development.

Establishing international core Profiles with coordinated National Extensions as necessary is central to the value of IHE.

2. The Problem

The IDR Profile defines a FHIR encoding of an imaging diagnostic report. To meet scoping constraints, it focussed on a distributable report that enables automation and support functions for the primary customer of the report, the referring physician. This involved profiling the structure and primary metadata and the impressions and recommendations sections in relative detail to facilitate clinical decision support, easier ordering of appropriate follow-up scans, application of relevant clinical guidelines, etc.

A detailed profiling of the Findings section of the report was deferred to “Phase II” since it is more complex, has a wider range of content, and arguably, serves a different primary customer, the subsequent radiologist/imaging clinician. For the referring physician use case, virtually all finding content of interest is present in the Impression section. For the radiologist, coded finding content could provide significant value in terms of efficient workflow and report quality. See Use Case (below) for some target functionality.

A second challenge is the emergence of multiple imaging report specifications with conflicting requirements and guidance. A standardized, uniform, encoding/format for imaging reports is, of course, highly desirable for systems that receive, display, process, database, and implement automations based on those reports. Creating and distributing reports with encoding variations increases implementation effort and reduces interoperability.

It would be beneficial for the groups involved to meet together to harmonize key technical details, resulting in a core global specification with (hopefully minimal) national/regional extensions that allow implementations to more easily understand and handle unavoidable variations. Specifically, there have been discussions with members of the HL7 EU Imaging Report Working Group about the possibility of harmonization efforts.

3. Key Use Case

Imaging “Problem List”

Tarik Alkasab has promoted the concept of an “imaging problem list” which consists of a compilation of the observations and conclusions from the imaging history of a given patient. This compilation would likely be prepared for each study on the reading worklist to support the pending interpretation process by the imaging clinician.

A key premise is that in general many findings from prior reports represent details that the current imaging clinician should weigh in on or at least mention in the current report, and specifically, past data on active issues is relevant and useful, and we should facilitate awareness and consumption of that information by the imaging clinician.

Possible functions a coded “problem list” might facilitate include:

• supporting protocoling of the current exam (views, scan range, contrast, technique) to facilitate effective follow-up of pertinent “problem list” items
• preparing a concise summary of the patients imaging history for the imaging clinician
• highlighting topics the imaging clinician has not commented on (completeness)
• identifying and/or automatically performing current measurements to mirror prior measurements
• plotting/presenting trends over time for certain details

Other simpler use cases also exist but are likely addressed by the tools for this one.

EHDS/XtEHR Use Case

Some of the differences in the HL7 EU Imaging specification are likely driven by interpreting particular data requirements in the European eHealth Network guidelines, which in turn are driven by a primary use case of cross-border request and retrieval of imaging studies and imaging reports by a health professional. Confirmation and clarification of the use case(s) will be an important part of harmonization and national/regional extension partitioning. E.g. the EU inclusion of all image-producing clinical specialities in scope, specifically including pathology, dental and surgery.

4. Standards and Systems

• IHE IDR Profile (Phase I)
• HL7 EU Imaging Report IG
• RadElement/CDE (Clinical Data Elements) Sets
  • At a technical level, a key aspect of encoding findings is the clustering of related observations (e.g. the dimensions, volume, margins, shape, etc of a tumor). Significant work on the semantics of such clusters has already been done in the form of “CDE Sets” in the RadElement project at RSNA.

5. Discussion

• There is some discussion underway in IHE Europe about publishing the HL7 EU specifications as IHE specifications

5. Technical Approach

Actors

• No new actors anticipated. Would use actors in IDR.

Transactions

• (NEW) May finish fleshing out the Store/Query/Retrieve skeleton that appears in IDR Phase I.

Profile

• Use Case for Radiologist Findings History/Problem List
• Use Case for EHDS Imaging Study Sharing (Reports)
• Concept Section for Findings Information Model
• Content Section for encoding Findings (with some examples)
• Vol 4 for residual regional details

Decisions/Topics/Uncertainties

• Observation Resource usage to encode hierarchical finding sets.
• Radelement/CDE Sets as models of clinical finding structures and value patterns
• Various points of harmonization (See IDR-HL7EU comparison Sheet for starters)
• EHDS/XtEHR background sync

6. Support & Resources

Members of the HL7 EU Imaging WG have agreed to participate and work on harmonizing the specifications.

Will reach out to suggested EHDS participants (Andreas Klingler from Siemens and Janos Vincze from GEHC who are presumably also engaging in the MADO work)

Members of the RSNA CDE activity are being contacted also.

It would be good to recruit some reporting vendors (as both creators and in the case of the Priors use case, as consumers)

7. Risks

• Scope creep if we try to claim broader imaging report coverage such as pathology, interventional imaging, etc.
• Several key updates to DiagnosticReport to better expand support beyond lab/etc to imaging report usage/use cases are part of the R6 ballot which FHIR is still trying to complete.
• For several key Resources (ImagingSelection, BodyStructure, Communication) FHIR will likely still not be normative in R6.

8. Tech Cmte Evaluation

Effort Evaluation (as a % of Tech Cmte Bandwidth):

• xx% for MUE
• yy% for MUE + optional

Editor:

Kevin O'Donnell

SME/Champion:

TBA <typically with a technical editor, the Subject Matter Expert will bring clinical expertise; in the (unusual) case of a clinical editor, the SME will bring technical expertise>