Structured Reporting Content and Transport

Proposed Workitem: Structured and Coded (Synoptic) Radiology Report Content Profile

• Proposal Editor: Kinson Ho/McKesson and Teri Sippel Schmidt/Karos Health teri.sippel@karoshealth.com with RSNA RIC committee members, Cancer Care Ontario, and other SIIM Members (see below)
• Editor: Kinson Ho (McKesson) and Teri Sippel Schmidt (Karos Health)
• Domain: Radiology

The Problem

== Note: This profile proposal has been modified in two ways since the 2015 profile proposal: 1.) the scope (number of use cases) has been severely limited (to two from seven) and 2.) transport method(s) have been added.

The intent of this profile proposal is to further profile DICOM/HL7 Part 20 (Sup 155) for structured reporting. This would include identifying Actors, Transactions, and Named Options, etc. The intent is to be able to test Part 20 at an IHE Connectathon.

DICOM Part 20 does not address transport mechanisms of the CDA, but transport mechanisms (XDS, FHIR, DICOM wrapped pdf and/or HL7 v2 ORU) would be included in this profile.

In this 2016 proposal, this profile has been limited to the identification of the 5 sections of the CDA report as defined in Part 20. A named Option will be specified to be able to include the Actionable Findings section. Other Use Cases (such as Radiology Recommendations, Quantitative (and coded) Measurements, etc.) will be not be specified currently, however, the intent is that a framework has been put into place to add additional named Options for the other CDA sections and entries in the future, after we have gained more experience and evaluated vendor uptake.

Clinical problem statement:

Today, radiology reports, unlike pathology and some cardiology reports, are typically text blobs sent in an HL7 v2 ORU or a text blob wrapped in a CDA. The reports are not structured to ensure that they are complete for the end user, for billing, population health analysis, radiation exposure monitoring, etc. They are not coded such that a computer system can act upon them and make them searchable. The intent of a coded and structured report is to create a better report for the ordering physician and make the reports actionable by a computer.

Additionally, RSNA, ECR, and CCO have put a substantial amount of money, time, and effort into the following structured templates initiatives:

• radreport.org - repository of expert structured rad report templates in MRRT format
• open.radreport.org - location to submit new rad report templates
• IHE RAD MRRT profile
• T-Rex report template editor

Value Statement: Please see: RSNA Reporting Initiative

Key Use Case

• The radiologist, reviewing a study at an image viewing system, instantiates the reporting tool- voice recognition or key entry (data entry method irrelevant).
• Hopefully, but not required, a structured and coded report template is displayed. (meant to integrate with MRRT, but not required)
• The radiologist completes the report and electronically signs the report.
• The content of the report is exported to an EMR and/or HIE in DICOM Part 20 format to be ingested in structured format.
• Because the report is structured and coded, the EMR is able to act upon the report to facilitate additional workitems being placed on worklists such as Actionable Findings Follow-ups.

Standards and Systems

This profile will further refine ("profile") DICOM/HL7 Part 20, but be fully DICOM/HL7 Part 20 (HL7 v3 CDA) compliant.

• A CDA Level 1 report will not be accepted.
• CDA Level 2 (sections identified and coded appropriately) will be the minimum acceptable level.
• This will be a content only profile, no transactions.
• There will be two actors: Document Creator and Document Consumer.
• Transport mechanisms will be specified and may include HL7 v2.x ORU w/ CDA payload, FHIR, DICOM wrapped CDA, or XDS.
• The only Named Option will be Actionable Findings. The other DICOM Part 20 CDA Sections and Entries will remain unspecified in this version.

Discussion

IHE is the correct venue for this profile for several reasons:

• There has been much discussion about how radiology (radiologists) need to demonstrate value and how the radiologists' product is the report. (See Paul Nagy's Dwyer SIIM 2015 presentation). And, yet, IHE Radiology does not address the radiologists' key product.
• DICOM/HL7 Part 20 (CDA) are fairly complex and not obvious to read. Having an IHE Profile including Named Options would give radiology, rad administrators, vendor product managers, and vendors sales people a common and more understandable language to be able to communicate consistently and in a meaningful way.
• Profiling DICOM Part 20 would provide an entre into the IHE Connectathon for interoperability testing between vendors, which does not exist in any way today.
• Given the interest by ECR, CCO, and RSNA, this is clearly of international interest and IHE provides an international venue.

Technical Approach

Base on DICOM/HL7 Part 20.

Specifically, see DICOM Part 20 section 7 for the high level list of CDA Sections. These include:

• • Clinical Information (history and clinical information) - may be text-only section (optional section)
  • Current imaging Procedure Description (information about the study which was just performed) - requires Study Inst UIDS, (section required)
  • Comparison Studies - may be text section only (optional section)
  • Findings - may be text-only section (optional section)
  • Impressions - may be text-only section (section required); would include a named Option for Communication of Actionable Findings in this section
  • Addendum - may be text-only section (optional section)

Specifically, see DICOM Part 20 section 9.8.10 for the "Communication of Actionable Findings" section which would be a named Option within this profile.

Existing actors

Content Creator Content Consumer

New actors

No new actors.

Existing transactions

Intent is to reuse existing transport transactions wherever possible.

New transactions (standards used)

Need to determine transport methods which will be specified, but may include:

• HL7 v2.x ORU wrapped CDA
• DICOM encapsulated CDA
• XDS encapsulated CDA
• FHIR

Impact on existing integration profiles

Compliments existing profiles, not intended to change them.

New integration profiles needed

This would be a new profile. The exact name could either mirror Part 20, or close.

Support & Resources

Contributors/reviewers who have already agreed to assist and allot time for clinical and technical reviews:

• Chuck Kahn, MD, HUP
• Paul Nagy, Johns Hopkins
• Eliot Siegel, MD, UMD
• Justin Cramer, MD, Nebraska
• Marta Heilbrun, MD, U of Utah

Risks

• CDA might be new to the IHE TC members.
• FHIR might be new to IHE TC members.

Open Issues

• Summary section from template is missing
• Standards and System section is missing systems and not listing some standards
• Breakdown of tasks should include the MRRT CPs, integration with XDS.b, updates to TCE and Code Mapping Whitepaper mentioned elsewhere.

• What is the focal problem(s) to be addressed. Current statement of the root Problem is that someone published Sup155 and the secondary problem is that RSNA, ECR, and CCO have put substantial money, time, and effort into some reporting initiatives.

• Reading between the lines, there is a long list of candidate problems
• Problem: Current reports are not uniform, not comprehensive, not easily managed, not efficiently produced, communicate poorly to referring providers, are not machine readable, do not easily meet accreditation criteria do not easily meet pay-for-performance incentives
• Related problems: actionable findings are often not followed up, it is difficult to analyze the accuracy of Radiology Recommendations, it is difficult to do research/analysis on report contents, autopopulate cancer registries, or evaluate report completeness against standardized cancer imaging report templates.
• Need to determine which items on the above list will be goals of the Profile.
• Expand Breakdown task 4 to address each of the goals considered in-scope. Add reviewing the data elements and requirements to achieve each of the selected goals.

• What technologies does the profile intend to include (i.e. which do you intend the Profile to require the Doc Creator to support and which the Doc Consumer to support (to reliably achieve the list of goals).

• Currently lists clinical data, coded terminology, technical parameters, measurements, annotations and key images, actionable findings, analysis of accuracy of recommendations, radreport.org, MRRT, Radlex Playbook, Radlex Lexicon, Sup155, TRex Editor
• The effort estimate should correlate with the number of technologies being incorporated/profiled

• Which of the listed goals will require the actor to have external information and given there will be no transactions, how do you envision the actor accessing that information?

• The outgoing transport of the report is being left open but it might be useful to discuss how the incoming data transactions will work.
• The outgoing transport for report is important but Radiology does not have a transaction for it. Perhaps it is time to create one for XDS and non-XDS environment
  • For XDS, should this structured report content simply be using the 'CDA Imaging Report with Structured Headings' formatCode or we need to create yet another specific formatCode indicating that the content is compliant to Part 20?

• Will MRRT be directly included/referenced in this profile
• What is the "minimal level" for compliance? ie., do we raise the bar above what is required by DICOM/HL7 Part 20?
• Will the 18-ish sections and subsections of Sup155 be individually packaged into Named Options?

• What IHE Profile currently has the largest number of named options and has it been confusing?
• Might be better to have a family of profiles that share a common core instead of named options (which aren't exposed well).

• Will you mandate any behavior on the receiver for each of the Options?

• i.e. will it directly address the related goals, or enable but not specifically address

• If the answers to the above questions are known or can be concluded in short order, do you think this feels like one profile or several?

• If they are not known, does this feel like it should start with a whitepaper?

Tech Cmte Evaluation

White Paper including a section with two examples on how we could profile using part 20 Effort Evaluation (as a % of Tech Cmte Bandwidth):

• 35%

Responses to Issues:

See italics in Risk and Open Issue sections

Candidate Editor:

Teri Sippel