Interactive Multimedia Reporting (IMR)

1. Proposed Workitem: Interactive Multimedia Reporting (IMR)

• Proposal Editor: David Kwan, Elliot Silver, Kinson Ho, Seth Berkowitz, Karen Thullner
• Editor: Kinson Ho
• Domain: Radiology

2. The Problem

IMR provides imaging findings and results in a contextual, educational/informative, and graphic manner that are easily accessible by providers and patients from anywhere. Interactive Multimedia Reporting (IMR) has been defined (by the HIMSS-SIIM Enterprise Imaging Workgroup) as “interactive medical documentation that combines clinical images, videos, sound, imaging metadata, and/or image annotations with text, tables, graphs, anatomic maps, and/or educational resources to optimize communication between medical professionals and their patients.” Interactive Multimedia Reporting improves communications and workflow; by providing clear, concise and contextual information for stakeholder users of clinical reports. Current IMR implementations that utilize proprietary technologies and techniques to create and distribute reports with rich content face challenges with wide scale sharing of such reports.

IMR Benefits:

• Linked and/or embedded images and annotated images saves surgeon and oncologist look-up time during patient treatment planning, and ensure correct patient look-up
• Improved radiologist workflow for comparison imaging, and patient study follow-up
• Time savings for radiologists, especially for repetitive data entry and follow-up queries during radiologist reporting sessions
• Improved accuracy (reduced data entry errors) and precision, through auto- insertion of images, measurements, links and annotations.
• Improved consumption of rad reporting:
  • Improved Report Clarity and Consistency
  • Improved patient satisfaction ratings, i.e., HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores
• Higher quality data source for artificial intelligence and machine-learning

Despite these potential benefits, IMR has not been widely adopted, partially due to interoperability limitations. Creators and diagnosticians reviewing the images do not include alphanumeric embedded annotations to identify and classify findings due to lack of integration of tables, graphs, diagrams, or anatomic maps with the textual report elements within the systems employed. Where IMR has been practiced, users external to these organizations find the links, tables, graphs, and anatomic maps in these reports inaccessible. An IHE profile for IMR would define standardized formats and exchange mechanisms usable by report creators and consumers at both the institution at which the report is created and at external institutions. Hyperlinks to images would be functional, and able to display referenced images by both internal and external authorized report consumers.

3. Key Use Case

The following use case illustrates current typical workflow, and an IMR implementation state where a profile could enhance the workflow.

Current State Use Case:

• 1. Radiologist choses patient study from the worklist. Images are launched in the PACS system. The reporting session begins.
• 2. Initiates a report creator/reporting application session using a reporting template.
• 3. Radiologist reviews images and begins a reporting session with an active reporting template in the report creator/reporting application.
• 4. Radiologists perform measurements on significant images and findings.
• 5. Radiologist dictates observations and findings including measurements, image number and series of noted observations into the active reporting template.
• 6. Radiologist completes and signs off the report; the report and images are sent to EMR and VNA.
• 7. Oncologist retrieves and reviews the report in the EMR client, including using manual navigation of image study to find image and findings noted in patient imaging report.

IMR Implementation Use Case:

• 1. Radiologist choses patient study from worklist; images are launched in PACS system; begins reporting session.
• 2. Initiates a report creator/reporting application session using a reporting template.
• 3. Radiologist reviews images and begins a reporting session with an active reporting template (based on procedure code) in the report creator/reporting application
• 4. Radiologist opens the IMR from a prior study (from 6 months ago) on PACS workstation. When image hyperlinks on the prior report are clicked, a viewport in the PACS workstation displays the appropriate image instance UID in the context of the parent DICOM series.
• 5. Radiologists continue to review current images while comparing them to prior images. Begins reporting on the active reporting template.
• 6. The radiologist measures a lung nodule on an axial image. The measurement and source image instance UID are transmitted in real time to the reporting application. Measurements and instance UID of source images are stored in the report as coded metadata and text in the narrative.
• 7. Radiologist completes and signs off the report. The report and images are sent to EMR and VNA.
• 8. The oncologist retrieves and reviews the report in the EMR client. The report contains hyperlinks to specific findings. The hyperlinks launch the enterprise viewer to display the appropriate image instance UID in the context of the parent DICOM series.

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4. Standards and Systems

Systems:

Primary Systems	Secondary Systems
* PACS	* Imaging Modality
* Report Creator	* A.I. App + Others
* RIS/EMR/HIS	* Image Displays
* Report/Image Display	* HIE, Patient portal

Standards:

PACS and Report Creator Communications	IMR Output and Communications
* FHIRcast	* Text/PDF
* DICOMweb WADO-RS	* FHIR (DiagnosticReport, ImagingStudy and Observation )

5. Technical Approach

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New actors

• Data Hub
• Data Publisher
• Data Subscriber

6. Support & Resources

The HIMSS SIIM Enterprise Imaging Community Workgroup for Interactive Multimedia Reporting has already coalesced a number of collaborators. Many of these collaborators have contributed to the proposal and are interested in working on the profile.

• Healthcare: Chris Roth (Duke), Les Folio (NIH), Cree Gaskin (UVA), Seth Berkowitz (Beth Israel/Harvard), , Alex Aisen (Independent), Shawn Clark (University of Miami), David Vining (MD Anderson).

• Vendors: Elliot Silver (Argentix Informatics), Kinson Ho (Change), Peter O’Toole (mTuitive), James Raynor (Epic), Nathan Gurgel (Fujifilm), Karen Thullner/Kurt Allen (PenRad Technologies), Adam Coal (Smile CDR), Alexander Goel (CAP/ACR/PuraJuniper).

Healthcare and industry participants bring their implementation experiences and clinical understanding to progress the IMR from theory to practice.

7. Open Issues

• To what degree will legacy systems be able to be actors in this profile?
• Will a push model between Report Creator and Report Repository be sufficient? Is a full FHIR server required?
• IMR will not specify the trigger when the Image Displays the real time user action (e.g. measurements) to the Data Hub. IMR will only define the real time communication using FHIRcast and the payload. Is this sufficient?
• Since there are many existing proprietary integrations between Image Display and Report Creator, IMR will not mandate the use of SMART on FHIR and define how the hub.topic and hub.url is communicated. However, these are prerequisites and will be communicated using existing integration between Image Display and Report Creator. Is this acceptable?
• Given the complexity of multimedia reports, the report structure and transport will be based on FHIR DiagnosticReport and using FHIR for transport. This will be totally separate from existing common HL7 ORU for radiology reports. Many reporting systems can actually produce different report output already.
• Should the FHIRcast portion be specified as an independent profile since it is by itself useable in other context?

Risks

• Market demand for IMR (including changes to reimbursements).
• The inclusion of technology making use of HL7 FHIR may mitigate the risk of developing an outdated profile.
• Lack of an IMR profile would lead to the numerous use-case driven solutions and technologies and lack interoperability between systems.

8. Tech Cmte Evaluation

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

xx% for MUE yy% for MUE + optional Editor:

Editor: Kinson Ho SME/Champion: Dr. Chris Roth