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.

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. Discussion

Provider and patient interest in IMR are growing. In support of this evolving practice and technology, The HIMSS-SIIM Enterprise Imaging Workgroup (HSEIWG) has published this article in the Journal of Digital Imaging in June 2021 , “Multispecialty Enterprise Imaging Workgroup Consensus on Interactive Multimedia Reporting Current State and Road to the Future: HIMSS‑SIIM Collaborative White Paper", Journal of Digital Imaging, ttps://doi.org/10.1007/s10278-021-00450-5 . This discussion in a major journal is a summary of the current state of IMR. Along with other complementary activities, such as the HIMSS-SIIM Body part labelling (nomenclature) initiative, is also an indication of community interest in IMR. The HSEIWG is developing a follow-up whitepaper on IMR Technical Developments Requirements and Considerations. We can expect a strong user-community interest and voice in this work (similar to the HSEIWG engagement in EBIW.)

To date, the few institutions that have successfully deployed IMR have predominantly used single-vendor RIS and PACS, and tailored dictation systems. Interoperability between multiple vendors is needed to enable wider use of IMR: needs to be passed between the viewer and the reporting application; some form of rich text needs to pass from the reporting application to the EMR; etc. IHE has a strong history of profiling solutions such as this that require consensus between multiple vendors or systems.

An IHE profile will define the ability to implement IMR, and how it is conveyed in an agnostic or vendor neutral technical profile; defining the ability to launch a viewer in the image context presented from the IMR link.