Simple Image and Numeric Report
Simple Image and Numeric Report (SINR) specifies how Diagnostic Radiology Reports (including images and numeric data) are created, exchanged, and used.
The Simple Image and Numeric Report (SINR) Integration Profile facilitates the growing use of digital dictation, voice recognition, and specialized reporting packages.
It utilizes the content structure of DICOM Structured Report for a simple imaging report. The content structure is simple: a title, an observation context, and one or more sections, each with a heading, observation context, text, image references, and optionally coded measurements. Some elements can also be coded to facilitate Such reports can be input to the formal diagnostic report, thus avoiding re-entry of information.
The key benefits of Simple Image Numeric Report profile are as follows:
- DICOM SR, enables maximum interoperability in Imaging Departments
- Export to Clinical Data Repositories with HL-7 V.2 defined mapping
- Non-transcription based information capture systems support, including;
- Numerical measurements from image processing applications
- Links to images stored in the image repository
- machine searchable structured content
- Integrated with the Reporting Workflow
- Adaptable to CDA and XML interfacing
The Simple Image and Numeric Report (SINR) Integration Profile facilitates the creation, management, distribution, storage, and viewing of reports created in imaging facilities.
The content structure uses the DICOM Structured Report for a simple imaging report. The content structure is simple: a title, an observation context, and one or more sections, each with a heading, observation context, text, image references, and optionally coded measurements. The Report complexity is extensible, limited only to the constraints of DICOM.
In the initial stage of diagnostic reporting, a reading physician records the diagnosis by generating a draft DICOM Structured Report object. Once the initial report is submitted, the reports are processed until the report is final. This may involve adding and changing report data as well as verifying the draft reports. Previous draft versions are maintained. Once final, the report may be amended with updates.
The Integration Profile allows for the flexibility of distributing the report external to the department at any time. But at a minimum, the final report will be made available for distribution.
Permanent storage of the reports is maintained through the use of DICOM Structured Reports. It also allows reports to be queried and retrieved throughout the enterprise by known DICOM queries.
Viewing reports only requires a viewer DICOM Structered Report viewing capability viewse reports A Report Reader provides a user interface to view DICOM Structured Reports that it retrieves from the Report Repository or External Report Repository Access.
The report may be maintained outside the department by the distruting the report via an HL7 format. The DICOM Structured Report may be queried and retrieved by a external DICOM SR-capable viewer.
Systems which are expected to have implemented actors from this profile include:
- Digital Dictation Systems
- Voice Recognition Systems
- specialized reporting packages
- Enterprise-wide information systems that manage the Electronic Medical Record
- Radiology departmental information systems that manage Radiology Reports (i.e., radiology information system (RIS))
- Radiology image & Report management/archiving systems that manage Radiology Reports (i.e., picture archiving and communication system (PACS))
Actors & Transactions:
Profile Status: Final Text
The SINR profile is a dependency to Reporting Workflow. This integrtion Profile defines the Workflow associated with managing the Diagnostic Reports crearted by this profile.
Other documents which are sometimes referred to as “reports” and may be encoded using DICOM SR (for example, procedure reports, CAD results and echocardiography measurement reports) however such documents do not follow the same kind of verification and distribution process described in this profile. These other documents serve different purposes and are instead addressed in the Evidence Documents profile.