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. The created report is submitted for management, distribution and storage by departmental inforamtion system.
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.
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 internal and external to the department requires a DICOM Structured Report-capable viewer.
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. The report may be distributed outside the department by an HL7 format. The DICOM Structured Report may be queried and retrieved by an any DICOM SR-capable system.
Systems which are expected to have implemented actors from this profile include:
- Digital Dictation Systems, with the ability to create and modify reports
- Voice Recognition Systems, with the ability to create and modify reports
- specialized reporting packages, with the ability to create and modify reports
- Enterprise-wide information systems that manage the Electronic Medical Record for recieving reports
- 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
- Reporting Workflow [RWF] uses Simple Image & Numeric Reports as inputs to the reporting process.
- Patient Information Reconciliation [PIR] is expected to reconcile Simple Image & Numeric Reports along with the rest of the patient data record.
- Evidence Documents [ED] may be used as inputs for Simple Image and Numeric Reports.
- Cross-enterprise Document Sharing for Imaging [XDS-I] can be used to share Simple Image & Numeric Reports between sites over a network.
- Portable Data for Imaging [PDI] can store Simple Image & Numeric Reports on media such as CDs.
- Import Reconciliation Workflow [IRWF] can fix patient ids, etc. of Simple Image & Numeric Reports when importing.