Difference between revisions of "Structured Reporting Content and Transport"

Revision as of 09:07, 6 September 2016

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

Proposal Editor: Teri Sippel Schmidt/Karos Health teri.sippel@karoshealth.com and Kinson Ho/McKesson 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

Quite often, there is a need to share an imaging study between hospitals. Sharing of imaging study via DICOM is well established, however, it is not the same for sharing of diagnostic reports that are associated with the study, even in the case that there already exists a shared infrastructure like a centralized archive. XDS / XDS-I is a solution to the problem, however, in practice, there are still many more hospitals connected via regular DICOM and HL7 only and there is no immediate plan to move to XDS / XDS-I.

The intent of this profile proposal is to provide a consistent mechanism to share diagnostic reports of imaging study such that the reports can be shared along with the corresponding imaging study consistently. This involves two independent and inter-related problems:

How to transport the report from one system to another?
How should the report be formatted such that there is a basic understanding of the content regardless of the originating reporting system?

Benefit of structured content in diagnostic reports:

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. They are not structured nor 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.

Finally, 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

Clinical Use Case - Reading a Radiology Study:

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.
Two of the actors will be: Document Creator and Document Consumer. These actors will be grouped with other actors for transport.
Transport mechanisms will be specified and may include HL7 v2.x ORU w/ CDA payload, FHIR, DICOM Encapsultated CDA, or XDS.b.
The only Named Option for content will be Communication of Actionable Findings. The other DICOM Part 20 CDA Sections and Entries will remain unspecified in this version.
There may be Named Options for transport mechanisms, in addition to a single defined/required transport mechanism.

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) is fairly complex and not easy 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

CDA Content based 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, but depends on transport mechanisms possibly.

Existing transactions

Intent is to reuse existing transport transactions wherever possible.

New transactions (standards used)

Need to determine transport methods which will be included, but could be:

HL7 v2.x ORU wrapped CDA
DICOM Encapsulated CDA
XDS.b encapsulated CDA (exists already)
FHIR Diagnostic Report Resource

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

IHE Rad TC may not be very familiar with CDA description or FHIR transaction.

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):

xx%

Responses to Issues:

See italics in Risk and Open Issue sections

Candidate Editor:

Teri Sippel and Kinson Ho

@@ Line 9: / Line 9: @@
 == The Problem==
+Quite often, there is a need to share an imaging study between hospitals. Sharing of imaging study via DICOM is well established, however, it is not the same for sharing of diagnostic reports that are associated with the study, even in the case that there already exists a shared infrastructure like a centralized archive. XDS / XDS-I is a solution to the problem, however, in practice, there are still many more hospitals connected via regular DICOM and HL7 only and there is no immediate plan to move to XDS / XDS-I.
-== 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 provide a consistent mechanism to share diagnostic reports of imaging study such that the reports can be shared along with the corresponding imaging study consistently. This involves two independent and inter-related problems:
+* How to transport the report from one system to another?
+* How should the report be formatted such that there is a basic understanding of the content regardless of the originating reporting system?
-The intent of this profile proposal is to further profile DICOM/HL7 Part 20 (Sup 155) for structured reporting.
+'''Benefit of structured content in diagnostic reports:'''
-DICOM Part 20 does not address transport mechanisms of the CDA, but transport mechanisms (XDS, FHIR, DICOM Encapsulated CDA IOD and/or HL7 v2 ORU) would be included in this profile.   One of the goals of the transport alternatives would be to provide a query/retrieve mechanism for reports (which HL7 v2 ORU does not provide).
-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.   They are not structured nor 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, radiology reports still tend to be the "Wild West" in terms of transport.   This profile would limit and further refine the number of transport mechanisms.
 Finally, RSNA, ECR, and CCO have put a substantial amount of money, time, and effort into the following structured templates initiatives: