Structured and Coded (Synoptic) Radiology Report Content Profile - Proposal

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

IN PROGRESS - NOT DONE YET, still working on this profile proposal, I have until Aug 15th - Teri.

• Proposal Editor: Teri Sippel Schmidt/Karos Health
• Editor: Teri Sippel Schmidt/Karos Health with RSNA RIC committee, Cancer Care Ontario, and other SIIM Members (see below)
• Date: N/A (Wiki keeps history)
• Version: N/A (Wiki keeps history)
• Domain: Radiology

Additional editors/reviewers who have already agreed to assist and allot time for reviews:

• Chuck Kahn, MD, RSNA, HUP
• Curt Langlotz, MD, Stanford
• Marta Hielbrun, MD, Utah
• Justin Cramer, MD, Utah
• Paul Nagy, JH
• David Kwan, Cancer Care Ontario
• Jon Zammit, Cancer Care Ontario
• Harry Solomon, GE
• Parag Tolat, MD, MCW
• Brad Erikson, MD, Mayo

2. The Problem

The intent of this profile is to profile DICOM/HL7 Part 20 (Sup 155) for structured reporting.

RSNA, ECR, and CCO have put a substantial amount of money, time, and effort into the following 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
• DICOM/HL7 Part 20 (prev DICOM Supplement 155) (Radiology Reports in CDA format)

Value Statement: (Taken directly from: RSNA Reporting Initiative

Radiology Reporting Initiative

What is the radiology reporting initiative?

The clinical report is an essential part of the service you provide to your patients. As a tool that communicates information to referring physicians, records that information for future use and serves as the legal record that documents the episode of care, it is of the utmost importance that the report be uniform, comprehensive, easily managed and "readable" to humans and machines alike. The RSNA radiology reporting initiative is improving reporting practices by creating a library of clear and consistent report templates. These templates make it possible to integrate all of the evidence collected during the imaging procedure, including clinical data, coded terminology, technical parameters, measurements, annotations and key images. Twelve subcommittees of subspecialty experts have created a library of best-practices radiology report templates. They are free and not subject to license restrictions on their reuse. These report templates: Create uniformity and improve your communication with referring providers Enable your practice to meet accreditation criteria Help your practice earn pay-for-performance incentives Through this initiative, RSNA is encouraging reporting vendors to develop software products that enable radiologists to create high-quality radiology reports more efficiently.

3. Key Use Case

• The radiologist, reviewing a study at an image viewing system, instantiates the reporting tool- voice recognition or key enter (irrelevant).
• 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.
• Because the report is structured and coded, research can be more easily conducted such as further analysis on the accuracy of "Radiology Recommendations", as just one example of many research examples.
• Because the report is structured and coded, Cancer Care Ontario can analyze the effects of <need help here, Dave Kwan>.

4. Standards and Systems

This profile will further refine 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.
• This will be a content only profile, no transactions.
• There will be two actors: Document Creator and Document Consumer.
• The method used to export/send the report will not be identified, but examples will be given (HL7 v. 2 ORU w/ CDA payload or XDS being two such examples).
• The key will be the Named Options and identifying which of the Part 20 CDA sub-sections will be brought to the forefront as named options.
• The discussion as to which DICOM Part 20 CDA sub-sections should become named options has already begun with the reviewers listed above for clinical input and is in the form of a google document which can be viewed here.

5. Discussion

Questions?