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Evidence and diagnostic reporting in the IHE context
International Congress Series 1268 (2004) 108 – 112
www.ics-elsevier.com
Evidence and diagnostic reporting in the IHE context Cor Loef Philips Medical Systems, Best, The Netherlands
Abstract. Capturing clinical observations and findings during the diagnostic imaging process is increasingly becoming a critical step in diagnostic reporting. Standards developers—notably HL7 and DICOM—are making significant progress toward standards that enable exchanging clinical observations and findings among the various information systems of the healthcare enterprise. DICOM—like the HL7 Clinical Document Architecture (CDA)—uses templates and constrained, coded vocabulary (SNOMED, LOINC, etc.). Such a representation facilitates automated software recognition of findings and observations, intrapatient comparison, correlation to norms and outcomes research. The scope of DICOM structured reporting (SR) includes many findings that products routinely create in digital form (measurements, computed estimates, etc.). In IHE, two integration profiles are defined for clinical data capture and diagnostic reporting: evidence document, and simple image and numeric report. This paper describes these two DICOM SR based integration profiles in the diagnostic reporting process. D 2004 Published by Elsevier B.V. Keywords: DICOM structured reporting; IHE; Evidence document; Simple image and numeric report
1. Introduction Capturing clinical data during the diagnostic imaging process is becoming essential for diagnostic reporting. Obstacles have been converting data into a digital coded format and the absence of standards. In the diagnostic imaging process, digital capture of findings has been routine for many years in cardiology, radiology, vascular and OB – GYN specialties. While DICOM has achieved great success with images, findings interoperability has struggled with proprietary solutions. Fortunately, DICOM structured reporting (SR) is removing this obstacle. In the meantime, the scope of digitally generated findings is increasing. New technology, such as computer aided diagnosis (CAD) and parametric imaging, will increase the volume of clinical digital findings. A key interoperability criterion is data comparability. Clinical software applications need to recognize evidence and findings, and sort, collate, compare, and match discrete clinical findings to norms. Comparability allows products to improve productivity and quality of task performance.
E-mail address: [email protected] (C. Loef). 0531-5131/ D 2004 Published by Elsevier B.V. doi:10.1016/j.ics.2004.03.362
C. Loef / International Congress Series 1268 (2004) 108–112
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2. DICOM structured reporting (SR) DICOM SR uses hierarchically organized coded vocabularies to express clinical data. SR templates constrain vocabulary and its hierarchical organization. Judiciously chosen atomic concepts can express a much larger scope of more complex, composite concepts such as clinical findings (often called postcoordination). The template specifies the concept codes and how they are structurally organized. Software requires a precise recipe to compose and recognize findings. Templates provide these recipes and specify the essential information required to assemble the finding in the report document. The cells in the template are directly tied to the clinical application. The report consumer must reassemble the finding from the cells in the template. DICOM SR templates facilitate expressing much more that just the finding: whether the value is derived as an average, links of the image to image cursors, or to other findings, and other context information may influence clinical judgment. These relationships may point to other content items in the SR content tree. 3. IHE integration profile: evidence document The evidence documents profile defines interoperable ways for observations, measurements, results and other procedure details recorded in the course of carrying out a procedure step to be output by devices, such as acquisition systems and other workstations, to be stored and managed by archival systems, and to be retrieved and presented or used by display and reporting systems. This allows detailed nonimage information, such as measurements, CAD results, procedure logs, etc., to be made available as input to the process of generating a diagnostic report either as additional evidence for the reporting physician or, in some cases, for selected items in the evidence document to be included in the diagnostic report.
Fig. 1. Evidence document actor diagram.
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Table 1 Evidence document templates Template ID
Template name
TID TID TID TID TID
Mammography CAD document root template OB – GYN ultrasound procedure report Hemodynamics report Chest CAD SR document root template Ultrasound procedure report template
4000 5000 3500 4100 5100 Vascular
The IHE scheduled workflow profile and/or the IHE post processing workflow profile manage the production of evidence documents. As such, the evidence document profile is required to be supported together with one or the other of those two profiles. Evidence documents represent one of the inputs to the reporting process and may provide details which get included in diagnostic reports described in the simple image and numeric report profile. 3.1. Actors and transactions Fig. 1 shows the actors directly involved in the evidence documents integration profile and the relevant transactions between them. 3.2. Process flow As with other evidence objects, evidence documents are usually created by the system operator, and used by the reading physician in the process of creating a diagnostic report, either by reviewing or interpreting the evidence document contents or by copying selected parts into the report. Evidence documents represent the uninterpreted information that is primarily managed and used inside an imaging department, although distribution outside the imaging department might be of interest as well. In contrast, the diagnostic reports described in the simple image and numeric reports profile represent the interpreted information which is the primary output of the imaging department and are available for wide distribution. 3.3. Evidence report content and structure Evidence documents belong to the family of evidence objects that also includes images, presentation states and key image notes. These are objects generated as a result of performing procedure steps on systems in a clinical department. The DICOM SOP Classes are: basic text, enhanced SR, comprehensive SR, chest CAD SR and mammography CAD SR. And a number of DICOM Supplements are currently under development: OB –GYN ultrasound procedure reports, chest CAD SR, catheterization lab SR, vascular ultrasound SR. The templates used in these evidence documents are listed in Table 1. 4. IHE integration profile: simple image and numeric report The simple image and numeric report integration profile facilitates the growing use of digital dictation, voice recognition and specialized reporting packages, by separating
C. Loef / International Congress Series 1268 (2004) 108–112
111
the functions of reporting into discrete actors for creation, management, storage and viewing. Separating these functions while defining transactions to exchange the reports between them enables a vendor to include one or more of these functions in an actual system. 4.1. Actors and transactions Fig. 2 shows the actors directly involved in the simple image and numeric report integration profile and the relevant transactions between them. 4.2. Process flow In the initial stage of a typical diagnostic reporting, a reading physician records the diagnosis by generating a draft DICOM structured report object, which is submitted to the report manager. Once a report is sent to the report manager, the report creator relinquishes control of the report to the report manager. Reports are processed and modified by the report manager. This involves adding and changing report data as well as verifying draft reports. At any time, the report manager can transmit reports to the report repository for external access, but at a minimum, the final report must be sent to the report repository. A report creator can effectively amend a report by submitting a new SR SOP Instance. The report repository provides permanent storage of DICOM structured reports. It also allows reports to be queried and retrieved throughout the enterprise by report readers. 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 external report repository access is a gateway to obtain other enterprise department reports, such as laboratory and pathology, from within the imaging department. DICOM structured reports are queried and retrieved by a report reader from the external report repository access. The enterprise report repository receives diagnostic reports in HL7 format.
Fig. 2. Simple image and numeric report actor diagram.
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Fig. 3. Simple image report pattern.
4.3. Simple image and numeric report content and structure Reports exchanged have a simple structure attractive to many imaging departments: a title, an observation context and one or more sections, each with a heading, observation context, text, image references and optionally coded measurements (see Fig. 3). Some elements can also be coded to facilitate computer searches. Such reports can be input to the formal diagnostic report, thus avoiding reentry of information. The created reports conform to the DICOM Basic Text SR Information Object Definition (IOD). If numeric values are required in the report, then the report creator creates a report that conforms to the DICOM Enhanced SR IOD. Reports created also conform to the DCMR template TID 2000.
www.ics-elsevier.com
Evidence and diagnostic reporting in the IHE context Cor Loef Philips Medical Systems, Best, The Netherlands
Abstract. Capturing clinical observations and findings during the diagnostic imaging process is increasingly becoming a critical step in diagnostic reporting. Standards developers—notably HL7 and DICOM—are making significant progress toward standards that enable exchanging clinical observations and findings among the various information systems of the healthcare enterprise. DICOM—like the HL7 Clinical Document Architecture (CDA)—uses templates and constrained, coded vocabulary (SNOMED, LOINC, etc.). Such a representation facilitates automated software recognition of findings and observations, intrapatient comparison, correlation to norms and outcomes research. The scope of DICOM structured reporting (SR) includes many findings that products routinely create in digital form (measurements, computed estimates, etc.). In IHE, two integration profiles are defined for clinical data capture and diagnostic reporting: evidence document, and simple image and numeric report. This paper describes these two DICOM SR based integration profiles in the diagnostic reporting process. D 2004 Published by Elsevier B.V. Keywords: DICOM structured reporting; IHE; Evidence document; Simple image and numeric report
1. Introduction Capturing clinical data during the diagnostic imaging process is becoming essential for diagnostic reporting. Obstacles have been converting data into a digital coded format and the absence of standards. In the diagnostic imaging process, digital capture of findings has been routine for many years in cardiology, radiology, vascular and OB – GYN specialties. While DICOM has achieved great success with images, findings interoperability has struggled with proprietary solutions. Fortunately, DICOM structured reporting (SR) is removing this obstacle. In the meantime, the scope of digitally generated findings is increasing. New technology, such as computer aided diagnosis (CAD) and parametric imaging, will increase the volume of clinical digital findings. A key interoperability criterion is data comparability. Clinical software applications need to recognize evidence and findings, and sort, collate, compare, and match discrete clinical findings to norms. Comparability allows products to improve productivity and quality of task performance.
E-mail address: [email protected] (C. Loef). 0531-5131/ D 2004 Published by Elsevier B.V. doi:10.1016/j.ics.2004.03.362
C. Loef / International Congress Series 1268 (2004) 108–112
109
2. DICOM structured reporting (SR) DICOM SR uses hierarchically organized coded vocabularies to express clinical data. SR templates constrain vocabulary and its hierarchical organization. Judiciously chosen atomic concepts can express a much larger scope of more complex, composite concepts such as clinical findings (often called postcoordination). The template specifies the concept codes and how they are structurally organized. Software requires a precise recipe to compose and recognize findings. Templates provide these recipes and specify the essential information required to assemble the finding in the report document. The cells in the template are directly tied to the clinical application. The report consumer must reassemble the finding from the cells in the template. DICOM SR templates facilitate expressing much more that just the finding: whether the value is derived as an average, links of the image to image cursors, or to other findings, and other context information may influence clinical judgment. These relationships may point to other content items in the SR content tree. 3. IHE integration profile: evidence document The evidence documents profile defines interoperable ways for observations, measurements, results and other procedure details recorded in the course of carrying out a procedure step to be output by devices, such as acquisition systems and other workstations, to be stored and managed by archival systems, and to be retrieved and presented or used by display and reporting systems. This allows detailed nonimage information, such as measurements, CAD results, procedure logs, etc., to be made available as input to the process of generating a diagnostic report either as additional evidence for the reporting physician or, in some cases, for selected items in the evidence document to be included in the diagnostic report.
Fig. 1. Evidence document actor diagram.
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C. Loef / International Congress Series 1268 (2004) 108–112
Table 1 Evidence document templates Template ID
Template name
TID TID TID TID TID
Mammography CAD document root template OB – GYN ultrasound procedure report Hemodynamics report Chest CAD SR document root template Ultrasound procedure report template
4000 5000 3500 4100 5100 Vascular
The IHE scheduled workflow profile and/or the IHE post processing workflow profile manage the production of evidence documents. As such, the evidence document profile is required to be supported together with one or the other of those two profiles. Evidence documents represent one of the inputs to the reporting process and may provide details which get included in diagnostic reports described in the simple image and numeric report profile. 3.1. Actors and transactions Fig. 1 shows the actors directly involved in the evidence documents integration profile and the relevant transactions between them. 3.2. Process flow As with other evidence objects, evidence documents are usually created by the system operator, and used by the reading physician in the process of creating a diagnostic report, either by reviewing or interpreting the evidence document contents or by copying selected parts into the report. Evidence documents represent the uninterpreted information that is primarily managed and used inside an imaging department, although distribution outside the imaging department might be of interest as well. In contrast, the diagnostic reports described in the simple image and numeric reports profile represent the interpreted information which is the primary output of the imaging department and are available for wide distribution. 3.3. Evidence report content and structure Evidence documents belong to the family of evidence objects that also includes images, presentation states and key image notes. These are objects generated as a result of performing procedure steps on systems in a clinical department. The DICOM SOP Classes are: basic text, enhanced SR, comprehensive SR, chest CAD SR and mammography CAD SR. And a number of DICOM Supplements are currently under development: OB –GYN ultrasound procedure reports, chest CAD SR, catheterization lab SR, vascular ultrasound SR. The templates used in these evidence documents are listed in Table 1. 4. IHE integration profile: simple image and numeric report The simple image and numeric report integration profile facilitates the growing use of digital dictation, voice recognition and specialized reporting packages, by separating
C. Loef / International Congress Series 1268 (2004) 108–112
111
the functions of reporting into discrete actors for creation, management, storage and viewing. Separating these functions while defining transactions to exchange the reports between them enables a vendor to include one or more of these functions in an actual system. 4.1. Actors and transactions Fig. 2 shows the actors directly involved in the simple image and numeric report integration profile and the relevant transactions between them. 4.2. Process flow In the initial stage of a typical diagnostic reporting, a reading physician records the diagnosis by generating a draft DICOM structured report object, which is submitted to the report manager. Once a report is sent to the report manager, the report creator relinquishes control of the report to the report manager. Reports are processed and modified by the report manager. This involves adding and changing report data as well as verifying draft reports. At any time, the report manager can transmit reports to the report repository for external access, but at a minimum, the final report must be sent to the report repository. A report creator can effectively amend a report by submitting a new SR SOP Instance. The report repository provides permanent storage of DICOM structured reports. It also allows reports to be queried and retrieved throughout the enterprise by report readers. 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 external report repository access is a gateway to obtain other enterprise department reports, such as laboratory and pathology, from within the imaging department. DICOM structured reports are queried and retrieved by a report reader from the external report repository access. The enterprise report repository receives diagnostic reports in HL7 format.
Fig. 2. Simple image and numeric report actor diagram.
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C. Loef / International Congress Series 1268 (2004) 108–112
Fig. 3. Simple image report pattern.
4.3. Simple image and numeric report content and structure Reports exchanged have a simple structure attractive to many imaging departments: a title, an observation context and one or more sections, each with a heading, observation context, text, image references and optionally coded measurements (see Fig. 3). Some elements can also be coded to facilitate computer searches. Such reports can be input to the formal diagnostic report, thus avoiding reentry of information. The created reports conform to the DICOM Basic Text SR Information Object Definition (IOD). If numeric values are required in the report, then the report creator creates a report that conforms to the DICOM Enhanced SR IOD. Reports created also conform to the DCMR template TID 2000.