HL7 CDA and DICOM SR Diagnostic Imaging Reports Helmut Koenig, MD SIEMENS AG – Healthcare Sector Co-Chairman DICOM WG20 / HL7 Imaging Integration WG

HL7 CDA and DICOM SR Diagnostic Imaging Reports Introduction Motivation Comparison of Structured Document Standards: DICOM SR vs. HL7 CDA Rel.2 Facilitation of Document Exchange between Imaging and Information Systems Use Cases / Scenarios Scope of SR Transformation Guide / CDA Implementation Guides Conclusions Strategies for Document Exchange October 9-11, 2010 DICOM International Conference & Seminar

DICOM International Conference & Seminar Introduction (1) Structured Documents: Provide the basis for extended search capabilities through: Defined document structure and contents (e.g. through XML elements and attributes) Use of terminologies (contolled vocabulary, defined semantics of concepts) Individual and inter-individual evaluation of: Outcome of imaging studies / procedures Diagnoses… CDA Snippet: <observation classCode="DGIMG" moodCode="EVN"> <id root= “SOP Instance UID” /> <code code="SOP Class UID " codeSystem="1.2.840.10008.2.6.1“ codeSystemName="DCMUID" displayName="Computed Radiography Image Storage“/> … <effectiveTime value="20060823223232"/> </observation> October 9-11, 2010 DICOM International Conference & Seminar

DICOM International Conference & Seminar Introduction (2) Goal: Leverage Communication of Document-Based Imaging Results for Coordination of Clinical Tasks Multiple Specialties in Intra- and Cross-Institutional Settings Provision of Relevant Images, Image-Based Quantitative Measurements and Interpretation Results for Planning Diagnostic and Therapeutic Activities DICOM WG20 created a set of harmonized Structured Document Standards DICOM Supplement 135 „SR Diagnostic Imaging Report Transformation Guide” which will be included in the new DICOM part 20 “Transformation of DICOM to and from HL7 Standards” HL7 CDA Diagnostic Imaging Report (DIR) Implementation Guide (focus: diagnostic imaging procedures) HL7 CDA Procedure Note Implementation Guide (focus: image-guided interventions) October 9-11, 2010 DICOM International Conference & Seminar

Comparison DICOM SR / HL7 CDA R2 Structure of DICOM SR and HL7 CDA R2: Analysis of SR Basic Diagnostic Imaging Report (Template 2000): Essential Metadata, Document Structure, SR Imaging Service Data and Context Information can be represented and mapped to CDA R2. Not only as narrative text, but as structured document content. Minimal Context Information on Subject (Patient/Fetus), Observer (Person/Device) and Procedure has been identified DICOM SR HL7 CDA R2 October 9-11, 2010 DICOM International Conference & Seminar

Comparison DICOM SR / HL7 CDA R2 Scope Imaging Clinical -> Common Structural Elements and Data Identified Text Representation Text Content Item Section Narrative Text (Attested Content) + Structured Entries -> TEXT Content Items Map to CDA Entries (Structured Part) Referenced within Narrative Text DICOM Object References Image / Composite Content Items (“Native” DICOM References) Use of WADO References (Web Access to DICOM Persistent Objects) -> Harmonize DICOM Composite Object Reference CMET Patterns (HL7 V3 NE 2008) with Term Info Patterns Encoding Binary XML October 9-11, 2010 DICOM International Conference & Seminar

Reporting Workflow: Terms & Definitions Evidence Document Uninterpreted Information (Primarily Managed and Used Inside the Imaging Department) Non-Image Information such as Measurements, CAD Results Used in the Process of Creating a Radiological Diagnostic Report Radiological Diagnostic Report Interpreted Information, Primary Output of the Radiology Department “Evidence Documents may be used 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.” Clinical Document May contain Results and Diagnoses from various Clinical Specialties Radiological Diagnostic Report may be included in the Clinical Document October 9-11, 2010 DICOM International Conference & Seminar

Reporting Workflow: Use Cases / Scenarios CDA = Clinical Document Architecture DIR = Diagnostic Imaging Report KOS = Key Object Selection SR = Structured Reporting October 9-11, 2010 DICOM International Conference & Seminar

DICOM International Conference & Seminar Original CDA R2 RMIM Document Header Related Acts: Encounter, Order, Parent Document… - Participations: PatientRole, Author… Document Body Section with Narrative Text Structured Section Entries External References Section October 9-11, 2010 DICOM International Conference & Seminar

CDA Document Key Elements <ClinicalDocument> ... <!--HEADER (PARTICIPATIONS, RELATED ACTS)--> <structuredBody> <section> <text></text> <!--NARRATIVE BLOCK--> </section> <text>...</text> <entry> <!--STRUCTURED ENTRIES--> <observation>…</observation> </entry> </structuredBody> </ClinicalDocument> October 9-11, 2010 DICOM International Conference & Seminar

Sample CDA Diagnosting Imaging Report (1) October 9-11, 2010 DICOM International Conference & Seminar

Sample CDA Diagnosting Imaging Report (2) October 9-11, 2010 DICOM International Conference & Seminar

Constrained CDA Model for Imaging Reports Clinical Document Header Relevant Participations (author, legal authenticator…) Relevant document related acts (parent document, order, service event…) Subject (record target/patient) and observer context (author) Structured Body Sections as top-level structure within structured body Special DICOM object catalog section (information on all DICOM objects referenced within the document) Section text (narrative block) contains attested content of the document Relevant Clinical Statement Entries: “Observation” (Text and Code), “Procedure” and “Act” (part of procedure context) entryRelationship Types used: “component”, “reason”, “subject”, “support” WADO references to relevant DICOM objects (i.e. images) October 9-11, 2010 DICOM International Conference & Seminar

Numeric Measurements and Image References CDA R2 Structured Representation October 9-11, 2010 DICOM International Conference & Seminar

DICOM International Conference & Seminar Conclusions Represention of Essential SR Imaging Service Data and Context Information in CDA R2 is Possible Document and Observation Context Preservation of Structural Information, i.e. for Measurements based on Image Data and their Interpretation Reuse of Identified Patterns for Other Document Types Mapping Supports Communication of Structured Imaging Results and Diagnoses to HL7 Speaking Information Systems Next Steps: Work on RSNA CDA Report Templates in Cooperation with DICOM WG8 October 9-11, 2010 DICOM International Conference & Seminar

DICOM International Conference & Seminar Acknowledgments Contributions to Documents and Sample Materials: L. Alschuler, R. Geimer, F. Behlen, PhD: CDA Diagnostic Imaging Report (DIR) Implementation Guide D. Donker, PhD: CDA Sample Document + XSL Stylesheet David S. Channin, MD: Basis for SR Sample Document, Sample Images B. Dolin, MD and Members of HL7 Structured Documents WG: Guidance on CDA Standard and Term Info Patterns October 9-11, 2010 DICOM International Conference & Seminar

Thank you for your attention ! References http://medical.NEMA.org/ http://www.HL7.org/ http://www.IHE.net/ Glossary ADT Admission – Discharge – Transfer AE Application Entity DICOM Digital Imaging and Communications in Medicine (http://medical.NEMA.org) DIS Departmental Information (Management) System DIMSE DICOM Message Service Element DIMSE-C DICOM Message Service Element-Composite DIMSE-N DICOM Message Service Element-Normalized DSS / OF Departmental System Scheduler / Order Filler HIS Hospital Information (Management) System HL7 Health Level Seven (www.HL7.org) IHE Integrating the Healthcare Enterprise (www.IHE.net) IAN Instance Availability Notification ID Identifier IE Information Entity IOD Information Object Definition MWL Modality Worklist MPPS Modality Performed Procedure Step OP Order Placer PACS Picture Archiving & Communications System PIR Patient Information Reconciliation PPWF Post-Processing Workflow PPS Performed Procedure Step RIS Radiology Information (Management) System RWF Reporting Workflow SCP Service Class Provider SCU Service Class User SOP Service-Object Pair SPS Scheduled Procedure Step SWF Scheduled Workflow UID Unique Identifier Thank you for your attention ! October 9-11, 2010 DICOM International Conference & Seminar

DICOM International Conference & Seminar Backup Slides October 9-11, 2010 DICOM International Conference & Seminar

DICOM International Conference & Seminar Glossary Acronyms: CDA = Clinical Document Architecture DIR = Diagnostic Imaging Report GSPS = Grayscale Softcopy Presentation State KOS = Key Object Selection RMIM = Refined Message Information Model (HL7 Version 3) SOP = Service Object Pair SR = Structured Reporting WADO = Web Access to DICOM Persistent Object (DICOM Part 18) Terms & Definitions: Evidence Document Uninterpreted Information (Primarily Managed and Used Inside the Imaging Department) Non-Image Information such as Measurements, CAD Results Used in the Process of Creating a Radiological Diagnostic Report Radiological Diagnostic Report Interpreted Information, Primary Output of the Radiology Department “Evidence Documents may be used 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.” Clinical Document May contain results and diagnoses from various clinical specialties Radiological Diagnostic Report may be included in the Clinical Document Check glossary DICOM Part 20 October 9-11, 2010 DICOM International Conference & Seminar

DICOM Reporting Strategy Clinical Document Order Specialized Diagnostics/ Interventions HL7 CDA DICOM SR Image Data Post - Processing Image Data Derived Obser vations Evidence Imaging Report Interpretation Observations Conclusions Diagnoses Patient Medical History / Relevant Prior Documents SR > CDA Rel.2 Transcoding 1b) Evidence Doc Import (Transcoded for Inclusion into CDA Imaging Report) 2a) SR Imaging Report Export (for CDA Clinical Summary Report) 1a) Evidence Doc Export (for CDA Imaging Report) Clinical Summary 2b) Imaging Report Import into CDA Clinical Summary Report) CCOW Access HL7 Message * Convey relevant information of clinical document , On one or more imaging procedures October 9-11, 2010 DICOM International Conference & Seminar