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

2. 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

3. 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=" “
codeSystemName="DCMUID" displayName="Computed Radiography Image Storage“/> …
<effectiveTime value=" "/>
</observation>
October 9-11, 2010
DICOM International Conference & Seminar

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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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

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

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

13. 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

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

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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

16. 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

17. Thank you for your attention !
References
Glossary
ADT Admission – Discharge – Transfer
AE Application Entity
DICOM Digital Imaging and Communications in Medicine (
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 (
IHE Integrating the Healthcare Enterprise (
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

18. DICOM International Conference & Seminar
Backup Slides
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DICOM International Conference & Seminar

19. 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

20. 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