1. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 1 DICOM Structured Reporting Current Status and Role in the Electronic Patient Record Harry Solomon Co-chair, DICOM WG1 - Cardiovascular Information

2. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 2 What is DICOM Structured Reporting? A means of encoding structured information … hierarchical tree of content items, using DICOM object syntax For vendor-independent exchange between systems … leveraging the DICOM object management infrastructure Providing unambiguous documentation of meaning … text, categorical codes, numeric measurements, inter-item relationships For the image-intensive clinical environment careful attention to clinical observation context robust references to DICOM images, waveforms

3. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 3 Structured Reporting is Not... DICOM SR is not just “reports” –any structured data exchanged between systems –measurements, analyses, sonographer notes... DICOM SR is not Structured Data Entry –Hierarchical pull-down menus to support report creation is often denoted “structured reporting” –DICOM does not standardize applications or data entry techniques –Structured data entry is a valuable means of creating SR content in certain circumstances

4. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 4 Where Can Cardiology Use SR? Clinical Reports (cath, echo, nuc, etc.) –to go along with our pretty DICOM pictures Analyses of raw image and waveform data –backing up the Clinical Report Documentation of the procedure –provide context for the raw data and analyses Input to a clinical database –for patient care over time, or outcomes analysis

5. Hemo Report Baseline Ref waveform Measurements … Post-intervention Ref waveform Measurements … Derived measurements Ref waveform Procedure Log 11:10 Patient prepped Cath Lab Report Patient 67 yr old male, history of … Ref prior ECG report Procedure Ref Log Narrative... Findings Hemodynamic Ref HD Report Narrative... Angiographic 70% stenosis... Ref image Intervention Stent placed in LAD … Ref image Complications Summary Cath Lab Example Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired 11:30 XA image acquired Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired 11:30 XA image acquired 11:47 PTCA 11:59 XA image acquired Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired 11:30 XA image acquired 11:47 PTCA 11:59 XA image acquired 12:02 HD waveform acquired Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired 11:30 XA image acquired 11:47 PTCA 11:59 XA image acquired 12:02 HD waveform acquired 12:21 Pt released to holding 12:24 HD Report

6. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 6 Structured Reporting is the glue that makes possible construction of an electronic patient record for cardiology

7. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 7 DICOM SR Status Work began in 1994 –Championed by Dr. Dean Bidgood Supplement 23: Structured Reporting - April 2000 –Defined general format for SR objects DICOM header, hierarchical tree of content items Concepts represented by coded terminology using external (non-DICOM) lexicons [e.g., Reed codes, SNOMED anatomy, ICD-9/10 diagnosis or procedure codes, SCP-ECG lead IDs] –Defined general classes of clinical reports –Extremely flexible

8. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 8 The Problem of Flexibility A document creator can put in anything in any structure A document reader must handle every possible document Need to constrain the SR content to enable meaningful receiving applications –Structure –Content

9. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 9 DICOM SR Status Supplement 53: Content Mapping Resource - May 2001 –Defined general structure for templates: document patterns –Mechanism for terminology context groups: constrained vocabulary subsets –Fundamental templates for documenting clinical context and for basic reports –DICOM lexicon for vocabulary not externally available

10. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 10 So Theoretically... DICOM Structured Reporting is ready to be implemented for cardiology! But Pragmatically …

11. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 11 Issues for Cardiology SR Uses not well covered by “clinical report” model –Procedure logs, preliminary measurement reports Many ways to encode the same information –Need consistent approach for interoperability Need tailored subset of SR for developers –Reduce the learning curve Need Cardiology-specific SR Templates and consensus Terminology

12. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 12 Cardiology SR Efforts Supplement 66: Cath Lab SR (WG1) –Procedure Log –Hemodynamics Report –ECG Report –Quantitative Analysis Report –Cath Lab Report Supplement 26: Ultrasound SR (WG12) –Echocardiography Report Both to be released for Public Comment this autumn

13. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 13 Procedure Log Issues Structure - flat Ordering - strictly time sequential Linkage of events - associative Procedure Step / Action ID SOP Class - distinct from reports Remote entries - new Application Event Logging Service Class

14. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 14 Hemodynamic Report Issues SOP Class - Cath Lab Measurements (together with QCA, QVA, IVUS measurements, etc.) –Distinction from report titles Structure - deep hierarchy Terminology - post-coordinated, context from hierarchy

15. Hemo Report Structure

16. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 16 Find out more http://www.pixelmed.com/srbook.html –David Clunie’s excellent introduction to DICOM SR ftp://medical.nema.org/medical/dicom/supps –text of draft supplements http://www.dicomwg12.org/structured_reporting –echocardiography SR subscribe to WG1 email list –send request to how_clark@nema.org

17. Solomon, DICOM SREuropean Society of Cardiology2 September 2001page 17 Thank you Questions? mailto://harry.solomon@med.ge.com