1. Use and Transformation of DICOM SR and CDA Release 2 Diagnostic Imaging Reports
Helmut Koenig, MD
Siemens Healthcare Co-Chairman DICOM WG20 and HL7 Imaging Integration WG

2. Overview on Presentation
Introduction
Comparison of Structured Document Standards: DICOM SR vs. HL7 CDA Rel.2
DICOM Reporting Strategy
Facilitation of Document Exchange between Imaging and Information Systems
Use Cases / Scenarios
Scope of SR Transformation Guide / CDA Implementation Guide
Conclusions
Strategies for Document Exchange
April 8-10, 2008
DICOM International Conference & Seminar

3. DICOM International Conference & Seminar
Acknowledgments
Contributions to Documents and Sample Materials:
D. Donker, PhD: CDA Sample Document + XSL Stylesheet
David S. Channin, MD: Basis for SR Sample Document, Sample Images
F. Behlen, PhD, L. Alschuler, R. Geimer : CDA Implementation Guide
B. Dolin, MD and Members of HL7 Structured Documents WG: Guidance on CDA Standard
April 8-10, 2008
DICOM International Conference & Seminar

4. DICOM International Conference & Seminar
Introduction
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 is Working on a Pair of Aligned Diagnostic Imaging Report (DIR) Implementation Guides to Harmonize Structured Document Standards
DICOM SR / HL7 CDA R2 Transformation Guide
CDA Implementation Guide
April 8-10, 2008
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 SR Imaging Service Data + Context 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
April 8-10, 2008
DICOM International Conference & Seminar

6. Comparison DICOM SR / HL7 CDA R2
Scope
Imaging
Clinical
-> Common 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)
-> DICOM Composite Object Reference CMET Patterns, HL7 V3 Normative Edition 2007/2008
Encoding
Binary
XML
April 8-10, 2008
DICOM International Conference & Seminar

7. DICOM International Conference & Seminar
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
April 8-10, 2008
DICOM International Conference & Seminar

8. DICOM Reporting Strategy…
...
April 8-10, 2008
DICOM International Conference & Seminar

9. DICOM International Conference & Seminar
Use Cases / Scenarios
Inclusion / Transformation: Complete or Partial Document
(Minimal Context Information has been specified)
DICOM Template Hierarchy Allows for Reuse of Mapped
Content for Various Document Types, such as Evidence
Documents
CDA = Clinical Document Architecture
DIR = Diagnostic Imaging Report
KOS = Key Object Selection
SR = Structured Reporting
April 8-10, 2008
DICOM International Conference & Seminar

10. Materials to Support the Reporting Processes
Guidance on the Use and Exchange of SR and CDA DIR Documents
Diagnostic Imaging Report (DIR) Transformation Guide
CDA DIR Implementation Guide
CDA DIR Refined Message Information Model (RMIM)
DIR SR and CDA Sample Documents + CDA Stylesheet
April 8-10, 2008
DICOM International Conference & Seminar

11. 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
Section
April 8-10, 2008
DICOM International Conference & Seminar

12. DICOM International Conference & Seminar
Constrained DIR RMIM
Clinical Document
Participations mapped except “informant”
Related acts mapped except “Consent” and “EncompassingEncounter” (only related Attender Participation)
Structured Body
NonXMLBody and Section recursive actRelationship (Nested Sections) not used, “informant” not mapped
Relevant Clinical Statement Entries: “Observation” (Text and Code), “Procedure” and “Act”
entryRelationship Types used: “component”, “reason”, “subject”, “support”
Not used: Entry Participations and External References
April 8-10, 2008
DICOM International Conference & Seminar

13. Overview on Mapping of Document Context & Structure
DICOM SR
HL7 CDA R2
Document Context Information
Transformed SR Document
ClinicalDocument
Original SR Document
ParentDocument
Preservation of Structural Information
Section Level Container Content Item
Section
Content Items and Relationships
CDA Entries and Entry Relationships
Participants
Author/Person Observer
Author
Attestor
Authenticator
Verifying Observer
Legal Authenticator …
April 8-10, 2008
DICOM International Conference & Seminar

14. Overview on Mapping of Observation Context
DICOM SR
HL7 CDA R2
Subject Context
Patient
recordTarget/Patient
Fetus
relatedSubject/SubjectPerson
Procedure (Diagnostic / Image-Guided Interventions)
Procedure
ServiceEvent (Document Level), Act/Procedure (Section Entry Level)
Order, Requested Procedure
Order
Observer
Person Observer
author/assignedAuthor/Person
Device Observer
author/assignedAuthor/AuthoringDevice
April 8-10, 2008
DICOM International Conference & Seminar

15. Numeric Measurements and Image References
CDA R2 Structured Representation
DICOM Code ”Group of Frames for Display” ->
April 8-10, 2008
DICOM International Conference & Seminar

16. 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
Potential Next Steps:
Work on Representation and Mapping of Evidence Document Contents
Specification of IHE Profile to Define Actors and Transactions
April 8-10, 2008
DICOM International Conference & Seminar

17. References Thank you for your attention ! http://medical.nema.org/
Thank you for your attention !
April 8-10, 2008
DICOM International Conference & Seminar

18. 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
April 8-10, 2008
DICOM International Conference & Seminar

19. DICOM International Conference & Seminar
DICOM Supplement 101
Includes TID 2005 and Use Cases
Text-based Transcribed Diagnostic Imaging Report
Includes References to Relevant Images (Conveyed by KOS “For Report Attachment”) in a separate “Key Images” Section
DICOM Image References
Optional GSPS References for GSPS applied to Images
TID 2005 can be transformed to CDA R2 (Subset of TID 2000)
April 8-10, 2008
DICOM International Conference & Seminar