1. RSNA Reporting Templates: Representation of Findings in CDA R2 Instances Helmut Koenig Co-Chair DICOM WG20

2. Annotations to Narrative Text Tagging text contents Mechanism specified by CDA R2 and used in CDA Diagnostic Imaging Report IG – Content ID in narrative block is referenced by structured entry – Structured entry includes code to define semantics of tagged content (Observation.code, Observation.value Concept Descriptor used depending on type of observation)

3. CDA Reference Mechanism for Annotations … Hilar mass … … … … Narrative Block Content Identifier Structured Entry Reference

4. Basic Observation Patterns Findings in RSNA Templates can be represented by the following types of CDA observation events: Quantity Measurement Observation Coded Observation

5. Quantity Measurement <code code="246120007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" displayName="Nodule size"> <translation code="mm" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM" codeSystemVersion="1.5"/> … Observation.code used to convey coded concept Observation.value uses Physical Quantity (PQ) Data Type The unit of measure is specified in the Unified Code for Units of Measure (UCUM) Registered Quantity Measurement Obs. Template

6. Simple Coded Observation (Assertion) … … „Assertion“ used as Observation.code Observation.value is the place for coded concept CD (Concept Descriptor) data type allows for use of multiple coding systems (translation codes) and post-coordination of codes SNOMED CT

7. Summary We need to define the scope of coded observations and get consensus on essential patterns needed in that context We should avoid post-coordination of codes wherever possible – RadLex compositional grammar? Allow for capturing of temporal aspects, i.e. clinically or operationally relevant time of observations (effectiveTime)