Enterprise-Wide Reporting and Continuity of Care: The Role of DICOM SR and HL7 CDA

1. Enterprise-Wide Reporting And The Continuity Of Care:The Role Of DICOM SR And HL7 CDADICOM Anniversary Conference and Workshop 2003 Helmut Koenig, MD (Co-Chair DICOM WG 20) Frank Krickhahn (Chair DICOM WG 8) Siemens Medical Solutions

2. Significance of Reporting • Radiology and Clinical Reports are the End-Products of Diagnostic Processes • Consolidation of current interpretation results that builds on relevant clinical information • Documents are crucial for cross-boundary, interdisciplinary and temporal continuity of care in that they convey the essential clinical diagnoses and facts • Health Information Infrastructure & Informational Continuity of Care

3. Health Information Infrastructure: The Reporting View

4. Standards Achievements • DICOM • Recent DICOM SR related supplements • Supplement 65 - Chest CAD SR • Supplement 66 - Catheterization Lab SR SOP Classes • Supplement 71 - Vascular Ultrasound SR • Supplement 72 - Echocardiography Procedure Report • Supplement 75 - Relevant Patient Information Query Service Class • Supplement 79 - Breast Imaging Report Templates • Supplement xx - Non-invasive Cardiovascular Analysis of CT/MR Procedures • Workflow Support (Modality and General Purpose Worklist SOP Classes) • Relevant Patient Information Query Service Class (Suppl. 75) • Web Access to DICOM Persistent Objects (WADO) (Suppl. 85)

5. Standards Achievements • HL7 / DICOM WG 20 Integration Issues • Order Entry and Results Reporting Messages (Version 2.x and 3) • Imaging Order Message (Version 2.5) • Clinical Document Architecture (CDA) Document Standard • Narrative Reports (CDA Release 1) • Narrative + Structured Reports (CDA Release 2) will contain imaging specific information

6. Current Situation & Actions Taken • Reporting needs pose considerable challenges due to the complexity of combining the required services and systems integration • How can this put into place in order to provide optimal support for reporting needs? • Revisit reporting and image interpretation use cases / gap analysis • Discussion started by DICOM WG10 and 20 which resulted in use cases which are ordered by complexity level

7. Hardcopy Image Reading +Dictation/Transcription (Use Case 1) Image Reading: • Hardcopy Reading • Hardcopy DICOM Print as Seen at Modality Reporting: • RIS-Based Transcription / Validation of Narrative Report • RIS-Based Report Storage and Management • Send Reports • Query Prior Reports

8. RIS Report Repository Filming network DICOM optional manual HL7/other Hardcopy Image Reading +Dictation/Transcription (Use Case 1) Report Storage / Mgmt. Electronic Report Paper print/ Mail/ Fax/E-mail send NarrativeInfo Only Electronic Report query Acquisition Transcription & Correction print Validation Film Archive Hardcopy Interpretation & Dictation

9. Hardcopy and Softcopy Image Reading +Dictation/Transcription (Use Case 2) Image Reading: • Hardcopy Reading • Hardcopy DICOM Print as Seen at Modality • Softcopy Reading • Hardcopy DICOM Print as Seen During Softcopy Reading Reporting: • RIS-Based Transcription / Validation of Narrative Report • RIS-Based Report Storage and Management • Send Reports • Query Prior Reports

10. RIS Report Repository Selected Images Filming network DICOM optional manual HL7/other Hardcopy and Softcopy Image Reading +Dictation/Transcription (Use Case 2) store Softcopy Interpretation & Dictation Report Storage / Mgmt. Electronic Report Paper print/ Mail/ Fax/E-mail send Electronic Report NarrativeInfo Only query Acquisition Transcription & Correction print Validation Film Archive Hardcopy Interpretation & Dictation

11. Acquisition Workflow Support +Burn CD/DVD (Use Case 3) Image Acquisition: • RIS-based Acquisition Workflow Support (Modality Worklist) Image Reading: • Hardcopy Reading • Hardcopy DICOM Print as Seen at Modality • Softcopy Reading • Hardcopy DICOM Print as Seen During Softcopy Reading • DICOM Store Images -> Burn CD/DVD Reporting: • RIS-Based Transcription / Validation of Narrative Report • RIS-Based Report Storage and Management • Send Reports • Query Prior Reports • Optional DICOM Store Reports -> Burn CD/DVD

12. RIS Report Repository Burn CD/DVD Off-Line Archive network DICOM optional Filming manual HL7/other Hardcopy and Softcopy Image Reading +Dictation/Transcription (Use Case 3) Modality Worklist store Selected Images Softcopy Interpretation & Dictation Report Storage / Mgmt. Electronic Report Paper print/ Mail/ Fax/E-mail send Electronic Report NarrativeInfo Only query Acquisition Transcription & Correction print Validation store Film Archive Hardcopy Interpretation & Dictation

13. PACS for Management of DICOM Persistent Objects (Use Case 4) Image Acquisition: • RIS-based Acquisition Workflow Support (Modality Worklist) Image Reading: • Hardcopy Reading • Hardcopy DICOM Print as Seen at Modality • Softcopy Reading • Hardcopy DICOM Print as Seen During Softcopy Reading • DICOM Store Images for Burning CD/DVD • PACS-based Storage and Management of DICOM Persistent Objects • Archive Imaging Studies • Query Prior Imaging Studies Reporting: • RIS-Based Transcription / Validation of Narrative Report • RIS-Based Report Storage and Management • Send Reports • Query Prior Reports • Optional DICOM Store Reports for Burning CD/DVD

14. RIS Report Repository Image Repository PACS network DICOM optional Filming manual HL7/other PACS for Management of DICOM Persistent Objects (Use Case 4) Modality Worklist store Object Storage / Mgmt. Electronic Report Electronic Report Selected Images Paper print/ Mail/ Fax/E-mail send Softcopy Interpretation & Dictation query NarrativeInfo Only Transcription & Correction Acquisition store Validation print store q/r store Off-Line Archive Burn CD/DVD Film Archive Hardcopy Interpretation & Dictation

15. Basic Integration of Report and Image Information (Use Case 5) Additions: Image Reading: • DICOM Store Images for Burning CD/DVD • Selection of Evidence Objects (I.e. Images) and Associated Presentation States Reporting: • RIS-Based Report Storage and Management • Send Reports • Query Prior Reports • DICOM Store Reports for Burning CD/DVD • Relate Evidence Objects to Report by Reference Note: Hardcopy Reading Skipped for Brevity

16. RIS Report Repository Image Repository PACS network DICOM optional manual HL7/other Basic Integration of Report and Image Information (Use Case 5) Modality Worklist store Object Storage / Mgmt. Electronic Report Electronic Report Paper print/ Mail/ Fax/E-mail send Softcopy Interpretation & Dictation query Inclusion of References to Selected Objects (I.e. Images) Transcription & Correction NarrativeInfo Only Acquisition Images Presentation States Key Image Notes store Validation store q/r store Off-Line Archive Evidence Documents Imaging Reports Burn CD/DVD

17. Access to Relevant Information (Use Case 6) Additions: Access to Relevant Information: • RIS/PACS-based Storage and Management of DICOM Persistent Objects • Interfaces/Gateway for Imaging Information Queries • Export Imaging Results/Evidence to EHR (Electronic Health Record) • EHR-Based Management of Patient Clinical History Information • Interfaces/Gateway for EHR Relevant Patient Information Queries Note: Hardcopy Reading + Burn CD/DVD Skipped for Brevity

18. Electronic Health Record / Financials Management RIS CIS Report Repository Clinical Inf. Repository Financial Inf. Repository FIS Image Repository PACS network DICOM Web Client Clinician Access optional manual HL7/other Access to Relevant Information(Use Case 6) Gateway Relevant Patient Information Query HL7 Interface DICOM SR Text DICOM Images export store HL7 CDA Rel. 1 JPEG Images Modality Worklist store Web Interface Object Storage / Mgmt. Electronic Report send Softcopy Interpretation & Dictation query WADO Web Interface Transcription & Correction NarrativeInfo Only WADO Acquisition DICOM Interface Web Gateway Images Presentation States Key Image Notes Validation store q/r

19. Postprocessing Workflow & Structured Reporting Based on Evidence Documents (Use Case 7) Additions: Postprocessing: • Postprocessing Workflow Support (Postprocessing Worklist) • Creation of Evidence Documents Results Reporting: • RIS-Based Report Storage and Management • Support for Transcription Worklist • Support for Interpretation Worklist Access to Relevant Information: • RIS/PACS-based Storage and Management of DICOM Persistent Objects • Interfaces/Gateway for Imaging Information Queries • Export Imaging Results/Evidence to EHR • EHR-Based Management of Patient Clinical History Information • Interfaces/Gateway for EHR Relevant Patient Information Queries Note: Hardcopy Reading + Burn CD/DVD Skipped for Brevity

20. Electronic Health Record / Financials Management RIS CIS Report Repository Clinical Inf. Repository Financial Inf. Repository FIS Image Repository Web Client Clinician Access PACS Post-Processing / CAD network DICOM optional manual HL7/other Postprocessing Workflow & Structured Reporting Based on Evidence Documents (Use Case 7) Gateway Relevant Patient Information Query HL7 Interface Modality Worklist export Interpretation / Sign-Off Worklist store HL7 CDA Rel. 1 JPEG Images DICOM SR Text DICOM Images Transcription Worklist store Web Interface NarrativeInfo Only Object Storage / Mgmt. Electronic Report send Extract Measurements &Add Codes Interpretation + Validation query Post-Processing Worklist WADO Transcription & Correction Web Interface WADO Images Evidence Documents /Validated ED Presentation States Key Image Notes SR with References: - Images, PS, KIN, ED Acquisition DICOM Interface Web Gateway Images Evidence Documents Presentation States Images Evidence Documents Presentation States store q/r

21. Terminology Service & Export of Structured Documents (Use Case 8) Additions: Reporting: • RIS-Based Report Storage and Management • Support for Dictation Worklist (Voice Recognition / NLP Substitutes Transcription) Access to Relevant Information: • RIS/PACS-based Storage and Management of DICOM Persistent Objects • Export Structured Documents to EHR (Rather than Narrative Report) Note: Hardcopy Reading + Burn CD/DVD Skipped for Brevity

22. Terminology Service Electronic Health Record / Financials Management RIS CIS Report Repository Clinical Inf. Repository Financial Inf. Repository FIS Image Repository Web Client Clinician Access PACS Post-Processing / CAD network DICOM optional manual HL7/other Coding Scheme Repository Terminology Service & Export of Structured Documents (Use Case 8) Gateway Relevant Patient Information Query HL7 Interface Modality Worklist export Interpretation / Sign-Off Worklist store HL7 CDA Rel. 2 JPEG Images Voice Recognition / Natural Language Processing DICOM SR DICOM Images store Web Interface Object Storage / Mgmt. Dictation Worklist Extract Measurements &Add Codes Interpretation, Correction + Validation Post-Processing Worklist WADO Web Interface WADO Images Evidence Documents /Validated ED Presentation States Key Image Notes SR with References: - Images, PS, KIN, ED Acquisition DICOM Interface Web Gateway Images Evidence Documents Presentation States Images Evidence Documents Presentation States store q/r

23. Conclusions • Use cases 1-4 are well understood and covered by DICOM • Use case 5: “Basic Integration of Report and Image Information“ • Selection of Evidence Objects and Associated Presentation States at the Interpretation Workplace • Inclusion of these selected references into narrative report and provision of the integrated information... • Could be the next step we should focus on and fill potential gaps

24. Questions • Do the scenarios meet your needs? • Is there anything missing?

25. Back-up Slides

26. Significance of Reporting • Radiology and Clinical Reports are the End-Products of Diagnostic Processes • Consolidation of current interpretation results that builds on relevant clinical information • Turnaround time and quality are critical factors for clinicians´ satisfaction • Report is the legally authenticated document (by electronic means or on paper) of the accountable physician • Documents are crucial for cross-boundary, interdisciplinary and temporal continuity of care in that they convey the essential clinical diagnoses and facts • Use of DICOM and standards like HL7 for ensuring the informational continuity of care in the scope of: • Departmental (i.e. Imaging) and Hospital Information Systems, Electronic Health Record (EHR) • Health Information Infrastructure (Hospital/Primary Care, Personal Health Management, Public Health)

27. Critical Factors for Reporting: Continuity of Information Perspective • Ease of access and availability of relevant information • Study Context: Current + prior imaging studies and reports • Patient Context: Access to relevant clinical information (Procedure and indication based) • Limitations primarily due to use of hardcopy images and paper reports • Completeness, diagnostic accuracy and ease of referencing evidence objects • Dictation/Transcription vs. Structured Reporting • Potential limitations due to use of narrative reports instead of template-based structured reports which include references to evidence objects • Workflow Support • HL7 Order Entry and Results Reporting Messages • DICOM Modality Worklist and General Purpose Worklist • Semantic Interoperability • Reference Terminology (Semantic Backbone)