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This document outlines the procedures for the integration of clinical documents, including patient medical history and prior documents, into specialized diagnostic orders. It focuses on the transformation of observations and conclusions from Clinical Document Architecture (CDA) into Digital Imaging and Communications in Medicine (DICOM) Structured Reporting (SR) formats. The report emphasizes the mechanisms for extracting relevant information, encapsulating CDA documents into DICOM formats, and utilizing departmental information systems such as radiology information systems to enhance patient care through effective data sharing.
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Clinical Document Patient Medical History / Relevant Prior Documents Clinical Summary Report Clinical Document HL7 Message Inclusion into * * Order Specialized Dignostics/ Interventions Image Data Post-Processing Summary/ Extract Image Data Derived Image Data Obser- vations SR -> CDA Rel.2 Transformation Evidence Document Evidence Doc Export Summary/ Extract Interpretation CCOW Access Imaging Report Export * Convey relevant information of clinical document Observations Conclusions Diagnoses HL7 CDA Imaging Report Evidence Doc Import DICOM SR On one or more Imaging procedures
Patient Medical History / Relevant Prior Documents Clinical Document • HL7 Order Message containing: • Reference pointer to CDA document • or • MIME encoded CDA document Departmental Information System e.g. Radiology Information System Order DIS • Discussion of different options: • MWL/GPWL: Reference Pointers to CDA Documents (Suppl.101) • Transformation of meaningful parts of the clinical document: CDA -> DICOM SR • DICOM Encapsulation of CDA and CDR (Supl.114) • DICOM Encapsulation of PDF Documents (Supl.104) Modality/ Workstation
