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DICOM INTERNATIONALCONFERENCE & SEMINARApril 8-10, 2008 Chengdu, China
Use and Transformation of DICOM SR and
CDA Release 2 Diagnostic Imaging Reports Helmut Koenig, MDSiemens HealthcareCo-Chairman DICOM WG20 and HL7 Imaging Integration WG
April 8-10, 2008 DICOM International Conference & Seminar 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
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
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
Header
Content Tree
Section incl.Narrative Text
Header
Content Tree
Root Content Itemincl. Report Title
DICOM SR HL7 CDA R2
April 8-10, 2008 DICOM International Conference & Seminar 6
Comparison DICOM SR / HL7 CDA R2
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
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
• …
– ...• …
ClinicalDocument
OrderSpecializedDiagnostics/Interventions
HL7 CDA
DICOM SR
Image DataPost-Processing
ImageData
DerivedImageData
Obser-vations
EvidenceDocument
ImagingReport
Interpretation
ObservationsConclusionsDiagnoses
ClinicalDocument
Patient MedicalHistory / RelevantPrior Documents
On one or moreImaging procedures
SR -> CDA Rel.2Transcoding
Evidence Doc Import
Imaging Report Export
Evidence Doc Export
Clinical SummaryReport
Inclusion into
CCOW Access
HL7 Message
* Convey relevant informationof clinical document
* *
*
Format: DICOM SR, HL7 CDA,Text, PDF
April 8-10, 2008 DICOM International Conference & Seminar 9
Use Cases / Scenarios
PostProcessing
Selection/Annotation of RelevantImages
Measurements, e.g.based on Pattern/Object
Recognition
Dictation
TranscriptionDiagnostic
Imaging Report(DIR)
TransformationEvidenceDocument
KOS
Interpretation
Clinical Report
DICOM SRor HL7 CDA
Inclusion
DICOM SR
HL7 CDA
Inclusion (DIR inSR Format)
DIR inCDA Format
DIR inSR Format
Inclusion(DIR in CDA
Format)
• 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 ArchitectureDIR = Diagnostic Imaging ReportKOS = Key Object SelectionSR = 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
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
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 RepresentationQuantityMeasurementclassCode*: <= OBSmoodCode*: <= EVNcode*: CD CWE [1..1] <= ExternallyDefinedActCodes (Concept NameCode Sequence)effectiveTime: TS [0..1] (Observation Date Time (0040,A032)languageCode: CE CWE [0..1] <= HumanLanguagevalue*: PQ [1..1] (DICOM Decimal String Data Type)
SopInstanceclassCode*: <= DGIMGmoodCode*: <= EVNid*: II [1..1] (SOP Instance UID (0008,0018)code*: CE CWE [1..1] <= ExternallyDefinedActCodes (SOP Class UID Code (0008,0016)title*: ST [0..1] (SOP Class UID derived name)text: ED [0..1] (WADO Reference)effectiveTime: TS [0..1] (Content Date (0008,0023) and Content Time (0008,0033)targetSiteCode: SET<CD> CWE [0..*] <= ActSitesubjectOrientationCode: CE CWE [0..1] <= ImagingSubjectOrientation
PurposeOfReferenceclassCode*: <= OBSmoodCode*: <= EVNcode*: CE CWE [1..1] <= ExternallyDefinedActCodes (PurposeOfReference Code: external DICOM codes CID3407, 7002, 7003, 7005 defined in DICOM Part 16)
ReferencedFramesclassCode*: <= ROIBNDmoodCode*: <= EVNcode*: CV CNE [1..1] <= ExternallyDefinedActCodes (Multi-Frame)
0..1 purposeOfReference
typeCode*: <= RSONcontextControlCode*: CS CNE [1..1] <= ContextControl "AP"contextConductionInd*: BL [1..1] "true"
reason
0..1 referencedFrames
typeCode*: <= COMPcontextControlCode*: CS CNE [1..1] <= ContextControl "AP"contextConductionInd*: BL [1..1] "true"
component
BoundaryclassCode*: <= OBSmoodCode*: <= EVNcode*: CE CNE [1..1] <= ExternallyDefinedActCodes (Spatial Boundary)value*: LIST<INT> [1..*] (Referenced Frame Number (0008,1160)
1..1 boundarytypeCode*: <= COMP
component
0..* sopInstance
typeCode*: <= SUBJcontextControlCode: CS CNE [0..1] <= ContextControl "AP"contextConductionInd*: BL [1..1] "true"
subject
Note:INFERRED FROM, R-INFERRED FROMDICOM Relationship TypesConstraint on SOP Classes
Note:DICOM Value Type NUMDICOM Data Type Decimal String mapped to value: PQ (Physical Quantity) Data Type
subject
0..* sopInstance
typeCode*: <= SUBJcontextControlCode*: CS CNE [1..1] <= ContextControl "AP"contextConductionInd*: BL [1..1] "true"
DICOM Code 113036 ”Group of Frames for Display” ->
April 8-10, 2008 DICOM International Conference & Seminar 16
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
http://medical.nema.org/
http://www.HL7.org/
http://www.IHE.org/
Thank you for your attention !
April 8-10, 2008 DICOM International Conference & Seminar 18
Glossary
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
Acronyms:CDA = Clinical Document ArchitectureDIR = Diagnostic Imaging ReportGSPS = Grayscale Softcopy Presentation StateKOS = Key Object SelectionRMIM = Refined Message Information Model (HL7 Version 3)SOP = Service Object PairSR = Structured ReportingWADO = Web Access to DICOM Persistent Object (DICOM Part 18)
April 8-10, 2008 DICOM International Conference & Seminar 19
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)