RSNA Reporting Templates: Representation of Findings in CDA R2 Instances

Helmut Koenig Co-Chair DICOM WG20

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)

CDA Reference Mechanism for Annotations

… Narrative Block Content Identifier < content ID="F1" >Hilar mass … … < reference value="#F1" /> … …

Structured Entry Reference

Basic Observation Patterns

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

Quantity Measurement

codeSystemName="UCUM" codeSystemVersion="1.5"/> … Registered Quantity Measurement Obs.

Template The unit of measure is specified in the Unified Code for Units of Measure (UCUM)

Simple Coded Observation (Assertion)

… SNOMED CT … • • • „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

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)