RSNA 2008 – Course 1029 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) for Advanced Reporting Harry Solomon GE Healthcare DICOM WG 8
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RSNA 2008 – Course 1029 Electronic Reports: HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) for Advanced Reporting Harry Solomon GE Healthcare DICOM WG 8 Structured Reporting HL7 Structured Documents TC DICOM WG 20 / HL7 Imaging Integration WG IHE Cross-Domain Reporting Task Force Disclosure • Harry Solomon – Employee, GE Healthcare – Instructor, Medical Informatics, Northwestern University 2 Acknowledgements • Fred Behlen, co-author of a previous version of this presentation • Fred Behlen, Bob Dolin, Liora Alschuler, Calvin Beebe – cochairs of HL7 Structured Documents Technical Committee, and authors of presentations on CDA used in this talk • Dave Clunie – former co-chair of DICOM Standards Committee, and author of the definitive book on DICOM Structured Reporting • Kevin O’Donnell – IHE Reporting Task Force 3 Objectives • Understand the key elements for effective radiology reporting, and issues with electronic reporting workflows • Understand the uses of HL7 CDA (Clinical Document Architecture) and DICOM SR (Structured Reporting) for advanced reporting workflows 4 Is this an electronic report? 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Followup CXR 1 month.|...<cr> 5 For our purposes • An electronic report is created using computer based techniques (workflow), includes some amount of structured and coded content, and may include “multimedia” (for radiology, images) • We will look at two technology standards that apply to electronic reporting 6 Key Elements of Radiology Reporting 7 Paper or Electronic Reports • Accurately convey the findings to the referring physician – Reflect the competence of the radiologist • Timely communication for patient care • Archived in the patient medical record • Legal record of imaging exam – Radiologist signature • Support ‘secondary’ uses – – – – Charge capture and billing Teaching and research Clinical data registries, clinical trials Process improvement • Produced making best use of radiologist’s time 8 Typical busy radiologist at Northwestern Memorial Hospital Benefits (+) and challenges (-) of Electronic Reports • Accuracy + Drive for quality improvement with quantitative data, CAD and other measurements + Possible major benefit with attached key images and graphical analysis (picture = 1000 words) – Will systems support graphical reports? • Timely communication + Probable improvement • Archived in the patient medical record – Where is the electronic medical record? (distributed, multiple copies) 9 Benefits and challenges of Electronic Reports (cont’d) • Legal record – What is a valid electronic signature? – Is an exact visual reproduction required, or only exact semantic content? • Secondary uses + Huge potential improvement, especially with structured and coded data + More accurate billing (avoid undercoding) • Use of radiologist’s time – Potential negative impact with transition from traditional dictation workflow – Radiologist pays the cost for improvements downstream 10 Planning for electronic reporting • What are your goals ? – Better capture of sonographer measurements into report – Add key images into reports – Ability to do research / data mining • What kinds of reports do you need? – – – – – Text only Text + image references Structured text Structured text + coded content Multimedia 11 This is Process Re-engineering! • Transition to electronic reports is hard – – – – New systems New architectures New policies and procedures Organizationally disjunct costs/benefits • Minimize the risk and the effort – A standards-based approach – Incremental evolution from current workflow – Leverage the work of IHE (Integrating the Healthcare Enterprise) 12 Radiology Reporting Workflows 13 Reporting Starts Before the Radiologist Sees the Study • Reason for exam (from order), patient history • Technical aspects of procedure – Protocol – Exam notes from tech • Post-processing results – Measurement and analysis applications (e.g., vascular, obstetric, cardiac) by tech – Computer Aided Detection results – Produced on modality, imaging workstation, or CAD server • These need to get to the radiologist and integrated into the report 14 Reporting Integration (1) • Review study evidence – Order and relevant clinical information – Images and relevant priors – Tech notes and post-processing results • Radiologist interpretation – on imaging workstation – Annotation (virtual grease pencil) – Key image selection – Measurement and analysis applications by radiologist • Radiologist findings reporting – on a different system? – Dictation + transcription / speech recognition – Structured data entry (forms-based) 15 Where’s Waldo going to prepare his report? Reporting Integration (2) • Report assembly – Findings and selected evidence/interpretation results • Radiologist signature – Auditable action, or digital encryption-based • Report communication – To referring physician – To “secondary” users (billing!, quality improvement) • Report archive – And subsequent access 16 Diagnostic reporting Image Viewing Application Reporting Application User control Diagnostic report ******************************************************************************** UNIVERSITY OF CHICAGO HOSPITALS RADIOLOGY CONSULTATION ******************************************************************************** 342 02/05/96 UNIVERSITY OF CHICAGO HOSPITALS BHIS #: 1234567 INPATIENT 201-23-90 RADIOLOGY CONSULTATION Hematology / Oncology CHANDLER, CAROLYN 342 02/05/96 Mitchell-6NE 49 FEMALE 201-23-90 BHIS #: 1234567 INPATIENT Hematology / Oncology Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Mitchell-6NE Clinical data: Biliary tube check. Carl M. Gompers, MD Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Clinical data: Biliary tube check. Change Perc Drainage CarlBiliary M. Gompers, MD Cath Proced -- Change Perc Biliary Drainage Cath Proced COMPARISON: 07/23/95 and 06/27/95 CHANDLER, CAROLYN 49 FEMALE Exam #46 on 01/08/96 -- Exam #46 on 01/08/96 FINDINGS: After the procedure was explained to the patient and informed COMPARISON: 07/23/95 and 06/27/95 & Int -- Exam #47 on 02/05/96 FINDINGS: After the procedure was explained to the patient and informed & Int -- Exam #47 on 02/05/96 FINDINGS: As above. IMPRESSION: FINDINGS: As above. Successful biliary tube change, and findings consistent with interval tumor IMPRESSION: growth. Successful biliary tube change, and findings consistent with interval tumor Simon A. Templar, MD / Richard Nixon, MD (R19) growth. Signed 02/9/96 at 8:48 AM 3 Simon A. Templar, MD / Richard Nixon, MD Signed 02/9/96 at 8:48 AM (R19) 3 Diagnostic Images Image Sources Viewing settings (ww/wl, rotation/flip) PACS Archive Orders, Prior Reports Report Information System 17 Reporting with annotation (use case - desired) Image Viewing Application Reporting Application User control Diagnostic Images Image Sources Viewing settings (ww/wl) PACS Archive Diagnostic report Image references & annotation Orders, Prior Reports ******************************************************************************** UNIVERSITY OF CHICAGO HOSPITALS RADIOLOGY CONSULTATION ******************************************************************************** 342 02/05/96 UNIVERSITY OF CHICAGO HOSPITALS BHIS #: 1234567 INPATIENT 201-23-90 RADIOLOGY CONSULTATION Hematology / Oncology CHANDLER, CAROLYN 342 02/05/96 Mitchell-6NE 49 FEMALE 201-23-90 BHIS #: 1234567 INPATIENT Hematology / Oncology Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Mitchell-6NE Clinical data: Biliary tube check. Carl M. Gompers, MD Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Clinical data: Biliary tube check. Change Perc Drainage CarlBiliary M. Gompers, MD Cath Proced -- Change Perc Biliary Drainage Cath Proced COMPARISON: 07/23/95 and 06/27/95 CHANDLER, CAROLYN 49 FEMALE Exam #46 on 01/08/96 -- Exam #46 on 01/08/96 FINDINGS: After the procedure was explained to the patient and informed COMPARISON: 07/23/95 and 06/27/95 & Int -- Exam #47 on 02/05/96 FINDINGS: After the procedure was explained to the patient and informed & Int -- Exam #47 on 02/05/96 FINDINGS: As above. IMPRESSION: FINDINGS: As above. Successful biliary tube change, and findings consistent with interval tumor IMPRESSION: growth. Successful biliary tube change, and findings consistent with interval tumor Simon A. Templar, MD / Richard Nixon, MD (R19) growth. Signed 02/9/96 at 8:48 AM 3 Simon A. Templar, MD / Richard Nixon, MD Signed 02/9/96 at 8:48 AM (R19) 3 Report with image references & annotation Information System 18 Reporting with annotation (what’s available) Image Viewing Application Reporting Application User control Image references & annotation Diagnostic Images Image Sources Viewing settings, image references & annotation PACS Archive Diagnostic report ******************************************************************************** UNIVERSITY OF CHICAGO HOSPITALS RADIOLOGY CONSULTATION ******************************************************************************** 342 02/05/96 UNIVERSITY OF CHICAGO HOSPITALS BHIS #: 1234567 INPATIENT 201-23-90 RADIOLOGY CONSULTATION Hematology / Oncology CHANDLER, CAROLYN 342 02/05/96 Mitchell-6NE 49 FEMALE 201-23-90 BHIS #: 1234567 INPATIENT Hematology / Oncology Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Mitchell-6NE Clinical data: Biliary tube check. Carl M. Gompers, MD Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Clinical data: Biliary tube check. Change Perc Drainage CarlBiliary M. Gompers, MD Cath Proced -- Change Perc Biliary Drainage Cath Proced COMPARISON: 07/23/95 and 06/27/95 CHANDLER, CAROLYN 49 FEMALE Exam #46 on 01/08/96 -- Exam #46 on 01/08/96 FINDINGS: After the procedure was explained to the patient and informed COMPARISON: 07/23/95 and 06/27/95 & Int -- Exam #47 on 02/05/96 FINDINGS: After the procedure was explained to the patient and informed & Int -- Exam #47 on 02/05/96 FINDINGS: As above. IMPRESSION: FINDINGS: As above. Successful biliary tube change, and findings consistent with interval tumor IMPRESSION: growth. Successful biliary tube change, and findings consistent with interval tumor Simon A. Templar, MD / Richard Nixon, MD (R19) growth. Signed 02/9/96 at 8:48 AM 3 Simon A. Templar, MD / Richard Nixon, MD Signed 02/9/96 at 8:48 AM (R19) 3 Orders, Prior Reports Report Information System 19 Reporting with measurements Image Viewing Application Reporting Application User control Diagnostic report ******************************************************************************** UNIVERSITY OF CHICAGO HOSPITALS RADIOLOGY CONSULTATION ******************************************************************************** 342 02/05/96 UNIVERSITY OF CHICAGO HOSPITALS BHIS #: 1234567 INPATIENT 201-23-90 RADIOLOGY CONSULTATION Hematology / Oncology CHANDLER, CAROLYN 342 02/05/96 Mitchell-6NE 49 FEMALE 201-23-90 BHIS #: 1234567 INPATIENT Hematology / Oncology Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Mitchell-6NE Clinical data: Biliary tube check. Carl M. Gompers, MD Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Clinical data: Biliary tube check. Change Perc Drainage CarlBiliary M. Gompers, MD Cath Proced -- Change Perc Biliary Drainage Cath Proced COMPARISON: 07/23/95 and 06/27/95 CHANDLER, CAROLYN 49 FEMALE Exam #46 on 01/08/96 -- Exam #46 on 01/08/96 FINDINGS: After the procedure was explained to the patient and informed COMPARISON: 07/23/95 and 06/27/95 & Int -- Exam #47 on 02/05/96 FINDINGS: After the procedure was explained to the patient and informed & Int -- Exam #47 on 02/05/96 FINDINGS: As above. IMPRESSION: FINDINGS: As above. Successful biliary tube change, and findings consistent with interval tumor IMPRESSION: growth. Successful biliary tube change, and findings consistent with interval tumor Simon A. Templar, MD / Richard Nixon, MD (R19) growth. Signed 02/9/96 at 8:48 AM 3 Simon A. Templar, MD / Richard Nixon, MD Signed 02/9/96 at 8:48 AM (R19) 3 EDD 0921 BPD 5.2 cm Diagnostic images & measurements Image Sources Viewing settings & confirmed measurements PACS Archive Measurement Sources Orders, Prior Reports Report Information System 20 The issues • How do we bridge the gap between the imaging side and the reporting side – Annotations, key images, and measurements • How do we include these enhanced features in reports? 21 HL7 Clinical Document Architecture Overview HL7 is a Standards Development Organization whose domain is clinical and administrative data 22 HL7 Clinical Document Architecture • The scope of the CDA is the standardization of clinical documents for exchange. • A clinical document is a record of observations and other services with the following characteristics: – – – – – Persistence Stewardship Potential for authentication Wholeness Human readability • A CDA document is a defined and complete information object that can exist outside of a message, and can include text, images, sounds, and other multimedia content. 23 Why do you need to know about CDA? • Executive Order 13,410 and EHR Safe Harbors Provision (Stark Act relaxation): certain healthcare IT systems must comply with federally recognized interoperability specifications • January 2008: HHS Secretary Leavitt recognizes first HITSP* Interoperability Specifications, including several components using CDA • While not (yet) specified for interoperability of radiology reports, HITSP considers CDA as basis for clinical documentation going forward *Healthcare IT Standards Panel of American National Standards Institute (ANSI), tasked 24 by Dept of Health & Human Services to recommend harmonized standards Clinical Document Characteristics • Persistence – Documents exist over time and can be used in many contexts • Stewardship – Documents must be managed, shared by the steward • Potential for authentication – Intended use as medico-legal documentation • Wholeness – Document includes its relevant context • Human readability – Essential for human authentication 25 CDA Use Cases • • • • • Diagnostic and therapeutic procedure reports Encounter / discharge summaries Patient history & physical Referrals Claims attachments • Consistent format for all clinical documents 26 Key Aspects of the CDA • CDA documents are encoded in Extensible Markup Language (XML) • CDA documents derive their meaning from the HL7 v3 Reference Information Model (RIM ) and use HL7 v3 Data Types • A CDA document consists of a header and a body – Header is consistent across all clinical documents identifies and classifies the document, provides information on patient, provider, encounter, and authentication – Body contains narrative text / multimedia content (level 1), optionally augmented by coded equivalents (levels 2 & 3) 27 CDA Standard • Release 1 (2000) – Standalone standard, based on early draft v3 RIM – Level 1 narrative and multimedia • Release 2 (2005) – Incorporated into HL7 v3 Standard (Normative Edition) – Level 2 structured narrative and multimedia, plus Level 3 coded statements • Implementation Guides – – – – – HL7 Care Record Summary (CRS) ASTM/HL7 Continuity of Care Document (CCD) IHE Patient Care Coordination Templates Common Document Types project (CDA4CDT) HL7 Diagnostic Imaging Report Implementation Guide New 28 CDA Release 2 Information Model Header Participants Start Here Doc ID &Type Body Context Sections/ Headings Clinical Statements/ Coded Entries Extl 29 Refs CDA Structured Body Arrows are Act Relationships • Has component, Derived from, etc. Entries are coded clinical statements • Observation, Procedure, Substance administration, etc. Structured Body Section Text Section Text Section Text Section Text Section Text Entry Coded statement Section Text Entry Coded statement Entry Coded statement 30 Sample CDA 31 Principle of Human Readability: Narrative and Coded Information • CDA structured body requires human-readable “Narrative Block”, all that is needed to reproduce the legally attested clinical content • CDA allows optional machine-readable coded “Entries”, which drive automated processes • By starting with a base of text, CDA allows incremental improvement to amount of coded data without breaking the model 32 Narrative and Coded Entry Example 33 CDA Non-XML Body • Alternative to XML Structured Body • Standard CDA header “wraps” existing document – Allows document management with consistent metadata • Body can be any MIME* type – Especially PDF (IHE Scanned Document Profile) *Multi-part Internet Mail Extension 34 CDA Implementation Guides • Published by HL7 – Care Record Summary – encounter notes, discharge summary – Continuity of Care Document – transfer of care (harmonized with ASTM Continuity of Care Record) – Diagnostic Imaging Report – with robust references to DICOM objects • Published by IHE Patient Care Coordination – – – – – – – Emergency Department Referral Pre-procedure History and Physical Scanned Documents Personal Health Record Extract Basic Patient Privacy Consents Antepartum Summary Emergency Department Encounter Summary 35 Diagnostic Imaging Report Implementation Guide Header Structured Body Section DICOM Object Catalog Section Reason for Study Section Findings Section Patient History Entries DICOM Study, Series, Image References References to DICOM objects in hierarchical context using native DICOM or WADO access References to DICOM images with optional Presentation State annotations Section Impressions Section Procedure Description Section Comparison Study Section Recommendations Entries (Annotated) Image References Section Key Images 36 DICOM Structured Reporting Overview DICOM is a Standards Development Organization whose domain is biomedical imaging 37 DICOM Structured Reporting • The scope of DICOM SR is the standardization of documents in the imaging environment. • SR documents record observations made for an imaging-based diagnostic or interventional procedure, particularly those that describe or reference images, waveforms, or specific regions of interest. 38 Why do you need to know about DICOM SR? • DICOM SR is used in key subspecialty areas that produce structured data in the course of image acquisition or post-processing, where: – Leveraging the DICOM infrastructure is easy and desirable – Results should be managed with other study evidence • Examples – – – – – Sonographer measurements Computer-aided detection results QC notes about images Radiation dose reports Image exchange manifests 39 Key Aspects of DICOM SR • SR documents are encoded using DICOM standard data elements and leverage DICOM network services (storage, query/retrieve) • SR uses DICOM Patient/Study/Series information model (header), plus hierarchical tree of “Content Items” • Extensive mandatory use of coded content – Allows use of vocabulary/codes from non-DICOM sources • Templates define content constraints for specific types of documents / reports 40 SR Content Item Tree Arrows are parent-child relationships • Contains, Has properties, Inferred from, etc. Content Items are units of meaning • Text, Numeric, Code, Image, Spatial coordinates, etc. Root Content Item Document Title Content Item Content Item Content Item Content Item Content Item Content Item Content Item Content Item Content Item 41 DICOM SR Example 42 DICOM SR Object Classes • Enhanced and Comprehensive - Text, coded content, numeric measurements, spatial and temporal ROI references – Templates for ultrasound, cardiac imaging • CAD - Automated analysis results (mammo, chest, colon) • Key Object Selection (KO) - Flags one or more images – Purpose (for referring physician, for surgery …) and textual note – Used for key image notes and image manifests (in IHE profiles) • Procedure Log - For extended duration procedures (e.g., cath) • Radiation Dose Report - Projection X-ray; CT 43 HL7 CDA and DICOM SR Compare and Contrast and Collaborate 44 “Evidence” and “Reports” • Evidence Documents – Includes measurements, procedure logs, CAD results, etc., created in the imaging context, and together with images are interpreted by a radiologist to produce a report – The radiologist may quote or copy parts of Evidence Documents into the report, but doing so is part of the interpretation process at his discretion – Appropriate to be stored in PACS as DICOM SR objects, with same (legal/distribution) status as images • Reports – Become part of the patient’s medical record, with potentially wide distribution – Good match to HL7 CDA 45 DICOM-HL7 Synergy (1) • DICOM and HL7 have recognized the need to work together • DICOM SR and HL7 CDA are congruent in key areas – – – – Document persistence Document identification, versioning and type code Document’s relation to the patient and to the authoring physicians Coded content using external vocabularies • SR strength in robust image-related semantic content; CDA strength in human readable narrative report 46 DICOM-HL7 Synergy (2) • • Methods for referencing CDA documents from within DICOM objects, and vice versa CDA documents can be included on DICOM exchange disks – As native CDA files, or encapsulated in a DICOM file – Indexed in DICOMDIR for integration with DICOM applications • • Transcoding from SR to CDA feasible for measurements, image references, observations DICOM WG10 (Strategic Advisory) suggested composing radiology reports directly in CDA format when appropriate 47 Approaches to integration • Use these standards! Ask for them from your IT providers • Leverage them in new combinations to achieve desired electronic reporting capabilities • Evolve from current workflows – but recognize there may be process reengineering 48 Loosely integrated reporting – add key images to reports Image Viewing Application Reporting Application User control Image references & annotation Viewing settings, Diagnostic image references Images & annotation Image references Image PACS & annotation Sources Archive Image retrieval Diagnostic report ******************************************************************************** UNIVERSITY OF CHICAGO HOSPITALS RADIOLOGY CONSULTATION ******************************************************************************** 342 02/05/96 UNIVERSITY OF CHICAGO HOSPITALS BHIS #: 1234567 INPATIENT 201-23-90 RADIOLOGY CONSULTATION Hematology / Oncology CHANDLER, CAROLYN 342 02/05/96 Mitchell-6NE 49 FEMALE 201-23-90 BHIS #: 1234567 INPATIENT Hematology / Oncology Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Mitchell-6NE Clinical data: Biliary tube check. Carl M. Gompers, MD Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Clinical data: Biliary tube check. Change Perc Drainage CarlBiliary M. Gompers, MD Cath Proced -- Change Perc Biliary Drainage Cath Proced COMPARISON: 07/23/95 and 06/27/95 CHANDLER, CAROLYN 49 FEMALE Exam #46 on 01/08/96 -- Exam #46 on 01/08/96 FINDINGS: After the procedure was explained to the patient and informed COMPARISON: 07/23/95 and 06/27/95 & Int -- Exam #47 on 02/05/96 FINDINGS: After the procedure was explained to the patient and informed & Int -- Exam #47 on 02/05/96 FINDINGS: As above. IMPRESSION: FINDINGS: As above. Successful biliary tube change, and findings consistent with interval tumor IMPRESSION: growth. Successful biliary tube change, and findings consistent with interval tumor Simon A. Templar, MD / Richard Nixon, MD (R19) growth. Signed 02/9/96 at 8:48 AM 3 Simon A. Templar, MD / Richard Nixon, MD Signed 02/9/96 at 8:48 AM (R19) 3 Orders, Prior Reports Report Information System Report w/ image ref & annot 49 Image Viewing Application Image selection Annotation Reporting Application ******************************************************************************** UNIVERSITY OF CHICAGO HOSPITALS RADIOLOGY CONSULTATION ******************************************************************************** 342 02/05/96 UNIVERSITY OF CHICAGO HOSPITALS BHIS #: 1234567 INPATIENT 201-23-90 RADIOLOGY CONSULTATION Hematology / Oncology CHANDLER, CAROLYN 342 02/05/96 Mitchell-6NE 49 FEMALE 201-23-90 BHIS #: 1234567 INPATIENT Hematology / Oncology Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Mitchell-6NE Clinical data: Biliary tube check. Carl M. Gompers, MD Admitting Diagnosis: NEUTROPENIC FEVER; HYPERBILIRUBEMIA Dictated report Clinical data: Biliary tube check. Change Perc Drainage CarlBiliary M. Gompers, MD Cath Proced -- Change Perc Biliary Drainage Cath Proced COMPARISON: 07/23/95 and 06/27/95 CHANDLER, CAROLYN 49 FEMALE Exam #46 on 01/08/96 -- Exam #46 on 01/08/96 FINDINGS: After the procedure was explained to the patient and informed COMPARISON: 07/23/95 and 06/27/95 & Int -- Exam #47 on 02/05/96 FINDINGS: After the procedure was explained to the patient and informed & Int -- Exam #47 on 02/05/96 FINDINGS: As above. IMPRESSION: FINDINGS: As above. Successful biliary tube change, and findings consistent with interval tumor IMPRESSION: growth. Successful biliary tube change, and findings consistent with interval tumor Simon A. Templar, MD / Richard Nixon, MD (R19) growth. Signed 02/9/96 at 8:48 AM 3 Simon A. Templar, MD / Richard Nixon, MD Signed 02/9/96 at 8:48 AM (R19) 3 Transcribed narrative DICOM GSPS object (annotations) DICOM KO object “For Report” Image Archive DICOM Query/Retrieve for all KO objects matching Accession Number Reporting System Validation Functions Reporting Integration Functions DICOM Encapsulated CDA object WADO Server WADO URI references to Images with GSPSs (JPEG rendering) CDA Report Other Use Cases to be Profiled • Quantitative measurement intensive reporting with DICOM SR inputs – Mammo with CAD input, Obstetric with sonographer measurements, Cardiac with functional assessments, CT with radiation dose – DICOM SR used to fill in report template before radiologist reviews case; radiologist verifies/edits transferred content, adds key images • Selected key measurements imported into report – Similar to Key Image / Annotation workflow 51 Conclusions • CDA now viewed as a primary format for diagnostic imaging reports – Template for CDA DI report in a balloted HL7 Implementation Guide • DICOM SR will see continued and expanding use for Evidence Documents created in the imaging setting – IHE Evidence Documents Integration Profile • Evolutionary workflows utilizing both standards in coordination are reasonable in the near term – Does not require tight integration of imaging and reporting applications 52