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Supplement 155 Imaging Reports using HL7 CDA. Status Report to WG-06 2014/04/01 Harry Solomon. Goals. Foundational architecture for an evolving family of imaging reports Initial templates for radiology reports, aligned with RSNA RadLex and Reporting Initiative - PowerPoint PPT Presentation
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Supplement 155Imaging Reports using HL7 CDA
Status Report to WG-062014/04/01
Harry Solomon
Sup 155 review 2
Goals
• Foundational architecture for an evolving family of imaging reports
• Initial templates for radiology reports, aligned with RSNA RadLex and Reporting Initiative
• Primarily narrative, with some discrete data; evolving to more discrete data over time
• Diagnostic and screening; evolving to interventional, cardiac, anatomic path, etc.
4/1/2014
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
4 /Harry Solomon /
Module 3-1 - CDA/
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 TypesA 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; allows document management, compilation of an individual patient's clinical documents into an electronic patient record
• Body contains narrative text / multimedia content (level 1), optionally structured into sections with coded titles and tagged narrative content (level 2), optionally augmented by coded equivalents to narrative (level 3)
CDA documents for a particular use may be constrained by a Template
5 /Harry Solomon /
Module 3-1 - CDA/
Core concepts of RIM
Every happening is an Act• Procedure, observation, medication, supply, registration,
etc.Acts are related through an ActRelationship• composition, preconditions, revisions, support, etc.Participation defines involvement in an Act• author, performer, subject, location, etc.The participants are Roles• patient, agent, responsible party.Roles are played and scoped by Entities• persons, organizations, material, places, devices, etc.
6 /Harry Solomon /
Module 3-1 - CDA/
… an administrationof albuterol…
RIM Classes and Color Coding
Act0..*1 0..*
1Entity ParticipationRole0..1
0..*
0..1
0..*
Plays
Scopes
A person …Mr Joe Public …
… playing the rolepatient …
… participates asthe subject of …
… an observationAsthma …
ActRelation-
ship0..1
0..*
1
1
Source
Target
… which is theReason for …
7 /Harry Solomon /
Module 3-1 - CDA/
CDA Release 2 Information Model
Header Body
ParticipantsSections/Headings
Clinical Statements/Coded Entries
ExtlRefsContext
Doc ID&Type
StartHere
8 /Harry Solomon /
Module 3-1 - CDA/
CDA Structured Body
Structured Body
SectionText
SectionText
SectionText
SectionText
SectionText
SectionText
EntryCoded statement
EntryCoded statement
EntryCoded statement
Arrows are Act Relationships • Has component, Derived from, etc.Entries are coded clinical statements• Observation, Procedure, Substance administration, etc.
EntryCoded statement
9 /Harry Solomon /
Module 3-1 - CDA/
Sample CDA
10 /Harry Solomon /
Module 3-1 - CDA/
Narrative and Coded Info
CDA structured body requires human-readable “Narrative Block”, all that is needed to reproduce the legally attested clinical contentCDA allows optional machine-readable coded “Entries”, which drive automated processesNarrative may be flagged as derived from Entries • Textual rendering of coded entries’ content, and contains no
clinical content not derived from the entries General method for coding clinical statements is a hard, unsolved problem• CDA allows incremental improvement to amount of coded
data without breaking the model
11 /Harry Solomon /
Module 3-1 - CDA/
Narrative and Coded Entry Example
Sup 155 review 12
Purposes of templates
• Reduce variability, improve interoperability • Normalize best practice• Support automation of report production• Support validation of report content
4/1/2014
Sup 155 review 13
Multiple layers of constraint
HL7 v3 RIMAbstract Data Classes
CDA r2Refined Data Classes and
structures for clinical documents
DICOM (Sup 155)Additional requirements and
templates for radiology reports
Professional ContentSpecific content for
specialized procedures
4/1/2014
Sup 155 review 14
Sup 155 as greenCDA
• greenCDA is the concept that CDA implementation can be simplified by abstractions bridging between use cases and CDA formal syntax requirements
• Defines data elements, using “business names”, that can be invoked by professional content specifications, without knowledge of CDA structures
• E.g., professional content can specify “impression:text”, or “contrast:name” and “contrast:volume”, and Sup 155 specifies how/where those are instantiated in a CDA structure
4/1/2014
Sup 155 review 15
Clinical Knowledge
Report Authoring Template
Report Authoring Process
Imaging Study Data
Clinician Interpretation
CDA Report Instance
Templates
Element Public
Interface
Element CDA
Structure
Report Formatting
Process
CDA Imaging Report
Document
Authoring Template Element Structure
IHE MRRT
RSNA RadReport
4/1/2014
Sup 155 review 16
Sup 155 editorial style
• Following conventions of HL7 CDA implementation guides, including Consolidated CDA, and emerging HL7 Templates Standard (in ballot reconciliation)
• Library of document, section, and entry templates • Templates specified as table aligned to XML, plus
supplemental narrative conformance statements (conceptually similar to Part 3 module style)
• XML examples provided• Not being generated from tooling (MDHT or Trifolia)
4/1/2014
Sup 155 review 17
Radiology Report Document TemplateName XPath Card. Verb Data
TypeValue
Radiology Report
ClinicalDocument
templateId 1..1 SHALL SET<II> @root 1..1 SHALL 1.2.840.10008.20.1.1Doc type code
code 1..1 SHALL CD
General header
1..1 SHALL General Header
Imaging header
1..1 SHALL Imaging Header
component 1..1 SHALL structuredBody 1..1 SHALL Current Procedure
component 1..1 SHALL Current Imaging Procedure Description
Clinical Information
component 0..1 MAY Clinical Information
Comparison Study
component 0..1 MAY Comparison / Previous Findings
Findings component 0..1 MAY Findings Impressions component 1..1 SHALL ImpressionsAddendum component 0..* MAY Addendum
component 0..1 SHOULD DICOM Object Catalog4/1/2014
Sup 155 review 18
Name XPath Card. Verb Data Type
Value
Comparison Study
section
@classCode
1..1 SHALL 2.16.840.1.113883.5.6 (HL7ActClass) = DOCSECT
@moodCode
1..1 SHALL 2.16.840.1.113883.5.1001 (ActMood) = EVN
templateId
1..1 SHALL SET<II>
@root
1..1 SHALL tbd
id 1..* SHALL II code 1..1 SHALL CD 18834-2, LOINC, “Radiology Comparison
study”
text text 0..1 SHOULD ED author
author0..1 MAY Observer Context
procedure entry 0..1 MAY Imaging Procedure
4/1/2014
Sup 155 review 194/1/2014
Name XPath Card. Verb Data Type
Value
Author AssignedAuthor @classCode 1..1 SHALL 2.16.840.1.113883.5.110
(RoleClass) = ASSIGNED templateId 1..1 SHALL SET<II> @root 1..1 SHALL 2.16.840.1.113883.10.20.6.2.4 id 1..1 SHALL person 0..1 SHOULD Name name 1..1 SHALL PN authoringDevice 0..1 SHOULD Device softwareName 1..1 SHALL ST
Sup 155 review 20
Subsections
• Some defined in templates for specific uses– Contrast, Radiation Dose, Fetus Finding
• Requirements for user-labeled subsections – Content for an arbitrary topic (a particular organ
or anatomic feature, a lesion, a tumor, etc.)– Required section.title with topic name– No section.code, hence no semantic post-
coordination to section entries
4/1/2014
Sup 155 review 21
Why no section.code in user-labeled subsection?
• section.code uses LOINC codes with scale=NAR– i.e., its value in section.text is a narrative block– A concept that scopes a value (observable entity)
• The concepts used as user-labels (typically anatomy) are the wrong “part of speech”– Do not have formal semantics of scoping a value– Need something like a post-coordinated phrase:
FindingsSection+FindingSite=<anatomy> (cf. DICOM)– CDA does not have section targetSiteCode or Participation
for anatomic site
4/1/2014
22 /Harry Solomon /
Module 3-1 - CDA/
Body and Narrative Sections
External Relations
• HL7• RSNA
– Radiology Reporting– RadLex
• IHE– MRRT
Sup 155 review 24
Relationship to HL7
• Builds on HL7 Diagnostic Imaging Report (DIR) CDA IG informative standard
• Leverages harmonization done for Consolidated CDA IG r2 (C-CDA)
• Public comment to be solicited in HL7 ballot cycle parallel to DICOM PC and LB periods
• May be balloted as HL7 standard (DIR r2), recognizing updates will be handled in DICOM continuous maintenance process
4/1/2014
Sup 155 review 25
Reuse of C-CDA Templates
• Intent is to be harmonized with C-CDA• But C-CDA is US Realm only – DICOM needs to
be Universal Realm• Challenges to re-use based on shortcuts taken
– Vocabulary bindings hard coded into templates– Vocabulary bindings US Realm only
4/1/2014
Sup 155 review 26
RSNA Reporting Initiative
4/1/2014
radreport.org
CT Brain (example)Clinical History * Medical history * Risk factors * Allergies, if relevant * Reason for exam, including medical necessity: [headache | stroke | dizziness | trauma]Imaging Technique * Time of image acquisition * Imaging device [MR, CT] * Image acquisition parameters, such as device settings, patient positioning, interventions (e.g., Valsalva) * Contrast materials and other medications administered (including name, dose, route, and time) * Radiation doseComparison * Date and type of previous exams reviewed, if applicableObservations * Extra axial spaces: [normal in size and morphology for the patient's age* | widened] * Hemorrhage: [none* ; subdural ; subarachnoid; epidural, intraventricular, parenchymal] * Ventricular system: [normal in size and morphology for the patient's age* | enlarged | small] * Basal cisterns: [normal* | enlarged | small] * Cerebral parenchyma: [normal*; microvascular changes; infarction; encephalomalacia; gliosis; hemorrhage] * Midline shift: [none* | leftward shift | rightward shift] …Impressions
Sup 155 review 28
RadLex tagged content
• RadLex is an RSNA lexicon designed to tag concepts for subsequent indexing/retrieval
• Atomic concepts only – no compositional grammar • Use CDA <linkHtml> non-attested link in narrative
block
<section> ... <text> ...<content>There is focal opacity at the right lung base most likely representing right lower lobe atelectasis.<linkHtml href=http://www.radlex.org/RID/RID1302 /><linkHtml href=http://www.radlex.org/RID/RID28493 /> </content></text> ... </section>
4/1/2014
Sup 155 review 29
Relationship to IHE MRRT
• Management of Radiology Report Templates is an IHE Profile that (inter alia) defines an HTML scheme for encoding report production templates
• Revisions needed for MRRT to use DICOM defined business names, supporting encoding of reports as CDA using Sup 155
• Informative annex in DICOM about use of templates in report production, including MRRT
• Should we invite IHE Radiology to submit revised HTML scheme for standardization in Sup 155?
4/1/2014
Sup 155 review 30
DICOM Stuff
4/1/2014
Sup 155 review 31
What about Part 20?
• Designed for mapping SR to CDA• Includes CDA structures also used in Sup 155
templates (e.g., DICOM Object Catalog, header structures, image references, etc.)
• Suggest general reworking combining current Part 20 with new material in Sup 155, to produce a replacement Part 20
• How to handle new version of current Part 20 material?
4/1/2014
Sup 155 review 32
Conformance
• What needs to specified in Part 2 with respect to conformance?
• Creator claim of document level templates– That would just be one, for now– How about specific uses and/or RSNA templates?
• No expected receiver claims beyond general HL7 CDA receiver conformance– Not intended to be in the DICOM conformance
world
4/1/2014
33
Schedule• April 1: WG-06 – review overall
strategy • May-Jun: WG-06 webinars for line
by line review• Jun 23-27: WG-06 –Release for PC• Mid July-mid Sept: Public Comment• Sept 8-12: WG-06 – review
comments and necessary revisions• Nov 10-14: WG-06 – Release for LB• Nov-Jan: Letter Ballot• Jan 12-16: WG-06 – Final Text Draft
• ?? Publish FT
• May 5-9: HL7 – review with Structured Documents WG, and “clean draft” Supplement
• Aug 8-Sep 8: HL7 Comment Only ballot
• Sep 15-19: HL7 – review comments
• Dec 12-Jan 12:HL7 Comment Only ballot
• Jan 19-23: HL7 – review comments and Final Text Draft
4/1/2014 Sup 155 review
Sup 155 review 34
Should Sup155 be DSTU?
• DICOM generally has not found DSTU to be useful
• HL7 uses it regularly, especially for CDA IG’s
4/1/2014