DICOM Structured Reporting Current Status and Role in the Electronic Patient Record

1. DICOM Structured ReportingCurrent Status and Role in the Electronic Patient Record Harry Solomon Co-chair, DICOM WG1 - Cardiovascular Information Solomon, DICOM SR European Society of Cardiology 2 September 2001

2. What is DICOM Structured Reporting? • A means of encoding structured information … • hierarchical tree of content items, using DICOM object syntax • For vendor-independent exchange between systems … • leveraging the DICOM object management infrastructure • Providing unambiguous documentation of meaning … • text, categorical codes, numeric measurements, inter-item relationships • For the image-intensive clinical environment • careful attention to clinical observation context • robust references to DICOM images, waveforms Solomon, DICOM SR European Society of Cardiology 2 September 2001

3. Structured Reporting is Not... • DICOM SR is not just “reports” • any structured data exchanged between systems • measurements, analyses, sonographer notes ... • DICOM SR is notStructured Data Entry • Hierarchical pull-down menus to support report creation is often denoted “structured reporting” • DICOM does not standardize applications or data entry techniques • Structured data entry is a valuable means of creating SR content in certain circumstances Solomon, DICOM SR European Society of Cardiology 2 September 2001

4. Where Can Cardiology Use SR? • Clinical Reports (cath, echo, nuc, etc.) • to go along with our pretty DICOM pictures • Analyses of raw image and waveform data • backing up the Clinical Report • Documentation of the procedure • provide context for the raw data and analyses • Input to a clinical database • for patient care over time, or outcomes analysis Solomon, DICOM SR European Society of Cardiology 2 September 2001

5. Cath Lab Example Procedure Log 11:10 Patient prepped Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired 11:30 XA image acquired 11:47 PTCA 11:59 XA image acquired 12:02 HD waveform acquired Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired 11:30 XA image acquired 11:47 PTCA 11:59 XA image acquired Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired 11:30 XA image acquired 11:47 PTCA 11:59 XA image acquired 12:02 HD waveform acquired 12:21 Pt released to holding 12:24 HD Report Procedure Log 11:10 Patient prepped 11:19 Percutaneous entry 11:23 XA image acquired 11:27 HD waveform acquired 11:30 XA image acquired Cath Lab Report Patient 67 yr old male, history of … Ref prior ECG report Procedure Ref Log Narrative ... Findings Hemodynamic Ref HD Report Narrative ... Angiographic 70% stenosis ... Ref image Intervention Stent placed in LAD … Ref image Complications Summary Hemo Report Baseline Ref waveform Measurements … Post-intervention Ref waveform Measurements … Derived measurements Ref waveform

6. Structured Reporting is the glue that makes possible construction of an electronic patient record for cardiology Solomon, DICOM SR European Society of Cardiology 2 September 2001

7. DICOM SR Status • Work began in 1994 • Championed by Dr. Dean Bidgood • Supplement 23: Structured Reporting - April 2000 • Defined general format for SR objects • DICOM header, hierarchical tree of content items • Concepts represented by coded terminology using external (non-DICOM) lexicons [e.g., Reed codes, SNOMED anatomy, ICD-9/10 diagnosis or procedure codes, SCP-ECG lead IDs] • Defined general classes of clinical reports • Extremely flexible Solomon, DICOM SR European Society of Cardiology 2 September 2001

8. The Problem of Flexibility • A document creator can put in anything in any structure • A document reader must handle every possible document • Need to constrain the SR content to enable meaningful receiving applications • Structure • Content Solomon, DICOM SR European Society of Cardiology 2 September 2001

9. DICOM SR Status • Supplement 53: Content Mapping Resource - May 2001 • Defined general structure for templates: document patterns • Mechanism for terminology context groups: constrained vocabulary subsets • Fundamental templates for documenting clinical context and for basic reports • DICOM lexicon for vocabulary not externally available Solomon, DICOM SR European Society of Cardiology 2 September 2001

10. So Theoretically ... • DICOM Structured Reporting is ready to be implemented for cardiology! But Pragmatically … Solomon, DICOM SR European Society of Cardiology 2 September 2001

11. Issues for Cardiology SR • Uses not well covered by “clinical report” model • Procedure logs, preliminary measurement reports • Many ways to encode the same information • Need consistent approach for interoperability • Need tailored subset of SR for developers • Reduce the learning curve Need Cardiology-specific SR Templatesand consensus Terminology Solomon, DICOM SR European Society of Cardiology 2 September 2001

12. Cardiology SR Efforts • Supplement 66: Cath Lab SR (WG1) • Procedure Log • Hemodynamics Report • ECG Report • Quantitative Analysis Report • Cath Lab Report • Supplement 26: Ultrasound SR (WG12) • Echocardiography Report • Both to be released for Public Comment this autumn Solomon, DICOM SR European Society of Cardiology 2 September 2001

13. Procedure Log Issues • Structure - flat • Ordering - strictly time sequential • Linkage of events - associative Procedure Step / Action ID • SOP Class - distinct from reports • Remote entries - new Application Event Logging Service Class Solomon, DICOM SR European Society of Cardiology 2 September 2001

14. Hemodynamic Report Issues • SOP Class - Cath Lab Measurements (together with QCA, QVA, IVUS measurements, etc.) • Distinction from report titles • Structure - deep hierarchy • Terminology - post-coordinated, context from hierarchy Solomon, DICOM SR European Society of Cardiology 2 September 2001

15. Hemo Report CONTAINER Post-Intervention Phase Baseline Phase Post-Contrast Phase CONTAINER CONTAINER CONTAINER Patient State Patient State CONTAINER CONTAINER Arterial Measurements Arterial Measurements Ventricular Measurements Gradient Measurements CONTAINER CONTAINER CONTAINER CONTAINER Anatomic Anatomic Location = Location = L Fem Art Aorta Systolic Pres Systolic Pres Diastolic Pres Diastolic Pres Mean Pres Mean Pres Hemo Report Structure

16. Find out more • http://www.pixelmed.com/srbook.html • David Clunie’s excellent introduction to DICOM SR • ftp://medical.nema.org/medical/dicom/supps • text of draft supplements • http://www.dicomwg12.org/structured_reporting • echocardiography SR • subscribe to WG1 email list • send request to how_clark@nema.org Solomon, DICOM SR European Society of Cardiology 2 September 2001

17. Thank you Questions? mailto://harry.solomon@med.ge.com Solomon, DICOM SR European Society of Cardiology 2 September 2001