Terminology for representation of Diagnostic Imaging Procedures

1. Terminology for representation of Diagnostic Imaging Procedures Dr Keith Foord Consultant Radiologist, East Sussex Hospitals National Programme for IT in the NHS Wednesday 1st December 2004

2. A national system of RIS coding and descriptors ? • Relates to needs of request/entry systems within ICRS – pre-RIS • Consistency and uniqueness in requesting terminology – pre-RIS and within RIS • Consistency in activity measurement - RIS • Consistency in clinical coding of events - RIS • But must be as intuitive and easy to use as possible • Should have national acceptance • For accurate communication of results data between hospitals – post RIS results reporting, cluster stores and national spine • For ‘Payment by results’ – accurate records of same patient activity – national tariffs

3. NHS Costings Code Book

4. Other sources RIS Descriptors and Codings from: Guildford North Bristol Hastings Eastbourne Calderdale Bart’s NWWM cluster

5. Descriptors Descriptors need to be UNIQUE in ICRS FOOT LEFT not unique When a user searches all of the examinations available for ‘Foot Left’ the search may return: FOOT LEFT, FOOT LEFT Swab, FOOT LEFT Physiotherapy, FOOT LEFT Dressing, etc., etc. But XR FOOT LEFTis unique

6. Radiology Short Codes Used in RIS as shortcuts For bookings For internal communications within Radiology To help group procedures For internal management / audit / activity For common use need a structure, ideally short (max. 6 letters/digits) and logical

7. Radiological Short Codes 1 2 3 4 5 6 Modality X – X-ray F – Fluoro I – Interventional/ Fluoro C – CT M – MRI U – U’sound N – Radionuclide Imaging P – PET E- Endoscopy Three or four letter body part / function code Post- qualifier (Extra or sub- descriptor) 4th letter reserved for R, L, B or W if procedure R or L lateralisable, Both or Whole body, otherwise can be used for any letter or number

8. Format for a midline or non lateralising structure, no post qualifier A B C D E Format for a lateralisable or whole body structure, no post qualifier A B C D F

9. Eg X-ray SIJ X S I J S Eg Right Hand X-ray X H A N R

10. Eg MRI Abdomen M A B D O Eg Whole body Bone scan N B O N W

11. Format for a midline or non lateralising structure, with a post qualifier A B C D E G Format for a lateralisable or whole body structure, with a post qualifier A B C D F G

12. Extra qualifiers (6th letter/number = G) • A Ablation • B Biopsy (Core or FNA) • D Drainage or Aspiration of fluid • E Embolisation • I Insertion of device • J inJection - as an objective of the procedure, not as part of the preliminary to this objective • M Mobile - for any modality, but particularly for 'portable' plain films and use of mobile image intensifiers • O tOmography in its wider sense. O may be added to any plain film examination to define planar tomography - or postcoordinated • P Plasty - as in angioPlasty or dacrocystoPlasty - ie balloon dilatation • R for Radiotherapy planning • S Stent • T Use of intraThecal contrast • X eXtraction - eg in retrieval of intravascular foreign bodies or removal of temporary IVC filter • 1 First part of study • 2 Second part of study • 3 Third part of study

13. Eg CT guided PELVic Biopsy C P E L V B Eg Interventional (Fluoroscopic) Right SFA Angioplasty I A S F R P

14. In order to group procedures many RIS systems lack the ability to post co-ordinate procedures together under one accession number. Particular examples are for 'both' plain film exams eg 'both ankles' and in CT where examinations often combine e.g. CT Chest, Abdomen, Pelvis. Pre co-ordination or grouping of these procedures is therefore required in advance. Pre co-ordination should not be used in RIS-PACS systems capable of full post co-ordination as with these individual procedure codes will be automatically or manually grouped prior to archiving and reporting Pre and Post Co-ordination (1)

15. Eg CT guided PELVic Biopsy C P E L V B This is pre-coordinated with the whole process described in the code

16. Examples of other pre co-ordinated studies

17. In modern RIS systems post co-ordination can be applied to group related procedures together. Some procedure codes such as 'U/S biopsy' by themselves do not define precisely what has happened although it would define the activity of “Performing a biopsy under ultrasound control and the consumables/activity associated with this.” Such codes need post co-ordinating with the relevant body part to fully inform activity statistics Similarly separate CT body part examinations can be post co-ordinated together to enable the multiple examinations to be reported together as one report. The advantage is a more sophisticated approach to audit, activity measurement and stocktaking Pre and Post Co-ordination (2)

18. C P E L V B C P E L V PLUS C B I O P B Are POST coordinated and describe both processes which are then reported as one. CT biopsy cost structures do not need to be built into multiple codes Eg CT guided PELVis Biopsy

19. C C H E S PLUS P G E N W Are POST coordinated and describe both processes which are then reported as one. Eg PET/CT for Chest

20. Codes for post co-ordination

21. Alphabetical list of all proceduresby DESCRIPTOR or CODE (1037 codes) Descriptors Codes

22. REQUESTING Layer(1st order) Right Oblique QR Left Oblique QL Right Lateral LR Left Lateral LL Weight Bearing WB Standing ST Axial AX AP20o 20 Judet’s JU Stryker’s SY Etc… IN RADIOLOGY Layer (2nd order) Supine SU Prone PR Decubitus DE Complex Oblique QC Angled Oblique 22,30,45 Frog laterals FR May need to combine with 1st order list eg DELR Sub-Descriptors / Codes

23. Total diagnostic examinations/interventions

24. NPfIT and Descriptors/Codes • Southern Cluster – IDX – GE PACS- ? Cerner RIS • London Cluster-IDX- Philips PACS-? Sectra RIS • NE & EEM Clusters- iSOFT-? Agfa PACS-? RIS • NWWM Cluster- iSOFT- ComMedica PACS –Kodak RIS • Has RCR endorsement • SNOMED CT can be integrated-matched (Dr David Nag)

25. SNOMED CT Carecast provides support for clinical coding using the SNOMED CT nomenclature for diagnosis and procedure codes. SNOMED CT codes will be applied to the patients record through manual selection by users, as well as an integrated bi-product of clinical processes (i.e. orders, assessments). SNOMED CT clinical coding is supported for inpatient and outpatient encounters.

26. SNOMED CT At the end of an episode / encounter of care, SNOMED CT codes are recorded in Carecast via the Discharge Summary / Encounter diagnosis and procedure codes. The SNOMED codes recorded in Carecast are sent to the 3M clinical encoder where clinical coding is completed in SNOMED CT, ICD10, Read, and OPCS4. Codes will be transferred back to Carecast and will update, not replace, the patient diagnosis and procedure codes. A full audit trail is available.

27. SNOMED CT Within Carecast P1R2, users will have the ability to manually record SNOMED CT codes within the following areas: §         Discharge Summary / Encounter §         Problems / Provisional Diagnoses Within Carecast P1R2, SNOMED CT codes will be recorded against the patients record, as a bi-product of clinical processes, in the following clinical areas:  §         Assessments §         Findings / Flowsheets §         Orders §         Results

28. Orders and Resultsin Radiology SNOMED CT Order codes can be derived from Order/Entry systems, but will be MUCH MORE ACCURATE if derived from the accepted and if required modified final RIS procedure entry with SNOMED CT matching. SNOMED CT Results codes from Radiology are a dilemma. A provisional radiological diagnosis which may be a list of differential diagnoses could be entered by a reporter (ie manually). Unlikely to happen ! The use of DICOM structured reporting may give the possibility of automatically constructing radiological diagnosis codes from the structured report

29. Incorporated into the report are captured images of key findings (which can be exploded to full screen presentation), structured diagnosis information, recorded audio, the ability to sort findings by anatomy or priority, to view prior findings associated with the corresponding patient and hyperlinks to related information. Structured reporting DICOM SR – is an ‘envelope’, but within this useful structure is available. User decides how much structure to use and controls with templates the type of content, if it is mandatory or optional and modes of expression

30. Structured reporting Link Features to Description New nodule superimposed with right fourth rib 10% Pneumothorax Cavitation Free air

31. David Clunie Development Director, Imaging Products ComView Corporation – Paper at SPIE, 2001 Structured reporting

32. David Clunie Development Director, Imaging Products ComView Corporation – Paper at SPIE, 2001 Structured reporting