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RSNA Reporting Templates: Representation of Findings in CDA R2 Instances

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

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RSNA Reporting Templates: Representation of Findings in CDA R2 Instances

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  1. RSNA Reporting Templates:RepresentationofFindingsin CDA R2 Instances Helmut Koenig Co-Chair DICOM WG20

  2. Annotationsto Narrative Text • Taggingtextcontents • Mechanismspecifiedby CDA R2 andused in CDA Diagnostic Imaging Report IG • Content ID in narrative block isreferencedbystructuredentry • Structured entryincludescodetodefinesemanticsoftaggedcontent (Observation.code, Observation.valueConceptDescriptoruseddepending on type ofobservation)

  3. CDA Reference MechanismforAnnotations <section> … <text> <content ID="F1">Hilar mass …<content> </text> <entry> <observation classCode="OBS" moodCode="EVN"> … <originalText> <reference value="#F1"/> </originalText> … </observation> … </section> Narrative Block Content Identifier Structured Entry Reference

  4. Basic Observation Patterns Findings in RSNA Templates canberepresentedbythefollowingtypesof CDA observationevents: • QuantityMeasurement Observation • CodedObservation

  5. Quantity Measurement <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.6.2.14"/> <code code="246120007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" displayName="Nodule size"> <originalText> <reference value="#Diam2"/> </originalText> </code> <effectiveTime value="20060823223912"/> <value xsi:type="PQ" value="45" unit="mm"> <translation code="mm" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM" codeSystemVersion="1.5"/> </value> … </observation> Registered Quantity Measurement Obs. Template • Observation.codeusedtoconveycodedconcept • Observation.valueusesPhysicalQuantity (PQ) Data Type The unit of measure is specified in the Unified Code for Units of Measure (UCUM)

  6. Simple Coded Observation (Assertion) <observation classCode="OBS" moodCode="EVN"> … <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <originalText> <reference value="#F1"/> </originalText> <value xsi:type="CD" code="309530007” codeSystem="2.16.840.1.113883.6.96“> <displayName value="Hilar Mass"/> </value> … </observation> • „Assertion“ usedasObservation.code • Observation.valueistheplaceforcodedconcept • CD (ConceptDescriptor) data type allowsforuseof multiple codingsystems (translationcodes) and post-coordinationofcodes SNOMED CT

  7. Summary • Weneedtodefinethescopeofcodedobservationsandgetconsensus on essential patternsneeded in thatcontext • Weshouldavoid post-coordinationofcodeswhereverpossible • RadLexcompositionalgrammar? • Allowforcapturingof temporal aspects, i.e. clinically or operationally relevant timeofobservations (effectiveTime)

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