Terminology for representation of Diagnostic Imaging Procedures - Update

1. Terminology for representation of Diagnostic Imaging Procedures - Update Dr Keith Foord Consultant Radiologist, East Sussex Hospitals

2. A national system of RIS coding and descriptors ? • Relates to needs of request/entry systems within ICRS – pre-RIS - SNOMED match to record request to Spine • Consistency and uniqueness in requesting terminology – pre-RIS and within RIS • Consistency in activity measurement - RIS • Consistency in clinical coding of events – RIS - SNOMED match • 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 - SNOMED match to ‘performed examination code’ to Spine • For ‘Payment by results’ – accurate records of same patient activity – national tariffs - SNOMED match / accurate HRGs • DICOM Structured Reporting

3. NHS Costings Code Book

4. Descriptors Descriptors need to be UNIQUE in NCRS 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

5. Unique codes for requestor, reporter, Trust, ward and unique ‘Accession numbers’ related to examination modality. Requestor and reporter ? National code or GMC/GDC/SR no. or cross match to this via look up table. May not be a doctor. Trust? 3 character codes eg RPX Ward ? 3 character prefix eg RPXBaird Accession No. ? 3 character prefix RPX123456. Needed as same model machines might generate identical numbers and no process between manufacturers to coordinate these.

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 Z- Image analysis or review 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. 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

10. 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 • 4 Fourth visit etc. – 5,6,7,8,9 – 10th = 0

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

12. 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)

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

14. In modern RIS systems post co-ordination can be applied to group related procedures together.All RIS systems supplied via LSPs should do this. 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)

15. 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

16. 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

18. Post Coordinating RIS single descriptors Full list of RIS Codes & Descriptors + Synonyms NACS Location & People codes SNOMED CT Descriptors and Codes RIS SNOMED CT Descriptors and Codes HL7 HL7 NCRS ‘Order’ Entry NCRS ‘Reporting’ Module List of Orderable Procedures SNOMED CT SNOMED CT Descriptors and Codes SPINE

19. 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 (RIS) Layer (2nd order) Same list + Supine SU Prone PR Decubitus DE Complex Oblique QC Angled Oblique 22,30,45 Frog laterals FR May need to combine together or with 1st order list eg DELR Sub-Descriptors / Codes

20. NPfIT and Descriptors/Codes • Southern Cluster – IDX – GE PACS- Kodak CR- HSS CRIS • London Cluster-IDX- Philips PACS-Philips(Fuji)CR-? RIS • NE Cluster- iSOFT- Agfa PACS-Agfa CR-? RIS • EEM Cluster- iSOFT- Agfa PACS -Agfa CR -? RIS • NWWM Cluster- iSOFT- ComMedica PACS –Kodak CR- Kodak RIS • Has RCR endorsement • SNOMED CT can be integrated-matched

21. SNOMED CT NCRS 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.

22. SNOMED CT At the end of an episode / encounter of care, SNOMED CT codes are recorded in NCRS via the Discharge Summary / Encounter diagnosis and procedure codes. The SNOMED codes recorded in NCRS 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 NCRS and will update, not replace, the patient diagnosis and procedure codes. A full audit trail is available.

23. SNOMED CT Within NCRS P1R2, users will have the ability to manually record SNOMED CT codes within the following areas: §         Discharge Summary / Encounter §         Problems / Provisional Diagnoses Within NCRS 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 (viz. the code for the request) §         Results (viz. the code for the procedure(s) performed, not the radiological diagnosis or report which will be transferred via HL7 messaging)

24. 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. This does not apply to ‘Procedure performed’ , but to a provisional radiological diagnosis which may be a list of differential diagnoses which could be entered by a reporter (ie manually). Unlikely to happen given pressures of work! The use of DICOM structured reporting may give the possibility of automatically constructing radiological diagnosis codes from the structured report

25. 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

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

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

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