Материал: part17

X Dictation-based Reporting With Image​

References (Informative)​

This Annex describes a use of Key Object Selection (KO) and Grayscale Softcopy Presentation State (GSPS) SOP Instances, in​ conjunction with a typical dictation/transcription process for creating an imaging clinical report. The result is a clinical report as a Basic​ Text Structured Report (SR) SOP Instance that includes annotated image references (see Section X.2). This report may also (or al-​ ternatively) be encoded as an HL7 Clinical Document Architecture (CDA) document (see Section X.3).​

Similar but more complex processes that include, for instance, numeric measurements and Enhanced or Comprehensive SR, are​ notaddressedbythisAnnex.ThisAnnexalsodoesnotspecificallyaddressthespecialissuesassociatedwithreportingacrossmultiple​ studies (e.g., the "grouped procedures" case).​

X.1 Basic Data Flows​

X.1.1 Dictation/transcription Reporting​

Duringthesoftcopyreadingofanimagingstudy,thephysiciandictatesthereport,whichissenttoatranscriptionserviceorisprocessed​ byavoicerecognitionsystem.Thetranscribeddictationarrivesatthereportmanagementsystem(typicallyaRIS)bysomemechanism​ notspecifiedhere.Thereportmanagementsystemenablesthereportingphysiciantocorrect,verify,and"sign"thetranscribedreport.​ SeeFigureX.1-1.Thisdataflowappliestoreportsstoredinaproprietaryformat,reportsstoredasDICOMBasicTextSRSOPInstances,​ or reports stored as HL7 CDA instances.​

Figure X.1-1. Dictation/Transcription Reporting Data Flow​

The report management system has flexibility in encoding the report title. For example, it could be any of the following:​

•​the generic title "Diagnostic Imaging Report",​

•​a report title associated with the department (e.g., "Radiology Report"),​

•​a report title associated with the imaging modality or procedure (e.g., "Ultrasound Report"), or​

•​a report title pre-coordinated with the modality and body part (e.g., "CT Chest Report").​

There are LOINC codes associated with each of these types of titles, if a coded title is used on the report (see CID 7000 “Diagnostic​ Imaging Report Document Titles”).​

The transcribed dictation may be either a single text stream, or a series of text sections each with a title. Division of reports into a​ limited number of canonically named sections may be done by the transcriptionist, or automated division of typical free text reports​ may be possible with voice recognition or a natural language processing algorithm.​

Foranelectronicallystoredreport,thesigningfunctionmayormaynotinvolveacryptographicdigitalsignature;anysuchcryptographic​ signature is beyond the scope of this description.​

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X.1.2 Reporting With Image References​

To augment the basic dictation/transcription reporting use case, it is desired to select significant images to be attached (by reference)​ to the report. During the softcopy reading, the physician may select images from those displayed on his workstation (e.g., by a point-​ and-click function through the user interface). The selection of images is conveyed to the image repository (PACS) through a DICOM​ Key Object Selection (KO) document. When the report management system receives the transcribed dictation, it queries the image​ repository for any KO documents, and appends the image references from the KO to the transcription. In this process step, the report​ management system does not need to access the referenced images; it only needs to copy the references into the draft report. The​ correction and signature function potentially allows the physician to retrieve and view the referenced images, correct and change text,​ and to delete individual image references. See Figure X.1-2.​

Figure X.1-2. Reporting Data Flow with Image References​

The transcribed dictation must have associated with it sufficient key Attributes for the report management system to query for the​ appropriate KO documents in the image repository (e.g., Study ID, or Accession Number).​

Each KO document in this process includes a specific title "For Report Attachment", a single optional descriptive text field, plus a list​ ofimagereferencesusingtheSRImageContentItemformat.ThereportmanagementsystemmayneedtoretrieveallKOdocuments​ of the study to find those with this title, since the image repository might not support the object title as a query return key.​

Multiple KO instances may be created for a study report, e.g., to facilitate associating different descriptive text (included in the KO​ document) with different images or image sets. All KOs with the title "For Report Attachment" in the study are to be attached to the​ dictated report by copying their content into the draft report (see Section X.2 and Section X.3). (There may also be KOs with other​ titles, such as "For Teaching", that are not to be attached to the report.)​

The nature of the image reference links will differ depending on the format of the report. A DICOM SR format report will use DICOM​ nativereferences,andotherformatsmayuseahyperlinktothereferencedimagesusingtheWebAccesstoDICOMPersistentObjects​ (WADO) service (see PS3.18).​

X.1.3 Reporting With Annotated Images​

The KO also allows the referencing of a Grayscale Softcopy Presentation State (GSPS) instance for each selected image. A GSPS​ instance can be created by the workstation for annotation ("electronic grease pencil") of the selected image, as well as to set the​ windowwidth/windowlevel,rotation/flip,and/ordisplayareaselectionoftheimageattachedtothereport.ThecreatedGSPSinstances​ are transferred to the image repository (PACS) and are referenced in the KO document.​

As with image references, the report management system may include the GSPS instance references in the report. When the report​ is subsequently displayed, the reader may retrieve the referenced images together with the referenced GSPS, so that the image is​ displayed with the annotations and other GSPS display controls. See Figure X.1-3.​

Note that the GSPS display controls can also be included in WADO hyperlinks and invoked from non-DICOM display stations.​

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Figure X.1-3. Reporting Data Flow with Image and Presentation/Annotation References​

X.2 Transcribed Diagnostic Imaging SR Instance Content​

This section describes the use of transcribed dictation and Key Object Selection (KO) instances to produce a DICOM Basic Text SR​ instance. A specific SR Template, TID 2005 “Transcribed Diagnostic Imaging Report”, is defined to support transcribed diagnostic​ imaging reports created using this data flow.​

X.2.1 SR Header Content​

The Attributes of the Patient and Study Modules will be identical to those of the Study being reported. The following information is​ encoded in the SR Document General Module:​

•​Identity of the dictating physician (observer context) in the Author Sequence​

•​Identity of the transcriptionist or transcribing device (voice recognition) in the Participant Sequence​

•​Identity of the report signing physician in the Verifying Observer Sequence​

•​Identity of the institution owning the report in the Custodial Organization Sequence​

•​Linkages to the order and requested procedures in the Referenced Request Sequence​

•​A list of all images in the study in the Current Requested Procedure Evidence Sequence (from MPPS SOP Instances of the Study,​ or from query of the image repository)​

•​A list of all images not in the study, but also attached to the report as referenced significant images, in the Pertinent Other Evidence​ Sequence​

X.2.2 Transcribed Text Data Format​

The transcribed dictation is used to populate one or more section containers in the content tree of the SR Instance. If the transcription​ consists of a single undifferentiated text stream, it will typically be encoded using a single CONTAINER content item with Concept​ Name "Findings", and the text encoded as the value in a subsidiary TEXT content item with Concept Name "Finding". When the​ transcription is differentiated into multiple sections with captions, e.g., using the concepts in CID 7001 “Diagnostic Imaging Report​ Headings”, each section may be encoded in a separate CONTAINER, with the concept from CID 7001 “Diagnostic Imaging Report​ Headings” as the container Concept Name, and the corresponding term from CID 7002 “Diagnostic Imaging Report Elements” as the​ Concept Name for a subsidiary TEXT content item. See Figure X.2-1.​

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Figure X.2-1. Transcribed Text Content Tree​

X.2.3 Image Reference Format​

ThecontentitemsfromeachassociatedKOobjectwillbeincludedintheSRinaseparateCONTAINERwithConceptName(121180,​ DCM, "Key Images"). The text item "Key Object Description" and all image reference items shall be copied from the KO content tree​ to the corresponding SR container. See Figure X.2-2.​

Figure X.2-2. Inputs to SR Basic Text Object Content Tree​

The KO and SR IMAGE content item format allows the encoding of an icon (image thumbnail) with the image reference, as well as​ a reference to a GSPS instance controlling image presentation. Whether or not to include icons or GSPS references is an implement-​ ation decision of the softcopy review station that creates the KO; the IMAGE content item as a whole may be simply copied by the​ report management system from the KO to the Basic Text SR instance.​

The intended process is that all KOs "For Report Attachment" are to be automatically included in the draft report. Therefore, the cor-​ rection and signature function of the report management system should allow the physician to delete image references that were in-​ cluded, perhaps unintentionally, by the automatic process.​

X.3 Transcribed Diagnostic Imaging CDA Instance Content​

ThissectiondescribestheuseoftranscribeddictationandKeyObjectSelection(KO)documentstoproduceanHL7ClinicalDocument​ Architecture (CDA) Release 2 document.​

Note​

While this section describes encoding as CDA Release 2, notes are provided about encoding issues for CDA Release 1.​

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X.3.1 CDA Header Content​

The header of the CDA instance includes:​

•​Identity of the patient ("recordTarget" participation)​

•​Identity of the requested procedure ("documentationOf" act relationship)​

•​Identity of the dictating physician ("author" participation)​

•​Identity of the transcriptionist ("dataEnterer" participation)​

•​Identity of the report signing physician ("legalAuthenticator" participation)​

•​Identity of the institution owning the report ("custodian" participation)​

•​Identity of the request/order ("inFulfillmentOf" act relationship)​

Note​

The markup components in CDA Release 1 use different names.​

X.3.2 Transcribed Text Content​

Each transcription section can be encoded in a Section in the CDA document. The Section.Code and/or Section.Title can be derived​ from the corresponding transcription section title, if any. Although the transcription text can be encoded in the Section.Text without​ further markup, it is recommended that it be enclosed in <paragraph> tags.​

X.3.3 Image References​

Images are referenced using hypertext links in the narrative text. These links in CDA are not considered part of the attested content.​

Note​

1.​The primary use case for this Annex is the dictation/transcription reporting model. In the historical context of that model,​ the images (film sheets) are usually not considered part of the attested content of the report, although they are part of​ the complete exam record. I.e., the report is clinically complete without the images, and the referenced images are not​ formally part of the report. Therefore, this Annex discusses only the use of image references, not images embedded in​ the report.​

2.​Being part of the attested content would require the images to be displayed every time the report is displayed - i.e., they​ are integral to understanding the report. If the images are attested, they must also be encapsulated with the CDA​ package. I.e., the CDA document itself is only one part of the interchanged package; the referenced images must also​ always be sent with the CDA document. If the images are for reference only and not attested, the Image Content Item​ may be transformed to a simple hypertext link; it is then the responsibility of CDA document receiver to follow or not​ follow the hyperlink. Moreover, as the industry moves toward ubiquitous network access to a distributed electronic​ healthcare record, there will be less need to prepackage the referenced images with the report.​

In the current use case, there will be one or more KO instances with image references. Each KO instance can be transformed to a​ Section in the CDA document with a Section.Title "Key Images", and a Section.Code of 121180 from the DICOM Controlled Termin-​ ology (see PS3.16). If the KO includes a TEXT content item, it can be transformed to <paragraph> data in that Section.Text of the​ CDA document. Each IMAGE content item can be transformed to a link item using the <linkHtml> markup.​

Within the <linkHtml> markup, the value of the href Attribute is the DICOM object reference as a Web Access to Persistent DICOM​ Objects (WADO) specified URI (see Table X.3-1).​

Note​

1.​When a DICOM object reference is included in an HL7 CDA document, it is presumed the recipient would not be a​ DICOM application; it would have access only to general Internet network protocols (and not the DICOM upper layer​ protocol), and would not be configured with the means to display a native DICOM image. Therefore, the recommended​ encodingofaDICOMObjectReferenceintheCDAnarrativeblock<linkHtml>usesWADOforaccessbytheHTTP/HTTPS​

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