The latest development in the standardization of information flow between radiologists and EHR systems was announced at the 94th annual meeting of the Radiological Society of North America (RSNA) by Health Level Seven (HL7) and the Health Story Project (previously known as the CDA for Common Document Types, CDA4CDT project).
According to M*Modal, one of the founders of Health Story, the new implementation guide for diagnostic imaging reports will create a standard channel for sharing the clinical detail in narrative radiology reports, allowing radiologists to make the information readily accessible to computerized clinical information systems.
The new HL7-approved CDA Implementation Guide for diagnostic imaging reports will help radiologists capture and share the whole report or patient story in a human and machine readable format that includes narrative and structured data. Diagnostic decision-making reports will be available to both referring clinicians and clinical systems.
The DIR implementation guide was developed in conjunction with the DICOM Work Group (WG) 20/HL7 Imaging Integration WG and is consistent with the transformation guide from DICOM Structured Reports to CDA that is now in ballot within DICOM. Health Story worked with DICOM WG 20/HL7 Imaging Integration WG volunteers in the final stages of refinement, consensus building and balloting within HL7.
“HL7 and DICOM closely cooperated on this project. The communication of structured documents between imaging and clinical information systems is an important step for informed clinical decision making,” said Helmut Koenig, MD, co-chair of DICOM WG 20/HL7 Imaging Integration WG (Siemens Healthcare).