When a picture ISN’T worth a thousand words, where do reports fit into VNA’s and Enterprise Imaging?

 

In traditional imaging systems like Radiology and Cardiology PACS the report is always with the images. In Radiology, the dictation system sends a copy of the report to PACS via HL7 which is ok since it is text. In cardiology it is either a textual report, or the cardiology system creates the report and therefore has a copy. As we get outside of the walls of those two systems, where does the report really live?

For those that don’t read to the end … the answer is DICOM SR  in your VNA but please keep reading!

In an environment where all users are logged into the EMR and launching images from there, it is not an issue as the EMR is now the system of record for the reports and will have a copy. Now, IMAGINE A WORLD (queue deep commercial voice) where images are sent for reading to various physician groups who are not logged into the EMR.  Reading the newest image is not an issue, but what about priors? In some teleradiology workflows prior reports are faxed, others copy and paste prior reports from the EMR, and still others simply read what is in front of them.

I submit that there is a better way. As we move forward with outsourcing reads, and facilities are divested and acquired regularly it makes no sense whatsoever to not keep reports with the images. The two are intrinsically linked and are important for different reasons as part of the patient record. Luckily there are several mechanisms to resolve this. Surprisingly I don’t see them often implemented.

Let’s start with the low hanging fruit, cardiology. Since most CPACS have reporting modules within the system the report is already with the images before the images are archived and / or sent elsewhere. While I am all for FHIR and emerging solutions I prefer to stick with what I can implement today, now, and yes there are options. The simplest is to do an HL7 export to the EMR. This will provide the text but no images. Often times CPACS will generate a PDF report but that ends up being imported as a separate document into the EMR and not linked. There are actually 3 options to export a content rich report besides emailing the pdf.

The first is to utilize HL7 and the encapsulated document (ED) standard. The standard does exist, and it can be done but I have not seen it nor talked to anyone who has tried. The second is to store the PDF document in the XDS, I am all about standards and a big believer in XDS. The problem is that first you have to HAVE an XDS repository which many don’t, and secondly you need a system to act as the XDS source, which many (most) imaging systems don’t do. There is a very easy answer to this problem and one that has been around for a very long time it just isn’t used.

The easy answer is to DICOM Encapsulate the PDF report and store it with the images as another series. Many CPACS do this natively, it is as simple as clicking a button in the configuration to “archive report with images”.   Why this is not done more often is a mystery to me. This is a very good option for CPACS which commonly creates pdfs as the report product but for other systems that rely more on plain text is the PDF the way to go?

There are several options for textual reports as well. HL7 interfaces between systems is an option but HL7 tends to be more of an all or nothing proposition. Again, XDS offers several opportunities, we stored the text reports as CDA objects in XDS, however this shares some of the previously stated limitations with XDS, namely the lack of adoption so far. Still, there is an old school solution to this problem. The DICOM Structured Report (SR).  By using the DICOM SR one can store the report with the images, any time the images are viewed or sent to another location the report goes with it with no additional steps.

I did this with my VNA from the beginning and it has been a huge success as my EMR Viewer can process the SR and therefore when looking at priors for history the report is available for review without the hospitalist having to go back and forth to the EMR to view the interpretation that goes with the images. Similarly, any time images are requested by another facility or need to be shared for patient care the report is always with the images, either as a DICOM SR or an encapsulated PDF. See that was worth reading to the end wasn’t it?

Kyle Henson

Please let me know what topics you would like to discuss

Kyle@kylehenson.org