HL7 Clinical Document Architecture (CDA) Implementation Guide Enhances Radiology Reporting

CHICAGO (Business Wire EON/PRWEB ) December 2, 2008 -- The latest development in the standardization of information flow between radiologists and electronic health record systems was announced today at the 94th Scientific Assembly and Annual Meeting of the Radiological Society of North American (RSNA) by Health Level Seven (HL7) and The Health Story Project (previously known as the CDA for Common Document Types or CDA4CDT project).

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

The HL7 CDA Diagnostic Imaging Report (DIR) Implementation Guide and DICOM DIR Transformation Guide provide the basis for improving the exchange of imaging results.

The Diagnostic Imaging Report is extremely important for the field of radiology where diagnostic imaging combined with structured narrative from dictation is imperative to rapid decision making

By providing radiologists with reporting standards, more records can be shared across the healthcare continuum in an accurate and efficient manner

We are pleased to support this work that can advance the future of healthcare clinical documentation by bridging the gap between narrative documents produced through dictation and the structured, computable records within an electronic health record

When information is accurate and shared in a readily available form, physicians will be able to use data to offer best practices and ultimately drive improved patient care.

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 an industry-accepted, human and machine readable format that includes rich narrative and structured data. High-quality diagnostic decision-making reports will be more easily 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. It is based on many years of work within the DICOM and HL7 communities by individuals and organizations dedicated to interoperability. Health Story worked closely 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). “The HL7 CDA Diagnostic Imaging Report (DIR) Implementation Guide and DICOM DIR Transformation Guide provide the basis for improving the exchange of imaging results."

In many cases the results of radiology studies are required before the next step in a patient’s treatment or diagnosis can be made. The new standard allows for the inclusion of the detail and the narrative that the referring physician wants and needs while retaining the computer interoperability required for automatic processing and clinical support.

“The Diagnostic Imaging Report is extremely important for the field of radiology where diagnostic imaging combined with structured narrative from dictation is imperative to rapid decision making,” said Michael Finke, CEO of M*Modal. “By providing radiologists with reporting standards, more records can be shared across the healthcare continuum in an accurate and efficient manner,” he added.

Today, approximately 600 million clinical documents are dictated in the United States each year, comprising around 60% of all clinical data. While these documents contain the majority of physician-attested information and are used as the primary source of information for reimbursement and proof of service, this clinical information is grossly underutilized due to limitations in ability of current computer-based record systems to access the information locked away in these documents.

“We are pleased to support this work that can advance the future of healthcare clinical documentation by bridging the gap between narrative documents produced through dictation and the structured, computable records within an electronic health record,” added HL7 Chair, W. Ed Hammond, PhD. “When information is accurate and shared in a readily available form, physicians will be able to use data to offer best practices and ultimately drive improved patient care.”

To date, Health Story has supported the development of four implementation guides using HL7’s Clinical Document Architecture (CDA), which have been approved as HL7 Draft Standards for Trial Use. In addition to the Diagnostic Imaging Report, the group has played a critical supporting role in production of guides for the Consultation Note, History and Physical and Operative Note allowing the information in these clinical areas to be shared in an accurate and efficient manner.

The Health Story Project will define and publish data standards for additional document types and will support their implementation and inform the industry about the availability and benefits of these standards. In conjunction with its re-branding as “The Health Story Project”, the group has initiated a five year plan to develop and bring to the HL7 ballot additional standards for discharge summaries, ambulatory and outpatient clinical notes as well as addressing standardization of reimbursement requirements within notes.

About HL7

Founded in 1987, Health Level Seven, Inc. (www.HL7.org) is a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services. HL7’s more than 2,400 members represent approximately 500 corporate members, including 90 percent of the information systems vendors serving healthcare.

HL7’s endeavors are sponsored, in part, by the support of its benefactors: Accenture; Booz Allen Hamilton, Boston Scientific Corporation, Centers for Disease Control and Prevention; Duke Translational Medicine Institute (DTMI); Eclipsys Corporation; Eli Lilly & Company; Epic Systems Corporation; the Food and Drug Administration; GE Healthcare Information Technologies; GlaxoSmithKline; IBM; Intel Corporation; InterSystems Corporation; Johnson and Johnson; Kaiser Permanente; McKesson Provider Technologies; Microsoft Corporation; Misys Healthcare Systems; NHS Connecting for Health; NICTIZ National Healthcare; Novartis; Oracle Corporation; Partners HealthCare System, Inc.; Pfizer, Inc.; Philips Medical Systems; Progress Software; QuadraMed Corporation; Quest Diagnostics Inc.; Siemens Medical Solutions Health Services; Solucient, LLC.; St. Jude Medical; the U.S. Department of Defense, Military Health System; the U.S. Department of Veterans Affairs; and Wyeth Pharmaceuticals.

Numerous HL7 Affiliates have been established around the globe including Argentina, Australia, Brazil, Canada, China, Colombia, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, India, Ireland, Italy, Japan, Korea, Mexico, The Netherlands, New Zealand, Singapore, Spain, Sweden, Switzerland, Taiwan, Turkey, United Kingdom and Uruguay.

About The Health Story Project:

Health Story, founded a little over two years ago as CDA4CDT, is an alliance of healthcare vendors, providers and associations that seeks to standardize electronic documents to enlarge and enrich the flow of data into the electronic health record and speed the development of interoperable clinical document repositories for use within enterprise, national and regional networks. The project was initiated by the American Health Data Institute (AHDI), Medical Transcription Information Association (MTIA), American Health Information Management Association (AHIMA) and M*Modal and is being managed by Alschuler Associates, LLC.

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