--- title: WG 4 SC 2 Outsource Teleradiology Reads and Reporting Workflow using FHIR Standard tags: fhir-project fhir-tr4-en slideOptions: transition: slide --- # [draft] Outsource Teleradiology Reads and Reporting Workflow using FHIR Standard <!-------> ## Table of Contents [TOC] <!-------> ## A. Introduction ### Current Radiology Image Exam Workflow Currently, there are 2 different types of radiology image exam workflow where the specification and requirement also differ between each other: <!--------> 1. Outsourcing teleradiology: use the specification of **IHE SWF** (Scheduled Workflow) ![](https://hackmd.io/_uploads/Sy03gL8xp.png) <center><i>Image 1. Radiology image exam business process within the hospital </i></center><br> <!--------> ![](https://hackmd.io/_uploads/SJm2NUdyT.png) <center><i>Image 2. Radiology image exam workflow within the hospital and its system</i></center> <!--------> 2. **Out-of-hospital** (Outsourcing teleradiology): use **IHE XDS-I** (Cross-Enterprise Document Sharing for Imaging) ![](https://hackmd.io/_uploads/rkgpV8_y6.png) <center><i>Image 3. Radiology image exam out-of-hospital workflow with the related system needed</i></center> <!-------> ## B. Background ### Challenges in Small Clinics Small clinic may **have imaging modalities** like X-Ray, USG, etc. But **lack on-site radiologists** who can interpret the images and generate radiology reports. ([See also solution for small clinic challenge for storing medical image](https://hackmd.io/@victoriatjia/fhir-rad-clinics-scenario)) <!--------> ![](https://hackmd.io/_uploads/rytUMU8e6.png) <center><i>Image 4. Steps required for small clinic who lack on-site radiologists</i></center> <!--------> ### Challenges in General Healthcare Facilities The current image exam in healthcare facilities is usually implemented using the **internal hospital specification**, thus **difficult** in **data sharing** and **collaboration** across different healthcare facilities <!-------> ## C. Goals Generate standardize workflow for teleradiology scenario where remote radiologists can efficiently access and interpret images, leading to quicker diagnoses and reports. <!-------> ## D. Method **Implementation of FHIR Solution in Radiology Image Exam Workflow** By implementing FHIR solution into the image exam workflow will results in: <!--------> **1. Within-the-hospital** The solution will be divided into two types: a. Imaging with an Order (2 FHIR Encounter) b. Imaging without an Order (1 FHIR Encounter): <!--------> 1a. Imaging with an Order (2 FHIR Encounter): * Patients need an imaging order from a doctor before they can proceed with the imaging procedure. * Typically involves two separate encounters: one for the consultation where the order is given, and another for the actual imaging in the radiology department. <!--------> 1b. Imaging without an Order (1 FHIR Encounter): * In some cases, like ophthalmology or obgyn, patients may be able to undergo imaging directly in the consultation room without the need for a separate order. * This streamlined process eliminates the need for an additional appointment in the radiology department <!--------> The **applicable solutions** in such condition is by * Build 1 FHIR server that can handle the order requests across multiple healthcare departments, handle the image exam or procedure result. * Build DICOMweb and Media server <!--------> **2. Out-of-hospital (Outsourcing teleradiology)** Outsource image exam or teleradiology image report * Build DICOMweb and Media server * Exchange FHIR Document and image based on [**XDS on FHIR**](https://hackmd.io/3-YA4NIlSduzirHccnIq6A). The information exchanged can include the radiology exam request/ referral form, radiology image exam result (FHIR ImagingStudy), radiology report (including the previous exam results). <!--------> ![](https://hackmd.io/_uploads/Hy1VzvLeT.png) <center><i>Image 5. Radiology image exam out-of-hospital workflow using XDS on FHIR</i></center> <!--------> <!--Notes: Many modalities, systems, client and healthcare professional APPs may be used in multiple countries. The standard specifications will require further in-depth discussion.--> **Two encounter workflow (scheduled workflow)** Includes an radiology image exam order and schedule for patients to participate in the process. Step 1. Create order for radiology image exam (ServiceRequest) Step 2. Another department accept the order Step 3. Make appointment (optional) Step 4. Patient report on arrival which generate Encounter - Step 4.1. Generate accession number - Step 4.2. Generate MWL (modality worklist) based on ServiceRequest and Encounter - Step 4.3. Study UID can be generated in RIS or DICOM MWL broker (*[See DICOM MWL](http://203.64.84.113/t/DICOM/DICOM_NetServices_MWL.ppt)*) Step 5. Call queue no. to enter the image examination room Step 6. Image QC (quality control) (optional) Step 7. Image saved and storage commitment Step 8. Image report process <!--**Single encounter workflow (scheduled workflow)** #tbd--> **The data exchange requirement in radiology image exam** * The image exam workflow can be divided into several sub-systems: * HIS（Hospital Information System): for generate image exam order * RIS（Radiologi Information System): for scheduling for patient and image modality * Modality: performing image exam * PACS: image storage management * Reporting system * The data are exchanged through multiple sub-systems, the recommended standard use in the data exchange is DICOM and FHIR standard (waveform, multimedia, and video data exchange standard need to be considered separately.) * The workflow of data exchange in each step can be seen in the [architecture diagram for image exam within hospital](https://mos2718.github.io/svgFHIR/Index.html) * For the out-of-hospital image exam can reference to XDS on FHIR for document exchange (for outsource teleradiology order and report) and DICOM WADO image * #actionItem: Provide a standard FHIR Document specification for teleradiology exam (includes image, digital pathology, genes and lab exam scenario) (PIC: Xiang Hao) * Radiology image report should include various examinations, correct annotation marking (including ROI), image finding, and report details (can be based on implementation requirements, manage a team, and provide specifications details. Currently, there are cooperative hospitals and doctors for breast cancer, lung cancer, and oral cancer use-cases) **Image Examination Process (Simple Version)** 1. Create patient 2. Create image exam service time (schedule and slot): reference to [RSNA report](https://radreport.org/home), create professional exam item, e.g. CT Angiography Transcatheter Mitral Valve Replacement 3. Patient consultation and image exam information (encounter): refer to the patient and slot 4. Create image finding (Observation): reference to the patient and encounter **Image Examination Process (Detail Version)** * The workflow in various image exam scenario. such as radiology, clinics, digital pathology, dermatology, and ophthalmology may be different. * We analyzed and provide various workflow example and the related FHIR resources as a referenen for other people. **Radiology image exam scheduling system workflow** 1. Receive radiology image exam order (serviceRequest) 2. Patient make appointment (optional) 3. Department Appointment or order list, choose the patient 4. Create an Encounter and move to the interface of choosing a patient 5. Depend on the image exam order, Appointment and Encounter generate MWL **Radiologist write report workflow:** 1. Search patient who need the radiology report to be write. 2. Retrieve the list of all previous image exam of the selected patient (Get imagingStudy) 3. Retrieve images (WADO-RS retrieve) 4. Generate image annotation, image finding, and reports (Post annotation and finding Observation and DiagnosticReport) **Specification which need to be standardize** 1. Teleradiology application form - FHIR Resources which need to be standardized: | Subject | FHIR Resource | | --------- | ---------- | | Requester institution | Organization, Person, Practitioner | | Teleradiology service provider | Organization, Person, Practitioner | | Patient | Patient | | Imaging data | ImagingStudy | | Teleradiology order |ServiceRequest| | Authorization contract |Consent| - Each resource needs to establish the fields and specifications it contains, such as: - The Teleradiology application form requires patient demographic information. To prevent privacy leaks, the less information provided will be better? - The requester institution need to send data to the correct hospital who provide the teleradiology service and also need to confirm that the hospital has the suitable radiologist - Terminology - In the ServiceRequest.code what terminology suitable for teleradiology scenario. Should we use LOINC code? e.g. [Radlex image procedure code](https://www.rsna.org/practice-tools/data-tools-and-standards/radlex-radiology-lexicon/procedure-names-radlex-playbook) 2. Image information 3. Image annotation: Loinc code terminology and numeric value of each test result item 4. Image finding 5. Imaging examination report 6. System integration architecture – What information need to be exchanged between the client and server subsystems? – Security and access control mechanism for data exchange **Teleradiology Workflow** | No. | Step | System |FHIR Resource | | ----- | ----- | ----- |----- | | 1 | The requester institution upload images to cloud | DicomWeb Server| Create ImagingStudy| | 2 | The requester institution fills out the teleradiology application form and authorize the teleradiology service provider to view the image | Portal| Create ServiceRequest, Consent| | 3 | The teleradiology service provider receives the application form | Portal | Get ServiceRequest | | 4 | The teleradiology service provider generates internal hospital image exam order | RIS| Create Encounter| | 5 | The radiology images are retrieved from the cloud and imported to the hospital's PACS Server| Portal, PACS, RIS| Get ImagingStudy | | 6 | Physicians in the teleradiology service provider review images based on the DICOM MWL | PACS, RIS | | | 7 | The physician of the teleradiology service provider write a radiology report on the PACS in their internal hospital | PACS, RIS || | 8 | The teleradiology service provider uploads the report to the cloud and authorizes it to the requester institution | Portal | Create Document (include ImagingStudy, Observation annotation, Observation finding, DiagnosticReport) | | 9 | The teleradiology service provider notify the requester institution to access the image | Portal| Update ServiceRequest.status| Notes: security, progress status follow-up, verification, billing and claim are not considered in this phase <!--### Related Systems * Server: Portal, Repositories (FHIR, DICOMweb, PACS) * Client: EMR client (from entrusting unit and trustee unit), RIS, data conversion gateways--> ## References - [External laboratory exam workflow]( https://hackmd.io/NU2MFgvyQ2WDYInTnm_3cw?view)