Terminology%20for%20representation%20of%20Diagnostic%20Imaging%20Procedures%20-%20Update

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Terminology for representation of Diagnostic
Imaging Procedures - Update

• Dr Keith Foord
• Consultant Radiologist, East Sussex Hospitals

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A national system of RIS coding and descriptors ?

• Relates to needs of request/entry systems within
  ICRS pre-RIS - SNOMED match to record request
  to Spine
• Consistency and uniqueness in requesting
  terminology pre-RIS and within RIS
• Consistency in activity measurement - RIS
• Consistency in clinical coding of events RIS -
  SNOMED match
• But must be as intuitive and easy to use as
  possible
• Should have national acceptance
• For accurate communication of results data
  between hospitals post RIS results reporting,
  cluster stores and national spine - SNOMED match
  to performed examination code to Spine
• For Payment by results accurate records of
  same patient activity national tariffs - SNOMED
  match / accurate HRGs
• DICOM Structured Reporting

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NHS Costings Code Book
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Descriptors
Descriptors need to be UNIQUE in NCRS FOOT LEFT
not unique When a user searches all of the
examinations available for Foot Left the search
may return FOOT LEFT, FOOT LEFT Swab, FOOT LEFT
Physiotherapy, FOOT LEFT Dressing, etc., etc.
But XR FOOT LEFT is unique
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Unique codes for requestor, reporter, Trust, ward
and unique Accession numbers related to
examination modality.
Requestor and reporter ? National code or
GMC/GDC/SR no. or cross match to this via look
up table. May not be a doctor. Trust ? 3
character codes eg RPX Ward ? 3 character prefix
eg RPXBaird Accession No. ? 3 character prefix
RPX123456. Needed as same model machines might
generate identical numbers and no process
between manufacturers to coordinate these.
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Radiology Short Codes
Used in RIS as shortcuts For bookings For
internal communications within Radiology To help
group procedures For internal management / audit
/ activity For common use need a structure,
ideally short (max. 6 letters/digits) and logical
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Radiological Short Codes
1
2
3
4
5
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Modality X X-ray F Fluoro I
Interventional/ Fluoro C CT M MRI U
Usound N Radionuclide Imaging P
PET E- Endoscopy Z- Image analysis or review
Post- qualifier (Extra or sub- descriptor)
Three or four letter body part / function code
4th letter reserved for R, L, B or W if
procedure R or L lateralisable, Both or Whole
body, otherwise can be used for any letter or
number
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Format for a midline or non lateralising
structure, no post qualifier
A
B
C
D
E
Format for a lateralisable or whole body
structure, no post qualifier
A
B
C
D
F
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Format for a midline or non lateralising
structure, with a post qualifier
A
B
C
D
E
G
Format for a lateralisable or whole body
structure, with a post qualifier
A
B
C
D
F
G
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Extra qualifiers (6th letter/number G)

• A Ablation
• B Biopsy (Core or FNA)
• D Drainage or Aspiration of fluid
• E Embolisation
• I Insertion of device
• J inJection - as an objective of the procedure,
  not as part of the preliminary to this objective
• M Mobile - for any modality, but particularly
  for 'portable' plain films and use of mobile
  image intensifiers
• O tOmography in its wider sense. O may be added
  to any plain film examination to define planar
  tomography - or postcoordinated
• P Plasty - as in angioPlasty or dacrocystoPlasty
  - ie balloon dilatation
• R for Radiotherapy planning
• S Stent
• T Use of intraThecal contrast
• X eXtraction - eg in retrieval of intravascular
  foreign bodies or removal of temporary IVC
  filter
• 1 First part of study
• 2 Second part of study
• 3 Third part of study
• 4 Fourth visit etc. 5,6,7,8,9 10th 0

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Eg CT guided PELVic Biopsy
C
P
E
L
V
B
Eg Interventional (Fluoroscopic) Right SFA
Angioplasty
I
A
S
F
R
P
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Pre and Post Co-ordination (1)

• In order to group procedures many RIS systems
  lack the ability to post co-ordinate procedures
  together under one accession number.
• Particular examples are for 'both' plain film
  exams eg 'both ankles' and in CT where
  examinations often combine e.g. CT Chest,
  Abdomen, Pelvis.
• Pre co-ordination or grouping of these procedures
  is therefore required in advance.
• Pre co-ordination should not be used in RIS-PACS
  systems capable of full post co-ordination as
  with these individual procedure codes will be
  automatically or manually grouped prior to
  archiving and reporting

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Eg CT guided PELVic Biopsy
C
P
E
L
V
B
This is pre-coordinated with the whole process
described in the code
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Pre and Post Co-ordination (2)

• In modern RIS systems post co-ordination can be
  applied to group related procedures together. All
  RIS systems supplied via LSPs should do this.
• Some procedure codes such as 'U/S biopsy' by
  themselves do not define precisely what has
  happened although it would define the activity of
  Performing a biopsy under ultrasound control and
  the consumables/activity associated with this.
• Such codes need post co-ordinating with the
  relevant body part to fully inform activity
  statistics
• Similarly separate CT body part examinations can
  be post co-ordinated together to enable the
  multiple examinations to be reported together as
  one report.
• The advantage is a more sophisticated approach to
  audit, activity measurement and stocktaking

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Eg CT guided PELVis Biopsy
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Eg PET/CT for Chest
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Sub-Descriptors / Codes

• REQUESTING Layer (1st order)
• Right Oblique QR
• Left Oblique QL
• Right Lateral LR
• Left Lateral LL
• Weight Bearing WB
• Standing ST
• Axial AX
• AP20o 20
• Judets JU
• Strykers SY
• Etc

• IN RADIOLOGY (RIS) Layer (2nd order)
• Same list
• Supine SU
• Prone PR
• Decubitus DE
• Complex Oblique QC
• Angled Oblique 22,30,45
• Frog laterals FR
• May need to combine together or with 1st order
  list eg DELR

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NPfIT and Descriptors/Codes

• Southern Cluster IDX GE PACS- Kodak CR - HSS
  CRIS
• London Cluster-IDX- Philips PACS-Philips(Fuji)CR-?
  RIS
• NE Cluster- iSOFT- Agfa PACS-Agfa CR-? RIS
• EEM Cluster- iSOFT- Agfa PACS -Agfa CR -? RIS
• NWWM Cluster- iSOFT- ComMedica PACS Kodak CR-
  Kodak RIS
• Has RCR endorsement
• SNOMED CT can be integrated-matched

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SNOMED CT
NCRS provides support for clinical coding using
the SNOMED CT nomenclature for diagnosis and
procedure codes. SNOMED CT codes will be
applied to the patients record through manual
selection by users, as well as an integrated
bi-product of clinical processes (i.e. orders,
assessments). SNOMED CT clinical coding is
supported for inpatient and outpatient
encounters.
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SNOMED CT
At the end of an episode / encounter of care,
SNOMED CT codes are recorded in NCRS via the
Discharge Summary / Encounter diagnosis and
procedure codes. The SNOMED codes recorded in
NCRS are sent to the 3M clinical encoder where
clinical coding is completed in SNOMED CT, ICD10,
Read, and OPCS4. Codes will be transferred back
to NCRS and will update, not replace, the patient
diagnosis and procedure codes. A full audit
trail is available.
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SNOMED CT
Within NCRS P1R2, users will have the ability to
manually record SNOMED CT codes within the
following areas          Discharge Summary /
Encounter          Problems / Provisional
Diagnoses Within NCRS P1R2, SNOMED CT codes will
be recorded against the patients record, as a
bi-product of clinical processes, in the
following clinical areas          
Assessments          Findings /
Flowsheets          Orders (viz. the code for
the request)          Results (viz. the code for
the procedure(s) performed, not the radiological
diagnosis or report which will be transferred via
HL7 messaging)
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Orders and Resultsin Radiology
SNOMED CT Order codes can be derived from
Order/Entry systems, but will be MUCH MORE
ACCURATE if derived from the accepted and if
required modified final RIS procedure entry with
SNOMED CT matching. SNOMED CT Results codes from
Radiology are a dilemma. This does not apply to
Procedure performed , but to a provisional
radiological diagnosis which may be a list of
differential diagnoses which could be entered by
a reporter (ie manually). Unlikely to happen
given pressures of work! The use of DICOM
structured reporting may give the possibility of
automatically constructing radiological diagnosis
codes from the structured report
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Structured reporting
DICOM SR is an envelope, but within this
useful structure is available. User decides how
much structure to use and controls with templates
the type of content, if it is mandatory or
optional and modes of expression
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Structured reporting
Link Features to Description
New nodule superimposed with right fourth rib
10 Pneumothorax
Cavitation
Free air
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David Clunie Development Director, Imaging
Products ComView Corporation Paper at SPIE, 2001
Structured reporting
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David Clunie Development Director, Imaging
Products ComView Corporation Paper at SPIE, 2001
Structured reporting