Foreign Exam Management use cases cover three main areas requiring standardization:

  • Document and Image Sharing
  • Imaging Report Format
  • Anatomic Region Code

Listed below are the available standards considered for each standardization category, the chosen alternative being highlighted.

Document and Image Sharing

Foreign Exam Management will be implemented by an organization participating a jurisdictions’ shared Diagnostic Imaging Repository (DI-R) system.  The DI-R will provide for registration and long term storage of sets of images and reports and standards based services that will be leveraged and, possibly, upgraded to support the FEM use case(s).

Standard

Fit for Purpose

Stewardship

Quality

Fits
Requirements

Implementation
Type 

Vendor Support

Canadian
Steward

SDO
Maintained

Complexity

Standard
Maturity

Training,
Support
and Tooling

IHE Cross-Enterprise Document Sharing - Imaging (XDS/XDS-I)

Closely

Production
in Canada 

High

Yes

Yes

High

 

High

Available

DICOM / HL7 v2 and Clinical Document Architecture (CDA)

Partial

Production
in Canada 

High

No

Yes

Medium

High

Unknown

Architectural Constraints and Considerations

Secondary Benefits

None of these standards impose significant architectural constraints

 

Recommendation

Supporting Rationale

IHE Cross-Enterprise Document Sharing - Imaging (XDS/XDS-I)

The IHE XDS-I.b profile specifies the use of existing standards including HL7 v2/CDA and DICOM to enable registration and sharing of images and reports.  A Canadian XDS Affinity domain guide is available to support implementation of the profile.

Note:

The IHE XDS/XDS-I profile builds upon the foundational HL7 and DICOM standards by identifying the roles of different actors participating in the information exchange and specifying how data exchange transactions and applicable standards enable document sharing.  It also prescribes an affinity domain process that was employed by the Canadian Diagnostic Imaging Community to constrain areas of optionality in the IHE XDS/XDS-I profile to Canadian requirements.  The XDS Affinity Domain Implementation Guide is the work product of this group.

Report Format

XDS/XDS-I supports a range of report formats through the use of different transaction and reporting

Standard

Fit for Purpose

Stewardship

Quality

Fits
Requirements 

Implementation
Type 

Vendor
Support 

Canadian
Steward 

SDO
Maintained 

Complexity

Standard
Maturity

Training, Support
and Tooling

Clinical Document Architecture (CDA) R2

Closely

Limited in
Canada 

Limited

No

Yes

High

Normative

Some

Portable Document Format (PDF)

Partial

Production
in Canada 

Ubiquitous

No

N/A

Low

N/A

Available

DICOM Structured Reporting (SR) /  Secondary Capture (SC)

Partial

Production
in Canada 

High

No

Yes

Medium

Normative

Unknown

Raw Text

Limited

Production
in Canada 

Unknown

No

No

Low

N/A

Not Appliccable

Architectural Constraints and Considerations

Secondary Benefits

Use of CDA document allows content to be rendered in all other formats.  Raw text based HL7 v2 ORU and DICOM SR are widely used and present in DI-R systems and require support.

PDF may preclude secondary use, while the structured data of a CDA document supports machine readability and may enable secondary use of clinical data, clinical decision support or application of administrative/demographic data to analytics/business intelligence.

Recommendation

Supporting Rationale

Clinical Document Architecture (CDA) R2

It is the goal of the Canadian XDS Affinity domain that reports will be stored in HL7 CDA format (using the pan-Canadian header format) as these reports (a) support required metadata, and (b) can be transformed to all other formats.

Anatomic Region Code

Metadata plays an important role in the identification of relevant priors during the fetch and pre-fetch use cases.  The significant coded metadata elements for the FEM use case are the acquisition modality of image and the anatomical region being studied.  Acquisition modality was adopted as prescribed.

 

Standard

Fit for Purpose

Stewardship

Quality

Fits
Requirements 

Implementation
Type 

Vendor
Support 

Canadian
Stewardship

SDO
Maintained 

Complexity

Standard
Maturity

Training, Support
and Tooling

Coarse Body Parts (SNOMED CT subset)

Closely

Production
in Canada 

High (Flat List)

No

Yes (IHE)

Low

Normative

Good

Anatomic Region (DICOM CID 4)

Limited

International

High

No

Yes

Low

Normative

Unknown

Architectural Constraints and Considerations

Secondary Benefits

Both terminology subsets referenced are published as flat lists with descriptions and codes.

Using pan-Canadian terminology subsets supports inter-jurisdictional interoperability.  SNOMED CT’s terminology model can be leveraged to support aggregation and analysis of the information captured within vaccination records.

Recommendation

Supporting Rationale

Coarse Body Parts (SNOMED CT subset)

The DICOM CID 4 value set is very detailed and generally inconsistent with the general approach of “casting a wide net” employed when fetching content within the FEM use cases.

Note:

Anatomic Region was localized for Canadian use.

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