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Foreign Exam Management

Immunization use cases cover

three

two main areas requiring standardization:

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

    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).

     

    Messaging

    Standard

    Fit for PuposePurpose

    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)FHIR Immunization

    Yes

    PilotProduction
    in Canada 

    Medium

    YesNo

    Yes

    HighMediumHigh

    Draft for Use

    		Yes

    DICOM / HL7pan-Canadian Immunization Messaging Standard (Public Health MR 02.05)

    Yes

    Production
    in Canada 

    High

    NoLow

    Yes

    MediumLocalized

    High

    Normative

    		UnknownYes

    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 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

    Yes

    Limited in
    Canada 

    Limited

    No

    Yes

    High

    		Normative

    Some

    Portable Document Format (PDF)

    Partial

    Production
    in Canada 

    High

    No

    N/A

    Low

    		N/A

    Good

    DICOM SR /  SC

    Partial

    Production
    in Canada 

    High

    No

    Yes

    Medium

    		Normative

    Unknown

    Raw Text

    Partial

    Production
    in Canada 

    Unknown

    No

    No

    Low

    		N/A

    None

    Architectural Constraints and Considerations

    Secondary Benefits

    Use of CDA document allows content to be rendered in all other formats.  Raw text based HL7 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.

    FHIR’s modular components, foundation on web standards and support for RESTful architectures make the standard generally less complex and more accessible to developers of client applications than the pan-Canadian standards which are based on HL7 v3.

    No notable secondary benefits.

    Recommendation

    Supporting Rationale

    It is recommended that Panorama based new implementations adopt FHIR.

    FHIR supports the use cases described above without further extension or localization. In the event that extension is required to support future requirements, FHIR provides a straightforward mechanism for creating extensions.

    Canada-specific terminology value sets can be used while remaining “FHIR conformant”, as the FHIR Immunization resource only specifies examples; implementers are free to use any value set they choose.

    FHIR has significant momentum among vendors and developers, meaning the long-term sustainability of FHIR-based implementations will likely be superior.

    There is a substantial ecosystem of open-source tools and reference implementations for FHIR that implementers can leverage to accelerate their projects.

    Terminology

    ...

    Standard

    Fit for Purpose

    Stewardship

    Quality

    Fits
    Requirements 

    Implementation
    Type 

    Vendor
    Support 

    Canadian
    StewardshipSteward 

    SDO
    Maintained 

    Complexity

    Standard
    Maturity

    Training, Support
    and Tooling

    Coarse Body Parts pan-Canadian Public Health Immunization Subsets  (SNOMED-CT subset)

    Yes

    Production in
    in Canada 

    High

    Yes

    Localized

    MediumLow

    		Normative

    Good

    iTerm ValueSet

    Yes

    Custom 

    Anatomic Region (DICOM CID 4)

    Limited

    International

    HighYes

    No

    YesLow

    Medium

    		NormativeN/A

    NoneUnknown

    Architectural Constraints and Considerations

    Secondary Benefits

    Both terminology subsets referenced are published as flat lists with descriptions and codesoptions were designed to support Panaroma's data model.

    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:

    ...

    It is recommended that new implementations adopt the custom reference value sets developed by Ontario.

    The pan-Canadian Public Health Immunization Subsets reflect Canadian requirements (e.g. Canadian vaccine lists), and is aligned with the PHAC Canadian Immunization Guide. It is being adopted in additional projects across Canada (including AB, SK, MB, Canadian Forces, CIHI), so additional implementations that adopt the Ontario standard will be well positioned for interoperability with these groups or organizations.