RIS-PACS Descriptors and Coding

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RIS-PACS Descriptors and Coding. Dr Keith Foord Consultant Radiologist, East Sussex Hospitals. A national system of RIS coding and descriptors ? Why? Must be as intuitive and easy to use as possible Should have national acceptance.
RIS-PACSDescriptors and CodingDr Keith FoordConsultant Radiologist, East Sussex HospitalsA national system of RIS coding and descriptors ? Why?Must be as intuitive and easy to use as possibleShould have national acceptance
  • Relates to needs of request/entry systems within NCRS – 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
  • 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
  • NHS Costings Code BookDescriptorsDescriptors need to be UNIQUE in NCRSFOOT LEFT not uniqueWhen 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 LEFTis uniqueRadiology Short CodesUsed in RIS as shortcutsFor bookingsFor internal communications within RadiologyTo help group proceduresFor internal management / audit / activityFor common use need a structure, ideallyshort (max. 6 letters/digits) and logicalRadiological Short Codes123456ModalityX – X-rayF – FluoroI – Interventional/FluoroC – CTM – MRIU – U’soundN – Radionuclide ImagingP – PETE- EndoscopyZ- Image analysis or reviewThree or four letter body part/ function codePost-qualifier(Extra or sub-descriptor)4th letter reserved for R, L, B or Wif procedure R or L lateralisable,Both or Whole body,otherwise can be used for anyletter or number Format for a midline or non lateralising structure, nopost qualifierABCDEFormat for a lateralisable or whole body structure, no post qualifierABCDFFormat for a midline or non lateralising structure, with a post qualifierABCDEGFormat for a lateralisable or whole body structure, with a post qualifierABCDFGExtra 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
  • Eg CT guided PELVic BiopsyCPELVBEg Interventional (Fluoroscopic) Right SFA Angioplasty IASFRPIn order to group procedures many old 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 within these individual procedure codes will be automatically or manually grouped prior to archiving and reportingPre and Post Co-ordination (1)Eg CT guided PELVic BiopsyCPELVBThis is pre-coordinated with the wholeprocess described in the codeIn 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 statisticsSimilarly 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 stocktakingPre and Post Co-ordination (2)CPELVBCPELVPLUSCBIOPBAre POST coordinated and describe both processes which arethen reported as one. CT biopsy cost structures do not need to be built into multiple codesEg CT guided PELVis BiopsyCCHESPLUSPGENWAre POST coordinated and describe both processes which arethen reported as one. Eg PET/CT for ChestRequestable proceduresFull list incl multisPost co-ord listUnique codes for requestor, reporter, Trust, ward and unique ‘Accession numbers’ related to examination modality.Requestor and reporter NCRS National code related to GMC/GDC/SR no. or cross match to this via look up table.May not be a doctor.Trust3 character NCRS codes eg RPXWard 3 character prefix eg RPXBairdAccession No. 3 character prefix RPX123456.Needed as same model machines might generate identical numbers and no process between manufacturersto coordinate these.PostCoordinatingRIS singledescriptorsFull list ofRIS Codes & Descriptors+ SynonymsNACSLocation &People codesSNOMED CTDescriptors and CodesRISSNOMED CTDescriptors and CodesHL7HL7NCRS‘Order’ EntryNCRS‘Reporting’ ModuleList ofOrderableProceduresSNOMED CTSNOMED CTDescriptors and CodesSPINEREQUESTING Layer(1st order)Right Oblique QRLeft Oblique QLRight Lateral LRLeft Lateral LLWeight Bearing WBStanding STAxial AXAP20o 20Judet’s JUStryker’s SYEtc…IN RADIOLOGY (RIS) Layer (2nd order)Same list +Supine SUProne PRDecubitus DEComplex Oblique QCAngled Oblique 22,30,45Frog laterals FRMay need to combine together or with 1st order list eg DELRSub-Descriptors / CodesSNOMED CTNCRS 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.SNOMED CTAt 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.SNOMED CTWithin NCRS P1R2, users will have the ability to manually record SNOMED CT codes within the following areas:§         Discharge Summary / Encounter §         Problems / Provisional DiagnosesWithin NCRS P1R2, SNOMED CT codes will be recorded against the patients record, as a by-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)Orders and Resultsin RadiologySNOMED 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 CTResultscodes 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 whichcould be entered by a reporter (ie manually). Unlikely to happen given pressures of work!The use of DICOM structured reporting may give the possibility ofautomatically constructing radiological diagnosis codes from the structured reportIncorporated into the report are captured images of key findings (which can be exploded to full screen presentation), structured diagnosis information, recorded audio, the ability to sort findings by anatomy or priority, to view prior findings associated with the corresponding patient and hyperlinks to related information.Structured reportingDICOM 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 expressionFrom the Point Dx websiteStructured reportingLink Features to DescriptionNew nodulesuperimposedwith rightfourth rib10% PneumothoraxCavitationFree airDavid ClunieDevelopment Director, Imaging ProductsComView Corporation – Paper at SPIE, 2001Structured reportingDavid ClunieDevelopment Director, Imaging ProductsComView Corporation – Paper at SPIE, 2001Structured reporting
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