HL7 Europe Imaging Study Report
0.1.0-build - ci-build 150

HL7 Europe Imaging Study Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 0.1.0-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/bvdh/bvdh-hl7eu-imaging/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Requirements: Actor Definitions

The following artifacts define the types of individuals and/or systems that will interact as part of the use cases covered by this implementation guide.

Imaging Study Report Creator

The actor responsible for creating the Imaging Report resources. Typically this role is combined with the ImReportProvider.

Imaging Study Report Provider

The actor responsible for providing the Imaging Report resources.

Behavior: Operation Definitions

These are custom operations that can be supported by and/or invoked by systems conforming to this implementation guide.

OperationDefinition: create a FHIR report from a DiagnosticReport

This operation generates a FHIR report from an DiagnosticReport resource that points to a Composition resource. Its behavior is identical to the Composition/$document operation but adds the DiagnosticReport and its referenced resources to the Bundle.

Structures: Logical Models

These define data models that represent the domain covered by this implementation guide in more business-friendly terms than the underlying FHIR resources.

Address model

EHDS refined base model for Address structure

Advance directive model

Healthcare directives concerning life or after life wishes of the patient

Alert model

Alert flag

Allergy intolerance model

EHDS refined base model for allergy/intolerance

Appointment model

EHDS refined base model for Appointment. This is a simplified model with minimal information - it is not intended to cover the full functionality of booking systems.

Attachment model

EHDS refined base model for This type is for containing or referencing attachments - additional data content defined in other formats. The most common use of this type is to include images or reports in some report format such as PDF. However, it can be used for any data that has a MIME type.

Body structure model

EHDS refined base model for Body structure

Care plan model

EHDS simplified model for care plan. The model includes very minimal information and is not designed to cover the full functionality of care plans.

Condition model

EHDS refined base model for a clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

Coverage model

EHDS refined base model for Coverage

Current pregnancy status model

Current pregnancy status

DataSet model

Common elements (including header) for all documents and their independently functioning parts, e.g FHIR resources.

Device model

EHDS refined base model for Device information

Device use model

EHDS refined base model for device use information

Discharge Report model

EHDS refined base model for Discharge Report

Document model

EHDS refined base model for common document data elements, including the common header. Data relevant to document type and its content for administrative and searching purposes.

Dosage model

EHDS refined base model for Dosage

Dosaging model

Logical model for usage instructions for administring the requested product. Based on FHIR Dosage complex data type. When implemented, this model may be reduced significantly according to the specific use case.

Encounter model

EHDS refined base model for Encounter

Endpoint model

EHDS refined base model for Endpoint

Episode of care model

EHDS refined base model for Episode of care

Family member history model

EHDS refined base model for family member history

Functional status

EHDS refined base model for Functional status

Health professional model

EHDS refined base model for Health professional (HP)

Human name model

EHDS refined base model for Human name

Imaging report model

EHDS refined base model for Medical Imaging Result Report

Imaging study model

EHDS refined base model for Imaging study

Immunisation model

EHDS refined base model for Immunisation

Infectious contact model

EHDS refined base model for an infectious contact

Laboratory observation model

EHDS refined base model for Observation performed by laboratory

Laboratory order

A - EHDS refined base model for Laboratory order

Laboratory order body model

B.1 - EHDS refined base model for Laboratory order body

Laboratory order header model

A.1 - EHDS refined base model for Laboratory order header data elements

Laboratory report body model

B.1 - EEHRxF refined base model for Laboratory result report body

Laboratory report header model

A.1 - EHDS refined base model for laboratory report header data elements

Laboratory report model

EHDS refined base model for Laboratory result report

Location model

EHDS refined base model for Details and position information for a place where services are provided and resources and participants may be stored, found, contained, or accommodated.

Media model

EHDS refined base model for A photo, video, or audio recording acquired or used in healthcare.

Medication administration model

EHDS refined base model for a single medication administration

Medication dispense decline model

Explicit statement about declining the dispense request (prescription), usually recorded in order to communicate the issue back to the prescriber. Reasons for declining a dispense may vary, but typically this statement is only sent when a following action is expected on the prescriber’s side (cancelling or changing the problematic prescription or the whole treatment).

Medication dispense model

Logical model for medication dispensation (based on request or independently)

Medication model

Logical model for prescribed/dispensed medication. The model is shared by statements, requests, dispensations, and treatment lines. Each of those may have different restrictions in FHIR profile. Model is suitable for generic/virtual medications as well as branded/real products.

Medication prescription model

Logical model for medication prescription. A prescription contains one or more prescription items.

Medication statement model

Statement about a single medication as part of a medication summary.

Observation model

EHDS refined base model for Observation information

Organisation model

EHDS refined base model for Health provider or any other type of organisation

Patient Animal model

EHDS refined base model for Patient:Animal

Patient model

EHDS refined base model for patient (subject of care) information

Patient summary model

EHDS refined base model for Patient Summary

Pregnancy history model

Pregnancy history for one pregnancy

Procedure model

EHDS refined base model for an action that is or was performed on or for a patient

Related person model

EHDS refined base model for Patient/subject guardian and other related person information

Service request model

EHDS refined base model for Specification of requested service or services

Social history model

EHDS model for social history observations

Specimen model

EHDS refined base model for A sample to be used for Analysis

Substance model

EHDS refined base model for Substance

Substance use model

Statement about using a substance (such as tobacco, alcohol, drugs, etc).

Telecom model

EHDS refined base model for Telecommunication contact information structure

Travel history model

Relevant information about the patient's recent travel history, for one visit

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

AdverseEvent: Imaging Adverse Event

Adverse Event that occurred during an imaging procedure.

Bundle: Imaging Report

Document Bundle for Imaging Report

Composition: Imaging Report

Clinical document used to represent a Imaging Study Report for the scope of the HL7 Europe project.

Device: Imaging Device

The device the made the image.

DiagnosticReport: Imaging Report

DiagnosticReport profile for Imaging Reports. This document represents the report of an imaging study. It is the anchor resource that refers to all structured data as well as the Composition resource that contains the narrative text of the report.
The structure of the modelled has been aligned with the DiagnosticResource as defined by IHE-RAD-HL7IDR. As this specification has not been published yet, the relevant extensions have been included in this specification.

DocumentReference: -MHD Imaging Report

A DocumentReference profile for the Report DocumentReference used in MHD deployments.

DocumentReference: Key Image

A document containing key images for a patient. It can refer to a DICOM or non-DICOM image. When referring to a DICOM image, the DocumentReference.content.attachment.url should be a WADO-URI. When referring to a non-DICOM image, the DocumentReference.content.attachment.url should be a direct URL to the image.

When the resource represents a DICOM instance it SHALL contain a the SOP Instance UID in the identifier element. When the resource represents a DICOM series it SHALL contain the Series Instance UID in the identifier element.

ImagingSelection: DICOM SR Instance

Imaging Selection referring to a DICOM SR instance

ImagingSelection: General

Imaging Selection

ImagingSelection: Key Image

Key images represented as an ImagingSelection

ImagingStudy: General

This profile represents an imaging study instance.

Observation: Gestational Age

Gestational Age Observation

Observation: Imaging Finding

Finding during imaging procedure.

Observation: Radiation Dose

A record for the radiation dose the subject has been exposed to during an imaging procedure. E.g. based on information from https://dicom.nema.org/medical/dicom/current/output/html/part16.html and https://build.fhir.org/ig/HL7/fhir-radiation-dose-summary-ig/index.html

Procedure: Imaging Acquisition

This profile on Procedure represents the imaging procedure.

ServiceRequest: Imaging Order

This profile on ServiceRequest represents the order for the Imaging Study and report.

Structures: Data Type Profiles

These define constraints on FHIR data types for systems conforming to this implementation guide.

Identifier: Accession Number

This profile on Identifier represents the Accession Number for the Imaging Order.

Within a Hospital Information System environment, accession numbers will usually uniquely identify a manifest or report but are not required to always map 1:1 with a report or manifest due to certain imaging workflows. The imaging report may not be uniquely identified by accession number in an overread scenario (two radiologists reading a single imaging study). The manifest may not be uniquely identified by accession number in the case that the RIS imaging request (accession number assigner) requires two imaging modalities to perform the exam, and thus produces two image manifests.

In order to ensure uniqueness across Hospital Information Systems, accession numbers are required to have a system value that identifies the namespace for the issuing authority (ensuring their global uniqueness).

Identifier: IHE-MHD Entry UUID

entryUUID Identifier holding a UUID, based on IHE-MHD R4.

Identifier: SOP Instance UID

This profile on Identifier represents the SOP Instance UID (0008,0018) for the Imaging Order.

Identifier: Study Instance UID

This profile on Identifier represents the Study Instance UID (0020,000D) for the Imaging Order.

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide.

Document DiagnosticReport Reference

This extension provides a reference to the DiagnosticReport instance that is associated with this Composition.

HL7IDR Communication

Communications captures what communications have been made with other care providers

HL7IDR DiagnosticReport Comparison Study

Studies used for comparison in part of diagnostic reporting

HL7IDR Imaging Procedure

Imaging procedure used for the imaging acquisition

HL7IDR Impression

Impression in the imaging report

HL7IDR Patient History

Patient history that are relevant for the report

HL7IDR Recommendation

Recommendations for any follow up actions

Instance Description

A description of the instance in an ImagingStudy.

Number of Frames

The number of frames in an ImagingStudy instance as required by Xt-EHR logical ImagingStudy logical model.

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

DiagnosticReport supportInfo codes

Codes to be used in DiagnosticReport.supportInfo for imaging reports.

Dose Length Units

Units for Dose Length.

Effective Dose Units

Units for Effective Dose.

Gray Square Units

Units for Gray Square.

Imaging Device Type

Imaging Device Type.

Imaging Procedure Type

This value set includes all imaging procedure types.

Imaging Study Performer Type Value Set

Imaging Study series performer type codes, it extends on the base set defined in the FHIR specification.

Radiology Report Types

The set of radiology types as defined by LOINC.

Reasons a section in an imaging report is empty.

Reasons a section in an imaging report is empty.

Section codes used to label annotations.

These codes define what an annotation annotates.

XDS Class Codes

A list of XDS class codes that can be used for filtering manifests (zie XDS_classCode_MetaData_Coding_System). Note: a IHE needs to make a formal FHIR CodeSystem for this.

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide.

Diagnostic Report Support Info Code System

Code system for codes to be used in DiagnosticReport.supportInfo for imaging reports.

Missing DICOM Terminology

Code system for codes that are defined in DICOM but for which no matching code system is available in FHIR.

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

Composition for the left/right foot study

Example of a ImComposition showing the report for the left/right foot study

DiagnosticReport for the left/right foot study

Example of a ImDiagnosticReport showing the report for the left/right foot study

Example Imaging Report

Example of an Imaging Report Bundle for a knee MRI report.

Imaging Report DocumentReference

MHD DocumentReference for the knee MRI Imaging Report example.

ImagingStudy for the left/right foot

Example ImagingStudy showing an MRI for the left foot

MHD Knee Mri Transaction Bundle Example

Transaction Bundle illustrating the upload of a knee MRI Imaging Report DocumentReference with embedded PDF report.