Preserving Clinical Context

General Comments:

USCDI specifies lots of clinical data classes and data elements

  • Resolving to myriad de-coupled fragments
  • With vanishingly little focus on:
    • Clinical context and vital inter-relationships, e.g., between problems, diagnoses, complaints, symptoms, encounters, history and physical findings, allergies, medications, vaccinations, assessments, goals/objectives, clinical decisions, orders, results, diagnostic procedures, interventions, observations, treatments/therapies, referrals, consults, protocols, care plans and status...
    • Elements and context + purpose of capture:  e.g., blood pressure, its measurement (systolic, diastolic), its unit of measure (mm/Hg), its reason for capture, its context of capture (sampling site, sampling method, patient position, at rest/during/post exercise...

It is crucial to consider and determine/resolve how clinical content and context are bound together and preserved in USCDI.  The ultimate end user (often a clinician) must be able to readily discern context and inter-relationships – otherwise USCDI places an undue (and often unresolvable) burden on this user.  Only the source EHR/HIT system can structure clinical content and context properly.  Once data is stuffed into the USCDI framework and related exchange artifact (e.g., FHIR resources) this opportunity is forever lost.

The American Medical…

The American Medical Association requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Imaging Diagnostics, Interventions and Procedures. The CPT code set contains a comprehensive and regularly curated list of diagnostic and interventional radiology procedures. Because of the federal and private initiatives to provide patients access to their health care data using claims data, including CPT as a standard would support the exchange of this information. CPT was created over 50 years ago and is a uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set.  Use of the CPT code set is federally required under HIPAA.

Recommendations for Section II: Content/Structure & Imp Specs

Recommendations for Section II:  Content/Structure Standards and Implementation Specifications

  1. Break this into two blocks – the new block would be titled: Interoperability Need: Format of Medical Images for Exchange and Distribution

In that block insert the:

(See image 1 from uploaded file)

followed by a row:

Implementation Specification,  PS3.3 Digital Imaging and Communications in Medicine (DICOM) Standard – Part 3: Image Object Definitions,  Final,  Production,  5 black circles, No, Free, Yes

  1. For now, keep the 2nd block as is (same as the original block)

Recommendations for Section II_DICOM.docx

Regenstrief - Comment

Please correct the typo of Regenstreif to Regenstrief. Also, there are two relevant value sets that should be listed here. The first is the “LOINC/RSNA Radiology Playbook”. This set is identified by the OID and the URI is The current FHIR R4 Mixed Normative/Trial Use Ballot #2 binds to this collection as code set for the ImagingStudy.procedureCode.

The second is the collection of terms in LOINC representing imaging procedures/reports. This set is called “LOINC Imaging Document Codes” and includes all radiology procedures as well as terms from some other imaging specialties. It is identified by the OID and the URI This is the value set named in C-CDA’s Diagnostic Imaging Report template and DICOM’s standard for Imaging Reports using HL7 CDA.

We concur with the…

We concur with the recommendation of LOINC as the vocabulary standard for this domain. The Regenstrief Institute and the RSNA have created a unified terminology standard for radiology procedures that builds on the strengths of LOINC and the RadLex Playbook. The LOINC/RSNA Radiology Playbook File now contains a unified representation of all existing LOINC and RadLex Playbook content, connecting LOINC radiology terms to a rich set of attributes represented with Radlex terms. The LOINC/RSNA Radiology Playbook File is now jointly published as part of the main LOINC release and it's Maturity should be listed as Production (it is actively being used by radiology centers, in health information exchanges, etc).

In addition, Regenstrief curates a value set of LOINC Imaging Document Codes (OID: that contains terms for imaging procedures/reports from Radiology, Endoscopy, Cardiology, and other imaging specialties. This is the value set named in C-CDA’s Diagnostic Imaging Report template and DICOM’s standard for Imaging Reports using HL7 CDA.

RadLex seems to be the way…

RadLex seems to be the way to go, LOINC is nonspecific wrt to Radiology.  Need value set identified from whichever standard is selected.

Some misunderstanding: there…

Some misunderstanding: there is a LOINC code for every RSNA/Radlex study and vice versa (RSNA used LOINC codes).