Tests that result in visual images requiring interpretation by a credentialed professional.

Data Element

Information from the submission form

Imaging Reference

The technical details of the retrieval access path to indicate network services that can be used to access DICOM studies, series, or instances content and metadata (e.g., a DICOMweb server endpoint providing QIDO-RS, WADO-RS, or WADO-URI). Different imaging archive servers may have different capabilities, protocols or requirements; and the specified access path may differ. See Implementation notes regarding ImagingStudy.endpoint in the FHIR ImagingStudy resource.

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This Data Element is related to Diagnostic Imaging Report.
“DICOM Image Files” is recommended as a high priority data element for USCDI v3 by the U.S. Core Data for Interoperability Task Force 2021 (https://www.healthit.gov/sites/default/files/facas/2021-09-09_USCDI_TF_…). We agree strongly with the intent of this recommendation and this current submission is intended to clarify that the high priority data element is a link to the images, specifically the “Imaging Reference,” rather than inclusion of the image files themselves. This represents the current state of the art (and future state of the art as reflected in the above cited FHIR approach) with respect to the Task Force recommendation to add DICOM Image Files to the USCDI v3.
Indexing, storing and maintaining DICOM Images within a healthcare institution is functionality currently offered by the healthcare providers’ existing VNA and PACS systems.
DICOM Images are closely related to “Diagnostic Imaging Test” and “Diagnostic Imaging Report”.
The Diagnostic Imaging Test generates DICOM Images, which in turn are interpreted to generate the Diagnostic Imaging Report.
The Diagnostic Imaging Report or Diagnostic Imaging Test contain references to DICOM Images, as they are pivotal to the Diagnostic Imaging Workflow, but they do not generally contain links to the DICOM images.
The current state of the art for interoperability between EHRs (Electronic Health Record) and ancillary imaging systems is an EHR reference to imaging studies in a Picture Archive and Communication System (PACS), Vendor Neutral Archive (VNA) or Image Display client. This reference is currently achieved through either:
• HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM Release 1. This standard includes references to key images, frames and the DICOM object catalog through unique identifiers (UIDs) based on the DICOM study, series and image (instance) information model. The standard also includes optional Web Access to DICOM Persistent Object (WADO), also known as DICOMweb™ as visible hyperlinks within the report.
• More recently, the FHIR ImagingStudy resource. As in the CDA standard referenced above, ImagingStudy includes the elements DICOM Series Instance UID, SOP Instance UID and endpoint. The endpoint is a reference API to resources provided by a VNA, PACS or Image Display and include “DICOM WADO-RS, which is used to retrieve DICOM instances in native or rendered (e.g., JPG, PNG), formats using a RESTful API; DICOM WADO-URI, which can similarly retrieve native or rendered instances, except using an HTTP query-based approach; DICOM QIDO-RS, which allows RESTful query for DICOM information without retrieving the actual instances; or IHE Invoke Image Display (IID), which provides standard invocation of an imaging web viewer.”


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