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

Data Element

Diagnostic Imaging Report
Description (*Please confirm or update this field for the new USCDI version*)

Interpreted results of imaging tests. Includes structured and unstructured components.

Comment

NCQA recommendation for Diagnostic Imaging Report

Recommendation: The current USCDI element includes both the structured and unstructured components of the report. We recommend adding RadLex and SNOMED CT as appropriate vocabulary standards representing the clinical findings from the structured components of an imaging report.

Rationale: The clinical conclusions or findings resulting from a diagnostic imaging study represent important information to be exchanged via standard terminology to support appropriate follow-up care and care coordination. NCQA continues to develop measures that require the findings from imaging reports, which routinely represent the clinical findings using the ACR Reporting and Data Systems (RADS) or SNOMED CT.  Via quality measure testing with health systems and health plans, NCQA identified that while clinical findings are represented standardly, they are not always mapped to the available terminology codes. Adding SNOMED CT and RadLex vocabulary standards to the USCDI element will enhance standardization, reduce burden, and enhance interoperable exchange of these important data.

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