Nick van Terheyden MD, Presenter: Employee, Nuance Communications, Inc

Narrative documents are still highly preferred by radiologists because the narrative information is nuanced and precise - the type of details that cannot be adequately captured with templated text. Healthstory brings Harmony with a clear set of published data standards that specifies the structure and semantics of a clinical document for the purpose of exchanging Diagnostic Imaging Reports

Radiology reports contain information captured in narrative descriptions that encompass the uncertainties & nuance of medical imaging. Current solutions fail to effectively integrate the information and content contained in these reports.Accessing this information is challenging & much of the value remains locked away. Realizing the essential value of digital imaging requires an effective means of sharing semantically interoperable data.Building on the Healthstory consortium launched in 2007 by broadening the applicability of the emerging CCD standard to encompass additional use cases including the Diagnostic Imaging Report

The lack of an industry-wide standard for report content & format confounds interoperability efforts denying patients & clinicians the full value of the diagnostic report.This presentation will update attendees on the progress of the Healthstory project focusing on the details of the HL7/IHE Healthstory Consolidation Project operating under the ONC’s Standards & Interoperability Framework. The session will highlight available national standards that address this challenge and how to effectively make information captured in radiology reports available for reuse as structured data to support requirements for meaningful use

The consolidation project has the virtue of a targeted and closely crafted scope statement that is not intended to break new ground, rather to address issues of harmonization and implementability. The project has an aggressive 6 month time frame with a strong confidence to be able to deliver real world harmonized documents that satisfy the radiologists need for narrative and the structured tagged actionable clinical data necessary for clinical systems

van Terheyden, N, The Radiologist’s Speech: Realizing the Full Potential of the Diagnostic Report.  Radiological Society of North America 2011 Scientific Assembly and Annual Meeting, November 26 - December 2, 2011 ,Chicago IL. http://archive.rsna.org/2011/11015747.html