A flexible, multimodality structured reporting system based on medical and networking standards

Abstract

A structured reporting (SR) system has been developed based on current medical and networking standards to provide structured reporting for multiple hospital departments and specialties. Use of existing standards such as Digital Imaging and Communications in Medicine (DICOM), Health Level 7 (HL7), Extensible Markup Language (XML), and Internet protocols allow it to easily integrate and be used with existing hospital information and Picture Archiving and Communications Systems (PACS). The structured reports are based on templates. The templates define the tree structure of the content of each type of report and also the relationship between elements within a report. The templates can be extended and customized to support the individual needs of each institution. Each element in the template and report is tagged with a code to provide a means for data mining and outcomes analysis applications. Standard lexicons such as LOINC (Logical Observation Identifiers Names and Codes) can be used to provide data level compatibility between institutions for similar reports. XML is used to store the templates and preliminary reports, and stylesheets written in the Extensible Stylesheet Language (XSL) are used to generate the human-readable output for each report. The stylesheets can also be extended and customized by report type. For archival purposes, the final reports are converted to a DICOM structured report object and transferred to a DICOM PACS. A web browser can be used to view and edit reports through the use of a simple Universal Resource Locator (URL) mechanism, allowing the reporting system client to be integrated with a variety of workstations.