Show Me Your Cda: Structured Report Editor For The HIBA Multimedia HER

CAMPOS, FERNANDO; LUNA, DANIEL R.; KAMINKER, DIEGO; PLAZZOTTA, F.; CANCIO, ALFREDO H.; SORIANO, E

Congreso; 10th International HL7 Interoperability Conference; 2009

Among the main objectives of the Multimedia EHR of the Hospital Italiano de Buenos Aires (HIBA) is the need to include not only text and images in the reports but also structured clinical information coded using a controlled vocabulary. A structured reporting system was designed to achieve this goal, including the use of macros and templates. The reporting system organizes the radiological information into knowledge trees. Each one of these trees? concepts is represented in the clinical terminological server of the HIBA. The reports are generated and stored as a CDA R2 document including the narrative text, the links to the images, and each finding and observation represented as a CDA R2coded entry. Also the input of the structured editor as a plug-and-play run-time integrated component is also a CDA R2 document combined with some editor behavior parameters. In this context, we defined as our best solution for the output of the structured editor a CDA R2 document. When we discussedthe input for the editor component, we followed the same logic and also used a CDA R2 document for as part of the input. This radiology editor output is based on the RSNA guides and the CDA R2 IG for imaging, and also in HIBA own implementation guide for CDA R2 document used in its EHR. Since thiseditor is also part of an agreement between the Hospital Italiano de Buenos Aires and UDIAT Parc Taulí? of Catalunya, Spain, it has multi-language capabilities (Spanish, Catalan, or English as user interface language and the same choice of languages as output language (CDA R2 instance languageused for text and descriptions inside the narrative sections and entries)