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SNOMED CT Expo 2016
Presentation or Poster Abstract
Title: Breast imaging structured reports. Implementing a
SNOMED CT in Uruguay
Presenter: Lilián Acosta Cosse, MD, Radiologist, Medical Advisor, Salud.uy/AGESIC/Uruguay
Audience
Health professionals and specialists, researchers in radiology
Objectives
To improve efficiency and quality of breast radiology reports in order to keep a continuous and
comprehensive patient care.
Abstract
The semantic regulations for communication of radiology reports are a challenge to innovation.
Even though ICTs have been included in political and economic initiatives as well as in programs for
both quality improvement and access to healthcare, radiological reports delivered as part of the
radiologists’ work have remained centered in free prose and text for more than a century. The
structured report was designed to organize the clinical information containing and improved
informatics exchanging requirements. It has not yet been widely accepted in the medical
community, partly because specialists and healthcare providers are mainly interested in workflow
and productivity. The Diagnostic Imaging Integrated Network (RIDI) and the National Teleimaging
System (SNT) in Uruguay as well as the adoption of health standards (HL7) are improving the health
care model based on the users and the continuous healthcare. Evidence-based medicine,
standardized medical documents and less use of paper are changing the medical daily environment.
Digital imaging, RIS/PACS with almost instantaneous access to images and teleradiology, challenge
radiology departments to have normalized reports in time to secure safe communication and
exchange of clinical data, without the risking lower quality. SNOMED CT has been adopted by the
Salud.uy program as the standard for terminology services in order to resolve syntactic and
semantic interoperability. It has clinical advantages that flexibly include controlled terminology,
wide coverage of diseases, findings, treatments, procedures, etc. At the beginning of 2015 the
creation and conciliation of contents and structure of CDA DIR for mammographic and breast
ultrasound reports was initiated at RIDI. Radiologists, breast specialists and the Radiology Dept. of
the Medical School of the National University (UDELAR) participated and determined a degree of
specificity in agreement with the interoperability and degree of development of our informatics
tools. The BI-RADS® system the better-established breast imaging system reports with a preestablished and clear vocabulary was used for lesion classification. The terminological services
team of the Salud.uy Program created at the SNOMED CT ‘Uruguay’ extension a subgroup of simple
pre-coordinated breast references by translation, compilation and creation of some terms not
found in the hierarchy. Documents created in RIDI are based on recommendations and technical
guidelines issued by the Salud.uy Program by using the HL CDA-R2 standard encapsulated in DICOM
for the pre-reports templates. From 2015 to date, in the centers comprised by RIDI more than 4258
reports have been done with a controlled terminology to express diagnosis of breast lesions as well
as radiological and ultrasound breast patterns. References include new terms for breast imaging
procedures comprising the national catalog for studies and procedures.