Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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.