Creation and Storage of Standards-based Pre-scanning Patient Questionnaires in PACS as DICOM Objects

Abstract

Radiology departments around the country have completed the first evolution to digital imaging by becoming filmless. The next step in this evolution is to become truly paperless. Both patient and non-patient paperwork has to be eliminated in order for this transition to occur. A paper-based set of patient pre-scanning questionnaires were replaced with web-based forms for use in an outpatient imaging center. We discuss this process by which questionnaire elements are converted into SNOMED-CT terminology concepts, stored for future use, and sent to PACS in Digital Imaging and Communications in Medicine (DICOM) format to be permanently stored with the relevant study in the DICOM image database.

Literature review of SNOMED CT use

“…In those cases, the options in the forms were fixed and did not require users to search for SNOMED CT descriptions directly (n=8). Local terms were presented to users in the form of pick lists and radio buttons while the data were recorded in the background with SNOMED CT. Domains included cancer, [9][10][11][12] pressure ulcer wounds, 13 radiology, 14 obesity, 15 and family planning. 16 Second, search boxes and autocomplete fields were used to display results based on user input (n=5).…”

A survey of SNOMED CT implementations

“…Search algorithms should include partial multi-word searches [37], spelling corrections, word equivalency, and abbreviation and acronym expansion. The use of templates can also help to facilitate the recording of data into the correct data elements [38,39].…”

“…While there are many publications that describe technical aspects of SNOMED CT, compare the content coverage of SNOMED CT to other term sets and report the use of SNOMED CT in research studies [10], our search for publications describing how SNOMED CT is implemented in clinical settings yielded few results. Implementation publications focused mostly on data capture (e.g., structured data entry templates [11], clinical documentation [12][13][14], synoptic checklists [15], questionnaires [16], indexing clinical notes [17]) and to a lesser extent data retrieval through the use of synonyms (e.g., clostridium difficile Infections [18], neuromuscular blockade [19]) and decision support (e.g., nursing interventions for pressure ulcer wounds [23], detecting adverse drug events [20]). While there was a fair amount of detail on how SNOMED CT concepts were used in clinical systems, there were fewer details on how those concepts were stored and what methods were used to facilitate retrieval and decision support.…”