Submitted by bbialecki on 2023-08-31
ACR Comment to Elevate USCDI Diagnostic Imaging Level 2 Elements
The ACR recommends ONC elevate USCDI Diagnostic Imaging Level 2 elements Accession Number, Imaging Reference, and Requested Procedure Identifier to USCDI v5. While the Diagnostic Imaging Report and Diagnostic Imaging Test have existed since USCDI v2, the ability to reference the relevant DICOM image files themselves is critical to many patient care scenarios where the Diagnostic Imaging Report itself would be inadequate; these include scenarios such as surgical planning and disease staging. In the common scenario of Emergency Room patient transfers immediate access to images from another institution can prove critical to patient outcomes. It is especially critical when no contemporaneous radiologist reporting is available at and for transfer from the originating institution which is the case not infrequently. This would include the relevant diagnostic imaging data and the ability to identify and track unique health concerns of veterans of military service from within the DOD and VA systems as well as in external care locations by providing appropriate comparative exams for radiologist interpretation. Facilitation of transfers of care with source images from the originating institution facilitates access to higher level care benefiting patients in relatively underserved areas who would otherwise not be able to access such higher-level care. The ability to seamlessly exchange complete health information including the actual images and associated relevant metadata facilitates patient transfers in the context of load balancing during emergency situations such as mass casualty events or future pandemic conditions. Under those conditions, swift transfer of patients with as complete a record as feasible is a major contributing factor to successful crisis management. USCDI-TF-2021-Phase 3 recommended ONC should prioritize and encourage the advancement of DICOM Image File as a high priority data element, which the elevation of these Level 2 elements would accomplish. Additional patient care scenarios where these elements are critical include the prevention of duplicate exams and unnecessary radiation events, as well as the unnecessary rescheduling of patient appointments due to missing or unreadable data. Duplicate exams also drive unnecessary costs for our healthcare system. For patient safety, the creator maintains the image source of truth so that as appropriate updates are made, they become immediately available to providers. The Accession Number and Requested Procedure Identifier provide the necessary context to link the Diagnostic imaging Report to the DICOM Images, while the Imaging Reference provides the retrieval path to indicate network services that can be used to access the DICOM studies, series, or instances content and metadata. Requisite technology for touchless image exchange exists today and is readily commercially available at achievable cost. Expansion of USCDI as proposed would compel institutions to develop the supporting workflows to leverage image exchange technology successfully. As such, we believe that the (technical) implementation burden of image exchange is modest at best.
In support of the elevated maturity the following references are available:
- DICOM Part 18 WADO-RS was added in 2011 and is well supported by the vendor community. (https://dicom.nema.org/medical/dicom/2019a/output/chtml/part18/chapter_6.html)
- IHE Web-based Image Access was published in 2018 and has been tested at IHE Connectathons successfully since. (https://www.ihe.net/uploadedFiles/Documents/Radiology/IHE_RAD_Suppl_WIA_Rev1.1_TI_2018-03-22.pdf)
- The FHIR ImagingStudy resource has been elevated to Maturity Level 4 providing the foundation for Imaging Reference. ( https://build.fhir.org/imagingstudy.html)
- The management of the ImagingStudy and ServiceRequest resources is a currently proposed workitem for IHE. (https://wiki.ihe.net/index.php/Enabling_SWF_on_FHIR)
- The integration of FHIR resources and DICOMweb for imaging is a focus of the HL7 Imaging Integration group at FHIR Connectathons. (https://confluence.hl7.org/display/FHIR/2023+-+09+Imaging)
- The Imaging ServiceRequest has been profiled in multiple FHIR IGs extending the v2 to FHIR HL7 message mapping directly to Imaging. (https://fhir.ch/ig/ch-rad-order/index.html) (https://confluence.hl7.org/display/IMIN/Draft+IG+Project+Proposal+-+Imaging+ServiceRequest+Profile) (https://confluence.hl7.org/display/IMIN/Imaging+Service+Request+Hierarchy)
- The Argonaut SMART Imaging project provided a unified solution for accessing imaging studies alongside clinical data using a single authorization flow, thus proving across multiple vendor platforms the maturity of the objects and their ability to be supported across the internet securely alongside all the other resources currently specified in USCDI v1-v4. (https://confluence.hl7.org/display/AP/SMART+Imaging+Access)
Rural and underserved areas would benefit greatly as the likelihood of patient transfer to larger institutions for care is increased: making images available prior to the patient’s physical arrival can be crucial to the determination of necessity of transfer, better clinical outcomes through expedition of transfer, and eliminates the need for unnecessary duplicate exams. To address any concerns about gaps in transmission infrastructure that may have been previously raised, the ACR would like to point out the significant ongoing federal and state investment in rural infrastructure which would directly support these needed data elements. USDA ReConnect has already invested more than $1 billion dollars to date and continues to fund the expansion of high-speed broadband infrastructure in unserved rural areas and tribal lands. The Biden administration in August 2023 announced $667 million in new funding to build more broadband internet access in the U.S. The grants and loans are spread across 22 states, but will target rural, remote, and unserved communities. The American Rescue Plan Act earmarked $350 billion for a variety of services for state and local agencies, including expanded broadband access. The Infrastructure Investment and Jobs Act put another $65 billion in broadband funding on the table, $42 billion of which will be in the form of grants to states. The Rural Broadband Accountability Plan is a new effort by the FCC to monitor and ensure compliance for universal service high-cost programs including the Rural Digital Opportunity Fund and Connect America Fund Phase II Auction. The FCC’s high-cost universal service program is approving billions of new investment dollars to bring connectivity to consumers in areas lacking access to broadband. All these investments in rural technology support the needs of these underserved areas when this technology is leveraged to provide DICOM Images as USCDI-TF-2021-Phase 3 recommended to ONC in 2021 and is supported by the technology advances of FHIR and DICOM, proven through IHE, HL7 and the Argonaut project efforts. While these investments may take time to establish more equitable access to broadband transmission infrastructure, they are underway and the technology to leverage it exists. Patients and their institutions who already have this in place should be enabled to reap the benefits and not be blocked by those using infrastructure as an excuse. Every day which passes by where we do not upgrade these USCDI data elements is a day when the benefits outlined in this comment text accrue to a more limited group of patients than is achievable and desirable.
Submitted by NCQA on 2023-09-20
NCQA Comment on Diagnostic Imaging Test: for USCDI v5
NCQA recommends updating the terminology to include CPT, SNOMED, ICD-PCS in addition to LOINC, which represent terminology routinely used to capture diagnostic imaging tests, such as CT scans and mammography.