Diagnostic Imaging Reports in a CCD

I clearly missed something somewhere, probably because I assumed nobody would try to include a document in an document after having hammered people about it for a decade. My first real blog post was on this topic.

Here’s the challenge:  According to the Meaningful Use test procedures for View Download and Transmit: Diagnostic imaging reports are to be included in CCD content.  The test data blithely suggests this content:

·         Lungs are not clear, cannot rule out Anemia. Other tests are required to determine the presence or absence of Anemia.

I can see where this summary of a full report might appropriately appear in “Results” section of a CCD document, but this isn’t an diagnostic imaging result. Here’s a some sample Diagnostic Imaging Reports: http://usarad.com/pdf/xray/cr_chest.pdf, http://www.smartteleradiology.com/sites/default/files/sample-reports/CR-Sample-Chest-01.pdf, http://www.mtinformation.com/medical-reports/x-ray-samples.  I’m reminded of Liora’s “This is a document” slides she uses in her Intro to CDA class, and for good reason.

The content might be stored as a text report, a word document, a PDF, or even worse, a scanned image.  It really depends on what the supplier of the report provides.

The NIST guidance is sub-regulatory, but these are the testing guidelines set forth for the certifying bodies.  However, what I also missed is that the regulation also says that CCD is the standard for imaging reports.  It's in that line of text that reads:

(2) When downloaded according to the standard specified in § 170.205(a)(4) following the CCD document template, the ambulatory summary or inpatient summary must include, at a minimum, the following data (which, for the human readable version, should be in their English representation if they associate with a vocabulary/code set):

(i)Ambulatory setting only. All of the data specified in paragraph (e)(1)(i)(A)(1), (2), (4), and (5) of this section.

(ii)Inpatient setting only. All of the data specified in paragraphs (e)(1)(i)(A)(1), and (3) through (5) of this section.

Clear as mud right?  Here's what (e)(1)(i)(A)(5) says:

(5) Diagnostic image report(s).

Oh damn.

But wait? I can create a DIR, change the document type and header details a bit, and then magically it becomes a CCD.  So, can I create a CCD for each Diagnostic image, and in that way have a "summary" representation of the report.

Nope: Back to the test guide:

3. The tester uses the Validation Report produced by the ETT: Message Validators – C-CDA R2.1 Validator in step 2 to verify the validation report indicates passing without error to confirm that the VDT summary record is conformant to the standard adopted in § 170.205(a)(4) using the CCD document format, including: the presentation of the downloaded data is a valid coded document containing:

•  all of the required CCDS data elements as specified in sections (e)(1)(i)(A)(1); 
•  for the ambulatory setting, the Provider’s Name and office contact information as specified in section (e)(1)(i)(A)(2); 
•  for the inpatient setting, admission and discharge dates and locations, discharge instructions and reason(s) for hospitalization) as specified in section (e)(1)(i)(A)(3);
•  laboratory report(s) as specified in section (e)(1)(i)(A)(4), when available; and 
•  diagnostic imaging report(s) as specified in section (e)(1)(i)(A)(5), when available.  

Oh well.  Seems like I need to get my hammer out, this time to fit an entire document into a sentence shaped hole.