DiagnosticReport FHIR Resource Proposal

DiagnosticReport

Owning committee name

Orders & Observations WG

Interested Work Groups

• Anatomic Pathology
• Clinical Genomics
• Imaging Integration
• Public Health and Emergency Response

FHIR Resource Development Project Insight ID

952

Scope of coverage

The findings and interpretation of diagnostic tests performed on patients and/or specimens. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretation, and formatted representation of diagnostic reports.

Note the use of the Observation resource to represent the actual result. There are many circumstances where the use of the Observation resource alone is sufficient to record clinical information, such as clinical observations made directly by a clinician or patient.

RIM scope

ActClass = OBS and children MoodCode = EVN

Resource appropriateness

Diagnostic reporting is central to the business of healthcare. The basic process of healthcare is the diagnosis and treatment of patients. The diagnostic report is the primary means of communicating diagnostic results to providers, particularly in domains such as laboratory, radiology, pathology, etc.

Expected implementations

Can be expected to be implemented by Diagnostic Laboratories, Radiology systems and specialist Investigation services (eg endoscopy services), and to be consumed by EHR/PHR/EMR systems.

Content sources

• HL7 v3 Laboratory Standard - Normative
• HL7 v2.x
• HL7 Radiology Report standards (for instance the DR Structured Report in C-CDA)
• OpenEHR?

Example Scenarios

• A report from a Laboratory after a blood test was ordered. May exist in multiple versions reflecting an interim report first, followed by a final report
• A report from a Radiology service on Xrays taken after an injury
• A pathologists report
• A psychiatric assessment
• A veterinary outbreak assessment

Resource Relationships

• Order
• OrderResponse
• DiagnosticOrder
• Observation
• Specimen
• Substance
• Supply
• ImagingStudy

Timelines

• Vote by WG (Ready for ballot): July 2013
• Ballot: September 2013

gForge Users

• Patrick Loyd
• Lorraine Constable

Issues

• need to refine RIM definition to differentiate from observations
• Does scope include things like psychiatric reports, reports on outbreaks, etc.?
• What's the boundary between a diagnostic report and a Document containing observations?
• Need to explain details about the relationships to other resources are