医学影像存储与传输系统中结构化报告的初步应用研究

Preliminary application study of structured reporting in PACS

目的研究医学数字影像通信标准(DICOM)下应用结构化报告(SR)的可行性和中文化实现,探讨DICOMSR对影像诊断报告当前应用现状的影响,以及对远程诊断的意义。方法根据2003版DICOM标准中SR的规范,利用现有的医学影像存储与传输系统(PACS)中影像诊断报告数据库,实施诊断报告的“基本文本”型的SR转化并提交至DICOM图像服务器,以及实施对应的超文本标记语言(HTML)和可扩展标记语言(XML)文档,HTML文档用于浏览,XML用于与医疗卫生信息传输标准(HL7)规范的交流。结果影像诊断报告转化成DICOMSR的文档后,将其附加在患者检查的对应图像序列中,实现诊断报告与图像的一致性存储和调阅。结论结构化的报告文件可以与DICOM图像存放在一起,这对于图像以及报告的归档具有极其重要的意义,它将改变我们传统的报告文件与图像文件相互独立存放的若干缺陷,将影像科的资料统一到PACS中,特别是对远程诊断和计算机辅助诊断结果的输出提供了便捷的方法。

Objective To study the feasibility and the realization of Chinese structured reporting (SR), and to discuss the effects of DICOM SR on the current imaging report and teleradiology. Methods With the SR rules in DICOM version 2003, the current imaging reports in the database of PACS were transformed into basic SRs, which were submitted to a DICOM server. Also, the reports were transformed into HTML and XML documents for viewing and exchanging. Results The basic SR document was attached to the series of the same patient, with the same method of storage and viewing. Conclusion It is very important for the report to be stored with the images from which it is derived, and this method will improve the current ways of the storage and viewing of images and reports. This is a convenient method for teleradiology and computer aided detecting (CAD).