Tests that result in visual images requiring interpretation by a credentialed professional.

Data Element

Diagnostic Imaging Report
Description

Interpreted results of imaging test that includes the study performed, reason, findings, and impressions. Includes both structured and unstructured (narrative) components.

Comment

Recommendation for terminology standard designation

SNOMED International recommends that ONC designate SNOMED CT U.S. Edition as an applicable vocabulary standard for the Diagnostic Imaging Report data element, specifically for coding clinical findings, diagnoses, and procedure-related observations documented within structured imaging reports. 

SNOMED CT clinical finding and procedure hierarchies provide a comprehensive, internationally recognized terminology for radiology findings, complementary to RadLex, which addresses imaging-specific procedural and anatomical concepts. 

NCQA has formally recommended the combined use of SNOMED CT and RadLex for structured imaging report coding, reflecting established clinical and industry consensus on the complementarity of these standards.

ONC's FHIR-based certification requirements reference the HL7 FHIR DiagnosticReport resource as the primary interoperability mechanism for imaging reports. This resource supports SNOMED CT as a value set for report findings and conclusions. 

Naming SNOMED CT as an applicable vocabulary standard for Diagnostic Imaging Reports would align USCDI v7 with existing FHIR implementation guidance and with the interoperability requirements of CMS value-based care programmes, including the Enhancing Oncology Model and Radiation Oncology Model, that require structured, coded imaging data exchange. The absence of any named vocabulary standard in the current draft creates risk of implementation fragmentation across the certified health IT market.

NCQA recommendation for Diagnostic Imaging Report

Recommendation: The current USCDI element includes both the structured and unstructured components of the report. We recommend adding RadLex and SNOMED CT as appropriate vocabulary standards representing the clinical findings from the structured components of an imaging report.

Rationale: The clinical conclusions or findings resulting from a diagnostic imaging study represent important information to be exchanged via standard terminology to support appropriate follow-up care and care coordination. NCQA continues to develop measures that require the findings from imaging reports, which routinely represent the clinical findings using the ACR Reporting and Data Systems (RADS) or SNOMED CT.  Via quality measure testing with health systems and health plans, NCQA identified that while clinical findings are represented standardly, they are not always mapped to the available terminology codes. Adding SNOMED CT and RadLex vocabulary standards to the USCDI element will enhance standardization, reduce burden, and enhance interoperable exchange of these important data.

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