Scott, Philip

English

Name not available

Electronic transfer of radiology
reports to other hospitals and
general practitioners
RAD Magazine, 40, 467, 23-24
Dr Philip Scott
Chair, HL7 UK; Senior lecturer,
Centre for Healthcare Modelling and Informatics,
University of Portsmouth
email: philip.scott@port.ac.uk
Introduction
Compared to most clinical specialities, radiology
has extensive, mature and sophisticated infor-
mation technology support. Given this, it is per-
haps surprising that transmission of radiology
reports is not yet a routine electronic process. In
fact, the only information flow in the UK from
hospitals to general practitioners that is univer-
sally and exclusively electronic is for laboratory
results (specifically haematology, biochemistry
and microbiology). This has been operational
since 1999-2000 and is based on EDIFACT mes-
saging.1 Numerous NHS trusts have implemented
local or regional electronic solutions for discharge
summaries and outpatient letters, in some cases
using the NHS Interoperability Toolkit (ITK)
message specifications.2 However, there does not
yet exist a nationally available generic document
sharing capability between NHS primary and sec-
ondary care. This article is based on a presenta-
tion given at UKRC 2013 and specifically
addresses transfer of radiology reports to general
practitioners, with some consideration of inter-
hospital report communication.
Healthcare interoperability – the bigger picture
Interoperability is defined as “the ability of two or more sys-
tems or components to exchange information and to use the
information that has been exchanged”.3 The absence of gen-
eral interoperability in healthcare has been lamented, espe-
cially in the US health system, as part of the failure to
achieve necessary efficiency and safety improvements.4
Efforts to develop and implement standards for interop-
erability are almost as old as the first generation of health
information technology (HIT).5,6 Much progress has been
made with intra-organisational interoperability. Most NHS
hospitals have a common index for patient demographics,
typically in the patient administration system (PAS), which
is shared by departmental and central diagnostic systems
such as PACS and the radiology information system (RIS).
The protocols and capabilities are there for wider informa-
tion sharing, but their usage and configuration has depended
on local leadership, so diverse solutions have evolved to fit
particular health ‘ecologies’. The implementation challenge is
primarily human and organisational, not technological.
As with any significant organisational change, substantial
resources are needed to generate progress.7 Unlike hospital
clinicians, general practitioners were given financial incen-
tives to move to electronic patient records (EPRs).8 This is
now institutionalised in that the whole payment system for
GPs as independent contractors is driven by information
supply, usually at aggregate population level, derived from
their EPRs. An additional problem with implementing inter-
operable solutions is that the costs and benefits often fall
in different places – each node in the information network
(GP, radiology, laboratory and so forth) will typically need
some upgrade to participate in a new exchange standard,
but which users actually get the benefits? Efficiency and
financial savings often arise solely for consumers rather 
than providers in healthcare information communities. For
example, for GP reporting the laboratory or radiology depart-
ment still has to produce reports in the same way so there
is only minimal, if any, cost reduction whereas the general
practice will have both process efficiency improvements 
and potentially cash-releasing benefits from reduction in
scanning workload. Therefore, incentives have to be devised
at a regional level as shared community benefits and usually
require some ‘market management’ from healthcare 
commissioners.
Radiology reporting in the UK
An informal survey of health IT vendors and NHS trusts
identified five different configurations of electronic radio-
logy report transmission in the UK. The following sections
describe each category of solution and briefly evaluate their
relative merits. 
1. Hospital EPR viewer
This ‘portal’ approach is simply a GP view of the hospital
patient record, usually restricted to patients registered with
the given practice. Typically this is only available when the
trust has a hospital-wide EPR, although in some cases GPs
are given portal access to PACS. This is arguably the least
useful solution for the GP as it requires learning how to use
a different EPR and having to navigate large amounts of
irrelevant detail. Also, it still requires the practice to process
the paper report into the GP EPR through a scanning and
coding workflow.
2. Shared repository
A shared repository, or ‘data warehouse’, aggregates multi-
ple data sources into a virtual EPR. This often includes var-
ious types of primary care data, hospital correspondence,
diagnostic reports and administrative data such as sched-
uled clinic appointments. This approach enables the GP and
the hospital clinician to see a fairly complete picture of the
entire patient journey through various clinics, wards and
diagnostic services. This is particularly helpful when imple-
mented as a regional shared record that incorporates data
from several hospitals. The disadvantages are the same as
the portal.
3. Direct messaging
Direct messaging of reports into GP systems from the RIS is
typically achieved by generating HL7 version 2 messages.
HL7 is the dominant international standard for health infor-
mation exchange. While the ability to generate HL7 v2 out-
put is usually native to the RIS, the capability to receive
and process these messages is not standard in UK GP sys-
tems. Therefore ‘middleware’ of some kind is generally
needed to translate the HL7 format into a structure that
the GP system can understand, sometimes using the 
EDIFACT laboratory reporting mechanism described in the
introduction. This approach has the major advantage of inte-
gration with the GP system and hence with the practice
workflow. The disadvantage is the need for a translation
layer, however that is also usually implicit in all the solution
categories except the simplistic GP portal.
4. Messaging hub
The messaging hub (sometimes called health information
exchange (HIE)) solution is illustrated in figure 1. In effect,
this is a ‘clearing house’ that manages requests, reports and
billing (or activity reporting in the NHS) between multiple
requesters and reporters. This architecture would incorpo-
rate the translation layer required for GP direct messaging,
but has the additional advantages of multi-organisational
interoperability and support for the whole business process,
not just the report transmission. The disadvantages are the
complexity of supporting the multiple message types, and
consequent higher deployment cost, and the risk inherent
in wide area dependency on a single point of failure. The
latter point can be addressed by using a resilient design
such as a cloud service or locally clustered servers with
failover.
5. Integrated requesting and  reporting
Integrated requesting and reporting (in the UK often called
order communications) can link to an HIE, or can function
as a direct collaboration between a group of GPs and a diag-
nostic provider. The requesting and reporting functionality
can be accessed from a link in the main GP system, but
there is not usually full integration with routine general
practice operations. This category can offer additional fea-
tures such as checking the status of outstanding requests
and structuring requests to meet local referral guidelines.
The obvious limitation of this solution is that its scope is, by
definition, restricted to one component (albeit a crucial one)
of the healthcare information ecosystem. Another potential
weakness of this solution category is that some implemen-
tations use proprietary rather than international standards.
6. Comparison
Figure 2 compares and contrasts the relative degrees of
workflow integration and use of international standards
found in each of the solution categories. This is not to say
that one solution is always the best, or that there is neces-
sarily a wrong answer. Any improvement in healthcare
interoperability is to be welcomed, but a strategic approach
that is both standards-based and integrated with requester
and provider business processes clearly offers the greatest
potential benefit to the greatest number of users. The more
sophisticated approaches normally require proportionately
higher initial expense, but also offer the maximum potential
for quality improvement and process efficiencies. The choice
between solution architectures is fundamentally about what
business problem a health community is trying to solve.
Opportunities for the future
Another HL7 standard that has obvious potential for use in
radiology report transmission is clinical document architec-
ture (CDA), and its simplified version ‘greenCDA’.9-11 CDA
is an XML document format that specifies the structure and
semantics of clinical documents. Figure 3 shows a mind-
map of the logical structure of CDA. CDA is widely used in
numerous national and regional health information pro-
grammes, including the NHS in England, the US federal
programme and Australia, Austria, Brazil, Canada and
China to give an indicative ABC selection of other imple-
menters. 
Part of the attraction of CDA is that clinicians are com-
fortable with the concept of documents as the unit of infor-
mation exchange. Whereas messaging seems like a complex
technical process, document exchange is readily comprehen-
sible. Another advantage is that CDA allows for varying
degrees of sophistication in its usage. Entry-level CDA can
be as simple as a digital blob (binary large object – perhaps
a PDF file attachment) with a structured header. Figure 4
illustrates a minimal CDA structure, which is no more than
a text file with the machine-processable header.
CDA would seem to be an obvious design candidate in a
strategic architecture for radiology communications.
Conclusions
The NHS is known to tolerate unsafe processes to a level
that would be inconceivable in most service industries.12
Arguably, the absence of a national architecture for radio-
logy information exchange is an instance of this problem.
As the second NHS and social care information governance
review concluded, the motto for better care services should
be: “To care appropriately, you must share appropriately”.13
The technology and the standards exist to support safe
and usable solutions. Primarily, what is needed is leader-
ship and standardisation,14 though finding sufficient
resources for either of these is challenging in the continuing
austerity climate. 
Views expressed in this article are personal judgements
and do not represent HL7 UK.
References
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March 2014 from http://systems.hscic.gov.uk/interop/iscf2012/cases/
clinical.
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Figure 1
Typical messaging hub architecture. (Clip art ©Microsoft).
Figure 2
Comparison of report communication methods.
Figure 3
CDA logical structure (based on Benson 2012,15 with permission).
Figure 4
Example minimal CDA structure (based on Dolin 201316).
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calendarofevents/himss/2013/CDA%20and%20CCD%20for%20Patient%20
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Electronic transfer of radiology reports to other hospitals and general practitioners

Portsmouth University Research Portal (Pure)

An emerging standard for health communications: The HL7 standard.

Clinical Correspondence [electronic version].

Managing successful organizational change in the public sector. Public administration review

Pathology Messaging Implementation Programme (PMIP) [electronic version].

Semantic mapping to simplify deployment of HL7 v3 Clinical Document Architecture.

Simplifying HL7 version 3 messages. Stud Health Technol Inform 2011;169:709-713. 12,

Standard formats for electronic transfer of clinical data.

What it will take to achieve the as-yet-unfulfilled promises of health information technology.

Why general practitioners use computers and hospital doctors do not – Part 1: Incentives.

https://researchportal.port.ac.uk/portal/services/downloadRegister/1567707/Electronic_transfer_of_radiology_reports_to_other_hospitals_and_general_practitioners_final.pdf

Electronic transfer of radiology reports to other hospitals and general practitioners

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