A clinical report management system based upon the DICOM structured report standard

Computer based report systems have proven their utility in improving health care delivery. However the majority of these systems do not comply with any standard for codification, storage and transference of medical data, thus making difficult the interchange of data between different health institutions. This paper describes the development of a user-friendly report editor that produces documents compliant to the DICOM Structured Report-DICOM SR-standard. The strategy chosen to develop the editor was to combine a documentation template editor with a report instance editor that allows the use of previously built templates to ease the process of creating reports. The developed template editor helps the user though building report structures by indicating which information items are needed in order to document a particular type of examination and suggesting values for the information items. The report instance editor represents reports in an easily understandable graphical visualization, and allows the user to create and edit structured reports permitting the use of templates as start-points. It also contains mechanisms to let the user set other document´s information required to make it compliant to the DICOM SR standard. The editor is integrated into a DICOM server/client environment and can also be used as a client to other DICOM-SR compliant PACS systems. The report editor developed was already presented to the clinical staff of a community hospital in southern Brazil, where it is intended to be installed, used, and evaluated by the medical staff.