Electronic Record of Breast Imaging Diagnosis: Example Data Structure in FHIR
HTML XML - HAPI FHIR Test Server
Summary
This article demonstrates how detailed breast lesion data, such as from mammography, is structured using the FHIR Observation resource. It presents specific data elements to show a mechanism where clinical findings (like BIRADS assessment) are electronically recorded and exchanged according to standard specifications.
Details
This document provides a technical example of structuring detailed pathology information obtained from breast imaging, such as mammography, within the FHIR Observation resource format. Specifically, it structures various clinical findings—including 'Breast Composition Type,' 'Level,' 'Lesion Side,' and 'Focal Clock Position'—along with data based on multiple diagnostic criteria, such as the 'Final BIRADS Assessment Score (Category 3a)' and 'Lymph Node Shape/Assessment Score (Category 1).' The key technical feature is that it utilizes FHIR Observation to express these findings by referencing specialized medical terminologies like HL7 v2-0203, SNOMED CT, and RADLEX. This structuring goes beyond mere text records (Narrative). By giving standardized meaning to each data element, it enables information exchange (interoperability) between different Electronic Health Record systems. The use of specialized codes like SNOMED CT and RADLEX for describing diagnostic criteria and findings is particularly crucial for international medical information linkage. In the Japanese healthcare IT environment, having such a standardized data structure is essential. Adopting global standards like FHIR forms the foundation for building various advanced medical system linkages, including billing/reimbursement claims, remote diagnosis support, and integrating AI image analysis results. This example provides concrete guidelines on how highly specialized radiology data can be mapped onto standard specifications.
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