This IG is currently under development and can not be considered stable and ready for use. For questions and change requests regarding this IG, please create a ticket in BITS.

1 Introduction

1.1 Background

In 2018, the Dutch Association for Radiologists (NVvR) and the Dutch Association for Health Providers (VZVZ) unveiled the document “Landelijke beschikbaarheid radiologische beelden voor zorgverlener en patiënt: functionele vereisten” (English: “National availability of radiological images for healthcare professionals and patients: functional requirements”)[1]. This document asserts that the present state of information exchange within Dutch radiology is unsatisfactory. In 2016, nearly one in four radiology patients had a potential necessity for the interchange of studies (images, reports) among multiple healthcare professionals and/or referrers.

Current workaround solutions exist, yet they fall short; transferring pertinent documents from one locale to another is labor-intensive. This situation ensues an undesirable effect: each healthcare professional possesses only a segment of the patient’s file – a scenario not merely unwelcome but also perilous for continuity, safety, and patient-related outcomes. The shared vision, as outlined by the NVvR and VZVZ, is for every radiologist to have the capacity to explore a chronological record of every radiology-associated investigation concerning the patient.

The primary objectives of this joint document include:

The establishment of a centralized timeline, representing all radiological encounters of a patient including studies and referrals, within a span of three years.
Accessibility of this timeline in every radiologist’s working milieu, irrespective of their location at any given moment.
A singular timeline, encompassing all studies and referrals, furnishing the treating radiologist with Invaluable insight and a comprehensive overview regarding each patient.

1.2 About this document

The BBS (Dutch: Beeldbeschikbaarheid, English: Image Availability) implementation guide emanates as a technical extrapolation of the collaborative document between NVvR and VZVZ. This guide aims to counsel on the application of IHE profiles predicated on XDS, XCA, and MHD/WIA, as delineated in volumes 1 through 3 of the IHE IT Infrastructure Technical Framework. It sets forth a suite of guidelines and technical prerequisites for healthcare professionals in the Netherlands, facilitating the provision of radiology images and/or reports.

1.3 Glossary

Term	Description
Beeldbeschikbaarheid (BBS)	The Dutch name of this project, often abbreviated to BBS. Image Availability is the international name for this project.
BSN	The citizen service number (BSN) is a unique 9-digit personal number allocated to everyone registered in the Personal Records Database (BRP). Everyone who registers with the BRP is automatically given a BSN.
Documents	Encompasses reports and/or images (via an image manifest / DICOM KOS object) inclusive of patient identification, demographic details, author, creation date/time, content type, and additional metadata essential for delineating the source and provenance of the enclosed information.
FHIR	Fast Healthcare Interoperability Resources
IHE	IHE International
Images	Resultant of scanning a patient/specimen utilizing electromagnetic radiation, x-ray, ultrasound or other methodologies to engender visualizations of internal body structures for precise diagnostic purposes.
Image Availability	The name of this project, in the Netherlands known as Beeldbeschikbaarheid (abbreviated to BBS).
MHD	Mobile access to Health Documents
MHDS	Mobile Health Document Sharing
NIHEMDS	The NIHEMDS is the National IHE MetaData Set (Dutch: Nationale IHE MetaData Set)
NVvR	Nationale Vereniging van Radiologen: the Dutch Association of Radiologists
Reports	Summarizes the diagnostic consultant’s findings (radiologist, cardiologist, lab specialist, etc) based on observations derived from an underlying set of images/test results. A report, once endorsed/approved by a senior diagnostic consultant, becomes immutable.
Studies	Grouping of images and reports relating to a single patient for a common diagnostic need.
Timeline	A temporally ordered representation of all radiological encounters a patient has undergone. Each encounter yields radiology information pertinent to the patient in the guise of images and/or reports.
VZVZ	Vereniging van Zorgaanbieders voor Zorgcommunicatie: Dutch Association for Health Providers
WIA	Web image access, also known as DICOMweb
XCA	Cross-Community Access
XCA-I	Cross-Community Access Imaging
XDS	Cross-Enterprise Document Sharing
XDS-I	Cross-Enterprise Document Sharing Imaging
Zib	A zib delineates a clinical concept in such a manner that it serves as a modular unit in various healthcare scenarios and information systems. Zibs underpin the standardization of healthcare information.

2 Actors involved

The table below shows the relevant MHD and WIA actors and transactions with respect to the systems used.

Persons		Systems		MHD/WIA
Name	Description	Name	Actors	Transactions
Radiologist	This actor is responsible for generating and transmitting medical images, and related information, and making them available to the responding gateway. In this role, the radiologist (and/or health organization they work for) is the Document Source making them also responsible for the metadata added to the document(s).	PACS	Document Responder	ITI-66 Find Document List
				ITI-67 Find Document References
				ITI-68 Retrieve Document
			Document Recipient	ITI-65 Provide Document Bundle
				ITI-105 Simplified Publish
				ITI-106 Generate Metadata
			Imaging Document Source	RAD-107 WADO-RS Retrieve
Treating physician	This actor is a healthcare professional that requests access to reports and related information from image-generating healthcare professionals.	EHR	Document Consumer	ITI-66 Find Document List
				ITI-67 Find Document References
				ITI-68 Retrieve Document
			Document Source	ITI-65 Provide Document Bundle
				ITI-105 Simplified Publish
				ITI-106 Generate Metadata
		EHR/Mobile Tablet	Imaging Document Consumer	RAD-107 WADO-RS Retrieve

3 Boundaries and relationships

The BBS specification applies to the exchange of documents, images and other related information between radiology healthcare professional in the Netherlands. It does not specify how documents and/or images are generated or stored, but rather how they are made available to other healthcare professionals. Therefore, healthcare professionals are not only responsible for the documents that are provided to the community, but also how their infrastructure is connected to said community to provide cross-community access. Also, note that only national citizens that have a BSN are in scope for this release.

For the current alfa release only the cross-community access via synchronous XCA-I is in scope. Future releases of this information standard will address non-XCA exchange. The Documents in scope for this release are PDF only. Other documents will be addressed in future releases. In consultation with the NVvR, both dictating and authenticating radiologists are not shown in the timeline, it suffices that this information is displayed in the report.

3.1 MedMij Images (Beelden) information standard

Images (Beelden) is a Dutch national initiative for the exchange of medical images between patients to healthcare organizations. The BBS and the Images standard both aim to improve the exchange of medical images. However, the Images information standard is a specific implementation of medical image exchange from patient to healthcare professional, while BBS provides a framework that can be used between healthcare professionals. They are therefore two different standards that should not be confused with each other during implementation.

3.2 Consent

The patient's legal consent is not in scope for this Implementation Guide: we assume that the radiologist and/or treating physician has consent from the patient to share their information.

3.3 IHE

For BBS, we assume that the reader is familiar with the mentioned IHE IT Infrastructure Domains. This document is not an introduction to XCA and/or XDS and will only focus on requirements from the IHE profiles, combined with the metadata set for BBS, which is relevant for national use in the Netherlands. This implementation guide also only focuses on achieving cross-gateway interoperability between actors in the Netherlands.

4 Required Metadata

Within BBS we use a combination of data sets, which has implications on the required metadata. Optional metadata is advised, as this could provide the consumer with more information. Responsibility for the quality of metadata lies with the Document Source. Since this document is part of an alfa release, it is very likely that there will be metadata added, adjusted and/or removed in future releases.

4.1 IHE

Starting from Chapter 5, we introduce the various use cases. In these use cases, we advise the usage of various IHE transactions which include the following required metadata:

DocumentEntry.patientId ($XDSDocumentEntryPatientId). This is defined by IHE-NL as BSN and will be used in this guide as a 9-digit unique identifier.
DocumentEntry.availabilityStatus ($XDSDocumentEntryStatus). This defines the lifecycle status of the DocumentEntry: Approved or Deprecated.

4.2 NIHEMDS

The NIHEMDS is the National IHE MetaData Set (Dutch: Nationale IHE MetaData Set) and is published on ART-DECOR. The NIHEMDS is under constant revision and construction, further adjustments in the NIHEMDS that have implications on the BBS metadata will be communicated in future releases.

5 Use case 1: Retrieve Timeline Data (Raadplegen Tijdlijn Data)

5.1 Introduction

This use case delineates the procedure for accessing a sequential record of a patient's radiological interactions, encompassing studies and referrals, utilizing the WIA/MHD(s) standard. It sketches the interplay among the radiologist, treating physician, and the implicated systems, ensuring a fluid retrieval and display of timeline data.

5.2 Procedure Steps

Request Initiation: The treating physician employs the EHR/Mobile Tablet to kickstart a request for the timeline data of a specific patient.
Document List Query: The system orchestrates an ITI-66 Find Document List transaction directed at the PACS, which takes on the role of the Document Responder.
Document References Retrieval: On garnering a favorable response, the system launches an ITI-67 Find Document References transaction to further hone the document list based on delineated parameters.
Document Retrieval: Subsequently, the system conducts an ITI-68 Retrieve Document transaction to fetch the actual documents.
Timeline Data Presentation: The procured data is structured and showcased as a timeline to the treating physician.

This structured outline encapsulates the step-by-step flow of events to fulfill the objective of retrieving and presenting timeline data, aiding in a seamless and comprehensible delineation of the procedure for all involved parties.

5.3 Actors

The actors for this use case are the following:

Persons		Systems		MHD/WIA
Name	Description	Name	Actors	Transactions
Radiologist	This actor is responsible for generating and transmitting medical images, and related information, and making them available to the responding gateway. In this role, the radiologist (and/or health organization they work for) is the Document Source making them also responsible for the metadata added to the document(s).	PACS	Document Responder	ITI-66 Find Document List
				ITI-67 Find Document References
				ITI-68 Retrieve Document
			Document Recipient	ITI-65 Provide Document Bundle
				ITI-105 Simplified Publish
				ITI-106 Generate Metadata
			Imaging Document Source	RAD-107 WADO-RS Retrieve
Treating physician	This actor is a healthcare professional that requests access to reports and related information from image-generating healthcare professionals.	EHR	Document Consumer	ITI-66 Find Document List
				ITI-67 Find Document References
				ITI-68 Retrieve Document
			Document Source	ITI-65 Provide Document Bundle
				ITI-105 Simplified Publish
				ITI-106 Generate Metadata
		EHR/Mobile Tablet	Imaging Document Consumer	RAD-107 WADO-RS Retrieve

5.4 Mapping

6 Use case 2: Retrieve Images (Raadplegen Beelden)

Zoals ze het bij immunisatie hebben en met die link

7 Use case 3: Retrieve Reports (Raadplegen Verslagen)

en de aangepaste versie met BBS transactie

8 Use case 4: Send Images (Sturen Beelden)

This use case is in development!

9 Use case 5: Send Reports (Sturen Verslagen)

This use case is in development!

10 Profiles and transactions

The BBS information standard makes use of the following zibs (from the 2020 release) and IHE transactions.

10.1 HCIMs

Zib NL	HCIM EN
Patient	Patient
Verrichting	Procedure
Zorgverlener	HealthProfessional
Zorgaanbieder	HealthcareProvider

10.2 IHE

IHE Profile	Description
Mobile access to Health Documents	The Mobile access to Health Documents (MHD) Profile defines one pair of actors and a transaction to submit or push new “document entries” from the mobile device to a receiving system. Another set of actors and transactions is used to query a list of “document entries” having specific metadata, and to retrieve a document.
Web Image Access/DICOMweb	WIA offers methodologies for image sharing and interactive viewing of imaging studies via RESTful services, independent of the backend image management infrastructure.
ITI-65 Provide Document Bundle	This transaction facilitates the transmission of a bundle of documents and metadata from a Document Source to a Document Recipient, including patient documents and reports.
ITI-66 Find Document Lists	Utilized to locate List Resources that meet certain parameters. A Document Consumer requests a Bundle, containing a List resource, from the Document Responder.
ITI-67 Find Document References	This transaction enables an initiating gateway to request the retrieval of a patient's health record from a responding gateway. The initiating gateway sends a query request using ITI-38, then uses the retrieved metadata to access the patient's health record from the responding gateway.
ITI-68 Retrieve Document	This transaction lays down the procedure to locate DocumentReference resources with specified parameters. The Document Consumer requests a DocumentReference from the Document Responder, who then responds with a FHIR bundle containing the Document Reference resources aligned with the set parameters.
ITI-105 Simplified Push	This transaction outlines the procedure to transmit a Simplified Publish Request from a Document Source to a Document Recipient.
ITI-106 Generate Metadata	This transaction delineates the method to transmit a Generate Metadata Request from a Document Source to a Document Recipient.
RAD-107 WADO-RS Retrieve	This action retrieves DICOM instances rendered as images, text-based documents, or other representations depending on the target resource. Primarily aimed at providing user agents with a simplified interface for displaying medical images and related documents, without necessitating an extensive understanding of DICOM data structures and encodings. It shares similarities with the Retrieve DICOM service regarding method, resources, header fields, and status codes, with primary distinctions lying in the resource component and the query parameters.

Implementation Guide BBS MHD/WIA version 1.0.0-alpha.2

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