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RadioGraphics EDITORIAL 1595

Editorial
RadLex: A New Method for Indexing Anatomic and Pathologic Taxonomies for the
Online Educational Materials1 ACR Index Code 642.3212*
Curtis P. Langlotz, MD, PhD
Anatomic Taxonomy
For several decades, the American College of Ra- 6. Lung, mediastinum, pleura
diology’s Index for Radiological Diagnoses (known 64. Left upper lobe
642. Lingula
as the ACR Index) (1) has served admirably as an
Pathologic Taxonomy
indexing system for radiology teaching files. The
.3 Neoplasms and neoplastic-like conditions
ACR Index was originally developed to categorize .32 Primary malignant neoplasm
and organize the image-based interesting cases .321 Carcinoma-type neoplasm
collected by radiologists, often in paper folders on .3212 Primary adenocarcinoma
office shelves. As radiology clinical practice and
radiology education move online, there is an in- *642.3212 signifies primary adenocarcinoma of the
lingula.
creasing need for an indexing system that works
equally well in the digital world. The Radiological
Society of North America’s (RSNA’s) project Rad-
Lex is designed to address that need. This edito- plasms and neoplastic-like conditions are repre-
rial discusses the ACR Index and introduces the sented by 3; primary malignant neoplasms are repre-
RadLex lexicon, a new method for indexing on- sented by 32; carcinoma-type neoplasms are rep-
line educational materials for radiologists and resented by 321; and primary adenocarcinoma
educators. is represented by 3212. This numbering scheme
enabled many radiologists to remember the codes
The ACR Index for familiar anatomic locations and diagnoses that
The ACR Index has several attractive features for they commonly catalogued in their personal im-
indexing image-based teaching files. First, it of- age libraries (Table).
fers both anatomic and pathologic identifiers. By Third, the numbering scheme employed by the
convention, ACR Index codes are decimal num- ACR Index ensures that teaching materials retain
bers. The numeric code for the anatomic location a similar organization across radiologists and in-
appears before the decimal point, and the nu- stitutions. For example, a thoracic radiologist
meric code for the pathologic entity appears after traveling to another institution will find the same
the decimal point. For example, the code for pri- relationship between lingular disease and left up-
mary adenocarcinoma of the lingula is represented per lobe disease in teaching files created by there.
by the ACR code 642.3212.
Second, the ACR Index was created to be used Shortcomings of the ACR Index
by humans. Each digit of the ACR Index code As teaching materials and other personal image
denotes a more specific term in the taxonomy. libraries have moved online, some of the at-
For example, lung, mediastinum, and pleura are tributes of the ACR Index that made it desirable
represented by 6; the left upper lobe is represented for organizing image-based teaching materials
by 64; and the lingula, a subdivision of the left have become substantial limitations (2,3). Com-
upper lobe, is represented by 642. Likewise, neo- puters now have the capacity to manage huge lists
of index terms and their interrelationships. These
online lexicons are valuable tools to index online
content. For example, SNOMED-CT (System-
RadioGraphics 2006; 26:1595–1597 ● Published online 10.1148
/rg.266065168
atized Nomenclature of Medicine–Clinical
1From
Terms, from the College of American Patholo-
the Department of Radiology, University of Pennsylvania
Health System, Radiology Administration, Penn Tower Lobby Level, gists, Northfield, IL) contains over 350,000 con-
399 S 34th St, Suite 100, Philadelphia, PA 19104. Received September cepts that can be used to organize the information
12, 2006; revision requested and received September 14; accepted Sep-
tember 14. The author is shareholder in eDictation and a consul-
in electronic medical records. Because the ACR
tant for Elsevier. Address correspondence to the author (e-mail: Index contains only a few thousand unique terms,
langlotc@uphs.upenn.edu). it is easier for humans to remember, but it offers
©
RSNA, 2006

Human limitations also require that the ganizations. Comparing Rad- nology systems can meet the needs of online radi. cardiovascular. most modern termi. over 90 radiologists have tifiers in the background. it is dexed with RadLex codes. listed the cooperation of numerous standards or- cepts.rsna. musculoskeletal. can be used to annotate. As nizations to create a consistent language to de- the shift to online educational materials has oc.8). scribe the devices. RadLex Web site (http://www. met in groups. thereby creating a single source for For example. Finally. the RSNA has em. identifying the chairs of the RadLex subcommit- nology systems completely hide the numeric iden. index. procedures. Over the past year. a set of pathologic terms. and imaging se- curred. To avoid duplicate immediately apparent that 642 must represent effort. the right lower lobe. and retrieve con- A second drawback of the ACR Index is its tent from MIRC. One of the primary including SNOMED-CT and the Foundational goals of this project is to create a terminology that Model of Anatomy (4). while meetings in winter and materials.org/radlex/). systems.6). or for most other lung seg. dex or in any other medical terminology system. to deliberate trieval of Electronic Images over draft term sets. SNOMED-CT terms as a starting point for the times makes it difficult to add or retire terms RadLex lexicon (9). RadLex already contains over 8. Meetings in fall 2005 focused To help usher in the era of electronic teaching on anatomic terms. by restricting detail. many of The RadLex Project which are not currently available in the ACR In- To address this limitation. can be designed to interact with the unique iden. These cooperating organizations have assisted in ments. including Digital Imaging and Com- numeric codes be brief. typically because these systems do RadLex will differ from the ACR Index in several not contain a complete set of imaging terms (7. For example. This fixed lege of American Pathologists to use a subset of relationship between digits and concepts some. and Indexing and Re. the ACR Index to the RadLex project. since software systems the lexicon after it is released. which contributed information processing limitations of humans. no extant medical termi. the RSNA has developed the Medical spring 2006 dealt with imaging findings and Imaging Resource Center (MIRC) (5. including thoracic. which is designed Thus. tees and will contribute to the dissemination of tifiers from human users. the ACR Index as well as a wide range of professional organiza- does not provide a code for the apical segment of tions drawn mostly from radiology subspecialties. there is a clear need for a more complete quences used to create imaging examinations. abdominal. Unfortunately. neurologic. The ACR Index avoids munications in Medicine (DICOM) (10) and long numeric codes that are difficult to remember Integrating the Healthcare Enterprise (IHE) (11). medical imaging terminology. the RSNA will be working for creation of electronic teaching files and other with numerous modality-based subspecialty orga- forms of annotated personal image libraries. the comprehensiveness of RadLex enables to fill in the gaps in other medical terminology indexing of images with more specific concepts. For coded with the ACR Index can be easily in- example. thereby The ACR Index numbering scheme uses digits to ensuring that image-based teaching materials represent logical relationships between terms.000 anatomic and pathologic terms. RadLex has augmented the ana- tomic and pathologic codes in the ACR Index with additional types of terms. These anatomic and pathologic tools that enables users to connect electronic terms are available for public comment on the teaching files to one another over the Internet. pediatric imaging subcommittees. The MIRC project offers an online authoring tool Over the coming year. the RSNA has en- without changing the codes of other nearby con. which was designed for the have the support of the ACR. RSNA also has arranged with the Col- one of the parts of the left upper lobe. To address this issue. The RSNA was fortunate to numbering scheme. including (a) the . 1596 November-December 2006 RG f Volume 26 ● Number 6 RadioGraphics much less detail than other terminology systems. since 64 signifies the left upper lobe. Lex to the ACR Index ology indexing. important ways. and computer-friendly index to describe imaging findings. barked on the RadLex project.

rsna. Bell DS. Care 1994. Chicago. RG f Volume 26 ● Number 6 Langlotz 1597 RadioGraphics devices. Rosse C. J After the draft RadLex term sets are revised Digit Imaging 2002. the ACR Index. of 5(6):503–510.org/radlex/service/ to explore a pilot version of Accessed September 12.rsna. taking advantage of the comprehensiveness and computational versatility of RadLex when it is released this fall. 2006. 1992.15(1):2– 4. ensure that new concepts are incorporated into 2006. CPT (Current Procedural tient Records Institute Working Group on Codes Terminology. radiologists biomedical informatics: the Foundational Model whose teaching materials are organized according of Anatomy.html. A reference ontology for course. A sig. including a tabular format.org/TR/owl-features/. Evaluation of UltraSTAR: database file. http://www. procedures. 2006. Index for Radio- and analytical difficulty of the interpretation. terials can be readily and automatically updated 5. Accessed September resource nears completion. ontology Web language (OWL) (13). 2006. Accessed September vember 2006. Integrating the Healthcare Enterprise home The developers of RadLex recognize that it page. Proc Annu Symp Comput Appl Med source vocabulary management tool called Pro. Available at: http://protege mail feedback at rl-feed@rsna. both to 12. how a term browser might work. What is SNOMED CT. Va: American (c) the diagnostic quality of the images. Reston.org/. 4. Accessed must continue to evolve to retain its utility. Carr C.Jan:216 –222. IHE. Siegel E.nema. RadLex will be available in a vari. A framework including harmonization with other popular for comprehensive health terminology systems in medical vocabularies and term sets. to the RadLex system. Healthcare Informatics Standards Board Vocabu- tion of Diseases. Protege home page. 12. 14. and. 500. ciation. Caldwell SA.15(15 suppl tensible markup language (XML) format called 1):201–205. Digital Imaging and Communications in Medicine home page. which existing lexicons for representing radiology report can be loaded directly into Excel. The completeness of ety of forms. Available at: http://medical. .edu/. September 12. Channin D.edu/. the RadLex thoracic lexicon. Accessed September 14. Methods Inf designed to be continuously supplemented and Med 1998. J Am Med Inform Assoc 1998. and public policy implications. 2006. 2006. . Available at: http://www. Mejino JL Jr. BrainInfo home page. RadLex terms also will be available for 9. criteria for selection. American College of Radiology. such as the United States: development guidelines. 2. 2006. performance of a collaborative structured data en- try system. Available at: at the time of the RSNA annual meeting in No. Cimino JJ. Another College of Radiology. BrainInfo (12). which can be loaded into an open. ANSI SNOMED-CT. from the American Medical Asso. Chute CG. Reiner B. Medical Image Resource Center 2002: an update on the RSNA’s Medical Image Resource Center. 9th Revision. and Structures. a variant of ex. RadLex and to maintain the cross-links between 13. Please consider . Medical RadLex will be available on the RSNA Web site Imaging Resource Center home page.w3. and imaging techniques used References to acquire radiology images. 11. based on public comments. J Biomed Inform 2003. browsing or searching via the Internet or while Available at: http://www. 3.37(4 –5):394 – 403.org/snomedct/ using the MIRC authoring tool. the first full release of 6. updated with incorporation of new concepts. SNOMED International. Desiderata for controlled medical vo- key distinguishing feature of RadLex is that it is cabularies in the twenty-first century. ICD9 (International Classifica.net/.rprc.snomed. Cohn SP. (b) the perceptual 1. Accessed September 12. and as a 8.washington. tégé (14).ihe. In particular.36(6):478 – to the ACR Index can rest assured that these ma.stanford. Accessed September 18. As the first version of the new RadLex . Available at: http://braininfo . IL). visit http://mirc 10.org/mirc/. OWL web ontol- RadLex and other vocabularies when they are ogy language overview. nificant ongoing effort will be required. World Wide Web Consortium. 12. 4th ed. 7. Radiological Society of North America. Greenes RA. Langlotz CP. and logical Diagnoses. Campbell JR.org. information. For a sample of what_is. Perry J. J Digit Imaging 2002. Available at: http://www updated. we welcome your e. from the World lary Working Group and the Computer-Based Pa- Health Organization).