DICOM STRATEGY - Presented at RSNA

DICOM StrategyDICOM Strategy

Cor Loef

co-chair DICOM WG10:Strategic Advisory Committee

Philips Medical Systems

December5, 2002 IHE @ RSNA 2002 2

Contents

• Scope of DICOM

• Charter WG10: Strategic Advisory Cmt

• Trends in Imaging-IT

• Strategy Planning process

• Collaboration with other SDOs


Scope of DICOM

• Mission of DICOM– Create and maintain international standards for

communication of bio-medical diagnostic and therapeutic information

• Goals of DICOM– Achieve interoperability and improve workflow

efficiency between imaging systems and other information systems


Charter of WG10

• To develop and maintain the long-term strategic plan of the DICOM Standards Committee. URL: http://medical.nema.org/dicom/geninfo/dicom_strategy

• To review standards and technology trends in healthcare, biomedical imaging, commerce, telecommunications, and informatics;

• To consider issues and opportunities related to the strategic evolution of DICOM;

• To provide liaison to other standards developing organizations: ISO, HL7, JIRA, CEN


Overview

• Scope of DICOM






Quality of care improved by information and IT:

All relevant information the care giver and patient need, anywhere and anytime, for the best clinical decisions through one common and simple user interface, adapted for the task.



HIS

RIS

Vertical IntegrationTrends in Imaging-IT:

Radiology

PACS

Cardiology

PACS

VL, US, NM

PACS

Horizontal Integration

Web distribution

OtherClinicalSystem

Web based PACS

At the desktop

Paradigm shift

Active workflow


Vertical Integration

The Healthcare Enterprise

HISHIS

Order Placer

ADTPatient Registration

RISRIS

IMAGING:IMAGING:•• PACS / ArchivesPACS / Archives

•• WorkstationsWorkstations•• ModalitiesModalities

Image Archive

Image Manager

Image Creator

Image Display

AcquisitionModality

DepartmentSystem Scheduler– Order Filler –

Modality Worklist

Patient Registration

New

Ord

er

Procedure Scheduled

ImagesStoredStorage

Commit

Q /RImages

PPSIn-Progress/ Completed


Active Workflow


Workflow in Radiology

DigitalRadiology

..010011...

Registration

..010011...

Preparation

..010011...

Examination

..010011...

Archiving

..010011...

Reporting

..010

011.

..

Transcription

..010011...

Demonstration

..010011...

Review

ing

..010

011.

..

Ref

erra

l

..010

011.

..

Image Distribution

..010011...Post Examination


PersonalizedWork list

For each user

Active Workflow


User’s default display protocol


Paradigm shift in PACS:Clinical Applications to PACS

Yesterday


Multi-slice CT: 1000+ images


Post-Processing everywhere

• Viewing & Advanced Image Processing:– clinical SW packages– move towards modalities, PACS and web

3D

Spine

Endo3D Cardiac MR


• Analysis tools to enhance clinical decisions:– Echo measurements & calculations– Left Ventricular Analysis– Quantitative Coronary Analysis

– Vascular X-Ray Analysis

– Vascular X-Ray Post-Processing


Radiology

PACS

Cardiology

PACS

Ultrasound

PACS

Visible Light

PACS

One Image Management Infrastructure

Radiology

workflow

Cardiology

workflow

Ultrasound

workflow

Pathology

workflow

Hospital Information System, Master Person Index




• Image (information) management system supports archiving/retrieving of all types of clinical objects (incl. visible light) and Structured Reports


DICOM SR Creation - Example -Radiology

Report Type:

Findings:

Conclusions:

Image Refs.:

Header::RIS dataRIS data

Image dataImage data

from PACSfrom PACS

Report TemplatesReport TemplatesFrom DICOM From DICOM standard:standard:

Coding SchemesCoding Schemesbehind pop-up menusbehind pop-up menus

ThoraxThorax……....……....……....

MassMass……....……....

Daim.Daim.Infiltr.Infiltr.

……....……....

(Pointer)

select select

Report Creator Report Creator

applicationapplication

(DIC

OM

) S

R O

bje

ct(D

ICO

M)

SR

Ob

ject


Web based PACS

At ModalityPACS Viewing

Station

Web Viewer

Webserver


Web and Security

At Modality

Web Viewer

PACS ViewingStation

Webserver

Security


“Electronic Health Record”

• Image Management system and Departmental Information Systems must be EHR-prepared (Query/Retrieve)

• EHR: emphasis today on visual integration on the desktop, will become the integrated, secure, patient centric, source of health information

• Need for coded vocabularies to represent medical knowledge and the patient’s health condition

• Web front-end:

– viewing not only of images but also waveforms, measurements, reports, lab results, etc

– need the capability to access the original medical images

– support for (DICOM) Structured Reporting

– XML and XML Schema for the exchange of clinical documents


EHR: Visual Integation

messagesmessages

ClinicalClinical

InformationInformation

SystemSystem

ClinicalClinical

InformationInformation

SystemSystem

Back-Office

IntegratedIntegrated

Clinical ViewingClinical Viewing

at the desktopat the desktop

Front Office

EfficiencyEfficiency

ImproveImproveClinicalClinicalDecisionsDecisions


Overview

• Scope of DICOM






Strategic planning process

• In recent meetings WG10 has identified quite a number of strategic topics in the following domains:

– data acquisition, imaging technology– post-processing and presentation

– object management and archiving– data and result distribution– treatment planning– workflow management


The (multi-vendor) Integrated Imaging The (multi-vendor) Integrated Imaging SolutionSolution

ImageImageServerServer

CDCDExchangeExchange

DepartmentDepartmentInfo ServerInfo Server

Diagnostic Diagnostic WorkstationWorkstation

Image Image ArchiveArchive

Connection to Connection to other Networkother Network

and/or and/or TeleCardiologyTeleCardiology


Quality of Patient Care

Effective treatment planFast and accurate diagnosis

Images

Waveforms

Measurements

Collec t and presen t

Diagnose

Reduce Errors

Treatmentplan

Order

Report

Codes and vocabularies

StructuredPresentation

PersistentObject Ref

Codes and vocabularies


Topics in Acquisition domain:– Workflow outside the Radiology domain: RT, VL,

Cardio. Requires specialized workflow. Refreshing the worklist, event based.

– Amount of data generated, kind of data generated.• More, 3D, real-time, grayscale, color, time-sequence, text

• Text really broadens the scope: evidence documents, key image note, codes, vocabularies, templates. Need for simple, small documents, e.g. just a few measurements

• Amount of data will impact performance• Need to manage separate objects that do belong together, SOP

Class future. modeling instead of SOP ( HL7 way), separate info model from communication


Topics in Acquisition/Post-processing domain:– Integration, data from multiple modalities needed

together, fused, merge recipe. Requires synchronization in time and/or space.

• US + CathLab• PET + CT• MR + NM

– Communication technology• Media for exchange, profiles• Wireless (TCP/IP is on top of this, should be no issue)


Topics in Archive domain:– Delete service. All images come together in central

archive with satellites. Co-operation in a loosely connected environment.

– Co-operation between multiple loosely connected workflow managers.


Topics in Diagnostic Review domain:– Presentation, have only grayscale presentation currently.

• color, 3D, waveform, Cine, MR-multiframe• hanging protocols• multi-modality presentation• SR presentation

– Interactive collaboration, tele-radiology– Data mining, statistics, need for uniform definition.

• Should we organize a workshop on this topic?


Topics in Reporting domain:– Harmonization with CDA L3, XML encoding

– Next versions of TID 2000, templates– Codes, Vocabulary, Procedure Codes, Diagnostic

Codes, HIPAA induced codes


Topics in Result Distribution domain:– DICOM’s document paradigm: Persistent Object

Reference– Exchange information outside the DICOM domain– HIPAA, Privacy, Security, Authentication, VPN– CD/DVD for exchange


The distribution problem

Electronic Patient Record

Radiology

PACS

Cardiology

PACS

VL, US, NM

PACS

HIS

RIS

OtherClinicalSystem

Web Viewers

Webserver

Report Type:Findings:

Conclusions: Ima

g

e

R

e

f

s

.

:

Header::ThoraxThorax……....……....……....MassMass……....…….... Daim.Daim.Infiltr.Infiltr.

……....……....(Poi

n

t

e

r

)

URL/URI?


Topics in Treatment/Treatment planning domain:– CAD tools, HPGL standard, templates for implants

– 3D, image guided surgery, contours, locate images in 3D space

• multi modality aspect

– Image fusion


Strategic planning processSummary of the statements made:

–We started with the ultimate goal in mind: Quality of Patient Care, Continuity of Care, and the two contributing factors: fast and accurate diagnosis, and most effective treatment plan

–The key persons to support with information are the technologist, radiologist/cardiologist, and the referring clinician.

–Images, waveforms, measurement reports are generated and need an integrated presention to the key decision makers.

–We see this integration and presentation to the diagnostic decision maker as the top priority.


Strategic planning process

Statements (continued):–We have the feeling that much is available in DICOM

which is not deployed in practice to solve integration and presentation problems==> Education and promotion task

–There will be gaps as well.==> Identify the gaps in the Radiology, Cardiology, NM and US domain

–Imaging (related) information from other domains (-ologies) needs to be integrated as well==> Convince other -ologies to use the DICOM paradigm for their persistent objects.


Acquisition Interpretation

Radiology

Reporting

Acquisition Interpretation

Cardiology

Reporting

Ultrasound

NM

Other -ologiesArchiving plus Object management

1

2

3

3

4

Strategic priorities

Integration from acquisition via presentation to interpretation andreporting


Overview

• Scope of DICOM






Standards in Imaging-IT

1. Horizontal Integration DICOM

2. Vertical Integration IHE, DICOM, HL7

3. Electronic Patient Record ISO/CEN,DICOM,HL7,XML

4. Orders and Results IHE, DICOM, HL7

Management

5. Security IHE,IETF,DICOM,HL7,ASTM

6. Freedom of Application ISO/CEN, CCOW, IETF,

Workspot DICOM

When new technology is required, the strategy is to adopt proven

international, industry or de facto standards.


IHE - Integrating the Healthcare EnterpriseReducing the Barriers to Optimized Patient Care

• Fostering communication between vendors and users of medical information technology

• Gaining knowledge of the data required for optimal patient care decisions, i.e. understanding each others problems

• Driving the deployment and evolution of existing standards

• Eliminating the gaps and redundancies in data access.


Liaison with TC 215• Good Type A liaison since April 99.• Procedure

– TC 215 has agreed to rely on DICOM for Medical Imaging Standardization

– DICOM offers expertise in medical imaging, with world-wide users and vendors representation.

– Need to ensure coherence with other ISO standards group on imaging related issues (e.g. ISO JTC1 SC9 on JPEG 2000)

• New workitem: Web Access to DICOM’s Persistent Objects, co-operation of ISO TC 215/WG2 and DICOM– in DICOM a WG6 ad-hoc group is established to work on the

supplement, together with a group of ISO nominated experts


Collaboration with HL7• WG20: Integration of Imaging and Information Systems,

common DICOM-HL7 working group.• Works on the harmonization of the information models,

HL7 RIM and DICOM Real-World model.

• Works on the harmonization of DICOM SR and the HL7 CDA (Clinical Document Architecture) level 1,2,3– An informative annex to the DICOM standard will be created with

the mapping of DICOM header data element to CDA level 1.– CDA level 2 and 3 are progressing.

Documents

DICOM STRATEGY - Presented at RSNA