State of the Standards 2018 Kevin O’Donnell, MASc. Canon Medical Research
“If you build it, they will come…” Yeah, right.
Draft & Publish SDOs Standard Implement & Release Vendors in Product Install & Use Users in Practice
IHE • Secretariat: RSNA & HIMSS – www.ihe.org – secretary@ihe.net • Scope: – Profiling existing standards to address specific use cases in healthcare • 13 Domains – Radiology, Cardiology, IT Infrastructure, Lab/Pathology, Eyecare, …
IHE Process • Add Profiles to IHE Technical Frameworks • Steps: – (Annual Cycle) – Profile Proposal – Public Comment – Trial Implementation – Final Text
IHE Radiology – What’s New Recent TI Publications • Management of Acquisition Protocols (MAP) – Collect/Manage/Distribute CT Protocols • Standardized Operational Log of Events (SOLE) – Capture Operational Events related to Imaging • Results Distribution (RD) – Send Radiology Reports with key flags and metadata – (Foundation for FUNC – Follow-Up of Non-Critical actionable findings)
… MAP Motivation … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … One Scanner can have 100 or more protocols… … … … … … … … … … … … … Quality of Care – Good, consistent image quality depends on good protocols, used consistently Efficient Workflow – Hanging Protocols, Image Processing, Reporting Workflow depends on consistent series names, procedure codes, etc. Dose Management – Managing dose depends on managing protocols Analytics – Summarizing data depends on consistent tagging
Management of Acquisition Protocols (MAP) Centralized, cross-vendor review and approval Protocol Manager Scanner A (Workstation) • Upload protocols • Periodically review & approve Scanner B • Modify (within limits) • Re-distribute protocols and approvals Protocol Archive Scanner C
MAP Technology DICOM CT Defined Procedure Protocol IOD – Encodes a complete protocol (incl. private tags and constraints) DICOM Protocol Approval IOD – Encodes list of protocols and associated approvals DICOMweb - NPI Service – RESTful transactions to Store, Query, and Retrieve Non-patient Instances
SOLE Motivation Help sites solve operational problems; improve performance • “You can’t manage what you don’t measure” • Scope initially limited: – Imaging departments that use orders and schedules. – Activities between Order and Report. • Build on SWIM, Syslog, DICOM Schema (like ATNA), REST – Existing tooling, shared infrastructure
Use Case: Track Order to Ready-to-Read (Part I) * Courtesy Rob Horn
Use Case: Track Ready-to-Read to Report-Available (Part II) * Courtesy Rob Horn
Use Case: Bulk Analysis * Courtesy Rob Horn
Results Distribution (RD) Send reports to EMR (and external systems, e.g. for FUNC action) • FOCUS ! Existing infrastructure -> HL7 v2.x ORU • Enable SOME structured, coded data to begin to move industry • Useful gap solution, not end game • Important “baby steps” towards computer processable data * Courtesy Teri Sippel, Vital Images
Profiled HL7 v2.5.1 ORU * Courtesy Teri Sippel, Vital Images
Profiled OBX Segments • OBX – DICOM Study Instance UID • OBX – Finding • OBX – Radiologist’s Recommendation • OBX – Radiologist Requests Consultation • OBX - Radiologist Requests Feedback • OBX - Imaging Result Payload Note: OBX “type” indicated by LOINC Code in OBX-3 * Courtesy Teri Sippel, Vital Images
ACR Actionable Findings Categories Finding type ACR Actionable Meaning Finding Category Normal Normal As expected or unremarkable Non-actionable Non-Actionable Not quite normal, but no action to be taken (e.g., “the spleen is slightly enlarged”) Non-critical ACR Category 3 Medical attention required within days to months ; “incidental” (e.g., lung nodule) Urgent ACR Category 2 Medical attention required within hours (e.g., diverticulitis) Emergent ACR Category 1 Medical attention required within minutes (e.g., large pneumothorax) * Courtesy Teri Sippel, Vital Images
Standardized Mapping of Actionable Codes & Priority * Courtesy Teri Sippel, Vital Images
IHE Radiology – What’s Next Entering Trial Implementation • Encounter-Based Imaging Workflow (EBIW) – Part 1: Point-of-Care Ultrasound • Web Image Access (WIA) – Formerly MHD-I Entering Public Comment later this year (Sneak Preview) • Import and Display of External Priors (IDEP) – Proactively find and import priors over the network
What is Encounter-Based Imaging? Enterprise Imaging Order-based Imaging Encounter-based Imaging [CT, MR, PET, XA, MG, Echo] [PoCUS, Camera, iPhone,…] (Radiology, Cardiology, etc.) (Dermatology, Wound Care, Burn Unit, ER, etc., etc., etc., etc.) EBI = imaging captured in the context of an encounter between a patient and a care-provider (typically without an imaging order)
So What’s the Key?
Key Metadata • To manage the images, and readily find & use them again – Patient Metadata • Name, Date of Birth, Age, MRN, Other IDs, … – Encounter Metadata • Department, Specialty, Physician, Referring Physician, Admission ID, Admission Date/Time, Reason for Admission, … – Procedure Metadata • Modality, Imaging Procedure, Body Part, Reason for Imaging, Accession # , Acquisition Date/Time, Device, Operator, Acquisition Parameters (more for PoCUS than cameras), … – Pixel Metadata • Rows, Columns, Bit Depth, Pixel Size, Encoding, ... • … turning a JPEG into a medical document
Encounter-Based Imaging Workflow (EBIW) EMR Use Case 1: EMR, MPI, PAM, PDQ, etc. Point-of-Care Ultrasound (ER) Result • Scan wristband Aggregator Encounter [Gets metadata] • Manager Notify (Patient ID, Visit ID, Acq. Time, • Scan Patient Get Procedure Code, Imaging Context Accession #, • [Adds metadata] Body Part, etc.) • [Stores Images] • [Notifies EMR] PoC US Image Manager/ Archive
IHE EBIW Actors & Transactions
DICOM • Secretariat: MITA – dicomstandard.org – dicom@dicomstandard.org • Scope: – data and workflow compatibility between imaging systems and HIT systems – diagnostic, therapeutic & associated data in medical disciplines that use digital images • 31 Working Groups – CT, MR, Dentistry, Physics, Web Technology, etc.
DICOM Process • Add Supplements to DICOM Standard • Steps: – New Workitem Proposal – Public Comment – Letter Ballot – Final Text
DICOM – What’s New (2017) • Sup 189 Advanced Blending Presentation State • Sup 190 Volume Rendering Presentation State • Sup 191 Patient Radiation Dose Report • Sup 192 Protocol Approval Patient Dose Surface • Sup 194 RESTful Non-Patient Instances • Sup 197 Ophthalmic OCT Angiography • Sup 200 Transform NCI AIM & DICOM SR Measures • Sup 198 Retire WADO-WS • Sup 201 Retire Radiation Dose from MPPS
Advanced Blending Presentation State (Example) + Relative Opacity 0.6 DTI Anatomical (Relative Opacity 0.3) (Relative Opacity 0.7) Relative Opacity 0.4 + + fMRI fMRI fMRI * Courtesy Wim Corbijn (Relative Opacity 0.33) (Relative Opacity 0.33) (Relative Opacity 0.33)
Volume Rendering - Example 3D Voxel Data 2D Pixel Data Volumetric Graphic Annotation Projection Graphic Annotation Volume Graphics VOI LUT Cropping Classification RGBA P-Values or PCS-Values P-Values or PCS-Values Rendering Layer Cropping Specification Index value, Render Display Render Geometry Render Shading Volume Cropping * Courtesy WG-11
Patient Dose SR Modality FOR Modality Image Radiation Dose SR Radiation Exposure Information X-Ray - X-Ray exposure techniques Patient Dose Equipment - Table, Gantry Angle, Beam Geometry, collimation Surface - Dose measure: CTDI, DAP, ... Organ Dose Reporter System Equipment Information Patient Model Patient Dose - Table dimension FOR - Attenuating material, … Map Patient Registration Dose SR IOD Patient Registration Information - Patient position on table - Fiducials Patient - Registration of Patient FOR and Equipment FOR Model * Courtesy WG-28
Reactivated Working Groups WG-14 Security • Common members with MITA Cybersecurity • Ready to apply & extend DICOM WG-17 3D (Additive Manufacturing) • Aligned with SME (“Society of Manufacturing Engineers”) WG-23 Application Hosting (Data APIs) • APIs for query & data access appropriate to training AIs, and using AI to process a current study • Machine Learning buzz continues at RSNA, HIMSS, SIIM
DICOM – What’s Next • Sup 188 Multi-energy CT Image • Sup 164 Contrast Administration SR • Sup 183 Web Services Re-documentation • Sup 193 REST Notifications • Sup 203 DICOMweb Thumbnails
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