Presentation Title Presented by Name

Consistency, Presentation and Integration Existing Systems Systems to be Purchased PACS VNA Enterprise Viewer PACS PACS Profile Actor(s) CPI Evidence Creator Image Manager/Archive Image Display KIN Profile Actor(s) CPI Image Manager/Archive KIN Profile Actor(s) CPI Image Display IID KIN BIR

Consistency, Presentation and Integration Existing Systems Systems to be Purchased PACS Enterprise Viewer PACS PACS Profile Actor(s) CPI Evidence Creator Image Manager/Archive Image Display KIN Profile Actor(s) CPI Image Display IID KIN BIR

Consistency, Presentation and Integration Systems to be Purchased PACS Viewer Profile Actor(s) CPI Evidence Creator Image Manager/Archive Image Display KIN Profile Actor(s) CPI Image Display IID KIN BIR

Consistency, Presentation and Integration Existing Systems Systems to be Purchased PACS Viewer EHR/EMR/RIS Profile Actor(s) CPI Evidence Creator Image Manager/Archive Image Display KIN Profile Actor(s) CPI Image Display IID KIN BIR Profil e Actor(s) BIR Image Display Invoker

Viewing – Image Presentation Profiles The “view” part of “View/Download/Transmit” (MU Stage 2) Command to display versus fetching images to display Invoke Image Display (IID) Profile retrieve via DICOM, XDS-I, WADO-URI, -WS, -RS, … What to display all/specific/most recent/relevant prior studies key images – Key Image Note (KIN) Profile How to display it functionality – Basic Image Review (BIR) Profile annotations – Consistent Presentation of Images (CPI) Profile

IID – Profile Abstract “The Invoke Image Display Profile allows the user of an Image Display Invoker, typically a non-image-aware system like an EHR, PHR or RIS, to request the display of studies for a patient, and have the display performed by an image-aware system like an Image Display (PACS).”

IID – Problem Statement EHR/EMR/PHR/RIS/HIS/portals don’t store imaging studies EHR/EMR/PHR/RIS/HIS/portal users want to see images Static links to individual rendered consumer format images may are insufficient for interactive viewing, and may grow stale Interfaces from EHR/EMR/PHR/RIS/HIS/portals to PACS/VNA to request display of imaging studies possible but n:m customization/scaling problem US Meaningful Use requirements emphasize the need for the “View” part of “View, Download and Transmit” for imaging studies and results, possibly via a link

IID – Use Cases – View Studies Non-imaging expert – mobile browser + EHR – wants key images Imaging expert – desktop browser + EHR – wants complete set of images – may be zero footprint in browser, or thick client or separate PACS or separate hardware Remote user assessing need for transport – remote applications (EHR and PACS/VNA viewer) displaying on local hardware Local EHR user accessing imaging studies in remote (central/regional/federated) image repository – +/- single sign on (SSO) Patient/friend/relative using patient portal to EHR/PHR to view imaging report wants to view imaging studies in (separate) patient portal to PACS/VNA or regional image repository

IID – Process Flow

IID – URL Request Examples http://<location>/IHEInvokeImageDisplay ?requestType=PATIENT &patientID=99998410^^^AcmeHospital &mostRecentResults=1 &modalitiesInStudy=CT http://<location>/IHEInvokeImageDisplay ?requestType=STUDY &accessionNumber=9364923 &keyImagesOnly=true http://<location>/IHEInvokeImageDisplay ?requestType=STUDY &studyUID=1.2.840.113883.19.110.4,1.2.840.113883.19.110.5 &viewerType=IHE_BIR

IID – Interactive Viewing Requirement Image Display shall provide interactive viewing. Navigate within the requested studies (including change studies, series, and scroll between images and frames) Manipulate the appearance of the displayed image (window, zoom and pan)

IID – Summary The Invoke Image Display profile provides a minimalist means of image-enabling non-image-aware systems It uses the simplest available HTTP-based technology It supports patient and study level invocation, usable with or without a priori knowledge of individual study identifiers It requires servers to provide interactive viewing, and both review or diagnostic quality, and key images, under the control of the user Is completely independent of the source of the images (PACS, VNA, etc.) and the technology used to store/access them Key challenge is motivating EHR vendors to switch to standard IID rather than existing proprietary solutions for the same problem

Image Display Actor An actor in many profiles Scheduled Workflow (SWF) Profile PWF, CPI, KIN, ED, NM, PDI, ARI, MAMMO, etc. Behavior in Retrieve Images transaction [RAD-16] some SOP-class specific behavior (e.g., for DX, NM) some profile-specific behavior (e.g., for MAMMO) Basic Image Review (BIR) Profile – detailed functionality Invoke Image Display (IID) Profile – separates its usage

BIR – Use Cases Basic Viewer Option (PDI Profile - Media Creator) physician viewing of media operating room viewing of media patient viewing of media Basic Imaging Review Profile viewing from PACS/VNA inside/outside enterprise viewing from other enterprise, regional archive viewing through EHR/PHR

BIR – Value Proposition Increase user satisfaction & efficiency Reduce confusion training & technical support burden repeat studies (cost & radiation dose) delays & errors in patient care

BIR – Process Flow

BIR – Image Display – Behavior – I Display of gray scale and color images from any modality Cross-sectional modalities like CT, MR and PET Projection radiography modalities: CR, DX, XA and XRF Ultrasound and nuclear medicine Basic rendering of the images as encoded Without additional image processing No pseudo-coloring, MPR, volume rendering, fusion

BIR – Image Display – Behavior – II Visual navigation of series of single and multi-frame images using thumbnails Side-by-side comparison of at least two sets of images, whether they be multi-frame images, series from the same study, or different studies Synchronized scrolling, panning and zooming Annotation of laterality, orientation Spatial localization (anatomic reference) Annotation of demographics, management, technique

BIR – Image Display – Behavior – III Simple measurements of linear distance and angle as used by clinicians for change detection and treatment planning Cine capability to allow review of multi-frame images that involve cardiac motion (e.g., cardiac US, XA, CT or MR) NO ADDITIONAL FUNCTIONALITY PERMITTED OK to have a tool to select “advanced mode”

BIR – Standard User Interface Behavior Direction of mouse movement (e.g., windowing, scrolling) Mouse actions (left button click) Keyboard shortcuts Icons – “not intended to be used exactly with the bitmap illustrated … as long as they are recognizable as being the same symbol” – based on IEC 60878 symbols to the extent possible

BIR – Summary BIR improves user experience (CD & “on-line”) Minimum set of features defined by expert panel of representative referring physicians Too much, too little or just right? Does not preclude vendor-specific added value through “advanced mode” but does require adherence to principles & standard user interface requirements Challenging where there is an installed base of viewers or existing “look and feel”

KIN – Profile Abstract “The Key Image Note Integration Profile specifies transactions that allow a user to mark one or more images in a study as significant by attaching to them a note managed together with the study. This note includes a title stating the purpose of marking the images and a user comment field.”

KIN – Summary The Key Image Note profile provides a standard mechanism for storing (and interchanging) a list of one or more key images It uses the standard DICOM Key Object Selection (KOS) object (which is a constrained form of DICOM Structured Report (SR)) Moves the “key image” functionality out of the proprietary database and into a standard form that can be shared across networks, media (CDs) Lives with the rest of the the DICOM study, independent of where it is stored (PACS/VNA, locally/remotely) or how it is accessed (DICOM, XDS, WADO, etc.)

Consistent Presentation of Images (CPI) Combines a solution for two classes of problem What a displayed image should “look like” i.e., how it should be transformed for display e.g., window center/width, pan/zoom, slip/rotate What annotations should be applied to it user-created text and/or vector graphics and overlays NOT the default “corner” annotations of identity, technique, etc. Uses the DICOM standard Grayscale Softcopy Presentation State (GSPS) object and Grayscale Standard Display Function (GSDF) Like KIN (KOS), lives with & interchanged with rest of DICOM study