Trends and future in DICOM standardization Cor Loef Philips Healthcare Program Manager Interoperability Best, The Netherlands Co-chair DICOM WG10 Strategic Advisory [2001-2012]

Trends and future in DICOM standardization Outline Overview of the DICOM domain DICOM vectors over years 1993-2013, & future Trend summary Conclusion

Acquisition Technology Domain of DICOM Workflow Print MR Media Distribution CT X-ray Advanced Visualization Archiving UltraSound Acquisition Technology Nuclear Structured Reporting Network Distribution Internet/Intranet Optical Therapy Electrical Security/Privacy

≈160 new supplements since 1993

DICOM standardization vectors

Acquisition Technology Drivers: Clinical domains: Ophthalmology Pathology Resolution Speed 3D Optics Intravascular What’s next: Hybrids New technology The Supplements for new acquisition technology started with the extension of the original Standard in the domain of NM, the new digital detector technology, Visible Light and waveforms. The Supplements in the period 2001-2005 included the next generation of enhanced objects for MR and CT, with multi-frame capabilities to address the need for faster transport of the exploded MR and CT image datasets. From 2006 onwards the enhanced capabilities and 3D support was brought to the NM, US and X-Ray modalities. Also the new clinical domains Ophthalmology, Dentistry and Pathology created their objects for digital acquisition, and new technologies for optical surface scanning, intra vascular optical coherence tomography and breast Tomosynthesis required the creation of special objects in DICOM. 1993   2000 2006 2013 2018

Structured Reporting Drivers: Radiation Dose CAD US Cardio Vascular What’s next: Clinical specialty needs Use of patient history for quality of healthcare improvement In 2000 the concept of structured reporting was introduced in DICOM. This enabled the creation of objects in DICOM that could capture much more semantic content such as measurements extracted from the acquired images, findings and conclusions. Ultrasound was the first specialty to create a number of those measurement structured reports, e.g. for OB-GYN procedure reports. Later every other specialty followed with the creation of structured reporting objects, e.g. for dose reporting, echocardiography, diagnostic reporting, chest and mammography CAD. 1993   2000 2006 2013 2018

Advanced Visualization Drivers: Display consistency Ease of use Ease of re-use 3D Quantitative Measurement Visualization What’s next: Clinical specialty needs In Volume visualization The advanced visualization support started with the support for grayscale calibration and the presentation state object, which is capable of encoding image annotations and image graphic manipulations external to the image objects. Next the support for consistent color presentation was added. And the growing support of 3D objects in DICOM spurred the creation of supplements for segmentation and registration, hanging protocols and structured display, and multi-dimensional presentation states. To support the hosting on a PACS of the advanced visualization and clinical decision support applications DICOM created a supplement with an API definition for application hosting. 1993   2000 2006 2013 2018

Media Drivers: Data explosion Consumer market media What’s next: Cloud The media support in DICOM basically follows the technology developments in the consumer industry. Whenever new media technology is ubiquitous, DICOM ensures that medical imaging content can be distributed by means of this media. This started with the various CD and MOD media, and later DVD, USB and Flash memory, and Blu-ray disk. 1993   2000 2006 2013 2018

Network Distribution Drivers: Transfer speed Web and Information Technology What’s next: Wireless Mobile The basis for networked distribution of imaging information in DICOM is TCP/IP. Over the years specific transfer syntaxes for the encoding of the pixel data stream have been added: MPEG, MPEG-2, MPEG-4, JPEG, JPEG 2000. In addition HTTP web technology based transfer and email transfer has also been added to DICOM: DICOM MIME type, and Web Access to DICOM persistent Objects by means of Web Services and RESTful services (WADO). 1993   2000 2006 2013 2018

Workflow Drivers: Efficiency in image acquisition, post-processing, reporting, therapy planning Data integrity What’s next: Regional workflow The support for workflow in DICOM started with the Modality Worklist and the Modality Performed Procedure Step, functions for conveying the patient and procedure information to the modality, and reporting the status of the acquisition exam. Then the scope of workflow support was extended by means of the General Purpose Worklist and Procedure Step, to cover also post-processing and diagnostic work. The most recent additions for workflow support in DICOM are the Unified Worklist and Procedure Step (replacing the General Purpose worklist), and the use of this Unified Worklist in Radiotherapy treatment delivery. 1993   2000 2006 2013 2018

Therapy planning and interventions Drivers: Radiotherapy Surgery What’s next: Image guided interventions Augmented reality The support in DICOM for therapy planning started with Radio Therapy planning and treatment. Recent additions are in the dental and surgery domain, with supplements for implants planning and surface segmentation. 1993   2000 2006 2013 2018

Security Drivers: Privacy concerns HIPAA What’s next: Deployment 1993 Over the years several security enhancements have been added to DICOM to address the growing concerns for patient privacy (HIPAA). This started with encryption via TLS support (Transport Layer Security) and Media security. Later additions added digital signatures for structured reports, audit trail messages, and a de-identification mechanism. 1993   2000 2006 2013 2018

Archiving Drivers: DICOM Composite object model Clinical applications What’s next: Distributed archives Regional/National Cloud Although archiving in DICOM appears to be quite stable, the PACS has to be prepared to receive and archive all new SOP classed coming for acquisition devices and generated structured reports, and support advanced visualization. Recently two supplements have been added that extend the use of the archiving function: supplements for the encapsulation of HL7 CDA and PDF documents in a DICOM container. 1993   2000 2006 2013 2018

Print Drivers: What’s next: Quality The End? Resolution Max Density Consistency Ease of Use Cost of Ownership What’s next: The End? Printing was already supported in the original DICOM standard in 1993. A number of additional print features were added for print queue management and printer configuration, and after that the features for DICOM printing have not been extended any more. This is in line with the move from film to digital for medical imaging. Technology •Photothermographic (dry laser) DRYVIEW laser imaging quality •True laser technology, •508 laser pixels per inch, •50 micron laser spot spacing , •14-bit pixel depth architecture, Throughput •Time to first print: 100 seconds, •Up to 70 films per hour: 14 x 17 in. (35 x 43 cm), •Up to 110 films per hour: 8 x 10 in. (20 x 25 cm) DRYVIEW Laser Imaging Film •Blue or clear 7-mil polyester base •Daylight-load film packaging (125 sheets) •Lifetime (100+ years) film archivability for demanding applications (oncology, mammography, pediatrics, etc.) •Printed film images with standard Dmax ◦3.1 Dmax — blue base ◦3.0 Dmax— clear base DRYVIEW Mammography Laser Imaging Film •Lifetime (100+) years film archivability •Enables higher Dmax images •3.6 Dmax with DVM film •4.0 Dmax with DVM+ film Choice of film sizes •The DRYVIEW 5950 Laser Imager supports the following film sizes: ◦14 x 17 in. (35 x 43 cm) ◦14 x 14 in. (35 x 35 cm) ◦11 x 14 in. (28 x 35 cm) ◦10 x 12 in. (25 x 30 cm) ◦8 x 10 in. (20 x 25 cm) Automatic Image Quality Control (AIQC) •Integrated DICOM interface supports printing from DICOM modalities •Built in with no separate DICOM server Network Connection 1993   2000 2006 2013 2018

Trend Summary Technology is a constant innovative driver for change, and new Acquisition Technologies will emerge, needing their encoding in DICOM objects. Continuous quality improvement of the clinical practice by evidence-based medicine, requiring deeper and broader semantic interoperability for data mining. This will lead to more DICOM Structured Reporting templates for evidence documents and CAD. The amount of acquired data by the acquisition modalities will continue to grow. The resulting information tsunami will require more use of 3D and 4D Advanced Visualization and Processing tools, and a continuous drive for speed in the Network Distribution. The need to support and orchestrate the post-acquisition processing, diagnostic and therapy Workflow will grow. The focus on the patient’s care cycle and clinical pathway through the healthcare enterprise will need a closer linkage between diagnosis, Therapy planning, and Image Guidance during Surgical Interventions. The geographical scope of imaging solutions has increased to regional solutions, and clinicians (and patients) want location independent, mobile, access to imaging information, with a link to the Electronic Patient Record. Network Distribution using Web Technology will be an important enabler for this trend. Looking at the history of DICOM over the last two decades, we have experienced the digitization of the radiology diagnostics, the move from analogue and film printing to digital. DICOM takes care of the basic workflow in the Radiology, Cardiology and NucMed department, and connects acquisition modalities with RIS, PACS, workstations with clinical applications, and printers (still). Even regional solutions and tele-radiology is widely supported. This has been a great success for DICOM. The basic Standard is established, and maintenance is needed for the existing Standard. Looking ahead in the current decade towards 2018, what’s to be expected for standardization development in DICOM, what are the trends? Here’s an outlook: Technology is a constant innovative driver for change, and new Acquisition Technologies will emerge, needing their encoding in DICOM objects. The number of clinical decision support applications will grow further, requiring deeper and broader semantic interoperability. This will lead to more DICOM Structured Reporting templates for evidence documents and CAD. The amount of acquired data by the acquisition modalities will continue to grow. The resulting information overload will require more use of 3D and 4D Advanced Visualization and Processing tools, and a continuous drive for speed in the Network Distribution. The need to support and orchestrate the post-acquisition processing and diagnostic Workflow will grow. The focus on the patient’s care cycle and clinical pathway through the healthcare enterprise will need a closer linkage between diagnosis, Therapy planning, and image guidance during surgical interventions. The geographical scope of imaging solutions has increased, and clinicians (and patients) want location independent, mobile, access to imaging information, with a link to the Electronic Patient Record. Network Distribution using web technology will be an important enabler for this trend.

Thank you for your attention ! Conclusion Access needed to both imaging data in DICOM and the rest of the patient’s clinical information in HL7. There are two domains: acquisition devices to PACS, and around and beyond the PACS. Web Technology will dominate the latter domain. DICOM will continue to grow to a total of 200 supplements in 2018 when celebrating 25 years of DICOM in South-Africa. Thank you for your attention !

References http://medical.nema.org/dicom/geninfo/Strategy.pdf http://www.hl7.org/implement/standards/fhir/ http://www.IHE.net/ Note: references to original pictures retrieved from the Internet and used this presentation are included in attached hyperlinks

Cor Loef http://www.linkedin.com/pub/cor-loef/1/911/650 Author Contacts Cor Loef http://www.linkedin.com/pub/cor-loef/1/911/650

Acquisition 1993-2000 # Title 4 X-Ray Angiographic Image Objects and Media Storage 6 X-Ray Fluoroscopic Image Object 7 Nuclear Medicine Image Object 12 PET Image Object 15 Visible Light Image (Single Frame) 30 Waveform Interchange 32 Digital X-Ray

Acquisition 2001-2005 # Title 49 Enhanced multi-frame MR Object 58 Enhanced CT Image Object 47 Visible Light Video 91 Ophthalmic Photography IODs 48 Intravascular Ultrasound IOD and Application Profile 45 Ultrasound Protocol Support 84 Ultrasound Region Calibration Clarification

Acquisition 2006-2013 # Title 43 3D (multi-dimensional) Ultrasound IODs and SOP Classes 116 3D X-Ray 83 Enhanced XA and XRF Image Storage SOP Classes 139 Enhanced XA/XRF IOD Informative Annex 117 Enhanced PET Image Storage SOP Class 141 Enhanced MR Color Image Storage SOP Class 110 Ophthalmic Coherence Tomography (OCT) Storage SOP Class 144 Ophthalmic Axial Measurements Storage SOP Class 146 Ophthalmic Visual Field (OPV) - Static Perimeter Measurements Storage SOP Class. 152 Ophthalmic Thickness Map Storage SOP Class 145 Whole Slide Imaging in Pathology 122 Specimen Identification and Revised Pathology SOP Classes 125 Breast Tomosynthesis Image Storage SOP Class 151 Intravascular Optical Coherence Tomography Image Storage SOP Class 154 Optical Surface Scanner Storage SOP Class

Structured Reporting 1993-2000 # Title 23 Structured Reporting 36 Codes and Controlled Terminology 26 OB-GYN Ultrasound Procedure Reports

Structured Reporting 2001-2005 # Title 53 DICOM Content Mapping Resource 50 Mammography CAD 65 Chest CAD SR SOP Class 79 Breast Imaging Report 66 Catheterization Lab SR SOP Classes 72 Echocardiography SR 76 Quantitative Arteriography and Ventriculography SR 71 Vascular Ultrasound SR 77 Intravascular Ultrasound SR

Structured Reporting 2006-2013 # Title 94 Radiation Dose Reporting 150 Radiation Dose Summary Information in Radiology Reports 159 Radiopharmaceutical Administration Radiation Dose Reporting 127 CT Radiation Dose Reporting (Dose SR) 126 Colon Computer-Aided Detection SR SOP Class 97 CT/MR Cardiovascular Analysis Report 128 Cardiac Stress Testing Structured Report 78 Fetal and Pediatric Echocardiography SR 129 Electrophysiology Structured Reports and Procedure Log Templates 130 Ophthalmic Refractive Structured Reports 143 Reporting of Macular Grid Thickness and Volume SR Template 135 SR HL7 CDA Mapping 155 Imaging Procedure Reports encoded in CDA template 115 Evidence Document SOP Classes

Advanced Visualization 1993-2000 # Title 28 Grayscale Standard Display Function 33 Soft Copy Presentation State Storage

Advanced Visualization 2001-2005 # Title 57 Expanded Secondary Capture 100 Color Presentation State 59 Key Object Selection SOP Class 73 Spatial Registration

Advanced Visualization 2006-2013 # Title 60 Hanging Protocol Object 123 Structured Display 133 Color Palette Storage SOP Class 124 Communication of Display Parameters 120 Extended Presentation States 156 Multi-Dimensional Presentation State 140 XA/XRF Grayscale Softcopy Presentation State Storage SOP Class 103 Real World Mapping SOP Class 111 Segmentation Storage SOP Class 112 Deformable Image Registration 157 Multi-Frame Converted Legacy Images

Media 1993-2000 # Title 1 Media Storage and File Format For Media Interchange 2 Media Storage Application Profiles 3 Media Format and Physical Media Interchange 27 Media Formats and Physical Media for Data Interchange 19 General Purpose CD-R Interchange Profile 18 Media Storage Application Profile for CT and MR Images 20 X-ray Cardiac (1024) Media Application Profile 25 Ultrasound Application Profile Media Extensions

Media 2001-2005 # Title 40 DVD using UDF Media 62 Higher Capacity MOD FAT 16 Media 69 640 MB and 1.3 Gbyte 90mm MOD Medium format and use in US profiles 80 DVD-R Media Application Profile 87 USB and Flash Memory Media Application Profiles 88 Media Creation Management SOP Class 92 Media Application Profile for Dentistry

Media 2006-2013 # Title 82 2.3 Gbyte 90mm MOD Medium Format for use in US profiles 153 Blu-ray Disc Media Application Profiles

Network Distribution 1993-2000 # Title 5 Ultrasound Application Profile IOD and RLE Transfer Syntax Extension 14 Unknown Value Representation

Network Distribution 2001-2005 # Title 42 MPEG Transfer Syntaxes and Encoding 61 JPEG 2000 Transfer Syntaxes 54 DICOM MIME Type 85 Web Access to DICOM Persistent Objects 67 Configuration Management 44 Clarify Network Addressing and Retire Non-TCP/IP Communication 90 SOP Class Relationships Negotiation

Network Distribution 2006-2013 # Title 105 JPEG 2000 Part 2 Multi-component Transfer Syntaxes 106 JPEG 2000 Interactive Protocol 137 MPEG2 MP@HL Transfer Syntax 149 MPEG-4 AVC/H.264 Transfer Syntax 113 Email Transport 148 WADO via Web Services 161 WADO by means of RESTful Services

Workflow 1993-2000 # Title 10 Basic Worklist Management (Modality) 17 Modality Performed Procedure Step SOP Class

Workflow 2001-2005 # Title 75 Relevant Patient Information Query Service Class 93 Instances Availability Notification 52 General Purpose Worklist

Workflow 2006-2013 # Title 96 Unified Worklist and Procedure Step 89 Worklist and Performed procedure Step Use Cases 121 Modality Procedure Plan and Protocol Storage 74 Utilization of Worklist in Radiotherapy Treatment Delivery 160 Second Generation RadioTherapy - Patient Positioning and Workflow

Therapy planning and interventions 1993-2000 # Title 11 Radio Therapy IODs Phase 1 29 RT Treatment Record IOD

Therapy planning and interventions 2001-2005 # Title

Therapy planning and interventions 2006-2013 # Title 102 Radiotherapy Extensions for Ion Therapy 147 Second Generation Radiotherapy 132 Surface Segmentation Storage SOP Class 131 Implant Templates 134 Implantation Plan SR Document Storage SOP 138 Crestal Implant Storage SOP Class

Security 1993-2000 # Title 31 Security Enhancements One: Transport Layer Security

Security 2001-2005 # Title 41 Security Enhancements Two: Digital Signatures 51 Media Security 55 Attribute Level Confidentiality

Security 2006-2013 # Title 95 Audit Trail Messages 86 Digital Signatures for Structured Reports 142 Clinical Trial De-identification Profiles

Archiving 1993-2000 # Title 8 Storage Commitment Service Class

Archiving 2001-2005 # Title

Archiving 2006-2013 # Title 104 DICOM Encapsulation of PDF Objects 114 DICOM Encapsulation of CDA and CDR 118 Application Hosting 119 Instance and Frame Level Retrieve SOP Classes

Print 1993-2000 # Title 37 Printer Configuration SOP Class 22 Presentation LUT (Print) 38 New Basic Image Overlay Box SOP Class Print Management Point-to-Point Communication Support 13 Queue Management (Print Queue SOP Class) 24 Stored Print related SOP Classes 39 Stored Print Media Storage

Print 2001-2005 # Title

Print 2006-2013 # Title