CE/IT Integration DICOM Key Concepts Technical Review Interconnectivity, interoperability and basic troubleshooting 1 Jeff Kabachinski Director, Technical Development Aramark Healthcare Technologies Thursday, July 23 rd, AM to 11AM

CE/IT Integration 2 What is Interoperability? HIMSS defines Interoperability as … Interoperability means the ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of healthcare for individuals and communities.

Today’s Agenda 3 HIS & its Constituent Networks PACS, RIS, LIS, PharmIT, ADT, MDDS, Medical IT A peek into PACS The OSI Reference Model Network Communication defined – how network traffic is configured Overview: Ethernet, TCP/IP & DICOM upper layers DICOM Standard Configuration DICOM statement review Service classes to act on the data DICOM Essentials – IODs, VRs, UIDs & Conformance Statements The JIT Genius One way to stay current

4 HIS HISHIS ADT, CPOE, HIS Master Patient Index RISRIS PACSPACS Rx-ITRx-IT LISLIS Medical Device Network Network MDISMDIS EHREHR RMONRMON

5 Picture Archival and Communication Systems  Networked computers, servers, and archives to store digital images  Accepts any image in DICOM format. (Digital Imaging and COmmunications in Medicine)  Serves as the file room, reading room, duplicator, and courier  Provides image access to multiple users at the same time, on- demand images, electronic annotations of images, and specialty image processing

6 DICOM Intro The DICOM Standard specifies a non-proprietary data interchange protocol, digital image format, and file structure for biomedical images and image-related information. DICOM addresses five general application areas (1)Network image management (2)Network image interpretation management (3)Network print management (4)Imaging procedure management (5)Off-line storage media management The main objective is to facilitate communication and interoperability. DICOM addresses all of the technical aspects necessary to allow complying OEMs to talk to and understand one another. The main objective is to facilitate communication and interoperability. DICOM addresses all of the technical aspects necessary to allow complying OEMs to talk to and understand one another.

7 LayerName Keywords 7Application Semantics 7Application Semantics 6Presentation Syntax 6Presentation Syntax 5Session Dialog Coordination 5Session Dialog Coordination 4Transport Reliable Data Transfer 4Transport Reliable Data Transfer 3Network Routing and Relaying 3Network Routing and Relaying 2Data Link Technology-Specific Transfer 2Data Link Technology-Specific Transfer 1Physical Physical Connections 1Physical Physical Connections LayerName Keywords 7Application Semantics 7Application Semantics 6Presentation Syntax 6Presentation Syntax 5Session Dialog Coordination 5Session Dialog Coordination 4Transport Reliable Data Transfer 4Transport Reliable Data Transfer 3Network Routing and Relaying 3Network Routing and Relaying 2Data Link 2Data Link 1Physical Physical Connections 1Physical Physical Connections The Layers OSI Reference Model

Physical Data Link Network Transport Session Presentation Application Logical Link Control Media Access Control Logical Link Control Media Access Control Medium for transfer of signal Method for getting data on & off the media Identifying your location on the Network Transfer of data Defining the data format Defining the connection Defining the app socket OSI Reference Model

AHAHDataData PHPHDataData SHSHDataData THTHDataData NHNHDataData DHDHDataData Bit Stream Application Presentation Session Transport Network Data Link Physical

AHAHDataData SHSHDataData THTHDataData NHNHDataData DHDHDataData Media Access Identifying your location on the Network Transfer of data Defining the data format Defining the connection Defining the app socket PHPHDataData Bit Stream Media OSI Reference Model

11 Ethernet Data Packet Architecture Timing Frame DestinationSourceAmount of data enclosedChecksum 7 Bytes 16 bytes 2 bytes 46 to 1522 bytes 4 bytes alternating 1s & 0s SFD: :00:A1:FD:23:C9 00:00:A1:1E:04:12 PreambleAddressingLengthDataCRC Shortest Packet Slot Time 6Bytes of the Ethernet destination address 6Bytes of the Ethernet source address 2Data length field 46Length of smallest data payload + 4For the CRC field 64Total # bytes in the shortest packet X 8Bits in a byte 512Total # of bits X 0.1μSBit 10Mbs 51.2μSSlot time

12 TCP/IP Protocol IP Data Packet Architecture Ethernet packet IP packet

13 TCP/IP Protocol Data Packet Architecture Ethernet packet IP packet TCP packet

TCP/IP Protocol Are “well known ports” assigned by the IANA (Internet Assigned Numbers Authority). Some examples: http uses port 80, FTP data - 20 FTP control -21, SMTP – 25, POP3 – 110, DICOM – 104, 1044, – Are requested from the IANA to become “registered ports”. For example: Googletalk has registered ports numbered 19294, 19295, – Unassigned open space or Free Space – an area open to use and often where cybercriminals play… TCP Port Number Ranges TCP port number or addresses are 2 bytes written as one number in decimal notation – from 0 to TCP Port Number Ranges Go to to get the current complete list of assigned and registered TCP port numbers.

TCP/IP Protocol Are “well known ports” assigned by the IANA (Internet Assigned Numbers Authority). Some examples: http uses port 80, FTP data - 20 FTP control -21, SMTP – 25, POP3 – 110, DICOM – 104, 1044, – Are requested from the IANA to become “registered ports”. For example: Googletalk has registered ports numbered 19294, 19295, – Unassigned open space or Free Space – an area open to use and often where cybercriminals play… TCP Port Number Ranges TCP port number or addresses are 2 bytes written as one number in decimal notation – from 0 to TCP Port Number Ranges Go to to get the current complete list of assigned and registered TCP port numbers. URL – Uniform Resource Locator Example: Example:

16 Data Packet Architecture Ethernet packet IP packet UDP packet TCP/IP Protocol

17 Physical Data Link Network Transport Session Presentation Application Logical Link Control Media Access Control Logical Link Control Media Access Control Medium to transfer signal Method for getting data on & off the media Identifying your location on the Network Transfer of data Defining the data format Defining the connection Defining the app socket OSI Model

18 Physical Data Link Network Transport Session Presentation Application Medium to transfer signal Method for getting data on & off the media Identifying your location on the Network Transfer of data Defining the data format Defining the connection Defining the app socket Wires Ethernet IP TCP/UDP NOS OSI Model

19 DICOM & the OSI Model

20 DICOM Intro The DICOM Standard specifies a non-proprietary data interchange protocol, digital image format, and file structure for biomedical images and image-related information. DICOM addresses five general application areas (1)Network image management (2)Network image interpretation management (3)Network print management (4)Imaging procedure management (5)Off-line storage media management DICOM consists of the following parts: PS 3.1: Introduction and Overview (this document) PS 3.2: Conformance PS 3.3: Information Object Definitions PS 3.4: Service Class Specifications PS 3.5: Data Structure and Encoding PS 3.6: Data Dictionary PS 3.7: Message Exchange PS 3.8: Network Communication Support for Message Exchange PS 3.9: Retired PS 3.10: Media Storage and File Format for Data Interchange PS 3.11: Media Storage Application Profiles PS 3.12: Media Formats and Physical Media for Data Interchange PS 3.13: Retired PS 3.14: Grayscale Standard Display Function PS 3.15: Security Profiles PS 3.16: Content Mapping Resource PS 3.17: Explanatory Information PS 3.18: Web Access to DICOM Persistent Objects (WADO) PS 3.19: Application Hosting PS 3.20: Transformation of DICOM to and from HL7 Standards DICOM consists of the following parts: PS 3.1: Introduction and Overview (this document) PS 3.2: Conformance PS 3.3: Information Object Definitions PS 3.4: Service Class Specifications PS 3.5: Data Structure and Encoding PS 3.6: Data Dictionary PS 3.7: Message Exchange PS 3.8: Network Communication Support for Message Exchange PS 3.9: Retired PS 3.10: Media Storage and File Format for Data Interchange PS 3.11: Media Storage Application Profiles PS 3.12: Media Formats and Physical Media for Data Interchange PS 3.13: Retired PS 3.14: Grayscale Standard Display Function PS 3.15: Security Profiles PS 3.16: Content Mapping Resource PS 3.17: Explanatory Information PS 3.18: Web Access to DICOM Persistent Objects (WADO) PS 3.19: Application Hosting PS 3.20: Transformation of DICOM to and from HL7 Standards The DICOM Standard has 18 parts Each part is a separate document Each part is a separate document All the grim details are here All the grim details are here PS3.3 has 1314 pages for example PS3.3 has 1314 pages for example Parts can be at different Rev levels Parts can be at different Rev levels Most have been updated in 2014 Most have been updated in 2014 Freely available at medical.nema.org Freely available at medical.nema.org The DICOM Standard has 18 parts Each part is a separate document Each part is a separate document All the grim details are here All the grim details are here PS3.3 has 1314 pages for example PS3.3 has 1314 pages for example Parts can be at different Rev levels Parts can be at different Rev levels Most have been updated in 2014 Most have been updated in 2014 Freely available at medical.nema.org Freely available at medical.nema.org

21 DICOM Terminology “I am sending a CT image to you” Service Class Information Object Definition Provider or SCP User or SCU SOP Service Class Provider Service Class User Service Object Pair

22 DICOM Terminology “I am sending a CT image to you” Service Class Information Object Definition Provider or SCP User or SCU SOP Service Class Provider Service Class User Service Object Pair All IOD details can be found in DICOM PS b

23 DICOM IOD’s Information object definitions (IODs) are simply a way to classify & encode data being transmitted via DICOM. Typically, the target information is digitized image information and any image related data (e.g., waveforms, formatted reports, radiation therapy dosage). Each IOD contains the description of its purpose and a list of the attributes that define it. The service class itself does not contain the values of the attributes, just which attributes will be included.

24 DICOM IOD’s Other sections of the standard that affect the IOD are: PS3.5: Data Structure and Semantics. This section addresses which image compression technique is used, as well the encoding rules necessary to construct the data stream (which in turn is made up of data elements). PS3.6: Data Dictionary. This is the centralized registry of DICOM Data Elements. Each element is defined with things like a unique tag that includes a group and element number, an element name, a value representation (alphanumeric), and the number of values per attribute.

25 DICOM IOD’s Think of the Data Dictionary as a lookup table for data types. The Data Dictionary is connected to the Value Representation (VR) and the encoding of the data elements. It’s important to be clued in to the format of VR and data elements so that you can recognize them in a DICOM message. PS3.14: Grayscale Standard Display Function. This section of the standard provides methods of calibrating a display system (monitor and printer) so that it presents grayscale images consistently. PS3.14 uses Barten’s model of the human visual system, another example of the important detail covered in the standard. PS3.16: Content Mapping Resource. This part covers the templates and coded terms for DICOM information objects. This part also contains the glossary of terms and any country specific translations of coded terms.

26 “I am storing an MR image with storage location A” Service Class Information Object Definition SCP SCU SOP Service Class Provider Service Class User Service Object Pair DICOM Terminology SOP = “Store this MR image”

27 DICOM Value Representations All Elements in the DICOM Data Dictionary are organized into groups and are labeled as (Group, Element) pairs. Groups are organized into 27 Value Representation categories. Examples: PN (0010, 0010) for patient name under the PN category. (0010, 0020) for patient ID VR formatting in a DICOM file would look like: (0010, 0010)Smith^Jim_(001, 0030) (0010, 0040)M

28 The 27 DICOM Value Representations Uses Little Endian encoding as default For example – A1 Little endian equals 161 in decimal Little endian equals 161 in decimal Big endian equals 26 Big endian equals 26 Need to ensure that the SCU and SCP agree!

29 DICOM Functions Conformance Statements The OEM’s DICOM Implementation Model The OEM’s DICOM Implementation Model SOP classes, Roles and Transfer Syntaxes used SOP classes, Roles and Transfer Syntaxes used Communication Stack & Cybersecurity Measures used Communication Stack & Cybersecurity Measures used UID – Unique IDentifiers An International Standard that has a Unique ID for almost every entity in DICOM – from SOP Classes and studies to pieces of equipment and individual images

30 The UID is formed using the DICOM registered ROOT and an organization defined specific SUFFIX. An SOP instance UID might look like: ROOT: SUFFIX: The DICOM UID

31 The UID is formed using the DICOM registered ROOT and an organization defined specific SUFFIX. An SOP instance UID might look like: ROOT: SUFFIX: To determine if any two SOP classes are the same – compare their UID’s To determine if any two SOP classes are the same – compare their UID’s SUFFIX: Can use whatever numbering scheme you choose but must be unique and less than 64 characters (total) including stops SUFFIX: Can use whatever numbering scheme you choose but must be unique and less than 64 characters (total) including stops To determine if any two SOP classes are the same – compare their UID’s To determine if any two SOP classes are the same – compare their UID’s SUFFIX: Can use whatever numbering scheme you choose but must be unique and less than 64 characters (total) including stops SUFFIX: Can use whatever numbering scheme you choose but must be unique and less than 64 characters (total) including stops The DICOM UID

32 The UID for DICOM transaction information is formed using a DICOM reserved ROOT: Therefore – if you open an unknown file in WordPad – for example – search for the text string If found you can be pretty certain that you’re dealing with a DICOM file. The DICOM UID

33 Knowledge Bits like these can help with your pattern recognition and build a foundation of DICOM network savvy The JIT Genius Plan 1.Work on the foundation 2.Build a reference library A strategy to keep pace - The JIT Genius Plan

34 Knowledge Bits like these can help with your pattern recognition and build a foundation of network savvy The JIT Genius Plan 1.Work on the foundation 2.Build a reference library A strategy to keep pace - The JIT Genius Plan Newton’s TELECOM Dictionary – Harry Newton Digital Imaging and Communications in Medicine: A Practical Introduction and Survival Guide - Oleg Pianykh Newton’s TELECOM Dictionary – Harry Newton Digital Imaging and Communications in Medicine: A Practical Introduction and Survival Guide - Oleg Pianykh

35 The JIT Genius Plan 1. 2.Build a reference library Newton's Telecom Dictionary is a great reference for telecom, data communications, networking, computing, and the Internet. Over 21,000 definitions it is over four times larger than any other telecom and IT dictionary, and includes wireless, broadband, intranet, e-commerce, and IT terms. Newton explains technical concepts in non-technical language. It’s an essential reference tool to anyone managing network and telecom systems and services. A Strategy to Keep Pace - The JIT Genius Plan

36 Knowledge Bits like these can help with your pattern recognition and build a foundation of DICOM network savvy The JIT Genius Plan 1.Work on the foundation 2.Build a DICOM reference library 3.Keep an eye on Healthcare IT: Healthcareitnews.com HealthIT.gov A Strategy to Keep Pace - The JIT Genius Plan

37 1.Work on the foundation 2.Build a DICOM reference library 3.Keep an eye on Healthcare IT websites. 4.Periodically Review These Sites for Reference and Free Tools To see registered TCP port assignments dicom.nema.org dicom.nema.org dicom.nema.org Free access to all DICOM standard sections Free access to all DICOM standard sections Access to free DICOM tools Access to free DICOM tools A Strategy to Keep Pace - The JIT Genius Plan

38 Knowledge Bits like these can help with your pattern recognition and build a foundation of network savvy The JIT Genius Plan 1.Work on the foundation 2.Build a reference library 3.Visit Key Sites 4.Visit the IANA and NEMA sites for free access to the DICOM standard and DICOM tools. A Strategy to Keep Pace - The JIT Genius Plan