Deploying DICOM in a Hospital/Clinic Donald E. Van Syckle DVS Consulting, Inc.

PACS is a Major Reason for Using DICOM When buying a PACS system you use DICOM to integrate: Modalities (e.g CT, MRI, X-ray, US, NM, etc.) Workstations such as a 3-d workstation, CAD, etc. Printers (color and grayscale) Radiology Information Systems (RIS) Others……… Commonly known by most hospitals

What Features of DICOM are Needed Basic DICOM features: Send and receive images Query and Retrieve from an archive Print images Download Patient information to modalities Not so basic DICOM features: Secure storage of images Track image acquisition workflow Store images as viewed by clinician Generate and display reports Tag important images Others……….. Basics only commonly known by most hospitals

Translate Features into DICOM Requirements This is a problem for hospitals as they do not know how to speak “DICOM” SOP Classes Information Objects Service Class User, Service Class Provider Storage Commitment Presentation State Others…………… NOT commonly known by most hospitals

Help Hospitals Learn How to Speak “DICOM” First Fundamental Lesson - SOP Classes SOP Classes are DICOM’s communication tools Saying “DICOM Compliant” does NOT really tell the story SOP Classes are what vendors implement and how hospitals integrate vendors Help Hospitals “translate” their required features and workflow into SOP Classes Question - “I need my modalities to integrate patient information with my RIS” Answer “Ok, you implement Modality Worklist SOP Class” Important education for PACS Administrators

Basic Features DICOM Storage DICOM Storage – “push” images Question for archives, workstations and modalities Vendors say “We support Storage” At a minimum it usually means, CT, X-ray, CR, MR, US, Secondary Capture (for a PACS) But you need to ask, does it include MG (mammo), NM, PET, Color US, Cardiac Echo (US multi-frame)? Specific to the modality (e.g. a CT image is NOT a US image) Send CT Images – CT Image Storage SOP Class – SCU Receive CT Images – CT Image Storage SOP Class - SCP Image Send

Basic Features Query/Retrieve and Print Query/Retrieve – “pull” images from archive Question for archives, workstations and some modalities Many PACS do not use DICOM when using own workstations Q/R is often only used with 3rd party workstations, such as 3D, NM workstation, etc. Workstation asking query Study Root Query/Retrieve Information Model – Find – SCU Archive being queried Study Root Query/Retrieve Information Model – Find – SCP Print – one simple question, Black/White (grayscale) and/or Color (RBG) Modality or Workstation – Basic Grayscale Print Management Meta SOP Class – SCU Printer - Basic Grayscale Print Management Meta SOP Class – SCP

Basic Features Modality Worklist Download HIS/RIS Data to Modality Patient Name/ID, Accession Number, procedure code, Study Instance UID, etc. Also requires Health Level Seven (HL7) Standard Patients (ADTs), Order (ORM)…. RIS or PACS – who do you pick? RIS or PACS Modality Worklist Information Model – Find – SCP Modality Modality Worklist Information Model – Find – SCU Name ID Accession # Procedure Time Joe Smith 1234-8 678-1236 CT Head 8:30am Jane Jones 24689 132001-9 CT Neck 9:00am Frank Able 978567 94650970 CT Head 10:00am …………… …….. ……. ………. ………

Modality Worklist More Detailed Questions How does the modality refresh its list? What does the modality convey in image header from MWL? What happens when tech determines order is wrong and needs to correct? How is RIS changed and how does that effect HL7 Cancel order/new order, update order? Did it change the accession number or study instance UID? How do I clean up the errors in my HIS/RIS/PACS IHE Patient Information Reconciliation? Manual clean up? Questions effect MWL and DICOM is becoming a little more complex

More Advanced DICOM Storage Commitment Guarantee secure storage of data on archive Real feature is to manage disk space on modality Automatically delete images on modality? User interfaces makes deletion easy? Modalities do Storage Commitment but do nothing? Modality – Storage Commitment Push Model SOP Class – SCU Archive - Storage Commitment Push Model SOP Class – SCP Difficult for hospitals to understand because they don’t see the workflow Image Send Storage Committed Storage Commit Request Archive Scanner

More Advanced DICOM Grayscale Softcopy Presentation State (GSPS) Store and view images as seen by clinician Also capture annotations, overlays, measurements, flip,etc. Look the same on all workstations Some detailed questions Who has permissions to store GSPS into medical record? Does PACS use GSPS or implement in proprietary ways? (important if you wish to view on 3rd party workstations) What types of images can workstation perform GSPS? Do monitors automatically calibrate to GSPS or manual? Create GSPS Workstation/Modality Grayscale Softcopy Presentation State Storage SOP Class – SCU Store or View GSPS – Archive/Workstation Grayscale Softcopy Presentation State Storage SOP Class – SCP

More Advanced DICOM Key Object Selection (Key Image Note) Mark images as significant images (KIN) Documents “why” they are significant and can apply GSPS Uses DICOM Structured Report (SR) Some detailed questions How do clinicians want to use KIN? Who has permissions to store KIN into medical record? Clinicians, Emergency Room, Specialists Does PACS use KIN or implement in proprietary ways? (important if you wish to view on 3rd party workstations) Create Key Image Note - Workstation Key Object Selection Document SOP Class – SCU Store or View Key Image Note – Archive/Workstation Key Object Selection Document SOP Class – SCP

More Advanced DICOM DICOM Structured Report (SR) Covers many areas in DICOM, most have been labeled “Evidence Documents” by IHE Some examples: Key Object Selection Document (Key Image Note) Mammography and Chest CAD OB-GYN Measurement Reports Simple Image and Numeric Reports Cath Lab reports Vascular Ultrasound Other… DICOM SR used to supplement image information

DICOM Used to Integrate into PACS Workstations – 3D, Nuclear Medicine, CAD, Quality Assurance Various Image Storage SOP Classes – SCU/SCP Study Root Query/Retrieve Information Model – Find – SCU Study Root Query/Retrieve Information Model – Move – SCU Basic Grayscale and/or Color Print Mgt Meta SOP Class –SCU Grayscale Softcopy Presentation State – SCU/SCP Various DICOM SRs – SCU/SCP Others Digitizers Secondary Capture Image Storage – SCU Modality Worklist Information Model – Find – SCU Storage Commitment Push Model SOP Class – SCU

DICOM Conformance Statements Documents how vendors implement DICOM into their products Required, Public, and often found on Web sites Follows a well defined format Facilitates comparisons of product implementations Detailed information aids a knowledgeable DICOM person greatly The problem – it is hard to read unless you learn how to speak “DICOM”

DICOM Conformance Statements At a minimum, hospitals (PACS administrators) need to read SOP Class Tables This Application Entity provides Standard Conformance to the following DICOM V3.0 SOP Classes as an SCU: SOP Class Name SOP Classes as a SCU Unique identifiers Compare a product’s SCU table with another’s SCP table

DICOM Conformance Statements New DCS format Executive Overview “Goal to explain DICOM understandable terms” SOP Classes User of Service (SCU) Provider of Service (SCP) Image Transfer   CT Image Storage Yes No Query/Retrieve Study Root Information Model FIND Study Root Information Model Move Workflow Management Modality Worklist Information Model - Find …. Print Management Basics Grayscale Print Mgt.

DICOM Conformance Statements After the overview, it really requires real DICOM experience to read the DCS Implementation Integration Training Know how to read DICOM Standard …… Need to learn DICOM terms and concepts SOP Classes, IODs, SCU/SCP… Abstract Syntax, Presentation Context… Modules, Attributes, Context Tables….. Vendors, Consultants, Training Helps

Beyond DICOM Reports into PACS DICOM SR not typically used for Clinician Report (I.e. Radiologist Report) Report owned by department information system (such as a RIS) however hospitals want to view on workstations Voice Recognition solutions speed delivery of report (but usually take longer to create and edit) Solutions vary between PACS but most implement HL7 ORU messages and store in proprietary ways into PACS This solution means a 3rd party workstation cannot view report another question “Can other workstations besides PACS review reports?” HL7 V3 Clinical Document Architecture (CDA) should open up reporting documents

Beyond DICOM Networking Skills Required DICOM uses standard network technology and this skill is very important (relationship with IT) Need to understand TCP/IP, routers, hubs, switches, cables DICOM network configuration is prone to human error AE Title, TCP Port Numbers, IP Address Archive technology important Databases, RAIDs, Magnetic Tape How much on-line storage do you need

Integration Services Professional services are offered by PACS vendors and consultants Vendors understand their products and can typically tailor the integration better to their systems Independent consultants typically understand many PACS (not just one solution) and can typically better employ best of breed solutions and help with “finger pointing” Both types of consulting services can greatly increase the probability of a successful outcome

DICOM a Proven Success Since 1993 Thank You and Enjoy the Conference!