Understanding the DICOM SR Supplement

Understanding the DICOM SR Supplement
DICOM Structured Reporting Workshop March , Donald E. Van Syckle __________________________ DICOM WG 6 Chairman Director, MergeLink Professional Services

DICOM Structured Reporting (SR)
Results Management Get Prior Reports DICOM Since ‘93 But Not Widely Implemented Structured Reporting Standardized Early 2000 (April) Simple Reporting Basic and Enhanced Complex Reporting Comprehensive How About DICOM Reporting?

Not linked with images or other clinical data
Today’s Reporting There is a 7mm irregular, spiculated mass in the anterior 11:00 region of the left breast, associated with grouped heterogeneous and pleomorphic granular and fine linear branching casting calcifications. Impression: Malignant Lesion Free form text only Not linked with images or other clinical data

DICOM Structured Report
There is a 7mm irregular, spiculated mass in the anterior 11:00 region of the left breast, associated with grouped heterogeneous and pleomorphic granular and fine linear branching casting calcifications. Impression: Malignant Lesion MALIGNANCY Based on: MASS Size: 7mm Shape: irregular Margin: spiculated Associated with: CALCIFICATION Type: Heterogeneous Type: Branching Distribution: Grouped Today Tomorrow

What is Structured Report?
A “Databaseable Document” which: Provide unambiguous “semantic” documentation of diagnosis Provide context such as: (scheduled procedure, observer, previous reports and images…) Link text with images, waveforms, audio, measurements Coded entry using standardized or private lexicons Flexible enough to go beyond radiology imaging A“Databaseable Document” facilities computer outcome analysis

…it isn’t a document presentation standard!
What Isn’t DICOM SR? MALIGNANCY Based on: MASS Size: 7mm Shape: irregular Margin: spiculated Associated with: CALCIFICATION Type: Heterogeneous Type: Branching Distribution: Grouped …it isn’t a document presentation standard!

Key Concepts and Terms to Learn!
SR IOD Query/Retrieve Model Coded Entries Content Items Value Types Relationship Types Observation Context

Not Done Yet! Key Concepts and Terms to Learn
SR Document General SR Document Content Modification Rules Basic Structured Reporting Enhanced Structured Reporting Comprehensive Structured Reporting

Does DICOM SR IOD follow the same model as an image?
Yes!

Image Information Object Definitions
Image Pixel Module Patient Information Patient Module Study Information General Study Module Patient Study Module* Series Information General Series Module Frame of Reference Module General Equipment Module Image Information General Image Module Image Plane Module Contrast/Bolus Module Image Pixel Module Image Module VOI LUT Module* Overlay Plane Module* SOP Common Module

SR IODs Patient Information SR Document Tree Study Information
Specimen Ident. Module Patient Module Patient Information SR Document Tree Study Information General Study Module Patient Study Module* MALIGNANCY Based on: MASS Size: 7mm ….. Series Information SR Document Series General Equipment Module SR Document Information SR Document General SR Document Content SOP Common Module

SR Document Information
SOP Instances Linked Patient Information Patient ID Study Information Study Inst. UID Series Information Series Information Series Information Series Information Series Inst. UID Image Presentation State SR Document Information Other Composite IODs SOP Inst. UID Images, SR Documents, Presentation States, Stored Print, etc. can exist in same Study

SR IOD and Query/Retrieve Model
SR IODs mirror the Composite IOD model (i.e. images). SR objects are able to be linked to images, waveforms, stored print, presentations state, RT plans… “Pushing” SR SOP Instances accomplished via C-STORE “Pulling” SR SOP Instances accomplished via currently defined Query/Retrieve SOP classes.

An Illustration……... Chest, PA & Lateral (GCS,T78) Dr Andrew Smith …….
George Jones …... Procedure PA and Lateral radiographs were ……. Findings The PA demonstrates … A small opacity is visible in the base of lung in lateral view. Image CT recommended. Conclusions Possible Mass (ICD,XXX)

How do I build the SR document? Content Items Relationships

Content Items and Relationship
Document Title ‘Chest PA & LAT’ (GCS,T78) Recording Observer Name ‘Smith^Andrew^^Dr’ Has Obs. Context Has Obs. Context Observation Subject ‘Jones^George’ Document Heading ‘Procedures’ (GCS,H12) Contains Text ‘procedure (GCS,H12) = PA and Lateral radiographs were …….’ Contains Contains Document Heading ‘Findings’ (GCS,H34) Text ‘findings (GCS,H34) = The PA demonstrates… A small opacity is visible in the base of lung in lateral view. CT recommended.’ Contains Contains Document Heading ‘Conclusions’ (GCS,H56) Inferred From Image Reference Instance UID= Code ‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’ Contains

SR Document Tree Single Root Content Item
Followed by nested Content Items Root Content Item Content Item

Content Items

Types of Content Items (called Value Types)
CONTAINER TEXT PNAME DATETIME DATE TIME NUM IMAGE WAVEFORM COMPOSITE UIDREF SCOORD TCOORD CODE

The Root Content Item and CONTAINER Value Type
Document Title ‘Chest PA & LAT’ (GCS,T78) Root Content Item conveys Document Title Root Content Item is of type “CONTAINER” Containers used to convey headings and sub-headings Containers use Concept Name Code Sequence Concept Name =‘Chest PA & LAT’

In a “Coded Entry” Sequence Code Value Code Scheme Designator
How do I encode CONTAINERS? In a “Coded Entry” Sequence Code Value Code Scheme Designator Code Meaning

Coded Entries - Triplet Encoding
Required attributes are: Code Value - computer readable and searchable identifier that is unique within the Coding Scheme Code Scheme Designator - identifies the organization responsible for the code being used Code Meaning - human readable text provided for the convenience of users (64 maximum characters) The Code Scheme Designator plus the Code Value uniquely identify the code

Document Title ‘Chest PA & LAT’ (GCS,T78)

Coded Sequence Used to Define All Codes
“Requested Procedure = Chest X-Ray”

DICOM Defines the Ability To:
More precisely define the Coding Scheme Designator Extend existing Coding Schemes Define “Private Coding Schemes”

Recording Observer Name ‘SmithÂndrew^^Dr’
‘PNAME’ Value Type Recording Observer Name ‘SmithÂndrew^^Dr’ Name/Value Pair the name is a single Concept Name Code Sequence the value is the Person’s Name Concept Name Code Sequence = Recording Observer Name PNAME = ‘SmithÂndrew^^Dr’ PNAME Value Type Concept Name Concept Value

Recording Observer Name = ‘Smith^Andrew^^Dr’

Procedure (GCS,H12) ‘PA and Lateral radiographs were …….’
‘TEXT’ Value Type Procedure (GCS,H12) ‘PA and Lateral radiographs were …….’ Name/Value Pair Concept Name Code Sequence = Procedure TEXT = ‘PA and Lateral radiographs were …...’ TEXT Value Type Concept Name Concept Value

Procedure = ‘PA and Lateral radiographs ….

Image Reference Instance UID=3.56.18.9
‘IMAGE’ Value Type Image Reference Instance UID= If defining the “Purpose of Reference” then the Concept Name Code Sequence is used (i.e. Name/Value Pair) If not defining the “Purpose of Reference” then only the value is conveyed (i.e. image reference) IMAGE = ‘Instance UID = ’

Key Image = ‘ ….’

Code Conclusions (GCS,H56) ‘Possible Mass’ (ICD,XXX)’
‘CODE’ Value Type Code Conclusions (GCS,H56) ‘Possible Mass’ (ICD,XXX)’ Name/Value Pair Concept Name Code Sequence = Conclusions CODE = ‘Possible Mass’ (ICD,XXX)’

Code = ‘Possible Mass’ (ICD,XXX)

Value Types CONTAINER - Headings or categories (i.e. titles, sub-headings...) Document Title or Document section heading e.g. “Conclusions (GCS,H56)” PNAME - Name of the person whose role is described by the Concept Role of person e.g. name of the Recording Observer is “Smith^Andrew^^Dr.” TEXT - Free form textual expression of the concept (unlimited length) Type of text e.g. procedure (GCS,H12) = PA and Lateral radiographs were …’ IMAGE - UID references to Image SOP Instances Reference = SOP Class Instance UID CODE - Coded expression of the concept Type of code e.g. ‘Conclusion (GCS H56) = ‘Possible Mass’ (ICD,XXX)

Value Types NUM - Numeric value or measurement with associated units
Type of code e.g. “Diameter (GCS,H24) = 1.3 CM” DATE - Calendar date of occurrence Type of date e.g. “Time of Blood Pressure (GCS,H73) = March 3, 2000” TIME - Time of day of occurrence Type of time e.g. “Date of Blood Pressure (GCS,H73) = 8:30am” DATETIME - Concentrated Date and Time of occurrence Type of DateTime e.g. “Date and Time of Blood Pressure (GCS,H73) = March 3, 2000 at 8:30am” WAVEFORM - UID references to Waveform SOP Instances Reference = SOP Class Instance UID

Value Types COMPOSITE - UID references to Composite SOP Instances that are not images or waveforms Reference = SOP Class SOP Instance UID UIDREF- Unique Identifier identified by concept name Type of UID e.g. “Study Instance UID of Evidence Directly Examined by RO (GCS,H92) = “ ….” SCOORD - Spatial coordinates of a geometric ROI in Images "CLOSED 1,1 5,10" {SELECTED FROM: IMAGE xx}. TCOORD - Temporal coordinates of a ROI in Waveforms SEGMENT mS" {SELECTED FROM: WAVEFORM xx}.

How are the Content Items linked together in the SR Tree?
Relationship Types

Source and Target Content Items
Relationship Source Content Item Root Content Item Content Item Target Content Item

Relationship Types IODs may specify constraints on relationships
Parent/Child relationship between Source and Target Target Content Item Source Content Item Relationship CODE “conclusions = Possible Mass” CONTAINER “Conclusions” contains IODs may specify constraints on relationships

Relationship Types HAS OBS CONTEXT - Target conveying specialization of Observation Context needed for documentation of Source CONTAINER: “Chest PA and Lateral” {HAS OBS CONTEXT: PNAME: Recording Observer = “Smith^Andrew^^Dr.”} CONTAINS - Source contains Target CONTAINER “Findings” {CONTAIN: TEXT “Findings (GCS,H34) = The PA demonstrates… A small opacity is visible in the base of lung in ...”}

Relationship Types HAS CONCEPT MOD - Qualifies or describe the Concept Name of the Source; also used to quantify data greater than 64 characters CODE: “Chest X-Ray” {HAS CONCEPT MOD: TEXT “View = PA and Lateral”} HAS PROPERTIES - Description of properties of the Source CODE: “Mass” {HAS PROPERTIES: CODE: “diameter”} HAS ACQ CONTEXT - Target describes the condition present during data acquisition of the Source IMAGE: “36” {HAS ACQ CONTEXT : CODE “contrast agent”}

Relationship Types SELECTED FROM - Source Item conveys spatial or temporal coordinates selected from Target(s) SCOORD: “CLOSED 1,1,5,10” {SELECTED FROM: IMAGE: “36”} INFERRED FROM - Source conveys a measurement or other inference made from Target CODE: “Malignancy” {INFERRED FROM: CODE: “Mass”}

Observation Context is encoded in a Content Item
Describes who or what is performing the interpretations Whether the examination of evidence is direct or quoted What procedure generated the evidence that is being interpreted Who or what is the subject of the evidence that is being interpreted Observation Context is encoded in a Content Item

Observation Context Examples

Initial Observation Context
Defined outside the SR Document Content Tree Applies to all Content Items in SR tree Patient Information Patient Name Patient ID Patient Date of Birth Patient Sex ... Study Information Patient’s Weight Referring Physician's Name Accession Number Study Instance UID ... Series Information SR Document Information …….

Inheritance Rules in SR Tree
All inherit initial Ob. Co. HAS OBS CTX adds to Ob. Co. of parent node Node1 extended by NodeC1 (e.g. Recording Observer) Node2 inherits Ob. Co. of Node1 Node2 extended by Nodes C2 & C3 Node 1 Has Obs Ctx Contains Node C1 Node 2 Has Obs Ctx Has Obs Ctx Contains Node C2 Node C3 Node 3

Inheritance Rules HAS OBS CTX inherited by all by-value descendant nodes of parent regardless of relationship between parent and descendant Node3 and its descendents inherits Node 2 (1, C1, C2, C3) Ob. Ctx. is never replaced (i.e. tree of Content Items traversed top down from root) Ob. Ctx. shall not be inherited across by-reference relationships Node 1 Has Obs Ctx Contains Node C1 Node 2 Has Obs Ctx Has Obs Ctx Contains Node C2 Node C3 Node 3 :

By Reference Content Items
Allows referencing to other Content Items Document Relationship and Document Content Marcos are not included For example: CODE: “Probable Malignancy” {INFERRED FROM: CODE: “Mass”} Code ‘Findings (GCS H34) = Mass’ (ICD,XXX)’ Code ‘conclusions (GCS H56) = Probable Malignancy (ICD,YYY)’ Inferred From

Reference Content Item Identifier
Ordered set of integers Root Content Item = 1 Each subsequent integer represents ordinal position of the Content Item in which Content Sequence it belongs Walk through tree to determine ID Root Content Item Cont. Item ID 01 Content Item Content Item Cont. Item ID 01 01 Cont. Item ID 01 02 Content Item Content Item Content Item Cont. Item ID Cont. Item ID Cont. Item ID Not allowed for the simple Basic and Enhanced SOP Classes

“Probable Malignancy” {INFERRED FROM: CODE: “Mass”}

SR Document General & SR Document Content Modules
How do I read the SR specific Modules? Same as other DICOM Modules Except new documentation convention called “Macros”

Macros - a new convention for DICOM documentation...
Easy way to document codes, measurements, spatial coordinates, image references, etc.

Numeric Measurement Macro

SR Document General Module
Attributes identify the SR Document and provide context for the entire document Attributes are outside the SR Document Tree which simplifies Query access See SR Supplement Table C.17-2

Identification Attributes
SOP Class UID and SOP Instance UID (from SOP Common) Instance Number Content Date (same attribute as Image Date) Content Time (same attribute as Image Time) All Type 1 Fields - Date/Time important for managing reports

Status and Verifying Attributes
Completion Flag - PARTIAL or COMPLETE how to set the flag is open to implementation Completion Flag Description - free form text Verification Flag - UNVERIFIED or VERIFIED Verifying Observer Sequence identifies person(s) verifying the document and organization(s); required if flag = VERIFIED Prevailing final version = most recent Verification DateTime, VERIFIED, COMPLETE

Reference Request Sequence
Identifies Requested Procedure(s) being fulfilled by the SR document Study Instance UID Referenced Study Sequence Requested Procedure ID, Accession Number Requested and Performed Procedure Codes …. One SR document may cover multiple Requested Procedures

Related Document/Object Pointers
Predecessor Document Sequence SRs whose content has been included into document (prior reports, amendments, etc.) Current Requested Procedure Evidence Sequence All Composite SOP Instances created to satisfy the current requested Procedure(s) being reported upon Pertinent Other Evidence All Other SOP Instances considered pertinent to document and not listed in “Cur. Req. Proc. Evid. Seq.” Same SOP Instance cannot be in Current or Pertinent Sequences

Identical Documents Sequence
References all identical SR documents Entire SR document is the same except for UIDs (i.e. Study Instance, Series Instance, SOP Instance) When modifying an “Identical Document” the implementation must modify all “Identical Documents” or the new “modified” report is no longer an “Identical Document” All “Identical” SR documents reference each other

Three Identical Documents
Identical Doc Seq. Original Doc 1 Original Doc 3 Original Doc 2 Predecessor Doc Seq. Modified Doc 1 Modified Doc 3 Modified Doc 2 Identical Doc Seq.

SR Document Content Module
Attributes convey content of the SR Document Provides the “Root Content Item” (i.e. Document Title) Nests Content Sequences for all other Content Items See SR Supplement Table C.17.3 Document Relationship Macro Document Content Macro

SR SOP Instance Modification Rules
Specimen Ident. Module New SOP Instance if modify: SR Document General SR Document Content Series Instance UID Study Instance UID Patient Module Patient Information Study Information General Study Module Patient Study Module* Series Information SR Document Series General Equipment Module SR Document Information SR Document General SR Document Content SOP Common Module

SR IODs Basic Text SR IOD Enhanced SR IOD Comprehensive SR IOD
Minimal usage of coded entries Reference to SOP Instances restricted to leaves from text tree No by-reference Content Items (i.e. by-value only) Enhanced SR IOD superset of Basic Text but extended to include spatial and temporal regions of interest Comprehensive SR IOD superset of Basic Text and Enhanced, references to leaves not restricted and includes by-reference Content Items

Basic SR Relationship Restrictions (table A.35.1-2)

Enhanced SR Relationship Restrictions (table A.35.2-2)

Comprehensive SR Relationship Restrictions (table A.35.3-2)

DICOM Structured Reporting
Fits within the normal DICOM structure New ideas such as Content Items and Relationships Simple for Basic Text and Enhanced More Complex for Comprehensive Not just for Radiology and Cardiology but can be used for all “ologies”

Thank You!

Understanding the DICOM SR Supplement

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