1. Presentation Title
Presented by Name

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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).”

8. 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

9. 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

10. IID – Process Flow

11. IID – URL Request Examples
?requestType=PATIENT &patientID= ^^^AcmeHospital &mostRecentResults=1 &modalitiesInStudy=CT
?requestType=STUDY &accessionNumber= &keyImagesOnly=true
?requestType=STUDY &studyUID= , &viewerType=IHE_BIR

12. 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)

13. 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

14. 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

15. 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

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

17. BIR – Process Flow

18. 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

19. 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

20. 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”

21. 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 symbols to the extent possible

22. 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”

23. 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.”

24. 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.)

25. 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