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

2. Trends and future in DICOM standardization
Outline
Overview of the DICOM domain
DICOM vectors over years , & future
Trend summary
Conclusion

3. 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

4. ≈160 new supplements since 1993

5. DICOM standardization vectors

6. 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 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

7. 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

8. 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

9. 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

10. 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 In addition HTTP web technology based transfer and 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

11. 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

12. 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

13. 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

14. 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

15. 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 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

16. 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.

17. 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 !

18. References http://medical.nema.org/dicom/geninfo/Strategy.pdf
Note: references to original pictures retrieved from the Internet and used this presentation are included in attached hyperlinks

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

20. Acquisition #
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

21. 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

22. Acquisition #
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

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

24. 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

25. 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

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

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

28. 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

29. Media #
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

30. 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

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

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

33. 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

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

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

36. Workflow #
Title 75
Relevant Patient Information Query Service Class 93
Instances Availability Notification 52
General Purpose Worklist

37. 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

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

39. Therapy planning and interventions 2001-2005#
Title

40. 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

41. Security #
Title 31
Security Enhancements One: Transport Layer Security

42. Security #
Title 41
Security Enhancements Two: Digital Signatures 51
Media Security 55
Attribute Level Confidentiality

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

44. Archiving #
Title 8
Storage Commitment Service Class

45. Archiving #
Title

46. 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

47. 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

48. Print #
Title

49. Print #
Title