1. Nov 29, 2006IHE RSNA 2006 1 Integrating the Healthcare Enterprise Nuclear Medicine and IHE: Whats New? Jerold Wallis Mallinkcrodt Institute of Radiology IHE NM Technical Committee co-chair SNM DICOM Committee chair

2. Nov 29, 2006IHE RSNA 2006 2 Healthcare Connectivity Problem Vendor and User expertise Integration Profile Proposed solution Using existing standards Vendor implements solution into REAL product Vendor testing at Connect-a-thon Public Demonstration Healthcare Site Includes IHE in RFP

3. Nov 29, 2006IHE RSNA 2006 3 New in 2006 Import Reconciliation Workflow Profile Bringing outside studies into your PACS Prior comparisons Exams done elsewhere to be read locally Transfer of care Reconciliation of demographics Mammography Image Optimal softcopy image display Special Mammography issues NM Image with Cardiac option Image Fusion

4. Nov 29, 2006IHE RSNA 2006 4 IHE Radiology Integration Profiles Patient Info. Recon- ciliation Access to Radiology Information Consistent Presentation of Images Audit Trail & Node Authentication - Radiology Option Evidence Docs Key Image Notes Simple Image & Numeric Reports Presentation of Grouped Procedures Post- Processing Workflow Reporting Workflow Charge Posting XDS for Imaging NM Image Scheduled Workflow Teaching Files & Clinical Trials Export Portable Data for Imaging NM Image Cardiac NM Option Image Fusion

5. Nov 29, 2006IHE RSNA 2006 5 NM Image – The Problem Support in Products is inconsistent DICOM NM objects are different NM Display needs are different NM Cardiac Display needs are different Poor communication during product purchase NM Users are not adept at getting these requirements accurately included in RFPs Vendors are not adept at accurately representing their support for such features

6. Nov 29, 2006IHE RSNA 2006 6 General NM Viewing Suboptimal NMPACS

7. Nov 29, 2006IHE RSNA 2006 7 General NM Viewing Suboptimal NMPACS

8. Nov 29, 2006IHE RSNA 2006 8 General NM Viewing Suboptimal Click and move mouse down to adjust window level, right to adjust window center

9. Nov 29, 2006IHE RSNA 2006 9 Cardiac Viewing Suboptimal If sent as Short axis Images not displayed in a useful format. If sent as screen snapshots (ie, static Secondary Capture) Cant separately adjust stress and rest images Cant view gated cine

10. Nov 29, 2006IHE RSNA 2006 10 New this year ! Cardiac option Better addresses cardiac needs Minor restructuring of remaining profile = NEW

11. Nov 29, 2006IHE RSNA 2006 11 NM Image Abstract / Scope Content Profile for Users to request and Vendors to claim No New Actors or Transactions New Informative Text in Vol. 1 New Normative Text in Vol. 2

12. Nov 29, 2006IHE RSNA 2006 12 NM Image Goal Use general Radiology Infrastructure to satisfy Basic NM Data Needs Access to NM Images Access to usable presentations of NM Images Access to Clinical Processing Results

13. Nov 29, 2006IHE RSNA 2006 13 NM Image Standards Used DICOM NM Image Object DICOM Multiframe Secondary Capture Dynamic Results Collection of Static Results DICOM Secondary Capture Static Results ACC NM Cardiac Display format

14. Nov 29, 2006IHE RSNA 2006 14 NM Image Transaction Diagram

15. Nov 29, 2006IHE RSNA 2006 15 NM Image Actors Image Displays Acquisition Modalities Evidence Creators Image Manager/ Archives Display NM and Secondary Capture (SC & MFSC) Images Support specified display capabilities Handle specific NM DICOM attributes

16. Nov 29, 2006IHE RSNA 2006 16 Options: Image Displays General NM Option Whole body display Cardiac NM Option ACC NM Cardiac display Displays must support at least one of these options!

17. Nov 29, 2006IHE RSNA 2006 17 Handle multi-frame / multi-vector images Multiple simultaneous cines Grayscale and color result screens Dynamic and static result screens Original resolution and scaled Separate adjustment of upper and lower window levels Apply local color tables to grayscale screens Add new local color tables to system Display Series Description tag Image Display

18. Nov 29, 2006IHE RSNA 2006 18 NM Image Format Understood by dedicated NM systems Often Misunderstood by general storage and display systems Multiframe Dynamic Anterior Posterior Multi-energy NM Image Image vectors

19. Nov 29, 2006IHE RSNA 2006 19 Image Display Scale intelligently to avoid presenting postage-stamp size NM images Allow user to select different vectors/framesets of complex multi- frame images Allow user to separately adjust intensity for different framesets (eg, phases) in the same image

20. Nov 29, 2006IHE RSNA 2006 20 Upper and Lower Levels Upper and lower window levels (Not just center/width) Separate Design is up to vendor

21. Nov 29, 2006IHE RSNA 2006 21 Display Formats Grid display Frames from one image set A 32 … ………………… …………………… …………………A9A9 A8A8 A7A7 A6A6 A5A5 A4A4 A3A3 A2A2 A1A1 C1C1 C1C1 B2B2 B1B1 A2A2 A1A1 Fit display Frames from multiple image sets Comparison Display

22. Nov 29, 2006IHE RSNA 2006 22 ACC NM Cardiac Display Generate long axis from short axis images (MPR)

23. Nov 29, 2006IHE RSNA 2006 23 ACC NM Cardiac Display Generate long axis from short axis images (MPR) Display of 2 image sets (Stress and Rest) Follow ACC guidelines for display Use patient state tags to set display order Controls for adjusting stress and rest Image alignment, window upper and lower levels.

24. Nov 29, 2006IHE RSNA 2006 24 ACC NM Display Example Short axis Horizontal Long Vertical Long

25. Nov 29, 2006IHE RSNA 2006 25 ACC NM Display Example Short Horizontal Vertical Stress Rest Stress Rest Stress Rest Stress Rest

26. Nov 29, 2006IHE RSNA 2006 26 MPR Option: Image Displays Adds Image Display requirements to support Review of SPECT NM Images with Multi-planar reconstruction (MPR) Transaxial Sagittal Coronal Replaces Review Option

27. Nov 29, 2006IHE RSNA 2006 27 NM Image Actors Image Displays Acquisition Modalities Evidence Creators Image Manager/ Archives Create NM objects as specified (Series, attribute & vector handling) Include specific codes in Cardiac studies

28. Nov 29, 2006IHE RSNA 2006 28 NM Image Actors Image Displays Acquisition Modalities Evidence Creators Image Manager/ Archives Create NM objects as specified (Series, attribute & vector handling) Include specific codes in Cardiac studies Use Cardiac codes during processing

29. Nov 29, 2006IHE RSNA 2006 29 Result Screen Export Option

30. Nov 29, 2006IHE RSNA 2006 30 Result Screen Export Option: Evidence Creators Render Static Result Screens SIngle frame DICOM Secondary Capture or Multi-frame (preferred, displayed by stepping, not cine) Render Dynamic Result Screens Multi-Frame Secondary Capture Grayscale Byte True Color

31. Nov 29, 2006IHE RSNA 2006 31 NM Image Actors Image Displays Acquisition Modalities Evidence Creators Image Manager/ Archives Store/Retrieve NM & Secondary Capture (SC & MFSC) Objects Return Series Description at time of query

32. Nov 29, 2006IHE RSNA 2006 32 Image Fusion Profile

33. Nov 29, 2006IHE RSNA 2006 33 Image Registration and Fusion Translate Rotate Rigid Registration Scale Warp- optional (Deformable Registration) Fuse

34. Nov 29, 2006IHE RSNA 2006 34 Image Fusion- General Use Case Tech acquires two series of images. Tech reconstructs images, performs registration, and stores results. Workstation presents fused view based on full image data for Radiologist or Oncologist. PACS Display shows Fused views to Referring Physician CTMR

35. Nov 29, 2006IHE RSNA 2006 35 Fusion- The Integration Problem Results not readily transferable between systems Proprietary or inconsistent implementations Lack of guidance Results presented on different systems may not appear the same. Systems must correctly handle issues such as Identifying and retrieving the right datasets Matching data between single-slice and multi-slice datasets Performing spatial translations Rendering the fused display

36. Nov 29, 2006IHE RSNA 2006 36 Fusion- The Integration Solution A collection of DICOM objects exists to address the problem. Their use is constrained and clarified to avoid misinterpretation and promote compatibility.

37. Nov 29, 2006IHE RSNA 2006 37 Spatial Registration Object Not required for already-registered PET-CT data from a hybrid scanner SRO Image 1 Image 2 Transformation

38. Nov 29, 2006IHE RSNA 2006 38 Blending Presentation State Image 1 Image 2 SRO Transformation BPS Window – 1 Window – 2 Color Table Transparency

39. Nov 29, 2006IHE RSNA 2006 39 Image Fusion Actors Acquisition Modality Evidence Creator Image Manager [RAD 18] Creator Images Stored [RAD 57] Blending Presentation States Stored [RAD 56] Spatial Registrations Stored [RAD 10] Storage Commitment [RAD 14] Query Images [RAD 16] Retrieve Images [RAD 15] Query Presentation States [RAD 17] Retrieve Presentation States [RAD 58] Retrieve Spatial Registrations Image Archive [RAD 8] Modality Images Stored [RAD 57] Blending Presentation States Stored [RAD 56] Spatial Registrations Stored [RAD 10] Storage Commitment Image Display

40. Nov 29, 2006IHE RSNA 2006 40 Load CT and PET images Align images (automatically or manually) and fuse with desired blending factor Store the alignment, including Registration object Blending State (defining the blending factor, window levels and referencing all other objects) Storage can be on PACS or disk. Images do not need to be stored if already stored. Fusion- PreparationCT PET Registration Object Blending State

41. Nov 29, 2006IHE RSNA 2006 41 Blending state can be searched and retrieved from PACS Can be used to retrieve the image data and the alignment automatically. User selects a Blending state. Automatically load referenced objects. Alignment applied, PET re-sampled to CT and displayed fused automatically. Display is required to provide Scrolling through volume Adjustment of fusion blending and window levels MPR Side-by-side display Fusion- DisplayCT PET Registration Object Blending State

42. Nov 29, 2006IHE RSNA 2006 42 Essential Clinical Features MPR Fusion Side-by-side Registered

43. Nov 29, 2006IHE RSNA 2006 43 What are Benefits to the User? Consistency of results across vendors. Fusion on vendor A system Display on vendor B system Easy to list in RFP Easy to distribute and display fused images Applies to PET/CT, CT/MR etc

44. Nov 29, 2006IHE RSNA 2006 44 What are Benefits to the Vendor? The Fusion Profile Provides: A framework for interoperability with other vendors A baseline feature set to meet clinical needs Common approach for all modalities

45. Nov 29, 2006IHE RSNA 2006 45 NM Image and Image Fusion Profile Status Published for Trial Implementation. http://www.ihe.net/ Technical_Framework/index.cfm#radiology Vendors: Complying with the profiles will help meet users needs. Users: Ask vendors Do you offer systems that comply with the NM Image and Image Fusion profiles?

46. Nov 29, 2006IHE RSNA 2006 46

47. Nov 29, 2006IHE RSNA 2006 47Questions?