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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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 CT Head :30am
Jane Jones CT Neck :00am
Frank Able CT Head :00am
…………… …….. …… ……… ………

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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”

16. 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

17. 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.

18. 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

19. 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

20. 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

21. 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

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