Application of DICOM Structured Report Andrei Leontiev Dynamic

Application of DICOM Structured Report Andrei Leontiev Dynamic Imaging

DICOM Structured Report n Encoding for structured observations – Universal mechanism n Generic Applications – Basic Text, Enhanced, Comprehensive n Specialty Applications – Key Object Selection – CAD, US measurements, … – Patient Relevant Information Query April 1, 2005 DICOM Seminar – Singapore 2005

Encoding of Structured Reports

SR Intent • Support measurements by imaging devices • Enable collaborative reporting by any number of persons or devices n Enable links to key images n Enable links to regions of interest within images and waveforms n Template-driven content and structure April 1, 2005 DICOM Seminar – Singapore 2005

Simple Example of SR Shows example of simple diagnostic report n Multi-level structure n Text, codes, pointers to images n April 1, 2005 DICOM Seminar – Singapore 2005

April 1, 2005 DICOM Seminar – Singapore 2005

Report of Chest X-Ray (PA and Lateral. Views) Patient Jane Homer Study # 123456 Recorded by Dr. John Smith The finding is a mass measuring 1. 3 cm in diameter with an infiltrative margination. (Click to view) The baseline image is shown at Conclusions The conclusion is a probable malignancy, inferred from the infiltrative margination of the mass and the appearance shown by the best illustration of findings. (Click to view) Specific Image Findings The best illustration of findings is April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1. 2. 3. 4. 5. 6. 7. 100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1. 3 cm has properties margination=infiltrative (1. 4. 2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1. 4. 2 inferred from 1. 7. 1 Specific Image Findings best illustration of findings(1. 7. 1). April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

“contains” relationship not shown Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1. 2. 3. 4. 5. 6. 7. 100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1. 3 cm has properties margination=infiltrative (1. 4. 2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1. 4. 2 inferred from 1. 7. 1 Specific Image Findings best illustration of findings(1. 7. 1). April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

Concept Name /Value pairs used Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1. 2. 3. 4. 5. 6. 7. 100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1. 3 cm has properties margination=infiltrative (1. 4. 2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1. 4. 2 inferred from 1. 7. 1 Specific Image Findings best illustration of findings(1. 7. 1). April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

Concept Name without a value used as a heading (container) Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1. 2. 3. 4. 5. 6. 7. 100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1. 3 cm has properties margination=infiltrative (1. 4. 2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1. 4. 2 inferred from 1. 7. 1 Specific Image Findings best illustration of findings(1. 7. 1). April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

Concept Name without a value used as Purpose of Reference for IMAGE, SCOORD Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1. 2. 3. 4. 5. 6. 7. 100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1. 3 cm has properties margination=infiltrative (1. 4. 2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1. 4. 2 inferred from 1. 7. 1 Specific Image Findings best illustration of findings(1. 7. 1). April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

“Chest X-Ray” 1. 1 1. 2 Context CONTAINER “Recording Observer”=“Smith^John^^Dr^” Context 1. 4 Contains CODE “Finding”=“Mass” Properties 1. 4. 2 “Conclusions” Contains “diameter”=“ 1. 3” “cm” “margination”=“infiltrative” 1. 6. 1. 1 Infd From CODE CONTAINER “conclusion”=“probable malignancy” CODE Contains “Specific Image Findings” CONTAINER Contains 1. 7. 1 “best illustration of findings”= 1. 7. 1. 1 1. 8 NUM IMAGE “Baseline”= 1. 6. 1 1. 7 PNAME “… Acquisition Subject”=“Homer^Jane^^^” 1. 4. 1 1. 6 UIDREF “Study Instance UID. . . ”=“ 1. 2. 3. 4. 5. 6. 7. 100” 1. 3 1. 5 PNAME Modifier April 1, 2005 Seld From CODE “Views”=“PA and. DICOM Lateral” Seminar – Singapore 2005 IMAGE SCOORD Infd From 1. 6. 1. 2 Slide by D. Clunie

“Chest X-Ray” 1. 4 Contains CONTAINER “Finding”=“Mass” CODE 1. 4. 1 1. 4. 2 1. 6 Contains Properties “Conclusions” 1. 6. 1 1. 7 1. 6. 1. 1 Contains “margination”=“infiltrative” Infd From CODE CONTAINER “conclusion”=“probable malignancy” CODE Contains “Specific Image Findings” CONTAINER Contains 1. 7. 1 “best illustration of findings”= SCOORD Infd From 1. 6. 1. 2 April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

1 The numbering of items is implicit ! “Chest X-Ray” 1. 1 “Recording Observer”=“Smith^John^^Dr^” 1. 2 “Study Instance UID. . . ”=“ 1. 2. 3. 4. 5. 6. 7. 100” 1. 3 “… Acquisition Subject”=“Homer^Jane^^^” 1. 4 “Finding”=“Mass” 1. 4. 1 “diameter”=“ 1. 3” “cm” 1. 4. 2 “margination”=“infiltrative” 1. 5 “Baseline”= 1. 6 “Conclusions” 1. 6. 1 “conclusion”=“probable malignancy” “Specific Image Findings” 1. 7. 1 “best illustration of findings”= 1. 7. 1. 1 1. 8 April 1, 2005 “Views”=“PA and. DICOM Lateral” Seminar – Singapore 2005 Slide by D. Clunie

Inheritance of Context n Observation Context – includes top-level attributes of Composite IOD – may be attached to root node CONTAINER – is inherited along by-value relationships – is not inherited along by-reference relationships – may be extended (but not replaced) in children – may be attached to any content item, not just CONTAINER April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

General Patient Module: “Patient Name”=“Homer^Jane^^^” “Patient ID”=“ 234567” SR Comprehensive SOP Instance “Patient Sex”=“F” “Patient DOB”=“ 19991109” General Study Module: “Accession Number”=“ 123456” “Study ID”=“ 345678” “Chest X-Ray” Context Contains April 1, 2005 “Recording Observer”=“Smith^John^^Dr^” “Study Instance UID. . . ”=“ 1. 2. 3. 4. 5. 6. 7. 100” “… Acquisition Subject”=“Homer^Jane^^^” “Finding”=“Mass” DICOM Seminar – Singapore 2005 Slide by D. Clunie

“Chest X-Ray” Context Contains “Recording Observer”=“Smith^John^^Dr^” “Study Instance UID. . . ”=“ 1. 2. 3. 4. 5. 6. 7. 100” “… Acquisition Subject”=“Homer^Jane^^^” “Finding”=“Mass” Properties Contains “margination”=“infiltrative” “Conclusions” “conclusion”=“probable malignancy” “Specific Image Findings” Contains “best illustration of findings”= Seld From Modifier April 1, 2005 Infd From “Baseline”= Contains “diameter”=“ 1. 3” “cm” “Views”=“PA and. DICOM Lateral” Seminar – Singapore 2005 Infd From Slide by D. Clunie

“Obstetric Ultrasound” Obsn Context Contains “Mother of Fetus”=“Homer^Jane^^^” “Findings for Fetus” Obsn Context Properties “Fetus Identifier”=“Fetus A” “Gestational Age”=“ 16” “weeks” Infd From Contains “Findings for Fetus” Obsn Context Properties April 1, 2005 “BPD”=“ 27” “mm” “Fetus Identifier”=“Fetus B” “Gestational Age”=“ 16” “weeks” Infd From DICOM Seminar – Singapore 2005 Slide by D. Clunie “BPD”=“ 28” “mm”

“Obstetric Ultrasound” Obsn Context Contains “Mother of Fetus”=“Homer^Jane^^^” “Findings for Fetus” Obsn Context Properties “Fetus Identifier”=“Fetus A” “Gestational Age”=“ 16” “weeks” Infd From “BPD”=“ 27” “mm” “Inferred from” relationships may be by-value as well as by-reference, and are often more appropriate then “has properties” or “contains. ” April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

Post-Coordination: HAS CONCEPT MOD n Elaborates on meaning of Concept Name in – CONTAINER (headings) – CODE, TEXT, NUM … n May: – qualify meaning further – describe meaning – provide translations April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Clunie

“Chest X-Ray” Modifier April 1, 2005 CONTAINER “Views”=“PA and Lateral” CODE “Full Description”=“This is a report on a two-view (PA and lateral) Chest X-Ray examination. ” TEXT “Equivalent Meaning in Italian”=“Radiografia del. . . ” DICOM Seminar – Singapore 2005 TEXT Slide by D. Clunie

Post-coordinated. . . CODE “Finding”=“Mass” Properties “diameter”=“ 1. 3” “cm” Modifier NUM “method”=“Smith” CODE “threshold”=“ 75” “HU” NUM Pre-coordinated. . . “Finding”=“Mass” Properties April 1, 2005 CODE “diameter by Smith method @ 75 HU threshold” = “ 1. 3” “cm” DICOM Seminar – Singapore 2005 NUM Slide by D. Clunie

SR Applications

Three Base SR Classes n Three base SR classes are defined to allow encode any type of structured information: – Basic Text SR – Enhanced SR – Comprehensive SR n Distinguished by Value Types and Relationships supported April 1, 2005 DICOM Seminar – Singapore 2005

SR Templates n n To define appropriate structure for specialized applications, DICOM defines templates. Templates may be applied to: – Generic SOP Classes (Basic Text, Enhanced, Comprehensive) – Specialized SOP Classes (Mammo CAD, Chest CAD n Templates may be extensible and nonextensible April 1, 2005 DICOM Seminar – Singapore 2005

Evidence Documents Header: Report Type: OB / Gyn …. . BPD. . . …. . Findings: Query / Retrieve Image Refs. : Storage Commitment April 1, 2005 DICOM Seminar – Singapore 2005

Evidence Documents n Measurements and coded data – DICOM SR document Created by either Acquisition Modality or Workstation n Produced during acquisition or postprocessing workflows n Interpreted along with the images n April 1, 2005 DICOM Seminar – Singapore 2005

Evidence Documents Examples Mammography CAD n Chest CAD n OB-Gyn Ultrasound Measurements n Vascular Intervention Results n Echocardiography Measurements n April 1, 2005 DICOM Seminar – Singapore 2005

Typical Ultrasound SR Based on one of generic SR SOP Classes n Intended to precisely convey measurements and findings, relationships between them n Each specialized “report” uses its own template n April 1, 2005 DICOM Seminar – Singapore 2005

Legend for templates Value Type Concept Name = Value relationship Value Type Concept Name = Value CONTAINER, NUM, CODE, IMAGE … relationship Value Type Concept Name = Value Concept Names and Values of type CODE are triplets • Code Value • Coding Scheme Designator • Code Meaning (actually, just some text to evoke meaning to user) April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Sluis

Typical Top Level Template Structure CONTAINER Document Title … OB-GYN, Adult Echo, IVUS Ultrasound Vascular, Cath/Hemo … CONTAINER Patient Characteristics CONTAINER Summary CONTAINER Findings Heading Finding. Heading … … TID 1002 Observation Context Other Context e. g. procedure April 1, 2005 Template specified title Summary Findings DICOM Seminar – Singapore 2005 Findings Slide by D. Sluis

Document Headings CONTAINER Document Title contains CONTAINER Heading The heading may have semantics shared by children findings Specific: “Exercise Challenge” Generic: “Findings” has concept modifier … CODE Concept Modifier “Laterality” = “Left” “Finding Site” = “Cerebral Vessels” Findings April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Sluis

Discrete Numeric Findings Distributed semantics CONTAINER Group has concept modifier CODE Modifier Concept contains NUM Measurement Diameter, Area, Volume, Blood Velocity, Indices, Ratios, Time Interval … or pre-coordinated concept: BPD, FL … has concept modifier CODE Modifier Concept April 1, 2005 Laterality, Finding Site, Anatomic Site Modifier, Cardiac Phase … DICOM Seminar – Singapore 2005 Slide by D. Sluis

Vascular Content Hierarchy Document Title Section Heading Group CONTAINER Vascular Report contains CONTAINER Findings has concept modifier contains CONTAINER Anatomy has concept modifier CODE Laterality CODE Topographical Modifier contains NUM Discrete Finding Measurement April 1, 2005 property DICOM Seminar – Singapore 2005 Minimum Concepts Slide by D. Sluis

Vascular Templates CONTAINER Findings TID 5103 April 1, 2005 has concept modifier CODE Laterality Content Item Value Set Right, Left, or Unilateral DICOM Seminar – Singapore 2005 Slide by D. Sluis

Vascular Templates CONTAINER Findings contains CONTAINER Anatomy April 1, 2005 has concept modifier Content Item Value Set CODE Laterality TID 5104 DICOM Seminar – Singapore 2005 Slide by D. Sluis

Vascular Templates CONTAINER Findings contains CONTAINER Anatomy has concept modifier Content Item Value Set CODE Laterality TID 5104 has concept modifier CODE Longitudinal Modifier Optional specificity April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Sluis

Vascular Templates CONTAINER Findings contains CONTAINER Anatomy has concept modifier Content Item Value Set CODE Laterality TID 5104 has concept modifier CODE Topographical Modifier contains NUM Measurement April 1, 2005 DICOM Seminar – Singapore 2005 Slide by D. Sluis

Findings Origin and Context NUM Measurement TID 300 Measurements Inferred from SCOORD Inferred from IMAGE Inferred from NUM Inferred from CODE has acquisition context has properties April 1, 2005 Coordinates Image Numeric dependency Equation or Table Image Mode Image View Normality, Significance CODE, TEXT DICOM Seminar – Singapore 2005 Normal Range, …Slide by D. Sluis CODE

Dx Reports • Based on DICOM SR • Allows to include without transcription: - measurements - image links - structured content • Integrated with the imaging workflow • Friendly to XML implementations • Easy to export to the EPR (HL 7) April 1, 2005 DICOM Seminar – Singapore 2005

Simple Structure • • • Minimal Structure : Coded Title and Headings Full image links from specific sections of report Observation Context (who, what, when) may be section specific April 1, 2005 DICOM Seminar – Singapore 2005

Added Measurements Simply adds Measurements to Simple Image Reports April 1, 2005 DICOM Seminar – Singapore 2005

Key Object Selection Documents Initiated by the desire to have simple Key Image Note n Developed as generic “manifest” – collection of pointers to images (or even specific frames) n Specifies intent of selection, simple textual note n Non-extensible template n April 1, 2005 DICOM Seminar – Singapore 2005

for referring physician Here you can see the renal osteopathy. For teaching Fibroosteoclasia April 1, 2005 DICOM Seminar – Singapore 2005

Note 2 Note 3 for referring physician for physician Here you can seereferring the This is the hematoma. renal rupture. Hematoma everywhere Note 1 Different notes on different images Note 1 for refering physician Here you can see the renal rupture. Note 2 for refering physician This is the hematoma. Same note on different images Note 3 for refering physician Hematoma everywhere April 1, 2005 Note 3 for refering physician Hematoma everywhere DICOM Seminar – Singapore 2005 Note 3 for refering physician Hematoma everywhere

Title of KOSD is a Codes Of Interest The note title defines the semantics of Rejected for Quality Reasons the reason of significance. For Referring Provider For Surgery Key Image Notes can be queried by code. For Teaching For Conference For Therapy For Patient The user comments are meant to be informal. For Peer Review For Research Quality Issue Reporting April 1, 2005 DICOM Seminar – Singapore 2005

Key Image Notes n One use of KOSD is to attach « electronic post-it™ » to images to communicate: – specific examination events – image quality issues – consultancy n KOSD can be stored in the archive and later retrieved April 1, 2005 DICOM Seminar – Singapore 2005

Workflow of SR objects Header: Report Type: OB / Gyn …. . BPD. . . …. . Findings: Evidence Documents Radiology Report Header: Report Type: Findings: OB / Gyn …. . BPD. . . …. . Interpretation Gestational Impressions: Age . . . Image Refs. : April 1, 2005 Key Image Notes DICOM Seminar – Singapore 2005 Dx Report

Patient Information Query n n n A simple query that allows retrieve ANY patient information, provided SCP can format it using specified template Useful for retrieval of relevant information about patient, e. g. , from HIS Intended for use on Modalities and other equipment that is already DICOM enabled April 1, 2005 DICOM Seminar – Singapore 2005

Patient Information Query n Few matching keys: – Patient Name – Patient ID – Template identifier n Useful for retrieval of relevant information about patient, e. g. , from HIS April 1, 2005 DICOM Seminar – Singapore 2005

Patient Information Query n Several Template identified for this purpose – General Relevant Patient Info – Relevant Patient Info for Breast Imaging April 1, 2005 DICOM Seminar – Singapore 2005

Questions? April 1, 2005 DICOM Seminar – Singapore 2005