A Working Group of Our Own A Working Group of Our Own (DICOM WG-26)(DICOM WG-26)

Bruce Beckwith, MDBruce Beckwith, MDDepartment of PathologyDepartment of Pathology

Beth Israel Deaconess Medical Center Beth Israel Deaconess Medical Center Harvard Medical SchoolHarvard Medical SchoolBoston, MassachusettsBoston, Massachusetts

Current StateCurrent State

Future StateFuture State

OutlineOutline

DICOM overviewDICOM overview

DICOM pathology supportDICOM pathology support

Use in PathologyUse in Pathology

Issues to addressIssues to address

DICOMDICOM

DDigital igital IImaging and maging and CoCommunications in mmunications in MMedicineedicine

Initially drafted as jointly sponsored effort of the Initially drafted as jointly sponsored effort of the American College of Radiology and the National American College of Radiology and the National Electrical Manufacturers Association (ACR-NEMA), Electrical Manufacturers Association (ACR-NEMA), which became the DICOM committee in 1998which became the DICOM committee in 1998Ver. 1 released 1985Ver. 1 released 1985– Physical 50 pin hardware abstraction layer standardPhysical 50 pin hardware abstraction layer standard– Never implementedNever implemented

Ver. 2 released 1988Ver. 2 released 1988– Initial interest from radiological manufacturing community onlyInitial interest from radiological manufacturing community only

DICOM V3.0 released 1992DICOM V3.0 released 1992Visible light supplement 1999 (endoscopy/microscopy)Visible light supplement 1999 (endoscopy/microscopy)

DICOM GovernanceDICOM Governance

Voluntary standards groupVoluntary standards groupHoused at NEMA in VirginiaHoused at NEMA in VirginiaCurrently 2Currently 266 working working ggroupsroupsParticipantsParticipants– IndustryIndustry– Professional and trade groupsProfessional and trade groups– Standards developing bodies and government Standards developing bodies and government

agenciesagencies– Anyone who has a material interestAnyone who has a material interest

Pathology in DICOMPathology in DICOM

Visible Light working group was initial Visible Light working group was initial homehome

Created Supp. 15 Created Supp. 15

Minimal pathology activity since thenMinimal pathology activity since then

Dec 2005, created a new group for Dec 2005, created a new group for Pathology (WG-26)Pathology (WG-26)

Working Group 26Working Group 26

Open to all interested partiesOpen to all interested parties

3-4 meetings per year3-4 meetings per year

70+ subscribers to the mailing list70+ subscribers to the mailing list35+ organizations35+ organizations

9 countries9 countries

Working with IHE (Japan and France) and Working with IHE (Japan and France) and HL7 Pathology groupsHL7 Pathology groups

DICOM Supplement 15DICOM Supplement 15

Support forSupport for– gross imagesgross images– microscopic imagesmicroscopic images– accession numbersaccession numbers– case historycase history– SNOMEDSNOMEDTMTM nomenclature and others nomenclature and others– ssome imaging system specificationsome imaging system specifications– compatible with all DICOM database systemscompatible with all DICOM database systems

How DICOM is UsedHow DICOM is Used

To communicate between image sources To communicate between image sources (radiographic instruments) and PACS(radiographic instruments) and PACS

To communicate between PACS and display To communicate between PACS and display workstationsworkstations

To communicate between RIS and PACSTo communicate between RIS and PACS

To communicate between image sources and To communicate between image sources and enterprise image archiveenterprise image archive

Image ExchangeImage Exchange

DICOM standard is for communication DICOM standard is for communication related to digital imagesrelated to digital imagesUses externally defined file formats to Uses externally defined file formats to encode the image dataencode the image dataIncludes metadata with the image dataIncludes metadata with the image dataUses an object oriented data modelUses an object oriented data model16-part standard document16-part standard document– http://medical.nema.org/dicom/2006/http://medical.nema.org/dicom/2006/

Typical VL Message ComponentsTypical VL Message Components

Header Constructs•Patient demographics•Study capture parameters•Equipment parameters•Pixel/voxel dimensions•Diagnostic data

Image Data•Primary image plane data•Overlay data•Arbitrary waveform data•ROI data•Diagnostic ROI-localized modifier data•Access/authentication/watermark dataSer

vice

Cla

ss W

rap

per

Optional Components

Structured Reporting Data•Self-referential XML schemata•Clinical Data•Specimen Data•Tissue Array Data•Research Access data•Clinical Trial Data•Chain of custody data•………………….•Ancillary Schemata/DTD definitions•Ancillary XML

Picture Archiving & Picture Archiving & Communication SystemsCommunication Systems

Store images acquired by multiple Store images acquired by multiple instrumentsinstruments

Serves images to various workstationsServes images to various workstations

Uses DICOM for messagingUses DICOM for messaging

Typically only utilized for radiology imagesTypically only utilized for radiology images

May have workflow limitationsMay have workflow limitations

Enterprise Image ArchiveEnterprise Image Archive

Centralized storage for medical imagesCentralized storage for medical images

Share across many departmentsShare across many departments

Not limited to radiology or even DICOMNot limited to radiology or even DICOM

Not tightly coupled to any workflowNot tightly coupled to any workflow

Can be write once – read many (no Can be write once – read many (no deletion)deletion)

Imaging ComparisonImaging Comparison

RadiologyRadiology– digital acquisitiondigital acquisition– automatic image captureautomatic image capture– clinician interpretableclinician interpretable– many patient requestsmany patient requests– large storage needslarge storage needs– digital images save moneydigital images save money– large budgetslarge budgets– strong standards for strong standards for

storage and transferstorage and transfer

PathologyPathology– analog primary dataanalog primary data– manual image capturemanual image capture– hard to interpret for non-hard to interpret for non-

pathologistspathologists– few patient requestsfew patient requests– extreme storage needsextreme storage needs– digital imaging costs moredigital imaging costs more– modest budgetsmodest budgets– limited pathology specificlimited pathology specific

standards standards

Current State in PathologyCurrent State in Pathology

Many PACS vendors are compliant with Visible Many PACS vendors are compliant with Visible Light images for pathology, endoscopy, etc.Light images for pathology, endoscopy, etc.

Growing number of imaging products targeted at Growing number of imaging products targeted at pathology are DICOM compliantpathology are DICOM compliant

Anatomic pathology laboratory information Anatomic pathology laboratory information systems offer limited image managementsystems offer limited image managementVeteran’s Administration:Veteran’s Administration:

Pathology imaging vendors must be DICOM compliant and Pathology imaging vendors must be DICOM compliant and store images in VISTA PACSstore images in VISTA PACS

Small, but growing adoption of DICOMSmall, but growing adoption of DICOM

Barriers to Adoption of Barriers to Adoption of Current ProductsCurrent Products

TurfTurf– PACS systems have traditionally been the domain of RadiologyPACS systems have traditionally been the domain of Radiology– Movement toward storing all medical images in a central location Movement toward storing all medical images in a central location

with a single viewing mechanism still in infancywith a single viewing mechanism still in infancy

WorkflowWorkflow– May need to manually annotate files with image description, May need to manually annotate files with image description,

accession number, etc.accession number, etc.– If sending to PACS, need to order study firstIf sending to PACS, need to order study first

CostCost– Image acquisition and annotation takes time – no extra Image acquisition and annotation takes time – no extra

reimbursement currentlyreimbursement currently– Slide scanners and storage are costlySlide scanners and storage are costly

Path PACSPath PACS

Humin Tec (Korea)Humin Tec (Korea)– PACS system for pathology departmentsPACS system for pathology departments– 21 installations, all in Korea21 installations, all in Korea– Communicates with standard radiology PACSCommunicates with standard radiology PACS– Also offers station for specimen photographyAlso offers station for specimen photography

Apollo Telemedicine (USA)Apollo Telemedicine (USA)– PACS system allows acquisition and storage of imagesPACS system allows acquisition and storage of images– Installed at Milwaukee Veterans Administration Installed at Milwaukee Veterans Administration

HospitalsHospitals– Images can be stored in VISTA imaging systemImages can be stored in VISTA imaging system

Academic Center EffortsAcademic Center Efforts

UnivUniv. . of Pittsburghof Pittsburgh– AP LIS is image awareAP LIS is image aware– Gross specimen photos and single field microscopic Gross specimen photos and single field microscopic

images savedimages saved– Transmitted to Enterprise Image ArchiveTransmitted to Enterprise Image Archive– Clinicians can see only selected images on completed Clinicians can see only selected images on completed

casescases– Main clinician interest is specimen photosMain clinician interest is specimen photos– Main pathologist use is conferencesMain pathologist use is conferences

Issues to AddressIssues to Address

TechnicalTechnical– Need for additional data elements (block, slide, slide status, Need for additional data elements (block, slide, slide status,

more detailed imaging system description, etc.)more detailed imaging system description, etc.)– Support for whole-slide microscopic imagesSupport for whole-slide microscopic images

DICOM is limited to 64k x 64k pixel images currentlyDICOM is limited to 64k x 64k pixel images currently

– Support for multi-resolution (pyramidal) formats Support for multi-resolution (pyramidal) formats – Support for navigating and selecting a region of interest from Support for navigating and selecting a region of interest from

within entire slide imagewithin entire slide image– Support for multispectral and hyperspectral modality imagesSupport for multispectral and hyperspectral modality images

Non-technical Non-technical – Suggested workflow and use examples (IHE)Suggested workflow and use examples (IHE)– Support for DICOM from LIS vendorsSupport for DICOM from LIS vendors

ResourcesResources

DICOM web site: DICOM web site: medical.nema.orgmedical.nema.org

RSNA DICOM Intro RSNA DICOM Intro www.rsna.org/Technology/DICOM/intro/index.cfmwww.rsna.org/Technology/DICOM/intro/index.cfm

Medical Imaging FAQ: Medical Imaging FAQ: www.dclunie.com/medical-image-faq/htmlwww.dclunie.com/medical-image-faq/html