Fhir and Dicom

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FHIR and DICOM

Brad GenereauxFHIR Developer DaysNovember 20, 2015

@integratorbrad


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Who am I?

Name: Brad Genereaux Company: Agfa HealthCare Background:

10 years in Canadian healthcare IT Putting HL7 and DICOM into all the things

5 years with Agfa HealthCare Imaging integrator, architect, product manager

Co-chair DICOM WG-27 (Web Technologies)

@integratorbrad


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DICOM is Imaging


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Imaging Resources


THE NEED FOR IMAGING EVERYWHERE

What are we trying to solve:


Worth 1,000 Words

“While written descriptions of lesions and infectious processes may be detailed, the visual presentation of these conditions is much more accurate and effective for diagnosis and treatment.” Imaging: New Electronic Tool For Clinicians,

2003 (Susan I. Reynolds)


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What do we need to do?

Image-enable everything! Put the images in the EMR / EHR / reports Share them in collaborative workflows Generate quick previews using thumbnails Convey the patient condition in ways text just can’t

do


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If I Can’t Find It, It Does Not Exist If imaging studies are not available, patients will

be re-imaged Increased risk -> radiation Increased cost -> unnecessary exams Increased delay for the patient Increased delay for other patients (or need for additional

perhaps unnecessary capacity)


WHAT IS DICOM?Digital Imaging and Communications in Medicine

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Basic Imaging Workflow

Modality creates images in DICOM and transmits them to archive

Archive stores the images Radiologist requests images for reading Radiologist creates the report

?


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Active Modalities AR - Autorefraction AU - Audio BDUS - Bone Densitometry

(ultrasound) BI - Biomagnetic imaging BMD - Bone Densitometry (X-Ray) CR - Computed Radiography CT - Computed Tomography DG - Diaphanography DOC - Document DX - Digital Radiography ECG - Electrocardiography EPS - Cardiac Electrophysiology ES - Endoscopy FID - Fiducials GM - General Microscopy HC - Hard Copy HD - Hemodynamic Waveform IO - Intra-Oral Radiography IOL - Intraocular Lens Data IVOCT - Intravascular Optical

Coherence Tomography IVUS - Intravascular Ultrasound

KER - Keratometry KO - Key Object Selection LEN - Lensometry LS - Laser surface scan MG - Mammography MR - Magnetic Resonance NM - Nuclear Medicine OAM - Ophthalmic Axial

Measurements OCT - Optical Coherence Tomography

(non-Ophthalmic) OPM - Ophthalmic Mapping OP - Ophthalmic Photography OPT - Ophthalmic Tomography OPV - Ophthalmic Visual Field OSS - Optical Surface Scan OT - Other PLAN - Plan PR - Presentation State PT - Positron emission tomography

(PET) PX - Panoramic X-Ray REG - Registration

RESP - Respiratory Waveform RF - Radio Fluoroscopy RG - Radiographic imaging

(conventional film/screen) RTDOSE - Radiotherapy Dose RTIMAGE - Radiotherapy Image RTPLAN - Radiotherapy Plan RTRECORD - RT Treatment Record RTSTRUCT - Radiotherapy Structure

Set RWV - Real World Value Map SEG - Segmentation SMR - Stereometric Relationship SM - Slide Microscopy SRF - Subjective Refraction SR - SR Document STAIN - Automated Slide Stainer TG - Thermography US - Ultrasound VA - Visual Acuity XA - X-Ray Angiography XC - External-camera Photography


Extended imaging workflows

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Foreign studies Regional archives

Non-DICOM modalities

EHR / EMR

Mobile Devices

Sharing Portals

Prior studies

Long-term archives

Other modalities 3D visualization


Patient ;

1

Study 1

1Study x

Each patient has x studies, which has y series,

Instance 1

Instance z

Series 1

Series y

which has z instances… and could have f frames.

Image Hierarchy


Instance UID Height Width Position SOP Class UID

Instance Series UID Modality Description Series Number Body Part

Series Study UID Date of Study Description Refer Physician Accession Availability

Study

Image Metadata


DICOM Tagging

DICOM’s binary structure for representing meta-data; i.e., (0010,0010) -> Patient name (0008,0090) -> Referring physician name

Tags are defined using a VR (a data type) and an VM (multiplicity factor)

In the XML and JSON representations, it is easier


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Some simple rules

UIDs (i.e., Study, series and SOP instance UIDs) are intended to be globally unique Unlike accession numbers, which have historically

had collision problems You are not supposed to change DICOM

objects themselves; if you do, they must get an updated SOP Instance UID


Key Objects and Markup

Key Objects Way to represent a set of images besides “all of

the images” For example, “marked for review”, “marked for

quality issues”, “XDS publishable set” GSPS

Markup and annotations on the images Includes factors like window/level Applied on images or image sets


1. Get DICOM images 2. Get a DICOM viewer 3. Get a DICOM library

Blog post at http://goo.gl/hSNSUt

Hacking DICOM : Primer

http://goo.gl/hSNSUt


Good place to start :Cancer Imaging Archive https://goo.gl/RY2cFD

1. Get DICOM Images

https://goo.gl/RY2cFD

https://goo.gl/RY2cFD


Good place to start :MicroDicom http://www.microdicom.com/

2. Get a DICOM Viewer

http://www.microdicom.com/

http://www.microdicom.com/


Good place to start :DCM4CHE http://goo.gl/4h9ck8

3. Get a DICOM Library

http://goo.gl/4h9ck8

http://goo.gl/4h9ck8


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Imaging used to be hard

Image complication Retrieving images is done via a non-trivial protocol Processing images uses non-trivial file format Displaying images has much to take into consideration Saving images requires in-depth knowledge

Image ecosystem complication Image lifecycle (acquisition, ingestion, storage) challenging Metadata extraction requires parsing of binary data Scaling is a problem that must be addressed Storage and bandwidth/latency challenges are ever-present as

image sizes grow into gigabytes


DICOMWEB™ MAKES IT LOOK EASY

Imaging Interoperability enters the REST arena :


Becomes possible to consume content directly by clients (browsers, mobile) No “special tools” required Minimize what is

transferred Allows for rapid

development and consumption of content

Frees content from closed systems and spawns integrations into today’s technologies

Why Web for Imaging?

X


WADO (Web Access to DICOM Objects) was created in 2003, providing object level access only

MINT (Medical Imaging Network Transport) was created ~2011 (not part of DICOM) out of a recognition of the importance of REST transport, and has since been deprecated for newer, interoperable technologies

DICOMweb™ was thus developed, and resources have been added ever since

History of Medical Imaging on the Web


What is DICOMweb™?

EMR

PACS VNA XDS Image Processors

Teaching Systems Research Patients Care

Teams

DICOMweb™DICOMweb™DICOMweb™DICOMweb™DICOMweb™

DICOMweb™ DICOMweb™ DICOMweb™ DICOMweb™


DICOMweb™ Services• QIDO-RS (Query based on ID for DICOM Objects)• DICOM PS3.18 6.7Query• WADO-RS (Web Access of DICOM Objects)• DICOM PS3.18 6.5 Retrieve• STOW-RS (Store over the web)• DICOM PS3.18 6.6Store• UPS-RS (Worklist Service)• DICOM PS3.18 6.9Tasks• Capabilities Service• DICOM PS3.18 6.8Server Info


Study Date LinkAbdomen CT

Jan. 17, 2014

http://<url>

Chest CR Mar. 23, 2015

http://<url>

Query (QIDO-RS) Example

What studies do you have for John Doe?

GET ht

tp://s

erver.

com/st

udies/

?00100

010=DO

E^JOHN

* There is synergy here with FHIR ImagingStudy


Retrieve (WADO-RS) Example

Show me images for the Abdomen CT

GET ht

tp://s

erver.

com/st

udies/

1.2.3/

series

/4.5.6

/


Stored

Store (STOW-RS) Example

POST h

ttp://

server

.com/s

tudies

Store this image


Tasks (UPS-RS) Example

GET ht

tp://s

erver.

com/wo

rkitem

s/?007

41202=

DRBRAD

What do I need to do today?


Nov. 20, 2015

http://<url>

Abdomen CT

Nov. 20, 2015

http://<url>


Capabilities Example

OPTION

S http

://ser

ver.co

m/What can you do for me?

• QIDO-RS (Query based on ID for DICOM Objects)• DICOM PS3.18 6.7Query• WADO-RS (Web Access of DICOM Objects)• DICOM PS3.18 6.5 Retrieve• STOW-RS (Store over the web)• DICOM PS3.18 6.6Store• UPS-RS (Worklist Service)• DICOM PS3.18 6.9Tasks• Capabilities Service• DICOM PS3.18 6.8Server Info

* There is synergy here with FHIR’s Conformance


<DicomAttribute Tag="00080020" VR="DT" Keyword="StudyDate"> <Value number="1">20130409</value></DicomAttribute><DicomAttribute Tag="00080061" VR="CS" Keyword="ModalitiesInStudy"> <Value number="1">CT</value></DicomAttribute><DicomAttribute Tag="00100010" VR="PN" Keyword="PatientName"> <PersonName number="1"> <SingleByte> <FamilyName>Doe</FamilyName> <GivenName>John</GivenName> </PersonName></DicomAttribute><DicomAttribute Tag="0020000D" VR="UI" Keyword="StudyInstanceUID"> <Value number="1"> 1.2.392.200036.9116.2.2.2.1762893313.1029997326.945873 </Value></DicomAttribute>

Data Structures

XML

"00080020": { "vr": "DT", "Value": ["20130409"]},"00080061": { "vr": "CS", "Value": ["CT"]}, "00100010": { "vr": "PN", "Value": [ { "Alphabetic": { "Family": ["Doe"], "Given": ["John"] } }]},"0020000D": { "vr": "UI", "Value": [

"1.2.392.200036.9116.2.2.2.1762893313.1029997326.945873"

]}

JSON


DICOMweb™ CheatsheetVerb Path Type DescriptionPOST {s}/studies Store PS3.18 6.6

.1Store instances

GET {s}/studies?... Query PS3.18 6.7.1

Query for matching studies

GET {s}/studies/{studyUID} Retrieve PS3.18 6.5.1

Retrieve entire study

POST {s}/studies/{studyUID} Store PS3.18 6.6.1

Store instances

GET {s}/studies/{studyUID}/metadata Retrieve PS3.18 6.5.6

Retrieve metadata

GET {s}/studies/{studyUID}/series?... Query PS3.18 6.7.1

Query for matching series in a study

GET {s}/studies/{studyUID}/series/ {seriesUID}

Retrieve PS3.18 6.5.2

Retrieve entire series

GET {s}/studies/{studyUID}/series/ {seriesUID}/metadata


Retrieve series metadata

GET {s}/studies/{studyUID}/series/ {seriesUID}/instances?...

Query PS3.18 6.7.1

Query for matching instances in a series

GET {s}/studies/{studyUID}/series/ {seriesUID}/instances/ {instanceUID}


Retrieve instance

GET {s}/studies/{studyUID}/series/ {seriesUID}/instances/ {instanceUID}/metadata


Retrieve instance metadata

GET {s}/studies/{studyUID}/series/ {seriesUID}/instances/ {instanceUID}/frames/{frames}


Retrieve frames in an instance

GET /{bulkdataReference} Retrieve PS3.18 6.5.5

Retrieve bulk data

Verb Path Type DescriptionPOST {s}/workitems

{?AffectedSOPInstanceUID}PS3.18 6.9.1 CreateUPS

POST {s}/workitems/{UPSInstanceUID} {?transaction}

PS3.18 6.9.2 UpdateUPS

GET {s}/workitems{?query*} PS3.18 6.9.3 SearchForUPS

GET {s}/workitems/{UPSInstanceUID} PS3.18 6.9.4 RetrieveUPS

PUT {s}/workitems/{UPSInstanceUID}/state

PS3.18 6.9.5 ChangeUPSState

POST {s}/workitems/{UPSInstanceUID}/ cancelrequest

PS3.18 6.9.6 RequestUPS Cancellation

POST {s}/workitems/{UPSInstanceUID}/ subscribers/{AETitle}{?deletionlock}

PS3.18 6.9.7 CreateSubscription

POST {s}/workitems/1.2.840.10008.5.1.4.34.5/

PS3.18 6.9.8 SuspendGlobal Subscription

DELETE {s}/workitems/{UPSInstanceUID}/ subscribers/{AETitle}

PS3.18 6.9.9 DeleteSubscription

GET {s}/subscribers/{AETitle} PS3.18 6.9.10 OpenEventChannel

N/A N/A PS3.18 6.9.11 SendEventReport

Available at:http://dicomweb.org/DICOMweb-Cheatsheet.pdf

http://dicom.nema.org/medical/dicom/current/output/chtml/part18/sect_6.6.html#sect_6.6.1





































http://dicomweb.org/DICOMweb-Cheatsheet.pdf





DICOM Main Site http://dicom.nema.org

DICOMweb™ Reference PS3.18 http://goo.gl/bIFHV3 http://dicomweb.org

Get involved with DICOM Link to join mailing list off main DICOM website

Where do I find more information?


Available open-source server libraries dcm4chee Orthanc

Available open-source client libraries Cornerstone

Great resource: https://github.com/chafey/dicomWeb

Some DICOMweb™ Tools


dcm4cheehttps://github.com/mohannadhussain/dcm4chee4-quick-start-vagrant

Orthanchttps://github.com/chafey/orthanc-vagrant

DICOMweb™ Vagrants

https://github.com/mohannadhussain/dcm4chee4-quick-start-vagrant



https://github.com/chafey/orthanc-vagrant

https://github.com/chafey/orthanc-vagrant


FHIR AND IMAGINGOnwards to Imaging and FHIR

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ImagingStudy



Jan. 17, 2014

http://<url>

Chest CR Mar. 23, 2015

http://<url>

ImagingStudy Example

What studies do you have for John Doe?

GET ht

tp://s

erver.

com/fh

ir/

Imagin

gStudy

?subje

ct.nam

e=Doe%

2CJohn


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ImagingObjectSelection


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Hacking with FHIR+DICOMweb You can stage a FHIR server and a

DICOMweb server, and synchronize data We can hook you up with that!

SIIM (Society for Imaging Informatics in Medicine) has graciously offered access to their Hackathon infrastructure and unified datasets for FHIR Developer Days participants

Access will be good for 3 months


Supporting Healthcare Through Innovation, Creativity, and Discovery The Society for Imaging Informatics in Medicine (SIIM) is the leading healthcare professional organization representing the interests and goals of those who work with and whose work is affected by the rapidly changing world of imaging technologies and information management. SIIM seeks to spearhead research, education, and discovery of innovative solutions to advance imaging informatics, enable the best use of images throughout the healthcare enterprise, and improve the delivery and quality of patient care. SIIM facilitates this mission through activities such as: SIIM 2016 Annual Meeting | June 29 - July 1, 2016 | Portland, OR | SIIM2016.org 2016 SIIM Hackathon hosted at SIIM 2016 - aimed at supporting workflow and process

improvement across healthcare to provide a set of cloud-based APIs to highlight the next generation of health IT standards.

Innovation Challenge Prize hosted at SIIM 2016 - $10,000 to encourage, recognize and reward innovation that will lead enterprise imaging change.

Publication of the Journal of Digital Imaging. Educational Webinar Series, eCommunity, Online Learning Materials and More! SIIM.org

Imaging REST Resources and data provided by SIIM Hackathon

http://siim2016.org/

http://siim.org/


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Getting Access to SIIM Servers and Datasets If you are not a SIIM member:

Open your web browser to http://siim.org/ In the top-right, click “Join SIIM eCommunity”. On the registration page, select registration type as “Contact”, and

click Continue. Note: There is no cost to register as a Contact.

Complete the form, and accept the agreement. Notify me (Brad) of your username so I can grant you

access Click “My Profile” -> Groups -> Innovation: Hackathon

@integratorbrad

http://siim.org/


IHE RADIOLOGY, DICOM AND FHIR

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Web-based Image Capture Uses DICOMweb’s

Store (STOW-RS) methods to enable acquisition of images using web services

WIC Profile


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IID Profile

Invoke Image Display Connects user to a zero-footprint web viewer in a

standardized way to visualize an imaging study Aside from grabbing thumbnails using WADO-RS, this

is a great method for embedding a viewer with an EMR as a viewer should handle advanced functionalities (like applying GSPS and appropriate contrasting)


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MHD-I Profile

Mobile access to Health Documents for Imaging RESTful access to XDS-I imaging repositories Updated to use FHIR’s ImagingObjectSelection


Activity being investigated by the HL7 II Group RadReport.org defines ubiquitous international

radiology report templates Using an IHE profile called MRRT – Management of Radiology

Report Templates Standardized reports, with ontological references, can be

generated out of these templates Some of these attributes can be bubbled up to the

DiagnosticReport level, and exposed via a FHIR profile

MRRT, RadReport, and FHIR Profiles


PUTTING IT ALL TOGETHER


Image-Enabling Reports

FHIR® DICOMweb™

EMR Image Cache

Discover radiology reports as

CDA

Retrieve associated key images


Enabling Richer Worklists

FHIR® DICOMweb™

HIS Image Cache

Enrich with patient

metadata

Retrieve work list for

modality


THANK YOU!Any questions?

@integratorbrad

Fhir and Dicom

Healthcare

Transcript of Fhir and Dicom