FHIR & DICOM · 2019. 12. 10. · 19 Why not just FHIR? Scale and backward compatibility DICOM is...
Transcript of FHIR & DICOM · 2019. 12. 10. · 19 Why not just FHIR? Scale and backward compatibility DICOM is...
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FHIR & DICOM
Mohannad Hussain
Who am I?
• Software engineer by training
• Advanced Development Director at Philips
• Coordinator, SIIM Hackathon
@mohannadhussain
Slide credits go to Brad Genereaux
• Medical Imaging Alliance Manager at NVIDIA
• Involved in a number of the standard committees
• In past lives – product manager, developer, architect, integrator, hospital IT in Canada
@integratorbrad
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Special Thanks
• HL7 International and the FHIR community
• DICOM, NEMA, MITA
• SIIM
• Elliot Silver
RECAP: THE NEED FOR IMAGING EVERYWHERE FHIR® and DICOMweb™
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Diagnostic Imaging
• Obtained to elicit a differential diagnosis or
confirm a clinical suspicion
Procedural Imaging
• Obtained before, during, and after surgical
and percutaneous invasive procedures
Evidence Imaging
• Captured primarily for documentation of a
patient’s current state
Image-Based Clinical Reports
• i.e., image-enriched textual reports where
thumbnail image depictions of lesions identified
What do I mean by “imaging” ?
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Beyond Radiology: Enterprise Imaging
Defined as “a set of strategies, initiatives and workflows implemented across a healthcare enterprise to consistently and optimally capture, index, manage, store, distribute, view, exchange, and analyze all clinical imaging and multimedia content to enhance the electronic health record.”
A Foundation for Enterprise Imaging: HIMSS-SIIM Collaborative White Paper
http://link.springer.com/article/10.1007/s10278-016-9882-0
Christopher J. Roth, Louis M. Lannum, Kenneth R. Persons
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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If I Can’t Find It, It Does Not Exist
• If imaging studies are not readily available, patients may need to be re-imaged
• Increased patient risk (radiation, hospital-borne infections)
• Increased cost to the patient / healthcare system (unnecessary exams)
• Increased patient and caregiver discomfort and anxiety
• Increased delay for the patient (while re-imaging takes place)
• Increased delay for other patients (while re-imaging takes place)
• Or need for increased unnecessary capacity
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Simple Imaging Dept Workflow
1. Patient admitted to clinic 3. Order gets reviewed 2. Doctor creates order
4. Images get acquired 5. Report is written 6. Results are distributed
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Use Cases are Evolving
Patient-centred
Care
Enterprise
Imaging
Mobile Devices
and Apps
Cloud Services
and SOA
Value-based
Care
Computing
Power & AI/ML
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DICOM is Imaging
Standard for handling, storing, printing, and transmitting information in medical
imaging, and includes both a file structure and communication protocol
https://en.wikipedia.org/wiki/DICOM
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Patient ;
1
Study 1
1
Study 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
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Image Metadata
Study
•Study UID
•Date of Study
•Description
•Refer Physician
•Accession
•…
Series
•Series UID
•Modality
•Description
•Series Number
•Body Part
•…
Instance
• Instance UID
•Height (Rows)
•Width (Columns)
•Position
•SOP Class UID
•…
HOW DOES FHIR RELATE TO MEDICAL IMAGING? FHIR® and DICOMweb™
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Synergistic Relationship
Health
Record
HL7
Discrete Data
DICOM
Imaging
*
Documents
DICOM: 1993
WADO: 2003
DICOMweb: ~2011
CDA: 2000
XDS: 2007
PDF, TIFF, etc.
HL7 v2.x: 1989
HL7 v3: 2005
FHIR: 2014
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When to use which?
FHIR is used for information-
centric workflows
• E.g., EMRs, EHRs - to discover available studies and work with order- and report-centric metadata
DICOM / DICOMweb is used for
imaging-centric workflows
• E.g., PACS, post-processing - to retrieve, process, and parse the DICOM instances
Information Centric Imaging Centric
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HL7 II / DICOM WG-20
• Joint effort between the two SDOs to ensure alignment within standards, eliminate duplication, and ensure respective needs are met in both communities
• HL7 - Imaging Integration
• DICOM WG-20 - Integration of Imaging and Information Systems
• FHIRcast
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Why not just FHIR?
• Scale and backward compatibility
• DICOM is one of the most widely deployed healthcare messaging standards in the world
• 100,000s of modalities (devices) producing images, decades in production
• ~ 2 trillion images annually (50% in the US)
• ~ 450 Petabytes per year stored on disk; doubles every 5 years
• ~ 4.5 Exabytes globally total
• Images created at least as far back as 1993 are still compatible today
• It would be a massive effort without much value, need, or industry support to switch to a new standard
IMAGINGSTUDY IN FHIR FHIR® and DICOMweb™
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Recap: Simple Imaging Dept Workflow
1. Patient admitted to clinic 3. Order gets reviewed 2. Doctor creates order
4. Images get acquired 5. Report is written 6. Results are distributed
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Imaging Workflow on FHIR
Visit Order Protocol
Acquire Report Access
ServiceRequest
CarePlan
ServiceRequest
Procedure
DiagnosticReport
ImagingStudy
Encounter
EpisodeOfCare
1. Patient admitted to clinic 3. Order gets reviewed 2. Doctor creates order
4. Images get acquired 5. Report is written 6. Results are distributed
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ImagingStudy (R4)
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ImagingStudy Example
description started endpoint
Abdomen
CT
Jan. 17,
2014
http://<url>
Chest CR Mar. 23,
2015
http://<url>
What studies do
you have for John
Doe?
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ImagingStudy Result Snippet
{
"resourceType": "ImagingStudy", "id": "example",
"text": {
"status": "generated",
"div": "<div>CT Chest. John Smith (MRN: 09236). Accession: W12342398. Performed: 2011-01-01. 3 series, 12 images.</div>"},
"identifier": [
{ "use": "official", "system": "urn:ietf:rfc:3986", "value": "urn:oid:2.16.124.113543.6003.1154777499.30246.19789.3503430045“ } ],
"status": "available",
"subject": { "reference": "Patient/dicom“ }, "started": "2011-01-01T11:01:20+03:00", "numberOfSeries": 1, "numberOfInstances": 1,
"series": [
{
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:oid:2.16.124.113543.6003.2588828330.45298.17418.2723805630"
},
"number": 3, "description": "CT Surview 180", "numberOfInstances": 1,
"modality": {
"system": "http://dicom.nema.org/resources/ontology/DCM", "code": "CT"
},
"bodySite": { "system": "http://snomed.info/sct", "code": "67734004", "display": "Upper Trunk Structure“ }, "instance": [
{
"identifier": {"system": "urn:ietf:rfc:3986", "value": "urn:oid:2.16.124.113543.6003.189642796.63084.16748.2599092903“ }, "number": 1,
"sopClass": { "system": "urn:ietf:rfc:3986","code": "urn:oid:1.2.840.10008.5.1.4.1.1.2"}
} ] } ] }
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The “Study” Part
DICOM Study UID, accession number
Modalities (CT, MRI, etc) Patient Reference
Date of study
Ordering physician
Procedure Type
Free-text description
Encounter or visit
Order
Reading radiologist
Reason for Exam
Retrieval Location (see upcoming slide)
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The “Series” Part
DICOM Series UID
Modality for series
Series description
Part of body of series
Side of the body
Retrieval Location
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The “Instance” Part
Type of Object
DICOM Instance UID
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Endpoint Resource
Imaging Types: • dicom-wado-uri: Classic retrieve
• dicom-wado-rs: RESTful retrieve
• dicom-qido-rs: RESTful query
• ihe-iid – Invoke Image Display
URL to the DICOMweb service
endpoint
Study UID
Series UID
http://server.org/wadors/studies/1.2.3/series/4.5.6/instances/7.8.9
Instance UID
WADO-RS Call:
REAL WORLD USE CASES FHIR® and DICOMweb™
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Image-enabling the EMR
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Example: Get Study Thumbnail
WADO-RS Call:
GET
https://server.com/wado/studies/
2.16.124.113543/series/2.16.124.11
3543.2/instances/2.16.124.113543.2
.3/rendered?viewport=50%2C50
Accept: image/jpeg
Thumbnail
Web format
ImagingStudy Call: GET http://server.com/fhir/ImagingStudy?patient.id=12345
{
"resourceType": "ImagingStudy",
"id": "example",
"identifier": [
{"system": "urn:dicom:uid",
"value": "urn:oid:2.16.124.113543"}
],
"status": "available",
"subject": {"reference": "Patient/dicom"},
"started": "2011-01-01T11:01:20+03:00",
"numberOfSeries": 1,
"numberOfInstances": 1,
"series": [
{"uid": "2.16.124.113543.2",
"number": 3,
"modality": {
"system": "http://dicom.nema.org/resources/ontology/DCM",
"code": "CT"},
"description": "CT Surview 180",
"numberOfInstances": 1,
"bodySite": {
"system": "http://snomed.info/sct",
"code": "67734004",
"display": "Upper Trunk Structure"},
"instance": [
{"uid": "2.16.124.113543.2.3",
"sopClass": {
"system": "urn:ietf:rfc:3986",
"code": "urn:oid:1.2.840.10008.5.1.4.1.1.2"
},
"number": 1
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• Authentication
• Authorization
• Firewalls
• That the thumbnail is relevant
• DICOM has voted to include a Thumbnail API as part of WADO-RS http://server.org/wadors/
studies/1.2.3/thumbnail
Thumbnail Use Case Caveats
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Image-Enabling Reports
FHIR® DICOMweb™
EMR Image
Cache
Discover
radiology
reports as
CDA
Retrieve
associated
key images
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Enrich Modality-side Acquisition
FHIR® DICOMweb™
HIS Image
Cache
Enrich with
patient
metadata
Retrieve work
l ist for
modality
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Richer Image Analytics for Triage/Detection
FHIR®
• Diseases / conditions
• Laboratory results
• Reports (structured)
DICOMweb™ • Images from
modalities
• Image metadata
Analytics enriched by the full story
of the patient, given the wealth of
healthcare information
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IHE Radiology Profiles on DICOMweb
• Encounter-Based Imaging Workflow (EBIW)
• Web Image Capture (WIC)
• Web Image Access (WIA) formerly called MHD-I
• Remote Radiology Reading Workflow (RRR-WF)
• Invoke Image Display (IID) - Special mention
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Interesting DICOM developments
• CP1509: Refactors mime types
• Sup202: Realtime video
• Sup203: Thumbnail service
• Sup204 and 206: Security updates
• Sup205: STL model encapsulation for 3D
CONCLUSIONS FHIR® and DICOMweb™
FHIR and DICOM
• Complementary services
• Built to meet the needs of
• Patient-centric care
• Modern web-driven architectures
• Secured and protected
• Backward-compatible, forward-thinking
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Where do I find more information?
• DICOM Main Site
• http://dicomstandard.org
• DICOMweb Reference
• https://www.dicomstandard.org/dicomweb/
• DICOMweb Standard
• http://dicom.nema.org/medical/dicom/current/output/chtml/part18/PS3.18.html
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DICOMweb™ Cheatsheet Available at: https://www.dicomstandard.org/dicomweb-cheatsheet/
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Get Involved in Imaging and Information Integration
• Intersection of FHIR and DICOM is covered by composite groups in both HL7 and DICOM
• Join WG-20 (DICOM) by visiting https://www.dicomstandard.org/participate/
• Join Imaging Integration (HL7) by joining II mailing lists and teleconferences, find out more at: http://www.hl7.org/Special/committees/imagemgt/
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• DICOM is an open community of stakeholders
• There are many ways to contribute and to use DICOM
• Join a Working Group • Stakeholders may join the roster of a
Working Group as an “Observer”. Observers are permitted to attend Working Group meetings and telephone conferences and will be placed on the WG e-mail list
• Friendly, welcoming, just join and listen in!
Get Involved in DICOM
WG-01: Cardiac and
Vascular
Information
WG-02: Projection
Radiography and
Angiography
WG-03: Nuclear
Medicine
WG-04:
Compression
WG-05: Exchange
Media
WG-06: Base
Standard
WG-07:
Radiotherapy
WG-08: Structured
Reporting
WG-10: Strategic
Advisory
WG-11: Display
Function Standard
WG-12: Ultrasound
WG-13: Visible
Light
WG-14: Security
WG-15: Digital
Mammography and
CAD
WG-16: Magnetic
Resonance
WG-17: 3D
WG-18: Clinical
Trials and
Education
WG-19:
Dermatologic
Standards
WG-20: Integration
of Imaging and
Information
Systems
WG-21: Computed
Tomography
WG-22: Dentistry
WG-23: Application
Hosting
WG-09:
Ophthalmology
WG-24: Surgery
WG-25: Veterinary
Medicine
WG-26: Pathology
WG-27: Web
Technology for
DICOM
WG-28: Physics
WG-29: Education,
Communication
and Outreach
WG-30: Small
Animal Imaging
WG-31:
Conformance
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Society for Imaging Informatics in Medicine (SIIM)
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 2019 Annual Meeting | June 26 – June 28, 2019 | Denver, CO | SIIM.org • Annual SIIM Hackathon hosted at SIIM - 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
• Regional meetings and an annual meeting dedicated to Machine Intelligence in Medical Imaging (C-MIMI)
• Publication of the Journal of Digital Imaging • Educational Webinar Series, eCommunity, Online Learning Materials and More! SIIM.org
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