DICOM Anniversary Conference, Monday, September 22, 2003, 1:30 p.m.

The History and Future of

DICOM and HL7

Behlen^Fred^M^^PhDAmerican College of Radiology

Co-Chair, DICOM Working Group 20

Co-Chair, HL7 Imaging Integration SIG

President, LAI Technology, Homewood, IL LAI technology

1..1 1..1

Today’s talk• History

– What is HL7?– Other SDOs, early connections

• Now– Comparative organizational structures– Connections and collaborations

• Future– Common information models– Information objects and services– CDA and reporting– Congruence, not coalescence

Hospital Enterprise

Radiology

Exam context

Diagnostic Imaging in the

Patient Care Process

Hospital Enterprise

Radiology

Exam context

Results,Images

Diagnostic Imaging in the

Patient Care Process

Hospital Enterprise

Radiology

Exam context

Results,Images

Diagnostic Imaging in the

Patient Care Process

$, £, ¥, etc.

Administrative HIS/RIS

. . .

Medical Informatics

Scope ofDICOM

DiagnosticImaging

Lab Data

. . .

PatientBedside

Monitoring

Scope of Standards

Scope ofHL7

Disagreements in Healthcare

Origins ANSI

HISPP SCAMC (AMIA)

Harmonization SessionsHL7

ACR/NEMA

HISPP MSDS

CEN TC251

ANSI JWGDIC

ISIS

DICOM-HL7 relationship

1996 IMSIG formed1999 DICOM proposes joint WG2000 DICOM WG20 formed, meets in

common with IMSIG (renamed IISIG)2001 DICOM & HL7 execute Memorandum

of Understanding2003 HL7 Version 2.5 Order Message for

Imaging (OMI)

HL7• ANSI-accredited standards development

organization, formed in 1987• 16+ year old membership organization

– 512 organizations– 862 individual members

• 14 Technical Committees (TCs)• 17 Special Interest Groups (SIGs)• 22 international affiliates• A week of working group meetings 3 times

annually, about 400 people attending more than 25 parallel sessions and tutorials

2119 voting members(Nov. 2001)

HL7

• Special projects on drug information, adverse event reporting, genomic encoding, admin simplification, public health surveillance, practice guidelines, EHR and more

• Working relationships with ASTM, CEN, DICOM, ebXML, GEHR, IEEE, LOINC, OASIS, SNOMED, X12, W3C and others

WG6

DSC

WGxx

Board ofDirectors

TSC

TCs

SIGs

1n

11

1

1

1n 1

n

Work items

Ballots

Charters

Ballots

DICOM HL7

WG6

DSC

WGxx

Board ofDirectors

TSC

TCs

SIGs

1n

11

1

1

Work items,Policy

Ballots

Charters

Ballots

IISIGWG20. . . . . .

DICOM HL7

Policy

• Version 2.5 – Order Message for Imaging (OMI)

• Version 3– Representing DICOM Procedure Model– Messages for imaging orders and reports

• Clinical Document Architecture (CDA)– Transforming DICOM SR into CDA documents– Diagnostic reporting in CDA format

IISIG/WG20 Work Areas

OMI Message Use Case

OMImessage

used

OrderEntry

Imaging DepartmentInformation System

Imaging DepartmentInformation System

ImagingModality(Device)

ImagingModality(Device)

ImagingModality(Device)

Enterprise

Imaging Department

DICOM

Hierarchy in OMI message

Order[ORC-2 Placer Order Number] – [ORC-3 Filler Order Number]Imaging Service Request[IPC-1 Accession Number]

Requested Procedure 2[IPC-2 RequestedProcedure ID]

Requested Procedure 3[IPC-2 Requested Procedure ID]

Procedure Step 1[IPC-4 RequestedProcedure Step ID]

ProcedureStep 1[IPC-4RequestedProcedureStep ID]

ProcedureStep 2[IPC-4RequestedProcedureStep ID]

Requested Procedure 1[IPC-2 RequestedProcedure ID]

Procedure Step 1[IPC-4 RequestedProcedure Step ID]

HL7 Version 3• First HL7 standard based on explicit information model

(the “RIM”)• Uses automated tooling to manage complexity• Components

– Reference Information Model (RIM)– Clinical Document Architecture (CDA)– Version 3 Messaging

• Uses XML encoding• High degree of compatibility with DICOM• Extensive use of OIDs (cf. UIDs)• Will change I.S. market as much as DICOM 3.0 changed

imaging market, mostly through CDA

Communication

dog

Communication

dog

Patient

V isit

Study

Study ContentNotification

makes has

describes

includes

StudyComponents

M odality PerformedProcedure Steps

Comprisedof

Comprisedof

includes includes contains See Note

R esults

contains

R eport

LookupTable

StoredPrint

R adiotherapyObjects

1-n

1

0-n

1

1-n

1

1

1-n1

1

1-n

1-n

1-n

1 1 1

0-n

0-n0-n

1-n

0-n

1

0-1

0-n

Series

Frame ofR eference

creates

SpatiallyDefines

Equipment

1-n 1-n 1-n

1-n

1-n

0-1

1

Curve

Overlay

0-n

Image

A mmendment

0-n

contains

1

Patient& visit

Study &acquisition

Storeddata

Patient IOD

V isit IOD

Study IOD

Basic StudyDescriptor IOD

references references

describes

references

Study ComponentIOD

M odality PerformedProc. Step IOD

Comprisedof

Comprisedof

references references references See Note

Results IOD

references

Interpretation IODImage IOD

Standalone CurveIOD

Standalone OverlayIOD

Standalone M odalityLUT IOD

Standalone V OI LU TIOD

Stored Print IODSee Figure 7.2b

R adiotherapy IODsSee Figure 7.2c

1-n

1

0-n

1

1-n

1

1

1-n1

1

1-n

1-n

1-n

1 1 1

0-n 0-n

0-n0-n0-n

1-n

0-n

1

0-10-n

Patient& visitIODs

Study &acquisitionIODs

StoreddataIODs

Message

Message

Mes

sage

Message

Mes

sage

Mes

sage

Message

Message

Referralauthorized_visits _qty : REALdesc : EDreason_txt : ED

Observation

value : ANYderivation_expr : STmethod_cd : SET<CV>target_s ite_cd : SET<CD>interpretation_cd : SET<CS>

Substance_administration

route_cd : CDdose_qty : IVL<PQ>rate_qty : IVL<PQ>dose_check_qty : SET<RTO>max_dose_qty : SET<RTO>approach_site_cd : SET<CD>substitution_cd : CV

Procedure

approach_site_cd : SET<CD>method_cd : SET<CV>target_s ite_cd : SET<CD>

Supply

qty : PQ

Dietenergy_qty : PQcarbohydrate_qty : PQ

Consent

Clinical_documentcompletion_cd : CVs et_id : I Is torage_cd : CVvers ion_ nbr : INTcopy_time : TSchange_reason_cd : CV

Containercapacity_qty : PQheight_qty : PQdiameter_qty : PQbarrier_delta_qty : PQbottom_delta_qty : PQseparator_type_cd : CDcap_type_cd : CD

Accessgauge_qty : PQapproach_site_cd : CDtarget_site_cd : CD

Devicemanufacturer_model_nm : STlast_cal ibration_tim e : TSs oftware _nm : STlocal_remote_control_state_cd : CEalert_ level_cd : CE

Employee

hazard_ exposure_txt : EDjob_class_cd : CVjob_title_nm : STprotective_equipment_txt : EDsalary_qty : MOsalary_type_cd : C Vjob_cd : CE

Living_subject

birth_time : TSdeceased_time : TSdeceased_ind : BLadminis trative_gender_cd : CEorgan_donor_ind : BLm ul tiple_bi rth_ind : BLbirth_order _nbr : INT

Mater ial

form_cd : CVeffective_time : IVL<TS>

Assigned_practitioner

position_cd : CVprimary_care_ind : BL

Certified_practitionerboard_certification_type_cd : CVrecertification_time : TS

Place

gps_txt : STposition_txt : EDaddr : ADdirections_txt : EDmobile_ind : BL

Manufactured_material

expiration_time : TSlot_nm : STstability_time : IVL<TS>

Inpatient_encounter

length _of_stay_qty : PQ

Non_Person_living_subjecttaxonomic_class ification_cd : CEbreed_cd : CEstra in_txt : EDeuthana sia_ ind : BLproducti on_class_cd : CEgender_s tatus_cd : CE

Patientconfidentiality_cd : CVvery_important_person_cd : CV

Organizationstandard_industry_class_cd : CEaddr : SET<AD>

Account

allowed_balance_qty : IVL<MO>currency_cd : C Vinterest_rate_qty : RTOnm : ST

Qualified_practitioner

fellowship_field_cd : CEresidency_field_cd : CE

Financial_act

net_qty : MO

Persondisabil ity_cd : CEethnic_group_cd : SET<CV>race_cd : SET<CV>ambulatory_status_cd : CVeducation_level_cd : CVliving_arrangement_cd : CVmarital_status_cd : CVreligious_affiliation_cd : CVaddr : SET<AD>specia l_accommodation_cd : SET<CV>mothers_maiden_nm : ST

Working_list

ownership_level_cd : CV

Public_health_case

detection_method_cd : CEtransmiss ion_mode_cd : CEdisease_imported_cd : CE

Outbreak

time : IVL<TS>

Transportation

Patient_encounterdis charge_disposition_cd : CVacuity_level_cd : CVbirth_encounter_ind : BLstatus_reason_cd : CVvaluables_desc : EDpre_admit_test_ind : BLreferral_source_cd : CVspecial_courtesies_cd : CVvaluables_location_desc : EDadm ission_s ource_cd : CVaccident_cd : CVurgency_cd : CV

Schedulable_resources lot_size_increment_qty : PQ

Resource_slot

slot_time : GTS

Acts (Financial)

Acts (Services)

Infrastructure (Structured documents)

HEALTH LEVEL 7 REFERENCE INFORMATION MODEL RIM_0110Version is basis for first committee-level ballots of Version 3. It was released July 2001, and reflects RIM changes through Harmonization on 07/20/2001

Bil lboard produced by:Rochester Outdoor Advertis ing

Roles

Guarantorcredit_rating_cd : CV

Diagnostic_image

subject_orientation_cd : CV

Imaging_modalitypixel_padding_qty : PQpixel_intensity_relationship_cd : CVspacial_resolution_qty : PQ

Query_ack

id : IIquery_status_cd : CVmessage_query_cd : CVresult_count_total : INTresult_count_current : INTresult_count_remaining : INT

Get_more_resultsquery_id : IIquantity : INTstart_result_nbr : INT

Query_message_interaction

Table

rules : CScellspacing : STcellpadding : STsumm ary : STwidth : STborder : INTframe : CS

Table_structure

halign : CSchar : STcharoff : STvalign : CSlocal_id : ST

Table_column_structure

span : INTwidth : ST

Table_cell

rowspan : INTcolspan : INTabbr : STaxis : STheaders : SET<ED>scope : CS

Link

Character_data

value : ST

Local_attr

name : STvalue : ST

Local_markup

ignore_cd : CSdescriptor : STrender : ST

Li nk_html

title : STname : SThref : EDrel : SET<CE>rev : SET<CE>

Entry

local_id : ST

0. .1

0. .*

contains0. .1

is_contained _in0. .*

Context_structure

local_id : ST

0..*

0.. 1

is_contained_in

0..*

contai ns

0.. 1

Infrastructure (Structured documents)

Infrastructure (Message control)

Enitites

Message Control

Covered_party

handicap_cd : CVstudent_ind : BL

Act_relationshiptype_cd : CSinversion_ind : BLsequence_nbr : INTpriority_nbr : INTpause_qty : PQcheckpoint_cd : CSsplit_cd : CSjo in_cd : CSnegation_ind : BLconjunction_cd : CS

Act_context

level_cd : CVlanguage_cd : CS

File_of_batchcontrol_ id : IIname : STcreation_tim e : TSreference_control_id : IIsending_appl ica tion_id : IIreceiving_application_id : IIsecurity : STfile_batch_count : INTfile_co mment : SET<ST>

Act

id : SET<II>mood_cd : CSclass_cd : CStxt : EDstatus_cd : CSactivity_time : GTSeffective_time : GTSconfidentiality_cd : SET<CV>repeat_nbr : IVL<INT>interruptible_ind : BLpriority_cd : SET<CV>independent_ind : BLavailability_time : TScd : CDreas on_cd : CVstatus_time : TS

0..*1

has_target

0..*

is_target_for

1

0..*1

has_source

0..*

is_source_for

1

1..*

0..*

originates_in_context_of

1..*

prov ides_context_f or

0..*

Attention_linekey_word_txt : STvalue : ST

Batch

control_id : IIname : STcreation_time : TSreference_control_id : IIsending_application_id : IIreceiving_application_id : IIsecurity : STmessage_count : INTbatch_totals : SET<INT>batch_comment : SET<ST>

0..10..*

conta ins

0..1

is_contained_by

0..*

Acknowledgementtype_cd : CVnote_txt : EDerror_detail_cd : CVexpected_sequence_nbr : INT

Message_interaction

message_type_id : IIresponse_cd : CS

Participation

type_cd : CStime : IVL<TS>note_txt : EDs ignatur e_cd : CVfunction_cd : CDawareness_cd : CVs ignatur e_txt : EDencounter_accom modation_cd : CVstatus_cd : CSmode_cd : CVsequence_nbr : INT

0. .* 1

for

0. .*

has

1

Relationship_link

effective_time : IVL<TS>type_cd : CS

Messagesending_application_id : IIid : SET<II>creation_time : TSinteraction_id : IIversion_id : STprofile_id : SET<OID>process ing_cd : CVsequence_nbr : INTreply_to_com : TELreceiving_application_id : SET<II>process ing_mode_cd : CVattachment_txt : EDaccept_ack_cd : CVapplication_ack_cd : CV

0..*1

can_ac company

0..*

can_include

1

0..1

0..*

contains

0..1

is_contained_by

0..*

1..*

1

acknowledges1..*

is _acknowl edged_by1

0..1

1

occurs_with0..1

has 1

0..1

0..*

is_communicated_as0..1

has_payload0..*

Roleclass_cd : CSeffective_time : IVL<TS>id : SET<II>s tatus_cd : CSposition_nbr : LIST<INT>qty : RTOcertificate_txt : EDaddr : SET<AD>telecom : SET<TEL>cd : CE

0..*1

has_as_parti cipant

0..*

participates_i n

1

0..*1

has_source

0..*

is_source_for

1

0..*1

has_target

0..*

is_target_for

1

Entity

id : SET<II>class_cd : CSdeterminer_cd : CSimportance_status_txt : EDqty : SET<PQ>telecom : SET<TEL>desc : EDstatus_cd : CScd : CEnm : SET<EN>risk_cd : CEhandling_cd : CE

1..*

0.. *

shall_receive 1..*

h as_ re cip ient

0.. *

1..1

0..*

sends 1..1

has_sender

0..*

0. .*0 .. 1

played_by

0. .*

pla ys

0.. 1

0. .*0.. 1

is_scoped_by

0. .*

scopes

0.. 1

Language_communication

language_cd : CEpreference_ind : BLmode_c d : CVproficiency_level_cd : CV

10 ..*

communicates_with

1

used_by

0 ..*

Financial_transactionpayment_terms_cd : CVdebit_exchange_rate_qty : RTOcredit_exchange_rate_qty : RTOinterest_rate_qty : RTO

Invoice_elementitem_nbr : REALitem_qualifier_cd : CEgross_qty : MOcoverage_source_cd : CEunit_qty : RTOnotify_subject_ind : BLmodifier_cd : CEfactor_nbr : REALpoints_nbr : REAL

Financial_contract

paym ent_terms_cd : CV

Role_heirEntity_heir

Sort_control

element_name : STsequence_nbr : INTdirection_cd : CV

Querymessage_query_cd : CVid : IIpriority : CVmodify_indicator : CVexecution_a nd_delivery_time : TSin itia l_qty : PQres ponse_modality_cd : CVreturn_element_group : SET<CV>

0..* 1

is_fo r

0 ..*

has

1

Relational_expressi on

element_name : STvalue : STrelational_operator_cd : CV

Query_by_selection

Selection_expression0..*

1

is_for 0..*

has_ex press ion 1

Logical_expression

relational_conjunction_cd : CV

1

0..*

has_left_side

1

is_lhs_for0..*

1

0..*

has_right_side

1

is _rhs_fo r0..*

Query_by_parameter

Parameter_list

Param eter

name : ST

0..*

1

is_parameter_of0..*

has 1

0..1

0..*

may_contain0..1

i s_part_of

0 ..*

A_parameter

value : ANY

Device_task

param eter_value : LIST<ANY>

Entity Role Participation Act

Message Control

Document Structures

Imaging Order R-MIM

Entity

Act

Participation

Act Relationship

Role CMET (Common Message Element Type)

The HL7 Clinical Document

Architecture (CDA)• CDA header– RIM-derived– Ground up compatibility with DICOM SR

• CDA Level One body– Based on subset of XHTML, fits any report

type– Has image link, coded vocabulary

• CDA Release 2 body– Permits data representation at various levels of

granularity– Passed first Committee ballot August 2003– Member ballot March 2004

HL7 Clinical Document

Architecture (CDA)• Level 1– Coded header, text content with simple

formatting objects(section, paragraph, list, table)

• Level 2– Standard codes for Level 1 sections

• Level 3– Full structured content derived from RIM

HL7 Clinical Document Architecture (CDA) Release 2• Release 1

– Coded header, text content with simple formatting objects(section, paragraph, list, table)

• Release 2– Standard codes for Level 1 sections

– Full structured content derived from RIM

Release 2 CDA• Release 2, Level One:

– alignment with current RIM, V3 methodology

– minor enhancements to CDA Header– added functionality for CDA Body

• Region of interest (cf. DICOM SCOORD)

• Release 2, Levels Two and Three– templates layered on basic XML spec

• Level Two: templates for headings• Level Three: templates for contents

– enables detailed clinical encoding

CDA Implementations• National & International

– PICNIC (European Union)– SCIPHOX (Germany)– HYGEIAnet/WebOnColl (Greece)– NHS South Staffordshire (United Kingdom)– Satakunta Macro Pilot (Finland)– e-Claims Supporting Document Architecture

(Canada)• Local & Regional

– Mayo Clinic (USA)– Buenos Aires project (Argentina)– Dalhousie U, QEII Health Sci Ctr (Canada)

HL7 Templates

• Joint project of Templates SIG, Structured Documents TC, Conformance SIG

• Open template registry/repository– will contain normative and non-normative

templates• Tools for generating and validating

templates will be developed• This will take a while

A Number of Connections

• WG20 / IISIG Other HL7 groups– Technical Committees

• Orders & Observations• Vocabulary• Structured Documents• Laboratory Automation and Point of Care Testing• Patient Care• Control/Query

– Special Interest Groups• Conformance• Electronic Health Records (EHR)• Security & Accountability• Templates

More Connections

• WG14 SASIG NEMA SPC IHE

• IHE Conformance SIG

• DICOM ISO @ HL7 venues– WG10 TC215/WG2

– WADO TC215/WG2• Also WADO Structured Documents TC

A Rewarding Partnership

• No big turf issues– DICOM doesn’t want to define enterprise

communications– HL7 has no ambition or bandwidth to model

specialty domain detail

• Each can learn from the other– DICOM experience with persistent objects– HL7 experience with modeling tools

• HL7 meetings are a good gathering place