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Boston, 19-21 June | @HL7 @FirelyTeam | #fhirdevdays18 | www.fhirdevdays.com

FHIR® and DICOMweb™

Brad Genereaux, Agfa HealthCare | Mohannad Hussain, Agfa HealthCare

Who are we?

Brad Genereaux

• Manager, Product Management, Agfa HealthCare

• Co-chair, HL7 Imaging Integration

• Co-chair, DICOM WG-20, Integration of Imaging and

Information Systems

• Co-chair, DICOM WG-27, Web Technologies

• In past lives - developer, architect, integrator, hospital IT in Canada

Mohannad Hussain

• Software engineer

• Team lead at Agfa HealthCare, Integrations and

Customizations

• Coordinator, annual SIIM Hackathon

@integratorbrad

https://www.linkedin.com/in/mohannadhussain

@mohannadhussain

https://www.linkedin.com/in/integratorbrad

• Tuesday

• 11:55am: DICOM® and DICOMweb™ Concepts - An Introduction

• Wednesday

• 11:00am: DICOM® and FHIR®

• 3:30pm: IHE profiles and FHIR

• 4:20pm: XDS on FHIR

Imaging Track

• You should:

• Understand the concepts of FHIR and how it applies to medical imaging and DICOMweb

• Understand how these standards can be combined to enable next-generation workflows and solutions

• Interactive session – please ask questions!

• FHIR Imaging exercises

Tutorial Objectives

RECAP: THE NEED FOR IMAGING EVERYWHERE FHIR® and DICOMweb™

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” ?

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.”

Beyond Radiology: Enterprise Imaging

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

• “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)

Worth 1,000 Words

• 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

If I Can’t Find It, It Does Not Exist

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

Patient-centred

Care

Enterprise

Imaging

Mobile Devices

and Apps

Cloud Services

and SOA

Value-based

Care

Computing

Power

Use Cases are Evolving

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

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

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

•…

Image Metadata

HOW DOES FHIR RELATE TO MEDICAL IMAGING? FHIR® and DICOMweb™

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

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

When to use which?

Information Centric Imaging Centric

• 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

• Shared co-chairs between these SDOs

• Elliot Silver, Change Healthcare

• Brad Genereaux (me), Agfa HealthCare

HL7 II / DICOM WG-20

• 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

Why not just FHIR?

IMAGINGSTUDY IN FHIR FHIR® and DICOMweb™

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

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

• ImagingStudy is an “event” in FHIR workflow, “basedOn” a ServiceRequest

• Don’t be fooled though - the ImagingStudy event is “imaging data being stored on disk”, and not an event associated with acquiring images from the patient directly

• ServiceRequest ~ Order

• Procedure ~ Acquisition

ImagingStudy Relation to FHIR Workflow

ImagingStudy (R4)

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?

{

"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"}

} ] } ] }

ImagingStudy Result Snippet

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)

The “Series” Part

DICOM Series UID

Modality for series

Series description

Part of body of series

Side of the body

Retrieval Location

The “Instance” Part

Type of Object

DICOM Instance UID

Endpoint Resource

• Based on the type, the base URL can be combined with the UIDs to form a request for retrieval

Imaging Types: • dicom-wado-uri: Classic retrieve

• dicom-wado-rs: RESTful retrieve

• dicom-qido-rs: RESTful query

• ihe-iid – Invoke Image Display

Base 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™

Image-enabling the EMR

• Use FHIR ImagingStudy to discover available imaging records, and then use DICOMweb to actually retrieve an image

• You can even provide users to connect to a zero-footprint web viewer if available • Slippery slope though - a DICOM viewer should be capable of handling advanced

functionalities (like applying GSPS, appropriate contrasting, 3D capabilities)

Example: Get Study Thumbnail ImagingStudy Call:

GET http://server.com/fhir/ImagingStudy?patient.id=12345

{"resourceType": "ImagingStudy",

"uid": "urn:oid:2.16.124.113543", "patient": {"reference": "Patient/12345"}, "endpoint" : [

{"connectionType":"dicom-wado-rs", "address":"https://server.com/wado"}],

"series": [ { "uid": "urn:oid:2.16.124.113543.2", "endpoint" : [

{"connectionType":"dicom-wado-rs", "address":"https://server.com/wado"}],

"modality": { "system": "http://dicom.nema.org/resources/ ontology/DCM",

"code": "CT" },

"description": "CT Surview 180", "bodySite": { "system": "http://snomed.info/sct",

"code": "67734004", "display": "Upper Trunk Structure"

}, "instance": [ { "uid": "urn:oid:2.16.124.113543.2.3",

"number": 1, "sopClass": "urn:oid:1.2.840.10008.5.1.4.1.1.2"

} ] } ] }

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

• 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

Image-Enabling Reports

FHIR® DICOMweb™

EMR Image

Cache

Discover

radiology

reports as

CDA

Retrieve

associated

key images

Enrich Modality-side Acquisition

FHIR® DICOMweb™

HIS Image

Cache

Enrich with

patient

metadata

Retrieve work

l ist for

modality

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

IHE Radiology Profiles on DICOMweb

• Web Image Capture (WIC)

• Web Image Access (WIA) formerly called MHD-I

• XDS-I used to be DICOMweb (long story)

• Remote Radiology Reading Workflow (RRR-WF)

• Invoke Image Display (IID) - Special mention

EXERCISES FHIR® and DICOMweb™

• Search for a patient by reference in FHIR

• Look at an “Imaging Study” of this patient • Discover the study structure in DICOM

• Let’s see some images!

Exercises

CONCLUSIONS FHIR® and DICOMweb™

• Complementary services

• Built to meet the needs of

• Patient-centric care

• Modern web-driven architectures

• Secured and protected

• Backward-compatible, forward-thinking

FHIR and DICOM

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

DICOMweb™ Cheatsheet Available at: https://www.dicomstandard.org/dicomweb-cheatsheet/

• 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/

Get Involved in Imaging and Information Integration

• 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

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

• HL7 International and the FHIR community

• DICOM, NEMA, MITA

• SIIM

• Elliot Silver

Special Thanks

• Tuesday

• 11:55am: DICOM® and DICOMweb™ Concepts - An Introduction

• Wednesday

• 11:00am: DICOM® and FHIR®

• 3:30pm: IHE profiles and FHIR

• 4:20pm: XDS on FHIR

Imaging Track

• Reach out!

• Find us here

• Tweet at me - @IntegratorBrad

• Find me on LinkedIn - https://www.linkedin.com/in/integratorbrad/

Questions?