1. IHE Workshop – February 2007What IHE Delivers 1 Marco Eichelberg IHE-D Technical Manager NM Image

2. IHE Workshop – Feb. 2007 2 NM Image The Problem DICOM NM objects are different and support in products is inconsistent NM cardiac display needs are different and support in products is inconsistent Clinical Analysis Programs are used extensively (particularly for Cardiology), but no support for distribution and display of those Result Screens NM Users are not adept at getting these requirements accurately included in RFPs Vendors (especially of general purpose systems) are not adept at accurately representing their support for such features

3. IHE Workshop – Feb. 2007 3 General NM Viewing Suboptimal NMPACS

4. IHE Workshop – Feb. 2007 4 General NM Viewing Suboptimal NMPACS

5. IHE Workshop – Feb. 2007 5 General NM Viewing Suboptimal Click and move mouse down to adjust window level, right to adjust window center

6. IHE Workshop – Feb. 2007 6 Cardiac Viewing Suboptimal If sent as Short axis  Images not displayed in a useful format. If sent as screen snapshots (ie, static Secondary Capture)  Can’t separately adjust stress and rest images  Can’t view gated cine

7. IHE Workshop – Feb. 2007 7 New in 2006 ! Cardiac Option  Better addresses cardiac needs Minor restructuring of remaining profile  General NM option  MPR option  (Review option retired)  (Comparison display eliminated)

8. IHE Workshop – Feb. 2007 8 NM Image Abstract / Scope Content Profile   for Users to request and Vendors to claim No New Actors or Transactions   Additional requirements on existing actors and transactions   Total of 4 options New Informative Text in Vol. 1   Clarifications of NM Workflow mapping to SWF   Explanation of NM Data   Explanations of NM Clinical Display concepts New Normative Text in Vol. 2  

9. IHE Workshop – Feb. 2007 9 NM Image Value Proposition Use general Radiology Infrastructure to: Satisfy Basic NM Data Needs  Access to NM Images  Access to usable presentations of NM Images  Access to Clinical Processing Results Satisfy NM Workflow Needs  Map Cardiac and Multi-phase Studies to SWF  Improved Query

10. IHE Workshop – Feb. 2007 10 NM Image Transaction Diagram

11. IHE Workshop – Feb. 2007 11 NM Image Standards Used DICOM NM Image Object DICOM Multiframe Secondary Capture  Dynamic Results  Collection of Static Results DICOM Secondary Capture  Static Results ACC NM Cardiac Display format

12. IHE Workshop – Feb. 2007 12 NM Image Actors Acquisition Modalities  Create NM objects as specified (Series, attribute & vector handling)  Include specific codes in Cardiac studies Evidence Creators  Create NM objects as specified (Series, attribute & vector handling)  Include specific codes in Cardiac studies Image Manager/Archives  Store/Retrieve NM & Secondary Capture (SC & MFSC) Objects  Support Query on Study Description Image Displays  Display NM and Secondary Capture (SC & MFSC) Images  Support specified display capabilities

13. IHE Workshop – Feb. 2007 13 Image Display Display NM and Result-Screen Images Support specified NM essential display capabilities Additional attribute handling  e.g. Patient State, Image Orientation, Detector Sequence, View Code Sequence

14. IHE Workshop – Feb. 2007 14 Options: Image Displays General NM Option  Whole body display Cardiac NM Option  ACC NM Cardiac display Displays must support at least one of these options!

15. IHE Workshop – Feb. 2007 15 Handle multi-frame / multi-vector images Multiple simultaneous cines Grayscale and color result screens Dynamic and static result screens Original resolution and scaled Separate adjustment of upper and lower window levels Apply local color tables to grayscale screens Add new local color tables to system Change intensity of grayscale result screens Display Series Description tag Image Display

16. IHE Workshop – Feb. 2007 16 NM Image Format Understood by dedicated NM systems Often Misunderstood by general storage and display systems Multiframe  Dynamic  Anterior  Posterior  Multi-energy NM Image Image vectors

17. IHE Workshop – Feb. 2007 17 Image Display Scale “intelligently” to avoid presenting postage-stamp size NM images Allow user to select different vectors/framesets of complex multi- frame images Allow user to separately adjust intensity for different framesets (eg, phases) in the same “image”

18. IHE Workshop – Feb. 2007 18 Display Formats Grid display  Frames from one image set A 32 … ………………… …………………… …………………A9A9 A8A8 A7A7 A6A6 A5A5 A4A4 A3A3 A2A2 A1A1 C1C1 C1C1 B2B2 B1B1 A2A2 A1A1 Fit display   Frames from multiple image sets

19. IHE Workshop – Feb. 2007 19 ACC NM Cardiac Display Generate long axis from short axis images Display of 2 image sets (Stress and Rest) Use patient state tags to set display order Follow ACC guidelines for display Controls for adjusting stress and rest  Image alignment  Window upper and lower levels.

20. IHE Workshop – Feb. 2007 20 ACC NM Display Example Short axis Horizontal Long Vertical Long

21. IHE Workshop – Feb. 2007 21 ACC NM Display Example Short Horizontal Vertical Stress Rest Stress Rest Stress Rest Stress Rest

22. IHE Workshop – Feb. 2007 22 Another ACC Display Example Different Layout Same stress and rest views

23. IHE Workshop – Feb. 2007 23 MPR Option: Image Displays Adds Image Display requirements to support Review of SPECT NM Images with Multi-planar reconstruction (MPR)  Transaxial  Sagittal  Coronal

24. IHE Workshop – Feb. 2007 24 Result Screen Export Option

25. IHE Workshop – Feb. 2007 25 Result Screen Export Option: Evidence Creators Render Dynamic Result Screens  Based on the following DICOM Objects: Multi-Frame Grayscale Byte Secondary Capture Multi-Frame True Color Secondary Capture  Creating multiple single frame objects is NOT sufficient. Render Static Result Screens  Using single frame DICOM Secondary Captures is sufficient  Using Multi-frame to render single or several related static result screens is recommended provides better image comment/label attributes provides implicit display order displayed by stepping, not cine Must generate appropriate Secondary Capture objects from any Result Screens created.

26. IHE Workshop – Feb. 2007 26 Points of Interest - NM Appendix E, Volume 1 (Informative)  New to Nuclear Medicine?  Trouble matching NM to Scheduled Workflow?  Start Here.  E.2 NM Workflow – What happens in NM procedures  E.3 NM Worklists – How to schedule/model it  E.4 NM Data – What to expect in the DICOM  E.5 NM Display – How it should be presented  Many subtleties here

27. IHE Workshop – Feb. 2007 27