1. Application of DICOM Structured Report Andrei Leontiev Dynamic Imaging

2. April 1, 2005DICOM Seminar – Singapore 2005 DICOM Structured Report Encoding for structured observations Encoding for structured observations –Universal mechanism Generic Applications Generic Applications –Basic Text, Enhanced, Comprehensive Specialty Applications Specialty Applications –Key Object Selection –CAD, US measurements, … –Patient Relevant Information Query

3. Encoding of Structured Reports

4. April 1, 2005DICOM Seminar – Singapore 2005 SR Intent Support measurements by imaging devices Enable collaborative reporting by any number of persons or devices Enable links to key images Enable links to regions of interest within images and waveforms Template-driven content and structure

5. April 1, 2005DICOM Seminar – Singapore 2005 Simple Example of SR Shows example of simple diagnostic report Shows example of simple diagnostic report Multi-level structure Multi-level structure Text, codes, pointers to images Text, codes, pointers to images

6. April 1, 2005DICOM Seminar – Singapore 2005

7. April 1, 2005DICOM Seminar – Singapore 2005 Report of Chest X-Ray (PA and LateralViews) Patient Jane Homer Study # 123456 Recorded by Dr. John Smith The finding is a mass measuring 1.3 cm in diameter with an infiltrative margination. The baseline image is shown at Conclusions The conclusion is a probable malignancy, inferred from the infiltrative margination of the mass and the appearance shown by the best illustration of findings. Specific Image Findings The best illustration of findings is (Click to view) Slide by D. Clunie

8. April 1, 2005DICOM Seminar – Singapore 2005 Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1.2.3.4.5.6.7.100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1.3 cm has properties margination=infiltrative (1.4.2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1.4.2 inferred from 1.7.1 Specific Image Findings best illustration of findings(1.7.1). Slide by D. Clunie

9. April 1, 2005DICOM Seminar – Singapore 2005 Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1.2.3.4.5.6.7.100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1.3 cm has properties margination=infiltrative (1.4.2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1.4.2 inferred from 1.7.1 Specific Image Findings best illustration of findings(1.7.1). “contains” relationship not shown Slide by D. Clunie

10. April 1, 2005DICOM Seminar – Singapore 2005 Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1.2.3.4.5.6.7.100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1.3 cm has properties margination=infiltrative (1.4.2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1.4.2 inferred from 1.7.1 Specific Image Findings best illustration of findings(1.7.1). Concept Name /Value pairs used Slide by D. Clunie

11. April 1, 2005DICOM Seminar – Singapore 2005 Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1.2.3.4.5.6.7.100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1.3 cm has properties margination=infiltrative (1.4.2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1.4.2 inferred from 1.7.1 Specific Image Findings best illustration of findings(1.7.1). Concept Name without a value used as a heading (container) Slide by D. Clunie

12. April 1, 2005DICOM Seminar – Singapore 2005 Chest X-Ray has concept modifier Views=PA and Lateral Recording Observer=Smith^John^^Dr^ Study Instance UID …=1.2.3.4.5.6.7.100 Patient-Data-Acquisition-Subject=Homer^Jane^^^ Finding=Mass has properties diameter=1.3 cm has properties margination=infiltrative (1.4.2) Baseline Image Conclusions conclusion=probable malignancy inferred from 1.4.2 inferred from 1.7.1 Specific Image Findings best illustration of findings(1.7.1). Concept Name without a value used as Purpose of Reference for IMAGE, SCOORD Slide by D. Clunie

13. April 1, 2005DICOM Seminar – Singapore 2005 CODE SCOORD CODE “Chest X-Ray” “Recording Observer”=“Smith^John^^Dr^” “Study Instance UID...”=“1.2.3.4.5.6.7.100” Context “… Acquisition Subject”=“Homer^Jane^^^” “Finding”=“Mass” Contains “Baseline”= Contains “Conclusions” Contains “Specific Image Findings” Contains “Views”=“PA and Lateral” Modifier Context “diameter”=“1.3” “cm” Properties “margination”=“infiltrative” Properties “conclusion”=“probable malignancy” Contains “best illustration of findings”= Contains Sel d From Inf d From CONTAINER PNAME UIDREF PNAME CODE NUM IMAGE CODE 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.4.1 1.4.2 1.6.1 1.7.1 1.7.1.1 1.6.1.1 1.6.1.2 Slide by D. Clunie

14. April 1, 2005DICOM Seminar – Singapore 2005 CODE SCOORD CODE “Chest X-Ray” “Finding”=“Mass” Contains “Conclusions” Contains “Specific Image Findings” Contains “margination”=“infiltrative” Properties “conclusion”=“probable malignancy” Contains “best illustration of findings”= Contains Inf d From CONTAINER CODE 1.4 1.6 1.7 1.4.1 1.4.2 1.6.1 1.7.1 1.6.1.1 1.6.1.2 Slide by D. Clunie

15. April 1, 2005DICOM Seminar – Singapore 2005 “Chest X-Ray” “Recording Observer”=“Smith^John^^Dr^” “Study Instance UID...”=“1.2.3.4.5.6.7.100” “… Acquisition Subject”=“Homer^Jane^^^” “Finding”=“Mass” “Baseline”= “Conclusions” “Specific Image Findings” “Views”=“PA and Lateral” “diameter”=“1.3” “cm” “margination”=“infiltrative” “conclusion”=“probable malignancy” “best illustration of findings”= 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.4.1 1.4.2 1.6.1 1.7.1 1.7.1.1 1 The numbering of items is implicit ! Slide by D. Clunie

16. April 1, 2005DICOM Seminar – Singapore 2005 Inheritance of Context Observation Context Observation Context –includes top-level attributes of Composite IOD –may be attached to root node CONTAINER –is inherited along by-value relationships –is not inherited along by-reference relationships –may be extended (but not replaced) in children –may be attached to any content item, not just CONTAINER Slide by D. Clunie

17. April 1, 2005DICOM Seminar – Singapore 2005 “Chest X-Ray” “Recording Observer”=“Smith^John^^Dr^” “Study Instance UID...”=“1.2.3.4.5.6.7.100” Context “… Acquisition Subject”=“Homer^Jane^^^” “Finding”=“Mass” Contains Context General Patient Module: “Patient Name ”=“Homer^Jane^^^” “Patient ID ”=“234567” “Patient Sex”=“F” “Patient DOB”=“19991109” General Study Module: “Accession Number ”=“123456” “Study ID ”=“345678” SR Comprehensive SOP Instance Slide by D. Clunie

18. April 1, 2005DICOM Seminar – Singapore 2005 “Chest X-Ray” “Recording Observer”=“Smith^John^^Dr^” “Study Instance UID...”=“1.2.3.4.5.6.7.100” Context “… Acquisition Subject”=“Homer^Jane^^^” “Finding”=“Mass” Contains “Baseline”= Contains “Conclusions” Contains “Specific Image Findings” Contains “Views”=“PA and Lateral” Modifier Context “diameter”=“1.3” “cm” Properties “margination”=“infiltrative” Properties “conclusion”=“probable malignancy” Contains “best illustration of findings”= Contains Sel d From Inf d From Slide by D. Clunie

19. April 1, 2005DICOM Seminar – Singapore 2005 “Obstetric Ultrasound” “Mother of Fetus”=“Homer^Jane^^^” “Fetus Identifier”=“Fetus A” “BPD”=“27” “mm” “Findings for Fetus” Obs n Context Contains Obs n Context “Gestational Age”=“16” “weeks” Properties Inf d From “Fetus Identifier”=“Fetus B” “BPD”=“28” “mm” “Findings for Fetus” Contains Obs n Context “Gestational Age”=“16” “weeks” Properties Inf d From Slide by D. Clunie

20. April 1, 2005DICOM Seminar – Singapore 2005 “Obstetric Ultrasound” “Mother of Fetus”=“Homer^Jane^^^” “Fetus Identifier”=“Fetus A” “BPD”=“27” “mm” “Findings for Fetus” Obs n Context Contains Obs n Context “Gestational Age”=“16” “weeks” Properties Inf d From “Inferred from” relationships may be by-value as well as by-reference, and are often more appropriate then “has properties” or “contains.” Slide by D. Clunie

21. April 1, 2005DICOM Seminar – Singapore 2005 Post-Coordination: HAS CONCEPT MOD Elaborates on meaning of Concept Name in Elaborates on meaning of Concept Name in –CONTAINER (headings) –CODE, TEXT, NUM … May: May: –qualify meaning further –describe meaning –provide translations Slide by D. Clunie

22. April 1, 2005DICOM Seminar – Singapore 2005 “Chest X-Ray” “Views”=“PA and Lateral” Modifier CONTAINER CODE “Full Description”=“This is a report on a two-view (PA and lateral) Chest X-Ray examination.” Modifier TEXT “Equivalent Meaning in Italian”=“Radiografia del...” Modifier TEXT Slide by D. Clunie

23. April 1, 2005DICOM Seminar – Singapore 2005 “Finding”=“Mass” “diameter”=“1.3” “cm” Properties CODE NUM “method”=“Smith” Modifier CODE Modifier “threshold”=“75” “HU” NUM “Finding”=“Mass” “diameter by Smith method @ 75HU threshold” = “1.3” “cm” Properties CODE NUM Post-coordinated... Pre-coordinated... Slide by D. Clunie

24. SR Applications

25. April 1, 2005DICOM Seminar – Singapore 2005 Three Base SR Classes Three base SR classes are defined to allow encode any type of structured information: Three base SR classes are defined to allow encode any type of structured information: –Basic Text SR –Enhanced SR –Comprehensive SR Distinguished by Value Types and Relationships supported Distinguished by Value Types and Relationships supported

26. April 1, 2005DICOM Seminar – Singapore 2005 SR Templates To define appropriate structure for specialized applications, DICOM defines templates. To define appropriate structure for specialized applications, DICOM defines templates. Templates may be applied to: Templates may be applied to: –Generic SOP Classes (Basic Text, Enhanced, Comprehensive) –Specialized SOP Classes (Mammo CAD, Chest CAD Templates may be extensible and non- extensible Templates may be extensible and non- extensible

27. April 1, 2005DICOM Seminar – Singapore 2005 Evidence Documents ….. Findings: Image Refs.: Header : Report Type: OB / Gyn BPD... ….. Storage Storage Commitment Query / Retrieve

28. April 1, 2005DICOM Seminar – Singapore 2005 Evidence Documents Measurements and coded data Measurements and coded data –DICOM SR document Created by either Acquisition Modality or Workstation Created by either Acquisition Modality or Workstation Produced during acquisition or post- processing workflows Produced during acquisition or post- processing workflows Interpreted along with the images Interpreted along with the images

29. April 1, 2005DICOM Seminar – Singapore 2005 Evidence Documents Examples Mammography CAD Mammography CAD Chest CAD Chest CAD OB-Gyn Ultrasound Measurements OB-Gyn Ultrasound Measurements Vascular Ultrasound Measurements Vascular Ultrasound Measurements Vascular Intervention Results Vascular Intervention Results Echocardiography Measurements Echocardiography Measurements

30. April 1, 2005DICOM Seminar – Singapore 2005 Typical Ultrasound SR Based on one of generic SR SOP Classes Based on one of generic SR SOP Classes Intended to precisely convey measurements and findings, relationships between them Intended to precisely convey measurements and findings, relationships between them Each specialized “report” uses its own template Each specialized “report” uses its own template

31. April 1, 2005DICOM Seminar – Singapore 2005 Legend for templates Value Type Concept Name = Value relationship Value Type Concept Name = Value Value Types CONTAINER, NUM, CODE, IMAGE … Concept Names and Values of type CODE are triplets Code Value Coding Scheme Designator Code Meaning (actually, just some text to evoke meaning to user) relationship Value Type Concept Name = Value Slide by D. Sluis

32. April 1, 2005DICOM Seminar – Singapore 2005 CONTAINER Finding Heading CONTAINER Finding Heading Typical Top Level Template Structure CONTAINER Document Title CONTAINER Patient Characteristics … … Template specified title OB-GYN, Adult Echo, IVUS Ultrasound Vascular, Cath/Hemo … TID 1002 Observation Context CONTAINER Summary … Other Context e.g. procedure CONTAINER … … Summary Findings CONTAINER Findings Heading Findings … Slide by D. Sluis

33. April 1, 2005DICOM Seminar – Singapore 2005 Document Headings CONTAINER Heading … Findings CONTAINER Document Title The heading may have semantics shared by children findings Specific: “Exercise Challenge” Generic: “Findings” “Laterality” = “Left” “Finding Site” = “Cerebral Vessels” CODE Concept Modifier has concept modifier contains Slide by D. Sluis

34. April 1, 2005DICOM Seminar – Singapore 2005 Discrete Numeric Findings CONTAINER Group NUM Measurement Diameter, Area, Volume, Blood Velocity, Indices, Ratios, Time Interval … or pre-coordinated concept: BPD, FL … CODE Modifier Concept has concept modifier CODE Modifier Concept has concept modifier Laterality, Finding Site, Anatomic Site Modifier, Cardiac Phase … contains Distributed semantics Slide by D. Sluis

35. April 1, 2005DICOM Seminar – Singapore 2005 Vascular Content Hierarchy CONTAINER Anatomy CONTAINER Findings CODE Laterality has concept modifier NUM Measurement CODE Topographical Modifier contains CONTAINER Vascular Report Document Title Section Heading Group Discrete Finding Minimum Concepts contains property Slide by D. Sluis

36. April 1, 2005DICOM Seminar – Singapore 2005 Vascular Templates CONTAINER Findings CODE Laterality has concept modifier TID 5103 Content Item Value Set Right, Left, or Unilateral Slide by D. Sluis

37. April 1, 2005DICOM Seminar – Singapore 2005 TID 5104 Vascular Templates CONTAINER Anatomy CONTAINER Findings CODE Laterality has concept modifier contains Content Item Value Set Slide by D. Sluis

38. April 1, 2005DICOM Seminar – Singapore 2005 TID 5104 Vascular Templates CONTAINER Anatomy CONTAINER Findings CODE Laterality has concept modifier CODE Longitudinal Modifier has concept modifier contains Optional specificity Content Item Value Set Slide by D. Sluis

39. April 1, 2005DICOM Seminar – Singapore 2005 TID 5104 Vascular Templates CONTAINER Anatomy CONTAINER Findings CODE Laterality has concept modifier CODE Branch Modifier has concept modifier contains Content Item Value Set Slide by D. Sluis

40. April 1, 2005DICOM Seminar – Singapore 2005 Vascular Templates CONTAINER Anatomy CONTAINER Findings CODE Laterality has concept modifier NUM Measurement CODE Topographical Modifier contains TID 5104 Content Item Value Set Slide by D. Sluis

41. April 1, 2005DICOM Seminar – Singapore 2005 Findings Origin and Context NUM Measurement SCOORD Inferred from IMAGE CODE Inferred from Equation or Table Inferred from has acquisition context Image Mode Image View CODE, TEXT Normality, Significance Normal Range, … has properties Coordinates Image NUM Inferred from Numeric dependency TID 300 Measurements Slide by D. Sluis

42. April 1, 2005DICOM Seminar – Singapore 2005 Dx Reports Based on DICOM SRBased on DICOM SR Allows to include without transcription: - measurements - image links - structured contentAllows to include without transcription: - measurements - image links - structured content Integrated with the imaging workflowIntegrated with the imaging workflow Friendly to XML implementationsFriendly to XML implementations Easy to export to the EPR (HL7)Easy to export to the EPR (HL7)

43. April 1, 2005DICOM Seminar – Singapore 2005 Simple Structure Minimal Structure : Coded Title and HeadingsMinimal Structure : Coded Title and Headings Full image links from specific sections of reportFull image links from specific sections of report Observation Context (who, what, when) may be section specificObservation Context (who, what, when) may be section specific

44. April 1, 2005DICOM Seminar – Singapore 2005 Added Measurements Simply adds Measurements to Simple Image Reports

45. April 1, 2005DICOM Seminar – Singapore 2005 Key Object Selection Documents Initiated by the desire to have simple Key Image Note Initiated by the desire to have simple Key Image Note Developed as generic “manifest” – collection of pointers to images (or even specific frames) Developed as generic “manifest” – collection of pointers to images (or even specific frames) Specifies intent of selection, simple textual note Specifies intent of selection, simple textual note Non-extensible template Non-extensible template

46. April 1, 2005DICOM Seminar – Singapore 2005 for referring physician Here you can see the renal osteopathy. For teaching Fibroosteoclasia

47. April 1, 2005DICOM Seminar – Singapore 2005 Different notes on different images Same note on different images for referring physician Here you can see the renal rupture. Note1 for referring physician This is the hematoma. Note2 for refering physician Here you can see the renal rupture. Note1 for refering physician This is the hematoma. Note2 for refering physician Hematoma everywhere Note3 for refering physician Hematoma everywhere Note3 for refering physician Hematoma everywhere Note3 for refering physician Hematoma everywhere Note3 for referring physician Hematoma everywhere Note3

48. April 1, 2005DICOM Seminar – Singapore 2005 Title of KOSD is a Code The note title defines the semantics of the reason of significance. Key Image Notes can be queried by code. The user comments are meant to be informal. Codes Of Interest Rejected for Quality Reasons For Referring Provider For Surgery For Teaching For Conference For Therapy For Patient For Peer Review For Research Quality Issue Reporting

49. April 1, 2005DICOM Seminar – Singapore 2005 Key Image Notes One use of KOSD is to attach « electronic post-it™ » to images to communicate: One use of KOSD is to attach « electronic post-it™ » to images to communicate: –specific examination events –image quality issues –consultancy KOSD can be stored in the archive and later retrieved KOSD can be stored in the archive and later retrieved

50. April 1, 2005DICOM Seminar – Singapore 2005 Workflow of SR objects Interpretation ….. Findings: Image Refs.: Header : Report Type: OB / Gyn BPD... ….. Dx Report Evidence Documents ….. Findings: Image Refs.: Header : Report Type: OB / Gyn BPD... ….. Radiology Report Impressions : Gestational Age... Key Image Notes

51. April 1, 2005DICOM Seminar – Singapore 2005 Patient Information Query A simple query that allows retrieve ANY patient information, provided SCP can format it using specified template A simple query that allows retrieve ANY patient information, provided SCP can format it using specified template Useful for retrieval of relevant information about patient, e.g., from HIS Useful for retrieval of relevant information about patient, e.g., from HIS Intended for use on Modalities and other equipment that is already DICOM enabled Intended for use on Modalities and other equipment that is already DICOM enabled

52. April 1, 2005DICOM Seminar – Singapore 2005 Patient Information Query Few matching keys: Few matching keys: –Patient Name –Patient ID –Template identifier Useful for retrieval of relevant information about patient, e.g., from HIS Useful for retrieval of relevant information about patient, e.g., from HIS

53. April 1, 2005DICOM Seminar – Singapore 2005 Patient Information Query Several Template identified for this purpose Several Template identified for this purpose –General Relevant Patient Info –Relevant Patient Info for Breast Imaging

54. April 1, 2005DICOM Seminar – Singapore 2005 Questions?