The Electronic Healthcare Enterprise: A Primer on PACS & Integrated Workflow

DICOM Basics All I Really Need to Know!

January 2003

DICOM Basics
Finding your way through the DICOM Maze . . .

DICOM Basics DICOM Myths

DICOM Trust Genie

ME!

There is a DICOM Genie that will cure all my problems!

DICOM Basics What is DICOM?

Acronym for . . .
Diagnostic Imaging and COmmunications in Medicine

Name MRN Age

Patient has Study contains Series contains Image

A standard for data exchange A common information model

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DICOM Analogy
Making a phone call
Use your new Digital/1X enabled cellular phone to call for your messages. The call does not go through . . .

What is the problem?

The area you are in does not support Digital enabled phones - only analogue phones! Example of a low-level communication failure.

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You get to a land line and make the call . . .
Your message says to call Antonio Correlli in Italy requesting you to speak at his conference. You call Antonios office and the person who answers does not speak your language nor do you speak their language. It is now established the hardware works (compatible), BUT, languages do not match and so still no communications.

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Fortunately, Antonios cousin happens to be in the office and does speak English - so you are suddenly able to communicate. In preparation of your trip you ask what temperature it is in Italy so you can pack appropriately. The cousin says it is 37 degrees at this time of year. The plan is to pack warm clothes. You arrive 10 days later in Italy and it is very hot!

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Antonios cousin told you the temperature he is most familiar with; 37 degrees Celsius. Your assumption was Fahrenheit. What is the problem? Differentiation of units between communications.

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You informed Antonios office of your need for two beds in your room. They reply it will not be a problem. You arrive at your room with your wife and two children. The room has two single beds. What is the problem? They thought you were bringing a co-worker and did not understand your need to bring your spouse and children.

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Technology Communications Requires Compatibility in . . .
Hardware compatible phone systems Protocols common languages Definitions units of temperature Models definition of a room with two beds

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DICOM addresses image communications needs What information do you want to communicate? What do you want to do with that information?

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DICOM example courtesy of

Steven C. Horii, M.D., F.A.C.R.

Department of Radiology University of Pennsylvania Medical Center

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Why DICOM?
OPEN SYSTEMS To achieve a higher level of communication, leading to increased efficiency and better workflow Enables technology to work for the user To facilitate connectivity and interoperability of medical imaging equipment

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Who uses DICOM?
Modality Providers, PACS Component Providers, Interface Engines

Who talks DICOM?

Modalities, PACS, HIS & RIS via PACS Gateway/Broker and brokerless

Is there a DICOM Version 4.0 on its way?

No, the standard is constantly evolving changes every two months DICOM has removed the 3.0 version in favour of the acronym of DICOM

DICOM Basics
DICOM is Not: The answer to all your networking problems A networking architecture nor dependent on network architecture Available for all older modalities A static standard never more than 2 month old Easy to understand Does NOT Guarantee Interoperability Does NOT cover every operation of PACS such as image deletion, migration or pre-fetching

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DICOM is . . .
Based on conformance with the Open System Interconnect (OSI) reference model OSI defines a 7-layer protocol stack DICOM is an application-level standard, which means it exists inside layer 7 (the uppermost layer)

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DICOM provides:
Standardized formats for images A common information model Application services Services for communication across a network and on removable media Voluntary Conformance Statements does not confirm interoperability between different devices Protocols for communication Point to Point Communication Not a Broadcast Communication like HL-7

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DICOM Standard Sections
Part Part Part Part Part Part Part Part Introduction & Overview Conformance Information Object Definitions Service Class Specifications Data Structures & Semantics Data Dictionary Message Exchange Network Communications Support for Message Exchange Part 9 Point-to-Point Support Communications Support for Message Exchange Part 10 Media Storage and File Format for Media Exchange 1 2 3 4 5 6 7 8

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DICOM Standard Sections
Part 11 Part 12 Part 13 Part 14 Part 15 Media Storage Application Profiles Media Formats & Physical Media for Media Interchange Print Management Point-to-Point Communications Support Grayscale Standard Display Function Security Profiles

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DICOM Engineer

DICOM Engineer

and work on the standard some more!!!

DICOM Basics

All I technically really need to know . . .

DICOM Basics
To successfully use DICOM in a multivendor environment there needs to be a correct matching of services and roles. How is this achieved?

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DICOM Service Classes are divided into multiple functional areas. The most relevant Service Classes apply to the following functions:
Storage Query and Retrieve (Q/R) Print Secondary Capture Modality Worklist Management Modality Performed Procedure Step Storage Commitment Printer Configuration Interchange Media Storage

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DICOM Service Class Principles
Each Service Class is divided into Users and Providers Users use the service of another device Service Class Users - SCU Providers provide the service for users Service Class Providers - SCP

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DICOM Service Classes
DICOM Service Class Users (SCU) DICOM Service Class Providers (SCP) DICOM Service Class User Uses a service of another device
Example DICOM Workstation uses the service of a DICOM printer to print images

DICOM Service Class Provider Provides a service to another device

Example DICOM Archive provides the service of storing patient exams sent from MRI

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DICOM Storage
Most common Service Class Enables the exchange of images and other DICOM Objects between devices Consists of a DICOM Header containing patient demographics, specific attributes and instructions related to the image that is contained within that DICOM file from that specific modality Plus the image data that comprises that digital image Native DICOM interface facilitates complete image manipulation and post image processing

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DICOM Storage
DICOM Storage SCU DICOM Storage SCP Diagnostic Workstation

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DICOM Query/Retrieve
Facilitates the query of databases or other devices for information Facilitates the retrieval of a copy of the objects such as images from the current residence to a new desired location Example:
Query a MR for a specific patient and retrieve the patients exam from the MR to the Diagnostic Workstation

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DICOM Query/Retrieve
Diagnostic Workstation

DICOM Query SCU

DICOM Query SCP

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DICOM Print Management
Facilitates the print of DICOM files/images from any print location to any DICOM printer located on the network Transfers the instructions to print along with the data to print Example:
The Diagnostic Workstations sends 12 images from a MR exam composed in a specific order to the DICOM laser printer

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DICOM Print
Diagnostic Workstation

DICOM Print SCU

DICOM Print SCU Laser Printer

DICOM Print SCP

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DICOM Secondary Capture

Facilitates the capture of images from non-DICOM legacy modality using either frame-grabber technology or digital stream to compose a DICOM image file Does not acquire all the specific image attributes and instructions therefore offers limited image manipulation and no post-processing abilities Example:
Film digitizer acquires film-based images DICOM Interface Black Box enables legacy Ultrasound unit to share images using DICOM format with limited functionality

DICOM Basics
DICOM Secondary Capture
Diagnostic Workstation

DICOM Print SCU

DICOM Secondary Capture SCP

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Conversion of legacy systems to DICOM
Legacy Systems existing equipment that will not be replaced for a period of time Examples Ultrasound, CT, Angio, R/F

Two methods for conversion

OEM software upgrade Native DICOM
Modality provides a digital output of image data with all appropriate DICOM header fields populated

DICOM Black Box vendors Merge, Dejarnette, Kodak, etc.

Frame Grabbers 8 bit Does a video frame grab to digitize the image DICOM Secondary Capture 12 bit does not populate all appropriate DICOM header fields for image manipulation I.E. Window/leveling

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DICOM Secondary Capture
DICOM Secondary Capture SCU

Legacy Radiography/ Fluorography

DICOM Conversion Box

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Modality Worklist Management
Facilitates the transfer of patient demographic information between the RIS and a modality Eliminates the need to re-key data Eliminates human error during re-entry of data ensures data integrity Example:
Patient data is transferred from RIS through PACS Gateway/Broker to MRI unit

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Broker Environment

HL- 7 Patient Demographics

RIS

DICOM Modality Worklist Management

PACS Gateway/ Broker

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Broker-less Environment

HL - 7 Patient Demographics

DICOM Modality Worklist Management

RIS

Modality Archive

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Storage Commitment
Facilitates a device to request another device to accept storage responsibility for images forwarded Facilitates the modality to delete local images once the archive has committed to store images Example:
MR forwards a storage commitment message to the archive to confirm the storage of Mary Smiths MRI exam

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DICOM Storage Commitment

DICOM Storage Commitment

Modality Archive

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Modality Performed Procedure Step
Informs other devices (RIS and PACS) when specific patient exams are started, current status, and complete (aborted) Messages how many series, and images in each series in each exam, consumables, radiation dose delivered, etc. Example:
MRI sends MPPS message to RIS indicating Mary Smith MR head exam is complete to trigger scheduling and billing MRI sends MPPS message to PACS Archive indicating that there were 3 series Series 1 contain 112 images, Series II contain 78 images, etc. to ensure the archive has received all images and can store all images.

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DICOM Performed Procedure Step
DICOM Performed Procedure Step Triggers Schedule Update & Billing Information
RIS

PACS Gateway/ Broker

DICOM Performed Procedure Step

Modality Archive

Triggers the addition of the exam to a reporting Worklist confirms images for storage

DICOM Basics
Interchange Media Storage
Defines the formats for file storage; compression; what images are written to media Basic Cardiac Angiography is most commonly accepted/ implemented
ISO 9660 CD-R Lossless JPEG compression 512 matrix 8- bit multi-frame cardiac X-Ray Angiography

Additional DICOM specified profiles:

General purpose exchange of any uncompressed images on CD-R Basic and 1K Angiography images compressed with lossless JPEG on CD-R CT & MRI images compressed with lossless JPEG on CD-R and 130 mm MOD Ultrasound Images uncompressed or compressed on CD-R, 90 mm and 130 mm MOD

Additional profiles will be added to the standard as applications and media change

DICOM Basics
DICOM Interchange Media
Hospital A

Clinic B CD Burner

Referring Physician Office

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Image Object Definitions (IOD)
IODs describe the data structures that contain image data and information Example: CT is 12 bit grayscale vs. Ultrasound is 24 bit colour Two key IOD sub-classes Single Frame Images and Multi-Frame Images Affect two key PACS components Archive and Image Display applications RFP Requirement all current and future applications for PACS

DICOM Basics
Single Frame Images- Currently Available
Secondary Capture (SC) Scanned Films Computed Radiography (CR) Digital X-Ray (DR) Computed Tomography (CT) Magnetic Resonance (MR) Ultrasound (US) Nuclear Medicine (NM) Radiotherapy (RT) Image, Dose, Plan, Structure Set, Record Hardcopy Image (HC) Grayscale Softcopy Presentation State Store (PR) Positron Emission Tomography (PET)

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Multi-Frame Images Currently Available
Ultrasound (US) Nuclear Medicine (NM) X-Ray Angiography (XA) X-Ray Fluoroscopy (XRF)

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Additional IODs Identified
Intra-oral Radiography (IO) Hardcopy Image (HC) Visible Light (VL) Endoscopy, Microscopy, Photography Waveforms (WV), Including ECG, Hemodynamic and Audio Time based waveforms Structured Reporting (SR)

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Example:
MRI sends an exam to the PACS archive
DICOM Storage SCU

Archive receives the exam and stores it

DICOM Storage SCP

Archive sends the exam to the Diagnostic Workstation

DICOM Storage SCP

Diagnostic Workstation displays the exam to be interpreted

DICOM Storage SCU

RIS

Diagnostic Workstation DICOM Query Verification DICOM Print Referring Physicians DICOM Retrieve

Patient Demographics HL - 7

PACS Gateway/ Broker

DICOM Modality Worklist Management

DICOM Storage

PACS Archive

DICOM Secondary Capture

DICOM Storage

DICOM Conversion Box

DICOM Secondary Capture

Questions