Deploying DICOM in a HospitalClinic

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Deploying DICOM in a Hospital/Clinic

• Donald E. Van Syckle
• DVS Consulting, Inc.

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PACS is a Major Reason for Using DICOM

• When buying a PACS system you use DICOM to
  integrate
• Modalities (e.g CT, MRI, X-ray, US, NM, etc.)
• Workstations such as a 3-d workstation, CAD, etc.
• Printers (color and grayscale)
• Radiology Information Systems (RIS)
• Others

Commonly known by most hospitals
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What Features of DICOM are Needed

• Basic DICOM features
• Send and receive images
• Query and Retrieve from an archive
• Print images
• Download Patient information to modalities
• Not so basic DICOM features
• Secure storage of images
• Track image acquisition workflow
• Store images as viewed by clinician
• Generate and display reports
• Tag important images
• Others..
• Basics only commonly known by most hospitals

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Translate Features into DICOM Requirements

• This is a problem for hospitals as they do not
  know how to speak DICOM
• SOP Classes
• Information Objects
• Service Class User, Service Class Provider
• Storage Commitment
• Presentation State
• Others

NOT commonly known by most hospitals
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Help Hospitals Learn How to Speak DICOM

• First Fundamental Lesson - SOP Classes
• SOP Classes are DICOMs communication tools
• Saying DICOM Compliant does NOT really tell the
  story
• SOP Classes are what vendors implement and how
  hospitals integrate vendors
• Help Hospitals translate their required
  features and workflow into SOP Classes
• Question - I need my modalities to integrate
  patient information with my RIS
• Answer Ok, you implement Modality Worklist SOP
  Class

Important education for PACS Administrators
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Basic FeaturesDICOM Storage

• DICOM Storage push images
• Question for archives, workstations and
  modalities
• Vendors say We support Storage
• At a minimum it usually means, CT, X-ray, CR, MR,
  US, Secondary Capture (for a PACS)
• But you need to ask, does it include MG (mammo),
  NM, PET, Color US, Cardiac Echo (US multi-frame)?
• Specific to the modality (e.g. a CT image is NOT
  a US image)
• Send CT Images CT Image Storage SOP Class SCU
• Receive CT Images CT Image Storage SOP Class -
  SCP

Image Send
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Basic FeaturesQuery/Retrieve and Print

• Query/Retrieve pull images from archive
• Question for archives, workstations and some
  modalities
• Many PACS do not use DICOM when using own
  workstations
• Q/R is often only used with 3rd party
  workstations, such as 3D, NM workstation, etc.
• Workstation asking query
• Study Root Query/Retrieve Information Model
  Find SCU
• Archive being queried
• Study Root Query/Retrieve Information Model
  Find SCP
• Print one simple question, Black/White
  (grayscale) and/or Color (RBG)
• Modality or Workstation Basic Grayscale Print
  Management Meta SOP Class SCU
• Printer - Basic Grayscale Print Management Meta
  SOP Class SCP

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Basic FeaturesModality Worklist

• Download HIS/RIS Data to Modality
• Patient Name/ID, Accession Number, procedure
  code, Study Instance UID, etc.
• Also requires Health Level Seven (HL7) Standard
• Patients (ADTs), Order (ORM).
• RIS or PACS who do you pick?
• RIS or PACS
• Modality Worklist Information Model Find SCP
• Modality
• Modality Worklist Information Model Find SCU

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Modality WorklistMore Detailed Questions

• How does the modality refresh its list?
• What does the modality convey in image header
  from MWL?
• What happens when tech determines order is wrong
  and needs to correct?
• How is RIS changed and how does that effect HL7
• Cancel order/new order, update order?
• Did it change the accession number or study
  instance UID?
• How do I clean up the errors in my HIS/RIS/PACS
• IHE Patient Information Reconciliation?
• Manual clean up?

Questions effect MWL and DICOM is becoming a
little more complex
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More Advanced DICOMStorage Commitment

• Guarantee secure storage of data on archive
• Real feature is to manage disk space on modality
• Automatically delete images on modality?
• User interfaces makes deletion easy?
• Modalities do Storage Commitment but do nothing?
• Modality Storage Commitment Push Model SOP
  Class SCU
• Archive - Storage Commitment Push Model SOP Class
  SCP

Difficult for hospitals to understand because
they dont see the workflow
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More Advanced DICOMGrayscale Softcopy
Presentation State (GSPS)

• Store and view images as seen by clinician
• Also capture annotations, overlays, measurements,
  flip,etc.
• Look the same on all workstations
• Some detailed questions
• Who has permissions to store GSPS into medical
  record?
• Does PACS use GSPS or implement in proprietary
  ways? (important if you wish to view on 3rd party
  workstations)
• What types of images can workstation perform
  GSPS?
• Do monitors automatically calibrate to GSPS or
  manual?
• Create GSPS Workstation/Modality
• Grayscale Softcopy Presentation State Storage SOP
  Class SCU
• Store or View GSPS Archive/Workstation
• Grayscale Softcopy Presentation State Storage SOP
  Class SCP

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More Advanced DICOMKey Object Selection (Key
Image Note)

• Mark images as significant images (KIN)
• Documents why they are significant and can
  apply GSPS
• Uses DICOM Structured Report (SR)
• Some detailed questions
• How do clinicians want to use KIN?
• Who has permissions to store KIN into medical
  record?
• Clinicians, Emergency Room, Specialists
• Does PACS use KIN or implement in proprietary
  ways? (important if you wish to view on 3rd party
  workstations)
• Create Key Image Note - Workstation
• Key Object Selection Document SOP Class SCU
• Store or View Key Image Note Archive/Workstation
  
• Key Object Selection Document SOP Class SCP

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More Advanced DICOMDICOM Structured Report (SR)

• Covers many areas in DICOM, most have been
  labeled Evidence Documents by IHE
• Some examples
• Key Object Selection Document (Key Image Note)
• Mammography and Chest CAD
• OB-GYN Measurement Reports
• Simple Image and Numeric Reports
• Cath Lab reports
• Vascular Ultrasound
• Other

DICOM SR used to supplement image information
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DICOM Used to Integrate into PACS

• Workstations 3D, Nuclear Medicine, CAD, Quality
  Assurance
• Various Image Storage SOP Classes SCU/SCP
• Study Root Query/Retrieve Information Model
  Find SCU
• Study Root Query/Retrieve Information Model
  Move SCU
• Basic Grayscale and/or Color Print Mgt Meta SOP
  Class SCU
• Grayscale Softcopy Presentation State SCU/SCP
• Various DICOM SRs SCU/SCP
• Others
• Digitizers
• Secondary Capture Image Storage SCU
• Modality Worklist Information Model Find SCU
• Storage Commitment Push Model SOP Class SCU

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DICOM Conformance Statements

• Documents how vendors implement DICOM into their
  products
• Required, Public, and often found on Web sites
• Follows a well defined format
• Facilitates comparisons of product
  implementations
• Detailed information aids a knowledgeable DICOM
  person greatly

The problem it is hard to read unless you learn
how to speak DICOM
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DICOM Conformance Statements

• At a minimum, hospitals (PACS administrators)
  need to read SOP Class Tables

Compare a products SCU table with anothers SCP
table
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DICOM Conformance Statements

• New DCS format Executive OverviewGoal to
  explain DICOM understandable terms

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DICOM Conformance Statements

• After the overview, it really requires real DICOM
  experience to read the DCS
• Implementation
• Integration
• Training
• Know how to read DICOM Standard
• Need to learn DICOM terms and concepts
• SOP Classes, IODs, SCU/SCP
• Abstract Syntax, Presentation Context
• Modules, Attributes, Context Tables..

Vendors, Consultants, Training Helps
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Beyond DICOMReports into PACS

• DICOM SR not typically used for Clinician
  Report(I.e. Radiologist Report)
• Report owned by department information system
  (such as a RIS) however hospitals want to view on
  workstations
• Voice Recognition solutions speed delivery of
  report(but usually take longer to create and
  edit)
• Solutions vary between PACS but most implement
  HL7 ORU messages and store in proprietary ways
  into PACS
• This solution means a 3rd party workstation
  cannot view report
• another question Can other workstations besides
  PACS review reports?

HL7 V3 Clinical Document Architecture (CDA)
should open up reporting documents
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Beyond DICOMNetworking Skills Required

• DICOM uses standard network technology and this
  skill is very important (relationship with IT)
• Need to understand
• TCP/IP, routers, hubs, switches, cables
• DICOM network configuration is prone to human
  error
• AE Title, TCP Port Numbers, IP Address
• Archive technology important
• Databases, RAIDs, Magnetic Tape
• How much on-line storage do you need

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Integration Services

• Professional services are offered by PACS vendors
  and consultants
• Vendors understand their products and can
  typically tailor the integration better to their
  systems
• Independent consultants typically understand many
  PACS (not just one solution) and can typically
  better employ best of breed solutions and help
  with finger pointing

Both types of consulting services can greatly
increase the probability of a successful outcome
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DICOM a Proven Success Since 1993

• Thank Youand Enjoy the Conference!