RADIOLOGY
RESEARCH
Current IHE Topics:
1. PDI,
Portable Data Imaging Integration Profile
2. MAMMO,
Mammography Image Integration Profile
Michael Flynn, PhD
Donald Peck, PhD
IHE
IHE: Integrating the Healthcare Enterprise
• “IHE is an initiative by healthcare professionals and
industry to improve the way computer systems in
healthcare share information.”
• “IHE promotes the coordinates use of established
standards such as DICOM and HL7 to address specific
clinical need in support of optimal patient care.”
AAPM 2008
• “Systems developed in accordance with IHE
communicate with one another better, are easier to
implement, and enable care providers to use
information more effectively.”
http://www.ihe.net/
2
IHE Member Organizations
AAPM 2008
IHE: Member Organizations
• 27 Healthcare Professional Associations
AAPM, ASTRO, RSNA, SNM …
• 104 Healthcare companies
• 8 Government Agencies
CDC, NIST, VA …
• 7 Standards Organizations
• 8 Healthcare provider organizations
• 8 Healthcare education & research orgs.
http://www.ihe.net/
3
IHE Domains
IHE: Active Domains
AAPM 2008
•
•
•
•
•
Cardiology
Eye Care
IT Infrastructure
Laboratory
Patient Care
Coordination
• Patient Care Devices
• Quality
• Radiation Oncology
• Radiology
• Mammography
• Nuclear Medicine
http://wiki.ihe.net/
4
Recent IHE Profiles
AAPM 2008
•
•
•
•
•
•
•
•
•
IHE Profiles relevant to Medical Physics
[NTPL-S] Normal Treatment Planning-Simple
[MMR-RO] Multimodality Registration, Radiation
Oncology
[TRWF] RT Treatment Workflow
[PWF] Post-Processing Workflow
[NM] Nuclear Medicine Image
[FUS] Image Fusion (in Trial)
[REM] Radiation Exposure Management (in Trial)
[MAMMO] Mammography Image
[PDI] Portable Data for Imaging
5
Outline
AAPM 2008
Part I
• [PDI] Portable Data for Imaging:
“provides reliable interchange of image
data and diagnostic reports on CDs for
importing, printing, or optionally, displaying
in a browser.”
Part II
• [MAMMO] Mammography Image:
“Specifies how Mammography images and
evidence objects are created, exchanged,
used and displayed.”
6
Learning Objectives
1. Understand from two examples how the IHE
profiles impact diagnostic radiology PACS.
2. Understand how to avoid problems when
exchanging image data between institutions.
AAPM 2008
3. Learn how recent mammography profiles can
be used when specifying systems for digital
mammography reading.
7
Topics
AAPM 2008
• AMA & patient safety
8
AMA A-06-539, 2006
AMA House of Delegates
2006 Resolution 539
Development of Standards for MRI Equipment and Interpretation
to Improve Patient Safety
• Whereas, Patients’ MRI data in CD format are not all compatible
with physicians’ computers; and
• Whereas, The MRI CD data is usually without a master key, legends
or localizing images so that the consultant cannot determine the
image sequence or the level of interest, creating significant patient
safety issues; and
• Whereas, Different MRI software arranges images in opposite
planes of view, left to right, superior to inferior,
inferior and vice versa; and
AAPM 2008
• Whereas, Errors can and do occur, potentially harming a patient,
when there is confusion as to the localization of pathology; and
• Whereas, Physicians must have the most reliable and standardized
data for best possible patient safety and outcomes; therefore be it
9
AMA A-06-539, 2006
AMA House of Delegates
2006 Resolution 539
Development of Standards for MRI Equipment and Interpretation
to Improve Patient Safety
• RESOLVED, That our American Medical Association convene a
meeting(s)
meeting(s) with representatives from MRI manufacturers, radiology
and other interested medical specialties, and imaging facilities,
facilities with
the goals of:
• (1) agreeing to standards in electronic imaging formats (e.g., left
to right, axial, coronal, sagittal);
AAPM 2008
• (2) developing standards of data manipulation and localization
consistent throughout all units for best interpretation of the
data; and
• (3) ensuring that each electronic format is equipped with the
capability of loading and launching its contained images on the
physician’s computer
10
AMA Board of Trustees, 2007
AMA B of T Report 30-A-07
Development of Standards for MRI .. to Improve Patient Safety
• CONCLUSION
AAPM 2008
• The lack of standardization of MRI information has important
patient safety, ethical, and liability implications for physicians
in a wide array of specialties and practice settings. …, the use
of nonstandardized imaging systems is a current threat to
high quality, medically appropriate, efficient, and safe care.
• Although the AMA-convened meeting of stakeholders was
productive, it was not conclusive. Meeting attendees
identified additional issues that must be addressed in order
to expedite standards setting for MRIs. Attendees also
identified other relevant stakeholders that should be a part
of future discussions.
11
AMA Board of Trustees, 2007
AMA B of T Report 30-A-07
Development of Standards for MRI .. to Improve Patient Safety
• RECOMMENDATIONS
• Recommend that stakeholders agree to a voluntary system of
MRI standardization and accreditation, and focus on
developing solutions across professional, payer, and industry
partners that promote interoperability and use of MRI data
and presentation and urge the development of a timetable
that would result in 50% interoperatibility within one year.
AAPM 2008
• If voluntary efforts fail and/or vendors and others are
reticent to act, advocate for mandated change through
legislative channels.
12
AMA A-08-523, 2008
AMA House of Delegates
2008 Resolution 523
MRI Safety and Standardization
•Whereas, This product is now becoming known as the “AMA Standard”
Standard”
digital imaging format for use by clinical care providers such as
cardiologists, orthopedists, neurologists, and neurosurgeons; and
•Whereas, This standard is seen as a model for creating better
patient safety by eliminating the current plethora of variable and
confusing programs; and
AAPM 2008
•Whereas, This effort, when adopted by software vendors, will still
allow for innovation and competition with expandable toolbars for
special features unique to themselves as well as for specialty needs;
and
•Whereas, Adoption will significantly eliminate the need for duplicative
studies by specialists who currently are unable to open and learn the
more than 70 variations of formatting data, creating delays and
inaccurate treatment plans; and
13
AMA A-08-523, 2008
AMA House of Delegates
2008 Resolution 523
MRI Safety and Standardization
AAPM 2008
•RESOLVED, That our American Medical Association continue
to promote and fund this successful effort for the next 18
months, convening key industry and specialty providers to
adopt this groundbreaking accomplishment (Directive to Take
Action); and be it further
•RESOLVED, That the results of this safety initiative be
reported back to the House of Delegates by the 2009 Interim
Meeting,
Meeting or sooner if goals are met prior to the 2009 Annual
Meeting. (Directive to Take Action)
14
Topics
AAPM 2008
• AMA & patient safety
• DICOM Media Standards
15
DICOM PS 3.10
DICOM Part 10
Media Storage and File Format for Media Interchange
• Defines a file format with a preamble containing
essential information normally exchanged during
association prior to DICOM image network
communication.
AAPM 2008
• Defines a directory file, DICOMDIR, that
indexes all images stored on the media.
16
AAPM 2008
DICOM Part 10 file format
The file metaheader contains
10 dicom tags (group 0002)
17
DICOM Part 10 DICOMDIR
“A single File with a File ID, DICOMDIR, shall exist
as a member of every File-set”
• It contains the DICOM Media Storage Directory
(see PS 3.3) which includes general information
about the whole File-set.
• Defines how to organize records to find images
of series of studies of patients.
AAPM 2008
• However, not mandatory and content ambiquous.
• Structured Documents as defined by an HL7
standard may be stored on DICOM Interchange
Media, and may be referenced from within the
DICOMDIR.
18
DICOM PS 3.11
DICOM Part 11
Media Storage Application Profiles
• This part of the DICOM Standard specifies
application specific subsets of the DICOM
Standard to which an implementation may claim
conformance.
AAPM 2008
• Such a conformance statement applies to the
interoperable interchange of medical images
and related information on storage media for
specific clinical uses.
• It follows the framework, defined in PS 3.10,
for the interchange of various types of
information on storage media.
19
DICOM PS 3.11
DICOM Part 11
Media Storage Application Profiles
Annex D - General Purpose CD-R and DVD
Interchange Profiles
Annex E - CT and MR Image Application Profiles
Annex H - General Purpose DVD with Compression
Interchange Profiles
AAPM 2008
Annex J - General Purpose USB and Flash Memory
with Compression Interchange Profiles
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DICOM PS 3.11, CT & MR
DICOM Part 11
AAPM 2008
CT and MR Image Application Profiles
STD-CTMR-MOD41
CT/MR Studies on 4.1GB MOD
STD-CTMR-CD
STD-CTMR-DVD-RAM
CT/MR Studies on CD-R
CT/MR Studies on DVD-RAM
STD-CTMR-DVD
CT/MR Studies on DVD
Handles single frame 8, 12 or 16 bit grayscale
and 8 bit palette color, uncompressed and
lossless compressed images.
21
DICOM PS 3.11, CT & MR
DICOM Part 11
General Purpose DVD with Compression Interchange
STD-GEN-DVD-JPEG
General Purpose DVD
Interchange with JPEG
STD-GEN-DVD-J2K
General Purpose DVD
Interchange with JPEG 2000
STD-GEN-SEC-DVD-JPEG General Purpose Secure DVD
Interchange with JPEG
AAPM 2008
STD-GEN-SEC-DVD-J2K
General Purpose Secure DVD
Interchange with JPEG 2000
Handles interchange of Composite SOP Instances such
as Images, Structured Reports, Presentation States
and Waveforms, either uncompressed or with lossless
or lossy JPEG[2000]
22
DICOM PS 3.12
DICOM Part 12
Media Formats and Physical Media for Media Interchange
Annex F - 120mm CD-R Medium (ISO-9660, level 1)
Annex J – UDF on 120 mm DVD-RAM Medium
Annex P – 120 mm DVD Medium
DVD-ROM/-R/-RW/+R/+RW, UDF or ISO-9660
Annex R – USB Connected Removeable Devices
FAT 16, USB 1.1 or 2.0
AAPM 2008
Annex V – ZIP File Media (PKWARE ZIP specs)
23
Topics
AAPM 2008
• AMA & patient safety
• DICOM Media Standards
• IHE PDI
24
IHE PDI
IHE Technical Framework
Volume III Transactions (Continued)
Revision 8, 30-Aug-2007
..
4.47 Distribute Imaging Information on Media
AAPM 2008
This section corresponds to Transaction RAD-47 of the
IHE Technical Framework. Transaction RAD-47 is used by
the Portable Media Creator and by media reading actors
(Portable Media Importer, Image Display, Report Reader,
Display and Print Composer).
..
25
IHE PDI
IHE Technical Framework
Volume III Transactions (Continued)
Revision 8, 30-Aug-2007
..
AAPM 2008
4.47.3 Referenced Standard
DICOM 2007 PS 3.10:
Media Storage and File Format for Data Interchange
DICOM 2007 PS 3.11:
Media Storage Application Profiles
DICOM 2007 PS 3.12:
Media Formats and Physical Media for Data Interchange
..
26
IHE PDI
AAPM 2008
IHE Technical Framework
Volume III Transactions (Continued)
Revision 8, 30-Aug-2007
..
4.47.4.1.2.1 Media File system and File Naming Restrictions
Since the DICOM content on the media is required to conform to
the DICOM standard, some of the requirements specified in PS
3.10, 3.11 and 3.12 are reiterated here for emphasis:
• Strict ISO 9660 Level 1 compliance
• No packet writing
• File and folder names referenced by the DICOMDIR file
restricted to 8 characters, uppercase letters, digits and
underscore only, with no extension
..
27
AAPM 2008
IHE PDI Added Value
28
IHE PDI Example
Content element(s)
Description
AAPM 2008
Identification Marking Marker with content per 4.47.4.1.2.2:
patient name
creation date
name of the institution that created the media
/README.TXT
File with content per 4.47.4.1.2.2
/INDEX.HTM
links to XHTML report and to another page (THUMBS.HTM)
with thumbnails that link the full resolution JPEG images
link to a launch point for the DICOM viewer in /VIEWERS
link to the list of importable data
/DICOMDIR
DICOM Directory file referencing all DICOM instances:
all DICOM images
the PS object
the SR object
29
IHE PDI Example
Content element(s)
AAPM 2008
/ DICOM/
/DICOM /12296
/DICOM /12297
.
.
.
/DICOM /NNNNN
/DICOM /98732
/DICOM /12312
Description
Directory with content per 4.47.4.1.2.2:
Image object 1
Image object 2
.
.
.
Image object N
DICOM Presentation State object
Basic Text DICOM Structured Report object
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IHE PDI Example
AAPM 2008
Content element(s)
Description
/IHE_PDI
/IHE_PDI /REPORT.HTM
/IHE_PDI /THUMBS.HTM
/IHE_PDI /T_12296.JPG
/IHE_PDI /T_12297.JPG
/IHE_PDI /I_12296.JPG
/IHE_PDI /I_12297.JPG
IHE PDI Web Content directory
XHTML report
navigation page that displays T_12296.JPG, T_12297.JPG
thumbnail of Image object 1
thumbnail of Image object 2
full resolution JPEG image for view within browser
full resolution JPEG image for view within browser
/VIEWERS/
/VIEWERS/VIEWER.EXE
Optional directory:
executable viewer
31
IHE PDI Changes
Change proposals to PDI are now being
prepared that aim to support the end user
experience in managing digital imaging
delivered via portable media.
They concern:
1. Expanding the supported media to include
DVDs and media with USB interface
AAPM 2008
2. Supporting compression of image files
3. Supporting the addition of file formats
that support video
32
Topics
AAPM 2008
•
•
•
•
AMA & patient safety
DICOM Media Standards
IHE PDI
Validation
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DRG specifications
www.dicom-cd.de/index.php.en
• CD media exchange
specifications similar to
IHE-PDI.
• Difference between the
DRG and IHE-PDI
specifications are
specifically described.
AAPM 2008
• IHE-PDI conformant
media meet DRG
specifications. The
reverse is not true.
• A harmonization effort
is in progress.
34
DRG Vaidation
DICOM WG10 Meeting, Berlin
Michael Onken , OFFIS
Phase 1:
Evaluation
free
Order
Data Acquisition
AAPM 2008
Interop.
Report
Certificate
yes
no
Short Test
Intensive Test
OK?
no
yes
Repeat?
yes
Interoperability Test
Certification
no
Phase 3:
Full test
Full
Test
Report
Initial Test?
Phase 2:
short test
Short
Test
Report
Abort
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DRG CD: Current status
DICOM WG10 Meeting, Berlin
AAPM 2008
Michael Onken , OFFIS
• April 2007, registration for DRG CD validation began
• OFFIS performs tests on behalf of DRG
• Company signs contracts with OFFIS
• OFFIS performs short/full test (phase 2 and 3)
• Certificates granted jointly by OFFIS and DRG
• Five companies already entered phase 2 and 3
• Another six companies in phase 1 (evaluation)
• First certified products expected by mid-2007
• Expiring of a DRG certificate
• Certificates granted for two full calendar years
(i. e. all certificates from 2008 will expire in 2010)
36
Outline
AAPM 2008
Part I
• [PDI] Portable Data for Imaging:
“provides reliable interchange of image
data and diagnostic reports on CDs for
importing, printing, or optionally, displaying
in a browser.”
Part II
• [MAMMO] Mammography Image:
“Specifies how Mammography images and
evidence objects are created, exchanged,
used and displayed.”
37
[MAMMO] Mammography Image
• Outlined in the IHE Radiology:
Mammography User’s Handbook
• Published March 2007
AAPM 2008
• Describes how to “solve” different aspects
of implementing digital mammography
38
MAMMO Profile
• Minimum contents for DICOM instances
• Image Data
• “for processing” and “for presentation” SOP Classes
• CAD data
• CAD SR
• Mammography Workflow
AAPM 2008
• Managing the process of creating, storing and using
Mammography Image content
• Basic display capabilities to suit specific
mammography review requirements
39
AAPM 2008
Mammography Image Profile
40
Mammo Image Profile
• Acquisition Modality
• FFDM & CR are required to create MG objects
AAPM 2008
• MG objects have 40 Attributes with specific
requirements that are mandatory in order to
comply with the Profile
41
Required Attributes of interest to Physicist
AAPM 2008
Acquisition
•
•
•
•
•
•
•
•
•
•
•
KVP
Exposure
Exposure Time
Filter Material
Anode Target Material
Body Part Thickness
Position Angle
Relative X-ray Exposure
Entrance Dose in mGy
Organ Dose
Date of Last Detector
Calibration
Display
•
•
•
•
•
•
•
VOI LUT Sequence
LUT Explanation
VOI LUT Function
Implant Present
Pixel Padding Value
Pixel Padding Value Range
Estimated Radiographic
Magnification Factor
42
AAPM 2008
Scheduled Workflow Profile
43
Scheduled Workflow Profile
• Image Manager/Archive
• Support both Modality Images and Evidence
Document Stored with Storage Commitment
• Support Query/Retrieve of both Images and
Evidence Documents
Acquisition
Modality
Evidence
Creator
[RAD 8] Modality Images Stored ↓
[RAD 10] Storage Commitme nt ↓
↓ [RAD 18] Evidence Document Stored
↓ [RAD 10] Storage Commitme nt
AAPM 2008
Image
Manager
Image
Archive
↓ [RAD 14] Query Images
↓ [RAD 16] Retrieve Images
↓ [RAD 44] Query Evidence Docume nts
↓ [RAD 45] Retrieve Evidence Docume nts
Image
Display
44
AAPM 2008
Portable data for Imaging Profile
45
AAPM 2008
Consistent Presentation of Images Profile
46
Mammography Images – “The Problem”
• Mammography image review relies on comparison
with prior image sets
• increases the occurrence of simultaneous review of
images from different systems
• Multi-vendor Mammography Systems
• Vary with detector technologies and sizes resulting
in varying image matrices sizes.
• Vary with contrast presentation methods resulting
in varying image presentation
• Mammography Image Review requires a minimal set
of display features
AAPM 2008
• zoom, LUT rendering, hanging protocols
47
AAPM 2008
Hanging Protocol – Incorrect
* adapted from D. Clunie, SCAR 2005
48
AAPM 2008
Hanging Protocols - Correct
* adapted from D. Clunie, SCAR 2005
49
AAPM 2008
Hanging Protocol
* adapted from D. Clunie, SCAR 2005
50
AAPM 2008
Hanging Protocol
* adapted from D. Clunie, SCAR 2005
51
AAPM 2008
Hanging Protocol
* adapted from D. Clunie, SCAR 2005
52
AAPM 2008
Hanging Protocol
* adapted from D. Clunie, SCAR 2005
53
Orientation of images
• The necessary DICOM attributes are mandatory
• Always present and correct - safety related issue
• Dependent on correct user input of laterality
• Technologist may need to verify correct laterality
after acquisition
• Should not try and setup the acquisition system to
encode the header to force the correct hanging
AAPM 2008
• Need to have vendor compliance with this IHE
Mammo Profile
54
Justification of images
• Radiologists like mammograms displayed
“back to back”
• Non-Mammography default layout is to
center image, rather than justify to one side
or the other
• Knowledge of desired layout, view and
orientation is encoded in image
AAPM 2008
• this should allow automatic justification
55
AAPM 2008
Image Justification
* adapted from D. Clunie, SCAR 2005
56
AAPM 2008
Image Justification
* adapted from D. Clunie, SCAR 2005
57
Image size
• Available display size may be different
than image pixel data size
• Images from different vendors or from
different detector modes in the same
product will have different pixel sizes
• All images need to display at their “true”
size, regardless of the image pixel size
AAPM 2008
• DICOM Imager Pixel Spacing attribute
specifies size of pixels in image
58
Example of different image sizes
Prior
AAPM 2008
Current
* adapted from D. Clunie, SCAR 2005
Prior
Current
59
AAPM 2008
Image size synchronization
* adapted from D. Clunie, SCAR 2005
60
Image Contrast Adjustment
VOI LUT
AAPM 2008
Linear LUT
61
Image Contrast Adjustment
• “For Presentation” Images shall have the
capability to apply all transformations
available, i.e.:
AAPM 2008
•
•
•
•
VOI LUT Sequence (0028,3010)
VOI LUT Function (0028,1056)
Window Width (0028,1051)
Window Center(0028,1050)
62
Image Display Functions
• Zoom
• Adjust zoom accounting for varying acquisition pixel sizes
• True size zoom accounting for display (monitor) pixel size
• Background unattenuated region suppression (termed “air gap”)
• When windowing the image, the detected background stays
black
• Image orientation
• Flipping according to Patient Orientation
AAPM 2008
• CAD rendering (using CAD SR)
• Annotations
• Set of required annotations to be displayed is defined
• ACR requires annotation be available on the PDI media
63
Film Print
• Print Composer/Server
• Support Print Request with Presentation LUT
• including the LIN-OD presentation LUT shape
AAPM 2008
• Use Requested Image Size to achieve “true size”
printing
• Support 12 bits printing
64
Questions?
AAPM 2008
?
65