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Digital Imaging and Communications in Medicine (DICOM)
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Supplement 169: Simplified Adult Echocardiography Report
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DICOM Standards Committee
1300 N. 17th Street, Suite 900
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Rosslyn, Virginia 22209 USA
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Version: Working Draft, Mar 21, 2014
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Developed pursuant to DICOM Work Item 2012-11-A
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Table of Contents
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Scope and Field .............................................................................................................................................. 3
Concepts ......................................................................................................................................................... 3
TODO .............................................................................................................................................................. 5
OPEN ISSUES ................................................................................................................................................ 6
CLOSED ISSUES ......................................................................................................................................... 11
Changes to NEMA Standards Publication PS 3.2-2011 ............................................................................... 15
Changes to NEMA Standards Publication PS 3.3-2011 ............................................................................... 15
Changes to NEMA Standards Publication PS 3.16-2011 ............................................................................. 16
SIMPLIFIED ADULT ECHOCARDIOGRAPHY TEMPLATES ............................................................... 16
TID 5QQQ
Echocardiography Procedure Report ................................................................. 16
TID 3QQ Pre-coordinated Echo Measurement ............................................................................ 18
TID 3QZ
Post-coordinated Echo Measurement .......................................................................... 18
CID newcid1
Echo Derivation .................................................................................................. 21
CID newcid2
Echo Finding Subjects ........................................................................................ 21
CID newcid3
Echo Measurement Type.................................................................................... 21
CID newcid4
Echo Measured Properties ................................................................................. 22
CID newcid0
Core Echo Measurements .................................................................................. 23
Changes to NEMA Standards Publication PS 3.17-2011 ............................................................................. 28
ANNEX ??: Mapping Guidance? Population Guidance? (Informative) ........................................................ 29
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Scope and Field
This supplement to the DICOM Standard introduces a simplified SR template for Adult Echocardiography
measurements.
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It provides similar content to that of TID 5200 while addressing details that were the source of
interoperability issues; in particular, varying degrees and patterns of pre- and post-coordination, multiple
codes for the same concept and numerous optional descriptive modifiers.
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The new template will be driven significantly by currently documented ASE Guidelines and Standards.
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Concepts
This text introduces concepts, principles, guidelines and convenient terms discussed by the committee that
influenced the contents of the supplement. It may help reviewers better understand the material. If it still
appears to be useful to implementers when the supplement moves to letter ballot it will likely be
66 incorporated into a section in Part 17.
64
Anatomic Sections: Were included as containers and headings in the old template to facilitate layout of
printed/displayed reports. These were a source of problematic variability and are not used in the new
template. Receivers may choose group measurements based on Finding Site or some other logic as they
70 see fit. By configuring this at the receiver it can be consistently organized in one place rather than having
to synchronize the behavior of many carts. SR objects are considered acquisition data/evidence. When
72 the findings are transcoded into CDA reports sections will likely be introduced in the CDA as appropriate.
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Finding Site: The location at which the measurement was taken. While some measurements will be a
measurement of the structure of the finding site itself, other measurements will measure something like
flow in which case the Finding Site is simply the location, not the actual subject of the measurement (e.g.
76 at a valve, be clear when it is the velocity of the blood, not the velocity of the valve leaflets).
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Method: Allows distinguishing between two measurements that tell you the same thing, derived in a
different way. If two measurements tell you something different, it's not a method.
Indexing: All Core Set measurements that index against BSA, and all post-coordinated measurements
that reference (LN, 8277-6, Body Surface Area) as their index are using the value recorded for BSA in the
Patient Characteristics TID. The TID can encode the equation used to derive the BSA.
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Myocardium refers to the tissue from the endocardium to the epicardium and includes the intraventricular
septum.
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Useful Tables:
CID 12222
CID 12224
CID 12226
94 CID 12227
CID 12233
96 CID 12236
CID 12250
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Orifice Flow Properties
Ultrasound Image Modes
Echocardiography Image Views
Echocardiography Measurement Methods
Cardiac Phases
Echo Anatomic Sites
Cardiac Ultrasound Common Linear Measurements
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Future Meetings:
2014 AIUM Las Vegas, NV 3/29/2014 – 4/2/2014
2015 AIUM Orlando, FL 3/21/2015 – 3/25/2015
102 2016 AIUM Las Vegas, NV 3/19/2016 – 3/23/2016
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TODO
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DONE
Choose between TID 5201 and TID 3602
3602 (used by FPC Echo) is more complete and has more mandatory elements
Go with 3602 – it means that technically a cart shouldn’t send an object without requiring the tech
to input a height weight.
Review Stress Echo template for template elements to consider/include
Review CID 12280 and 12281
Confirm if ASE specifies units and whether those match
Propose additional measurements “common to most vendors” – Paul will post an initial
spreadsheet for consideration.
Submit a CP to change “Image or Spatial Coordinates” to “Spatial Coordinates or Image”. The
former was confusing for some people, implying it was Coordinates that could either be image
coordinates or spatial coordinates.
Consider how consuming systems will handle Derivation (Min/Max/Mean/Selected).
e.g. if you have three measurements and a fourth that says ”Mean”, is it clear what to do.>>
<<Seems reasonable for consumers to accommodate this>>
Gopi – Diagram the four viewpoints (New Cart, Old Cart, New Receiver, Old Receiver) and how
they will use/understand/respond to new and old SRs when doing association negotiation and/or
extended negotiation and/or parsing the objects.
Earl – Consider how a 5200 parser would respond to being given a new object. It would be nice
if it provides some basic success.
Get New LOINC Codes
If we want to “improve” the definition of a LOINC code, we have to get a new code assigned to
our improved definition. Retiring the old code is optional.
PS 3.16 Annex G says that LN 11726-7 Peak Velocity is synonymous with Peak Systolic Velocity.
Is that true in LOINC? Is that what we want?
WG-6 Questions:
PS 3.16 Annex H seems to redefine the code meaning of many LN codes. What’s the history?
(Added to get more clear short names, ask Harry for details. OK for us to use too.)
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OPEN ISSUES
Scope
S1
Should TID 5200 (the original) be retired when the new TID is introduced?
A: Yes.
Probably depends on how we support vendor-specific and user-defined.
Should hopefully retire it. We can still ship products that are capable of sending 5200, but new
products probably shouldn’t bother. If we offer two Adult Echo templates, some percentage of
novice vendors will choose 5200 without understanding the implications.
On the other hand, if our “fallback” for non-Core measurements that can’t be coded in the
structured post-coordinated bucket is to suggest they be sent with 5200 then we shouldn’t retire it.
Maybe they can use generic Comprehensive SR.
S2
Is it necessary/practical to guarantee convertibility from Old-to-New SOP?
A: Guarantee, no.
We are trying to make sure that the new SOP is reasonably powerful so it may be reasonably
tractable.
Doing so would prevent making new information mandatory which would also restrict harmonization
with newer templates.
Could allow systems to output both and let recipients choose to use the new?
Note that a system that can’t fill in values could omit the measurement from the converted new
SOP.
S5
Have other international groups published “Core Set” papers we should include?
Get Public Comment input
- Look into JIRA (Japan) and EAE (Europe)
- (Japan signed on to at least one of the ASE papers)
S6
What is needed to address both the processing and reporting systems on the consuming side?
Processing may want to tweak/select direct measurements and recalculate derived measurements.
Reporting might want to just reach in for a single value.
Need to encourage adoption.
Note that some of the job is for the consuming system to filter/simplify based on its needs.
Possible approaches:
- have a “summary” section
- use a “Preferred” flag to highlight the values for simple consumers
- output two instances of the same IOD from the cart, one is sparse/summary (reporting), the
other is more complete (processing).
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S7
How much do we support “vendor-specific” measurements (beyond core)?
Common measurements could be added to the Core Set.
“Well behaved” measurements can go in the Post-Coordinated Measurement container.
That should handle a large number of typical variations. By using the spreadsheet to model the
core set, we’ll have a good set of “basis axes” for the Post-Coordinated Measurement container.
So what should we do about measurements that don’t fit in the Post-Coordinated bucket.
- We could add a “freeform” container with few rules
- We could add an “Additional Modifier Code Sequence” to the Post-Coordinated bucket or
simply allow it to be extended
- We could tell them they just have to make a Private SOP Class.
The danger is that “lazy implementers” might just put everything in the freeform section or otherwise
abuse the tools.
There is of course a tradeoff between interoperability/simplicity and being able to use this for ANY
measurement (particularly “ambiguous codes” that are 1-1 coordinated between sites and vendors)
What information gets recorded (eg display/screen name of the measurement on the original cart)
How does it get slotted into the database, and who does that configuration?
S8
Can the vendor-specific strategy also be used for user-defined measurements?
That’s the intent
Maybe this is the root case and vendor-specific is just user-defined where the vendor is a user?
Maybe the vendor presets are just too hard to navigate.
Note that part of the problem is that these may not be well modelled. They “just want a label and a
number” but then later they want intelligent handling of the data they have handicapped.
S10
What kind of a process should WG12 have (if any) to monitor and react to updates from ASE?
S11
S13
How/Should vendor education be addressed?
The new template makes finer distinctions than the old template. To reduce the validation load on
the consuming systems, confidence is needed that the producing system is in fact taking the
distinctions into account. E.g. Systole, vs End Systole, vs Atrial Systole. So if the pre-coordinated
code means exactly End Systole, then don’t use the pre-coordinated code if the system measures
at mid-systole.
Is TEE excluded?
Having View=mdc for most measurements means TEE is not excluded and that is good. Check if
there are TEE issues for ones where View is not mdc.
Structure
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St2
Should the list of Core Measurements be included directly in TID rows, or dereference through CID
tables?
Consider TIDs. This would allow making some measurements conditional on other measurements
and explicitly making units required, etc.
Since there are 150-200 core measurements, might want to break out a few sub TIDs to make it
more readable/manageable.
On the other hand, CIDs are much more readable for implementers.
St1
Create a new SOP Class?
A: Yes.
We will create a template and will give it a new UID. This allows negotiation for the new template
(and allows systems to reject the new template if they don’t support it). The contents still parse and
process as SR (i.e. dsrdump still works, parsers don’t need to be changed, etc.)
Of course the template can still be sent inside a generic SR SOP Class.
Could this be handled with extended negotiation at the template level? Has anyone implemented it?
Q (Earl) Would a generic or flexible 5200 parser handle the new template OK? If so, it’s a nice
avenue of legacy reader support.
Gopi – will diagram how this will work with New Sender – New Receiver, New Sender (how does
the sender know it is getting a new one, how does the sender know it’s a New R that handles it not
an Old R that drops it) – Old Receiver, Old Sender – New Receiver, Old Sender – Old Receiver.
** Proposing constraint that samples must be consistent with the stats
** Update the Selector/Derived as shown on the diagram on the whiteboard
Within the container (Pre-Coord; Post-Coord), should measurements be sorted by code?
A: No.
It would be a predictable/non-random order that would be simple to implement.
It would group multiple instances of the same measurement together.
But parsers have to handle any order anyway, and it’s a simple run through to sift for what you
need.
Should the Image Library container be MC based on use of REFER in the children?
It’s simplest to make it optional. Really the recipient can construct the library themselves?
The purpose is to describe the images, not just list them. So maybe it doesn’t really serve a
purpose here.
Do not use references from the children to the image library – it’s complex for the parser. Better to
just have a direct “by value” reference in the measurement to the specific image instance.
Or should the use of REFER or INFER be mandated below?
(Ann looking into more detail)
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Should the Core Spreadsheet be maintained?
The sorting and filtering and parsing could be very handy for some.
The details would not otherwise be included in the DICOM standard.
Consider somehow fitting it into Part 17?
C9
Coding
Do the Cardiac Phase/Cycle semantics refer to Mechanical or Electrical and the Chamber or the
Organ?
Most clear is to refer to the chamber. And be clear in the definition about time point vs time period
and if needed time point at the end, not mid.
Could allow that if not fully specified, the default chamber is the Left Ventricle, i.e. End Systole =
Left Ventricle End Systole
If just systole or diastole is referred to, it means the period of the full duration of systole or diastole.
Often the code meaning will refer to Systolic X.
Pre-coordinate but work off the codeset in CID 12233 (but need clear definitions, does SNOMED
provide them?)
C10
Should missing codes be added in LOINC, SNOMED or DICOM?
Most of the existing (mostly) pre-coordinated codes are from LOINC, most of the existing postcoordinated concepts are from SNOMED. When fully pre-coordinated codes exist in both, let’s
prefer LOINC. If we don’t have LOINC, but we do have SNOMED, do we still ask LOINC for a new
code, or do we just use the SNOMED? YES. If you need a LOINC measurement code, ask for
one.
For now, use DICOM Supp placeholder codes and consider this closer to or during Public
Comment.
Need to review the new LOINC codes introduced in Sup 78 and use if possible.
C11
How should values that have to be estimated by the operator/clinician be addressed?
Need to allow the method for some measurements to be “estimated”.
Should perhaps mandate that if there are derived/calculated values, then all input values must be
included in the SR as well so it will be recorded if some inputs are estimated.
May also need to use the tools to point specifically to the values that were used in a given equation.
C13
Does Hand Grip and Valsalva need to be encoded (in association with specific measurements)?
Maybe yes. This is significant for Mitral E Velocity. (and others?)
C14
What needs to be captured about the package/pre-processing before the measurement?
E.g. if presence of special speckle tracking or proprietary segmentation, where does that fit in?
Or is this about a unique method or a unique measurement vs about the package that was used.
Might need a method modifier.
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Should we try to unify/converge units across modalities?
A: No.
I.e. when the same measurement is made in CT, MR, XA, …
Probably outside scope for this supplement, but we have been sloppy and someone should tackle
it.
Do we need to record Stress Stage in a pre-coordinated way for each or specific measurements?
Is this better recorded at a higher level in the object? (would force separate objects for different
stages)
Is Stress Echo in scope for this Object? (It’s not handled in 5200 now – although it references 5202
which references the Echo section) Note that Wall Motion Scoring is not really used outside of
Stress. So do we want to bring in 5202 to our template. And if so, how does it work. It would start
breaking up into sections again.
How can a consumer identify/strip out derived values (that could be re-derived if needed?) vs
measured values?
Do we want to differentiate equation/derived “measurements” from those measured directly?
The derived don’t exactly have a view/mode/etc, or may be derived from elements in several
views/modes/etc.
Method modifier?
It’s what we add new ones of most.
Sometimes it matters.
Consider the difference between a value, like velocity, that can be directly measured or can be
derived from an equation. In the case of precoordination this is less of an issue since we simply
explain which it is, but needs consideration for user-defined.
Adding new methods has a rollout challenge
Note that DCM 125212 is underspecified relative to the other codes that follow it.
Supplemental information
No modifiers on core measurements
"For some attributes (e.g. the Image View for the Right Ventricule Free Wall Thickness) multiple
valid values exist and we don't really care which it is (mdc).
Prohibit senders from sending it (rather than allowing senders to code it and receivers to ignore it).
Most importantly, we don't want transmission to fail because the receiver has trouble handling it."
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Should ratios and indexes be modelled in the post-coordinated structure?
Representing a simple numerator/denominator relationship between two values might be tractable
and might address a lot of vendor and user-defined variations (e.g. wishing to index against BMI
instead of BSA, or taking a ratio of two values)
Significant resistance noted. Will evaluate once a structure for modelling this is proposed.
Review how TID5223 modelled indexes.
How should Indexed Measurements (e.g. by BSA) be encoded?
Is it fair to say that whenever an indexed measurement is stored, the unindexed measure is also
stored? (e.g. LVID & LVID/BSA)
We should likely require that whenever an indexed measure is stored, the index itself (BSA) also be
stored with the value that was used in the indexed measure. Are there cases where we might use
different values of BSA in the same acquisition set?
One approach would be to store the base value and the index and if anyone wants the indexed
value, they could compute it in a single step. That would be fine for databases and analysis
packages, but would it work for display overlays and report insertions?
Do we add an “Indexed by” attribute, and record the code for the index used, eg. BSA. Then the
Measurement could contain the nature of the base measure, as long as consumers are smart
enough to look at the Indexed by column to understand why a “diameter” measure is in cm/m2.
In the case of pre-coordinated codes, the Indexing is built into the concept.
Average of Septal & Lateral values used instead of separately? E:eprime ratio
CLOSED ISSUES
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Scope
S3
Should Cardiovascular History be reiterated in the Echo SR?
A: No.
If the worklist provides it, it might be OK to suggest it be copied, but otherwise, the Cart is not likely
to have access to this information unless the tech does manual data entry, in which case, it’s not
clear that the cart console is the best place/GUI to be typing it in. It would be better done by a
clerical person on another system (e.g. the HIS, the RIS or the CVIS).
Note that Indications have been included. Perhaps the same logic applies to those.
S4
What is in the core list of measurements?
A: The full set of concepts from the ASE papers, as collated in the ASE Core spreadsheet.
(about 150 currently) plus additional measurements proposed by vendors and found to be
reasonably “common”.
No new papers have come out recently so the original work stands (spanning 1989ish to 2012ish)
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S12
Should advanced equations be modelled?
A: No.
Too complex and open ended.
Should the vanilla template retain a few congenital codes?
A: Yes.
Want to allow a vanilla workup to record a few of these measurements without invoking the more
sophisticated Fet/Ped/Con template which supports a more complete workup. Forcing them to
switch to the FPC template could be problematic since some sites don’t expect that and won’t have
it configured.
The current list in the spreadsheet is sufficient.
Structure
St3
Should the TID Row Order be Significant or Insignificant?
A: Assume insignificant until a need is found for it to be significant.
Order significant would be a harder for producer but might be easier for consumers.
Coding
C1
Should the code meanings use uniform terminology or colloquial terminology?
A: Use uniform but don’t be pedantic.
Colloquial is somewhat random which might lead to coding errors. Use uniform terms unless they
get too unwieldy. In any case, Apps can display them in the GUI/report any way they like.
C2
Bias toward pre-coordination or post-coordination?
A. Pre-coordination.
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Make it mandatory
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Do not include modifiers
[Structure/Location/Finding Site] [Observable][Flow Direction?] [Cardiac Phase] [Method] etc
See Google Doc.
Would it be bad to allow lots of modifiers that reiterate semantics in the pre-coordinated code to
allow “dumb” applications to handle new codes in some way (e.g. add to the
For example some measurements will have “View not specified” since we don’t care and don’t want
codes for all the different variants.
<Do we allow a measurement to add a detail like view to a NOS code>
But maybe we say that user measurements are completely post-coordinated and all modifiers are
mandatory. But what process is this facilitating, and would it be better just to do the Conformance
statement.
Might want to have a user-defined-measurement flag (beyond the private coding scheme?)
And we might want to put the vendor and user defined measurements in another group/container.
Note that we will have to enforce some level of discipline on the user when creating/configuring new
measurements.
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C3
How can reasonable consistency of units be achieved?
A: Stick to what is stated in ASE, but flag & discuss deviations from the following:
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

Distance in cm
Area in cm2 (except BSA in m2)
Velocity in cm/s
Time in ms
Volume in ml
Mass in g
Flow in ml/s
Systems are welcome to do conversions when displaying measurements to users if some
sites/users have preferences that differ from the standard.
C4
Should $DerivationParameter, $Equation, or $Table be encoded?
A: No.
They add complexity. Few creators use them. Few consumers support them (or else they get
derailed when they are provided).
For the core set the equation is pre-coordinated in the measurement. For user-defined
measurements, it seems unlikely that consumers would parse/recomputed the value even if the
equation was included in-band, rather than just documenting it out of band. Arguably, equations
could be stuffed in the Code Meaning of the $Method (which is done in a couple of places in Part
16), since the only real user might be the clinician wanting to know what equation was used, but
usually they are named, not expressed.
Anyone with a concrete Echo use case for these should present it. (They are used somewhat in
OB for the GA calculations)
C5
Should $Quotation be encoded?
A: No.
It adds complexity. Few creators use it. Few consumers support it (or else they get derailed when
they are provided).
Anyone with a concrete Echo use case for these should present it.
C6
Should $Equivalent Meaning of Concept Name be encoded?
A: No.
It adds complexity. Few creators use it. Few consumers support it (or else they get derailed when
they are provided).
Anyone with a concrete Echo use case for these should present it.
C7
Should $Laterality and $Topographical Modifier be encoded?
A: No.
Don’t need them for Cardiology (although vascular does). Left/right chambers are not laterality.
Proximal/Distal/etc is not relevant.
Anyone with a concrete Echo use case for these should present it.
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C8
C12
Should $Measurement Properties be encoded?
A: No.
It adds complexity (normality codes, level of significance, statistical properties, ranges, range
authorities). Few if any creators use it. Few consumers support it (or else they get derailed when
they are provided).
Anyone with a concrete Echo use case for these should present it.
The Selection Method concept is useful though. It will be migrated into the Derivation.
Do Flow Direction semantics refer to the viewpoint of the probe or anatomy?
A: Anatomy is most clinically useful (see CID 12221).
While the probe knows towards/away, the app must help figure out the anatomic.
How should different BSA calculation methods be handled?
A: Core Set will code DuBois.
Other methods can be handled as vendor/user-defined. The receiver can also compute alternate
indexes.
What does Finding Site mean (in Post-Coordinated measurements)?
A: The nominal location where the measurement was taken. It may or may not be the
subject of the measurement. The latter is coded in Finding Subject.
For example, Doppler can measure the velocity of both blood and tissue. A Finding Site=Mitral
Valve and Finding Subject= Antegrade Flow means a measurement of the velocity of the antegrade
blood flow taken at the mitral valve.
Note there are a few ambiguous cases: the Pulmonary Pressure is the site of the mmHg finding
value, but a measurement sample was taken elsewhere to compute that finding.
Should we allow modifiers on Finding Site?
A: Not in Post-coordinated.
It is irrelevant in Pre-coordinated. It is seldom used in post-coordinated. Simplest is to use more
specific Finding Sites when needed.
If we allow an “Unconstrained bucket” then modifiers of everything could be allowed.
The main drivers for modifiers would be to allow tagging particular segments of a vessel or specific
parts of a Mitral Valve Leaflet. Modifiers could, however, open a can of worms for receiving
systems in terms of unexpected pairings.
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Changes to NEMA Standards Publication PS 3.2-2011
Digital Imaging and Communications in Medicine (DICOM)
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Part 2: Conformance
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Add Section:
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Describe documentation of vendor specific measurements. For example, the format could require that you
document the view, the mode, the method, etc, etc, etc
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124
Changes to NEMA Standards Publication PS 3.3-2011
126
Digital Imaging and Communications in Medicine (DICOM)
Part 3: Information Object Definitions
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Add new SOP Class if needed:
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<Likely needed but still a point of discussion> See Homework for Gopi to model the different cases.
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Changes to NEMA Standards Publication PS 3.16-2011
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Digital Imaging and Communications in Medicine (DICOM)
Part 16: Content Mapping Resource
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138
Add new Section to Annex A following Echocardiography Procedure Report Templates
SIMPLIFIED ADULT ECHOCARDIOGRAPHY TEMPLATES
140
The templates that comprise the Simplified Adult Echocardiography Report are interconnected as in Figure
A-x.1
TID 5QQQ
Simplified Echo
Procedure Report
TID 1204
Language of Content
Item and Descendants
TID 1001
Observation Context
TID 3602
Cardiovascular Patient
Characteristics
TID 3QQ
Precoordinated Echo
Measurement
TID 3QZ
Postcoordinated Echo
Measurement
TID 5204
Wall Motion Analysis
(TBD)
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Figure A.x-1: Echocardiography Procedure Report Template Structure
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TID 5QQQ
Echocardiography Procedure Report
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This template forms the top of a content tree that allows an ultrasound device to describe the results of an
adult echocardiography imaging procedure.
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148
It is instantiated at the root node. It can also be included in other templates that need to incorporate
echocardiography findings into another report as quoted evidence.
150
NL Rel with
Parent
1
VT
CONTAINER EV (125200, DCM, “Adult
1
Echocardiography Procedure
Report”)
HAS
INCLUDE
DTID (1204) Language of
1
CONCEPT
Content Item and Descendants
MOD
HAS OBS INCLUDE
DTID (1001) Observation
1
CONTEXT
Context
CONTAINS CONTAINER DT (121064, DCM, “Current
1
Procedure Descriptions”)
CONTAINS CODE
DT (125203, DCM, “Acquisition 1-n
Protocol”)
CONTAINS CONTAINER EV (121109, DCM, “Indications 1
for Procedure”)
2
>
3
>
4
>
5
>>
6
>
7
>>
CONTAINS CODE
8
9
>>
CONTAINS TEXT
CONTAINS INCLUDE
10
>
11
13
EV (121071, DCM, “Finding”)
M
U
M
U
M
U
1
1
U
U
1
U
>>
> CONTAINS CONTAINER EV (newcode001, DCM, “Pre-
1-n
M
1
M
>> CONTAINS INCLUDE
1-n
U
EV (121071, DCM, “Finding”)
DTID (3602) Cardiovascular
Patient Characteristics
CONTAINS CONTAINER EV (111028, DCM, “Image
Library”)
CONTAINS IMAGE
No purpose of reference
coordinated Measurements”)
DTID (3QQ) Pre-coordinated
Echo Measurement
BCID (12001) Ultrasound Protocol Types
U
1-n
>
12
TID 5QQQ – Simplified Echo Procedure Report
Type: Non-Extensible Order: Insignificant
Concept Name
VM Req Cond
Value Set Constraint
Type ition
DCID (12246) Cardiac Ultrasound
Indication for Study
$Measurement = DCID (newcid0) Core
Echo Measurements
$Units = corresponding value from Units
column of CID (newcid0)
14
>
15
>>
TBD
>
152
CONTAINS CONTAINER EV (newcode002, DCM, “Post- 1
coordinated Measurements”)
CONTAINS INCLUDE
DTID (3QZ) Post-coordinated
1-n
Echo Measurement
M
CONTAINS INCLUDE
U
DTID (5204) Wall Motion
Analysis
1-n
U
$Procedure = DT (P5-B3121, SRT,
"Echocardiography for Determining
Ventricular Contraction")
Content Item Descriptions
Row 8
A text string containing one or more sentences describing one or more indications, possibly with
additional comments from the physician or tech.
Row 11
All images which are referenced in the body of the SR will be listed here.
Row 13
Multiple instances of the same measurement code may be present in the container. Each instance
represents a different sample or derivation. This template makes no requirement that any or all samples
be sent. For example, a mean value of all the samples of a given measurement could be sent without
sending any or all of the samples from which the mean was calculated. Device configuration and/or
operator interactions determine what measurements are sent.
Supplement TBA: Simplified Adult Echocardiography Report
Page 18
<<Can we include the 5202/5203 here (even if it is a one line version) to communicate the
“symmetry”/compatibility with the “original template”>><<And where there are deviations communication
156 the rationale, e.g. we don’t send the finding site because it is inherent in the pre-coordinated measurement
code>>
154
158
TID 3QQ
Pre-coordinated Echo Measurement
160
This Template codes numeric echo measurements where most of the details about the nature of the
measurement have been pre-coordinated in the measurement code. In contrast, see TID 3QZ Postcoordinated Echo Measurement.
162
The pre-coordinated measurement code and units are provided when this Template is included from a
parent Template.
164
Note that this template is a simple subset of TID 300.
TID 3QQ Parameters
Parameter Name
Parameter Usage
$Measurement
Coded term or Context Group for Concept Name of measurement
$Units
Units of Measurement
166
TID 3QQ
Pre-coordinated Echo Measurement
Type: Non-Extensible Order: Insignificant
168
NL
Relation with
Parent
1
Value Type
Concept Name
VM
Req
Type
Condition
Value Set Constraint
NUM
$Measurement
1
M
Units = $Units
CODE
EV (121401, DCM,
“Derivation”)
1-n
U
DCID (newcid1) Echo
Derivation
>
INCLUDE
DTID (320) Image or
Spatial Coordinates
<<WG6: Since we have
some Echo 3D, do we
need TID 322 to add
SCOORD3D to TID 320?
Or can we just add to 320
directly? Or has someone
already done this?>>
<Duplicate in 3QZ>
1-n
U
$Purpose = EV
(121112, DCM,
"Source of
measurement”)
>
INCLUDE
DTID (321) Waveform or
Temporal Coordinates
1-n
U
$Purpose = EV
(121112, DCM,
"Source of
measurement”)
2
>
3
4
HAS
CONCEPT
MOD
170
Content Item Descriptions
Row 2
If Row 2 is not present, then the measurement is simply a sample.
172
TID 3QZ
Post-coordinated Echo Measurement
This Template codes numeric echo measurements where most of the details about the nature of the
measurement have been post-coordinated in modifiers and acquisition context. In contrast, see TID 3QQ
176 Pre-coordinated Echo Measurement.
174
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It is intended to be used for User-defined and Vendor-defined Echo Measurements.
TID 3QZ
Post-coordinated Echo Measurement
Type: Non-Extensible Order: Insignificant
178
180
NL
Relation with
Parent
1
182
Value Type
Concept Name
VM
Req
Type
Condition
Value Set Constraint
NUM
$Measurement
1
M
Units = $Units
CODE
EV (121401, DCM,
“Derivation”)
1
U
DCID (newcid1) Echo
Derivation
>
INCLUDE
DTID (320) Image or
Spatial Coordinates
1-n
U
$Purpose = EV
(121112, DCM,
"Source of
measurement”)
4
>
INCLUDE
DTID (321) Waveform or
Temporal Coordinates
1-n
U
$Purpose = EV
(121112, DCM,
"Source of
measurement”)
5
>
HAS CONCEPT
MOD
CODE
EV (G-C0E3, SRT,
“Finding Site”)
1
M
BCID (12236) Echo
Anatomic
6
>
HAS CONCEPT
MOD
CODE
EV (newcode003, DCM,
“Finding Subject”)
1
M
DCID (newcid2) Echo
Finding Subjects
7
>
HAS CONCEPT
MOD
CODE
EV (newcode004, DCM,
“Measurement Type”)
1
M
DCID (newcid3) Echo
Measurement Types
8
>
HAS CONCEPT
MOD
CODE
EV (newcode005, DCM,
“Measured Property”)
1
M
DCID (newcid4) Echo
Measurement
Properties
9
>
HAS CONCEPT
MOD
CODE
EV (G-C036, SRT,
“Measurement Method")
1
MC
BCID (12227)
Echocardiography
Measurement Methods
10
>
HAS ACQ
CONTEXT
CODE
EV (G-0373, SRT, “Image
Mode”)
1
M
DCID (12224)
Ultrasound Image
Modes
11
>
HAS ACQ
CONTEXT
CODE
EV (111031, DCM, “Image
View”)
1
M
BCID (12226)
Echocardiography
Image View
12
>
HAS CONCEPT
MOD
CODE
EV (R-4089A, SRT,
“Cardiac Cycle Point”)
1
MC
IFF the cardiac cycle
point is significant for
this measurement.
DCID (12233) Cardiac
Phase
13
>
HAS CONCEPT
MOD
CODE
EV (G-C048, SRT, “Flow
Direction”)
1
MC
IFF the flow direction
is significant for this
measurement.
DCID (12221) Flow
Direction
14
>
HAS CONCEPT
MOD
CODE
EV (R-40899, SRT,
“Respiratory Cycle Point”)
1
MC
IFF the respiratory
cycle point is
significant for this
measurement.
DCID (12234)
Respiration State
2
>
3
HAS CONCEPT
MOD
Echo Measurement Descriptions
Row 1
<< vendor values and user values would look similar except for Dictionary>>
<<Intention is that vendors can send a consistent fully pre-coordinated (private) code here so that parsers can
recognize post-coordinated measurements that have been previously analyzed/vetted/accepted/databased>>
<<Note that this depends on the vendor maintaining a stable list of these pre-coordinated codes it uses. What if
the vendor doesn’t feel like doing that. Should we make it a UID? Or have a DICOM Code for “This measurement
Supplement TBA: Simplified Adult Echocardiography Report
Page 20
has no stable continuity. Parse the post-coordinated details but assume nothing beyond those.”?>>
184
186
Row 5
The finding site reflects the anatomical location where the measurement is taken, preferably coded using
SNOMED to as fine detail as possible.
Row 6
The finding subject reflects the subject of the measurement.
In many cases, for example Aortic Root Diameter, the subject is the structure of the finding site.
In other cases, for example Mitral Valve Regurgitant Flow Peak Velocity, the finding site is the mitral valve, the
finding subject is the Regurgitant Flow and the measured property is the Peak Velocity.
Supplement TBA: Simplified Adult Echocardiography Report
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Add the following CID’s to Part 16 Annex B:
188
CID newcid1
Measurement Labels
Context ID newcid1
Measurement Labels
Type: Extensible
Version: yyyymmdd
190
Coding
Scheme
Designator
(0008,0102)
Code Value
(0008,0100)
Code Meaning
(0008,0104)
SRT
G-A437
Maximum – this sample was the maximum
SRT
R-404FB
Minimum – this sample was the minimum
DCM
121411
Most Recent Value – this sample was the most recent
DCM
121410
User chosen value – this sample was chosen (as representative)
by the user
SRT
R-00317
Mean – this isn’t a sample, it’s the average
Preferred – this is the single preferred value for this
measurement
DCM
192
CID newcid2
Echo Finding Subjects
Context ID newcid2
Echo Finding Subjects
Type: Extensible
Version: yyyymmdd
194
196
198
Coding Scheme
Designator
(0008,0102)
Code Value
(0008,0100)
DCM
newcode100
Structure of the Finding Site
DCM
newcode101
Behavior of the Finding Site
SRT
R-42047
Antegrade Flow (at the Finding Site)
SRT
G-0367
Regurgitant Flow (at the Finding Site)
CID newcid3
Code Meaning
(0008,0104)
Echo Measurement Type
Context ID newcid3
Echo Measurement Type
Type: Extensible
Version: yyyymmdd
200
Coding Scheme
Designator
(0008,0102)
Code Value
(0008,0100)
Code Meaning
(0008,0104)
DCM
newcode110
Direct
DCM
newcode111
Indexed
DCM
newcode112
Ratio
DCM
newcode113
Fraction
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DCM
newcode114
Calculated
202
CID newcid4
Echo Measured Properties
Context ID newcid4
Echo Measured Properties
Type: Extensible
Version: yyyymmdd
204
206
Coding Scheme
Designator
(0008,0102)
Code Value
(0008,0100)
Code Meaning
(0008,0104)
LN
20168-1
Acceleration Time
LN
59130-5
Alias Velocity
SRT
G-A166
Area
SRT
F-32070
Cardiac Ejection Fraction
SRT
G-038E
Cardiovascular Orifice Area
LN
20217-6
Deceleration Time
SRT
M-02550
Diameter
LN
59120-6
dP/dt by US
Duration
LN
20222-6
Ejection Time
LN
59093-5
Epicardial Area
LN
59132-1
Fractional Shortening
LN
59084-4
Isovolumic Contraction Time
LN
59083-6
Isovolumic Relaxation Time
LN
20256-4
Mean Gradient [Pressure] by Doppler
LN
20352-1
Mean Velocity
LN
20247-3
Peak Gradient [Pressure] by US.calculated
LN
34141-2
Peak Instantaneous Flow Rate
Peak Pressure
LN
11726-7
Peak Velocity
PISA Radius
LN
59085-1
Pre-Ejection Period
Pressure
LN
20280-4
Pressure Half Time by US.calculated
SRT
G-0390
Regurgitation Fraction
LN
59090-1
ROI Internal Dimension by US
LN
59089-3
ROI Thickness by US
SRT
F-32120
Stroke Volume
LN
12144-2
Systolic to Diastolic Velocity Ratio
SRT
F-02692
Vascular Resistance
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Velocity
LN
20354-7
Velocity Time Integral
Vena Contracta Width
208
SRT
G-D705
Volume
LN
33878-0
Volume Flow
DCM
122447
Wall Mass
CID newcid0
Core Echo Measurements
Context ID newcid0
Core Echo Measurements
Type: Non-Extensible Version: yyyymmdd
210
Coding
Scheme
Designator
(0008,0102)
Code Value
(0008,0100)
Code Meaning
(0008,0104)
Units
LN
18016-6
Aortic Valve Annulus Diameter
(cm, UCUM,
“centimeter”)
LN
18169-3
Aortic Valve Velocity-Time Integral
(cm, UCUM,
“centimeter”)
LN
11706-9
Aortic Valve Peak Systolic Flow
(m/s, UCUM,
“meter per second”)
LN
29431-4
Interventricular Septum Thickness Diastole
by US.M-mode
(cm, UCUM,
“centimeter”)
LN
29433-0
Interventricular Septum Thickness Systole
by US.M-mode
(cm, UCUM,
“centimeter”)
LN
29436-3
Left ventricular Internal Diameter Minor
Axis Diastole
(cm, UCUM,
“centimeter”)
LN
29438-9
Left Ventricle Internal Systolic Dimension
(cm, UCUM,
“centimeter”)
LN
LN
212
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214
Modify the following CID’s in Part 16 Annex B:
CID 12233
Cardiac Phase
Context ID 12233
Cardiac Phase
Type: Extensible Version: 20100317
216
218
Coding Scheme
Designator
(0008,0102)
Code Value
(0008,0100)
Code Meaning
(0008,0104)
SRT
F-32020
Systole
SRT
F-32010
Diastole
SRT
F-32011
End Diastole
SRT
R-FAB5B
End Systole
SRT
R-40B1B
Early Diastole
SRT
F-32021
Peak Systolic
SRT
F-32030
Atrial Systole
SRT
F-32040
Ventricular Systole
SRT
R-40B12
Ventricular Isovolumic Contraction
SRT
R-40B11
Ventricular Ejection
SRT
R-40B10
Ventricular Isovolumic Relaxation
SRT
R-40B1C
Diastolic Rapid Inflow
SRT
R-40B21
Diastasis
Full Cardiac Cycle
Left Atrial A-wave
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220
Add the following Definitions to Annex D
DICOM Code Definitions (Coding Scheme Designator “DCM” Coding Scheme Version “01”)
Code Value
Code Meaning
Definition
…
newcode001
Pre-coordinated Measurements
Measurements that are described by a single
pre-coordinated code.
newcode002
Post-coordinated Measurements
Measurements that are described by a collection
of (generally atomic) post-coordinated codes.
newcode004
Measurement Type
newcode005
Measured Property
newcode100
Structure of the Finding Site
The subject of a measurement is the physical
structure of the Finding Site, such as the mass or
diameter.
newcode101
Behavior of the Finding Site
The subject of a measurement is the behavior of
the Finding Site, such as the velocity or duration
of motion.
newcode110
Direct
newcode111
Indexed
newcode112
Ratio
newcode113
Fraction
newcode114
Calculated
Fully pre-coordinated terms:
Definition Template:
The <attribute> in <units> of the
<structure/characteristic> measured/calculated
at/during <time/phase> in <mode/view> using the
<method> normalized by <index>. The
measurement may have been taken using any
<leftovers>.
Consider removing units since that is not
fundamental to the concept and is communicated
in the $units anyway. Preference is to leave units
out of the definition and to tie them down in the
TID (or CID if we can do that).
May also talk to Daniel Vreeman – LOINC will
provide their atomic elements in a spreadsheet.
Download it.
Supplement TBA: Simplified Adult Echocardiography Report
Page 26
Aortic Valve Annulus Diameter
The diameter in cm of the Aortic Valve Annulus
measured at End Systole in 2D mode. The
measurement may have been taken using any
view or method.
Aortic Valve Flow VTI
The Velocity Time Integral in cm of the Aortic
Valve Flow measured during Systole in Doppler
mode. The measurement may have been taken
using any view or method.
Aortic Valve Flow Peak Velocity
The Peak Velocity in m/s of the Aortic Valve Flow
measured during Systole in Doppler mode. The
measurement may have been taken using any
view or method.
The Mean Velocity in m/s of the Aortic Valve
Flow measured during Systole in Doppler mode.
The measurement may have been taken using
any view or method.
Aortic Valve Flow Mean Velocity
Aortic Valve Peak Instantaneous
Gradient
Aortic Valve Mean Gradient
The Peak Instantaneous Pressure Gradient in
mmHg across the Aortic Valve measured during
Systole in Doppler mode using the Simplified
Bernoulli method.
The Mean Pressure Gradient in mmHg across
the Aortic Valve measured during Systole in
Doppler mode using the Simplified Bernoulli
method.
Aortic Valve Regurgitant Flow VTI
The Velocity Time Integral in cm of the Aortic
Valve Regurgitant Flow measured during
Diastole in Doppler mode. The measurement
may have been taken using any view or method.
Aortic Valve Regurgitant Flow
Volume by PISA
The Volume in ml of the Aortic Valve Regurgitant
Flow measured during Diastole in Doppler mode
using the PISA method. The measurement may
have been taken using any view.
Aortic Valve Regurgitant Flow Jet
Area to LVOT Area
The Ratio in % of the Aortic Valve Regurgitant
Flow Jet Area to the LVOT Area measured
during Diastole (?) in Doppler mode. The
measurement may have been taken using any
view.
Aortic Valve Regurgitant Flow
Effective Orifice Area
The Effective Orifice Area in cm2 of the Aortic
Valve Regurgitant Flow measured during
Diastole in Doppler mode using the volume
derived from the PISA method? The
measurement may have been taken using any
view.
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Aortic Valve Regurgitant Fraction
The Ratio in % of the Aortic Valve Regurgitant
Volume to the Aortic Valve Stroke Volume
measured in Doppler mode. The measurement
may have been taken using any view.
Aortic Valve Area by Continuity VTI /
BSA
An indexed value in cm2/m2 representing the
Area in cm2 of the Aortic Valve measured in
Doppler mode using the Continuity VTI method,
normalized to the Body Surface Area in m2.
Pulmonary Vein Flow S-wave Peak
Velocity
The Peak Velocity in m/s of the Pulmonary Vein
Flow measured during Systole in pulsed Doppler
mode. The measurement may have been taken
using any view or method and in any of the
Pulmonary Veins.
Pulmonary Vein Flow A-wave
Duration
The Duration in ms of the Pulmonary Vein Flow
measured during Atrial Systole in pulsed Doppler
mode. The measurement may have been taken
using any view or method and in any of the
Pulmonary Veins.
Delta D
The difference in duration in ms between the
duration of the Pulmonary Vein Flow measured
during Atrial Systole in pulsed Doppler mode,
and the duration of the Mitral Valve Flow
measured during Atrial Systole in pulsed Doppler
mode. The measurement may have been taken
using any view or method and in any of the
Pulmonary Veins.
222
Modify Definitions in Annex D as shown:
224
DICOM Code Definitions (Coding Scheme Designator “DCM” Coding Scheme Version “01”)
Code
Value
226
Code Meaning
Definition
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228
230
232
Changes to NEMA Standards Publication PS 3.17-2011
Digital Imaging and Communications in Medicine (DICOM)
234
Part 17: Explanatory Information
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236
Add Annex ??
ANNEX ??: Mapping Guidance? Population Guidance? (Informative)
238
Use Case 0: Store and Use Core Set
240
Use Case 1: Store and Display on PACS (non-semantic number)
[User configures Cart: define tool/interaction and link to new measurement = ID + Label String]
242
[User writes down detailed description of new measurement] (which then gets thrown in the shredder)
User takes measurement on Cart
244
Cart stores measurement value & units in SR for the exam under the ID+Label String
Cart sends SR to PACS
246
User selects an exam on PACS for display
PACS opens image and renders to screen
248
[User configures PACS: define layout/overlay and link row to SR Tag = ID]
PACS opens SR, finds ID, renders Label String, renders value+units
250
252
Q. Can we allow the customer to sometimes use LN code for the ID and sometimes local code? In
any case it would be handy to use the same ID on several carts so they
Use Case 2: Store and Insert in Report (non-semantic)
Same as PACS, but PACS=>Reporting Station, Layout=>Template, Render=>Insert
254
Use Case 3: Store and Plot Graph? Trending? Database? Etc.
256
May be useful to limit Use Case 3 to single/individual patient and push Big Data/Population health into Use
Case 4.
258
260
** Include a description of the sub-case where the object is from some other hospital. How do you track
down the paper? E.g. look in the header for the institution, call their Echo group, quote the name of the
measurement and ask for documentation.
Use Case X: Identifying matching different non-standard measurement codes from different
vendors
Also consider if they use the same measurement code, but different modifiers. (Could happen if the LN
code is not fully pre-coordinated). Maybe we should mandate that you have to use unique precoordinated
264 codes unless the LOINC is fully pre-coordinated.
262
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Q. How do we handle dumb reporting systems? Could send a two objects, a stripped down one for the
reporters and a fully fledged one for the CVIS. Could assume that the CVIS will pre-process and
268 spoonfeed the reporter. Could assume that the cart will be down-configured to minimal outputs. Could
imagine a flag. The cases are: how do I handle multiples of the same measurement (and know you should
270 take the last, or the mean) vs recognizing specialized (e.g. X by Method A and X by Method B to be
instances of generic X).
266
X1 = 3.2
X2 = 3.1 (location a)
274 X3 = 3.3
X4 = 3.1 (location b)
272
3.2
3.1
278 3.3
3.1
280 3.3 – Max
3.18 – Mean
282 3.1 – Most Recent
276
3.2 – Sample
3.1 – Sample
286 3.3 – Sample, Max
3.1 – Sample, Most Recent
288 3.18 - Mean
284
3.2 – Sample
3.1 – Sample
292 3.3 – Sample
3.1 - Sample
294 3.18 – Mean
3.3 – Max
296 3.1 – Most Recent
290