Understanding the DICOM SR Supplement

1. Understanding theDICOM SR Supplement DICOM Structured Reporting WorkshopMarch 29 -30, 2000 Donald E. Van Syckle__________________________DICOM WG 6 Chairman Director, MergeLink Professional Services

2. DICOM Structured Reporting (SR) • Results Management • Get Prior Reports • DICOM Since ‘93 But Not Widely Implemented • Structured Reporting • Standardized Early 2000 (April) • Simple Reporting • Basic and Enhanced • Complex Reporting • Comprehensive How AboutDICOM Reporting?

3. Today’s Reporting There is a 7mm irregular, spiculated mass in the anterior 11:00 region of the left breast, associated with grouped heterogeneous and pleomorphic granular and fine linear branching casting calcifications. Impression: Malignant Lesion Free form text only Not linked with images or other clinical data

4. DICOM Structured Report There is a 7mm irregular, spiculated mass in the anterior 11:00 region of the left breast, associated with grouped heterogeneous and pleomorphic granular and fine linear branching casting calcifications. Impression: Malignant Lesion MALIGNANCY Based on: MASS Size: 7mm Shape: irregular Margin: spiculated Associated with: CALCIFICATION Type: Heterogeneous Type: Branching Distribution: Grouped Today Tomorrow

5. What is Structured Report? • A “Databaseable Document” which: • Provide unambiguous “semantic” documentation of diagnosis • Provide context such as:(scheduled procedure, observer, previous reports and images…) • Link text with images, waveforms, audio, measurements • Coded entry using standardized or private lexicons • Flexible enough to go beyond radiology imaging A“Databaseable Document” facilities computer outcome analysis

6. MALIGNANCY Based on: MASS Size: 7mm Shape: irregular Margin: spiculated Associated with: CALCIFICATION Type: Heterogeneous Type: Branching Distribution: Grouped What Isn’t DICOM SR? …it isn’t a document presentation standard!

7. SR IOD Query/Retrieve Model Coded Entries Content Items Value Types Relationship Types Observation Context Key Concepts and Terms to Learn!

8. SR Document General SR Document Content Modification Rules Basic Structured Reporting Enhanced Structured Reporting Comprehensive Structured Reporting Not Done Yet!Key Concepts and Terms to Learn

9. Does DICOM SR IOD follow the same model as an image? • Yes!

10. Image Information Object Definitions Image Pixel Module Patient Module Patient Information General Study Module Patient Study Module* Study Information Frame of Reference Module General Series Module General Equipment Module Series Information Image Plane Module Image Pixel Module Contrast/Bolus Module Image Information General Image Module VOI LUT Module* Image Module SOP Common Module Overlay Plane Module*

11. MALIGNANCY Based on: MASS Size: 7mm ….. ….. SR IODs Specimen Ident. Module Patient Module SR Document Tree Patient Information General Study Module Patient Study Module* Study Information SR Document Series General Equipment Module Series Information SR Document Information SR Document General SOP Common Module SR Document Content

12. SOP Instances Linked Patient Information Patient ID Study Information Study Inst. UID Series Information Series Information Series Information Series Information Series Inst. UID Image Presentation State OtherComposite IODs SR Document Information SOP Inst. UID Images, SR Documents, Presentation States, Stored Print, etc. can exist in same Study

13. SR IOD andQuery/Retrieve Model • SR IODs mirror the Composite IOD model (i.e. images). • SR objects are able to be linked to images, waveforms, stored print, presentations state, RT plans… • “Pushing” SR SOP Instances accomplished viaC-STORE • “Pulling” SR SOP Instances accomplished via currently defined Query/Retrieve SOP classes.

14. Chest, PA & Lateral (GCS,T78) An Illustration……... Dr Andrew Smith……. George Jones…... Procedure PA and Lateral radiographs were ……. Findings The PA demonstrates … A small opacity is visible in the base of lung in lateral view. Image 32 CT recommended. Conclusions Possible Mass (ICD,XXX)

15. How do I build the SR document? • Content Items • Relationships

16. Document Title‘Chest PA & LAT’ (GCS,T78) Recording Observer Name‘Smith^Andrew^^Dr’ Content Items and Relationship Has Obs. Context Has Obs. Context Observation Subject‘Jones^George’ Document Heading‘Procedures’ (GCS,H12) Contains Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’ Contains Contains Document Heading‘Findings’ (GCS,H34) Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’ Contains Contains Image ReferenceInstance UID=3.56.18.9 Document Heading‘Conclusions’ (GCS,H56) Inferred From Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’ Contains

17. Root Content Item Content Item Content Item Content Item Content Item SR Document Tree • Single Root Content Item • Followed bynested Content Items

18. Content Items

19. CONTAINER TEXT PNAME DATETIME DATE TIME NUM IMAGE WAVEFORM COMPOSITE UIDREF SCOORD TCOORD CODE Types of Content Items(called Value Types)

20. Document Title‘Chest PA & LAT’ (GCS,T78) Recording Observer Name‘Smith^Andrew^^Dr’ Content Items and Relationship Has Obs. Context Has Obs. Context Observation Subject‘Jones^George’ Document Heading‘Procedures’ (GCS,H12) Contains Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’ Contains Contains Document Heading‘Findings’ (GCS,H34) Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’ Contains Contains Image ReferenceInstance UID=3.56.18.9 Document Heading‘Conclusions’ (GCS,H56) Inferred From Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’ Contains

21. The Root Content Item and CONTAINER Value Type Document Title‘Chest PA & LAT’ (GCS,T78) • Root Content Item conveys Document Title • Root Content Item is of type “CONTAINER” • Containers used to convey headings and sub-headings • Containers use Concept Name Code Sequence • Concept Name =‘Chest PA & LAT’

22. How do I encodeCONTAINERS? • In a “Coded Entry” Sequence • Code Value • Code Scheme Designator • Code Meaning

23. Coded Entries - Triplet Encoding • Required attributes are: • Code Value - computer readable and searchable identifier that is unique within the Coding Scheme • Code Scheme Designator - identifies the organization responsible for the code being used • Code Meaning - human readable text provided for the convenience of users (64 maximum characters) The Code Scheme Designator plus the Code Value uniquely identify the code

24. Document Title‘Chest PA & LAT’ (GCS,T78)

25. Coded SequenceUsed to Define All Codes “Requested Procedure = Chest X-Ray”

26. DICOM Defines the Ability To: • More precisely define the Coding Scheme Designator • Extend existing Coding Schemes • Define “Private Coding Schemes”

27. Document Title‘Chest PA & LAT’ (GCS,T78) Recording Observer Name‘Smith^Andrew^^Dr’ Content Items and Relationship Has Obs. Context Has Obs. Context Observation Subject‘Jones^George’ Document Heading‘Procedures’ (GCS,H12) Contains Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’ Contains Contains Document Heading‘Findings’ (GCS,H34) Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’ Contains Contains Image ReferenceInstance UID=3.56.18.9 Document Heading‘Conclusions’ (GCS,H56) Inferred From Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’ Contains

28. ‘PNAME’ Value Type Recording Observer Name‘Smith^Andrew^^Dr’ • Name/Value Pair • the name is a single Concept Name Code Sequence • the value is the Person’s Name • Concept Name Code Sequence =Recording Observer Name • PNAME = ‘Smith^Andrew^^Dr’ PNAME Value Type ConceptName Concept Value

29. Recording Observer Name =‘Smith^Andrew^^Dr’

30. Document Title‘Chest PA & LAT’ (GCS,T78) Recording Observer Name‘Smith^Andrew^^Dr’ Content Items and Relationship Has Obs. Context Has Obs. Context Observation Subject‘Jones^George’ Document Heading‘Procedures’ (GCS,H12) Contains Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’ Contains Contains Document Heading‘Findings’ (GCS,H34) Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’ Contains Contains Image ReferenceInstance UID=3.56.18.9 Document Heading‘Conclusions’ (GCS,H56) Inferred From Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’ Contains

31. ‘TEXT’ Value Type Procedure (GCS,H12)‘PA and Lateral radiographs were …….’ • Name/Value Pair • Concept Name Code Sequence = Procedure • TEXT = ‘PA and Lateral radiographs were …...’ TEXT Value Type ConceptName Concept Value

32. Procedure =‘PA and Lateral radiographs ….

33. Document Title‘Chest PA & LAT’ (GCS,T78) Recording Observer Name‘Smith^Andrew^^Dr’ Content Items and Relationship Has Obs. Context Has Obs. Context Observation Subject‘Jones^George’ Document Heading‘Procedures’ (GCS,H12) Contains Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’ Contains Contains Document Heading‘Findings’ (GCS,H34) Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’ Contains Contains Image ReferenceInstance UID=3.56.18.9 Document Heading‘Conclusions’ (GCS,H56) Inferred From Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’ Contains

34. ‘IMAGE’ Value Type Image ReferenceInstance UID=3.56.18.9 • If defining the “Purpose of Reference” then the Concept Name Code Sequence is used(i.e. Name/Value Pair) • If not defining the “Purpose of Reference” then only the value is conveyed (i.e. image reference) • IMAGE = ‘Instance UID = 3.56.18.9...’

35. Key Image =‘3.56.18.19 ….’

36. Document Title‘Chest PA & LAT’ (GCS,T78) Recording Observer Name‘Smith^Andrew^^Dr’ Content Items and Relationship Has Obs. Context Has Obs. Context Observation Subject‘Jones^George’ Document Heading‘Procedures’ (GCS,H12) Contains Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’ Contains Contains Document Heading‘Findings’ (GCS,H34) Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’ Contains Contains Image ReferenceInstance UID=3.56.18.9 Document Heading‘Conclusions’ (GCS,H56) Inferred From Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’ Contains

37. ‘CODE’ Value Type CodeConclusions (GCS,H56)‘Possible Mass’ (ICD,XXX)’ • Name/Value Pair • Concept Name Code Sequence =Conclusions • CODE = ‘Possible Mass’ (ICD,XXX)’

38. Code =‘Possible Mass’ (ICD,XXX)

39. Value Types • CONTAINER - Headings or categories (i.e. titles, sub-headings...) • Document Title or Document section heading e.g. “Conclusions (GCS,H56)” • PNAME - Name of the person whose role is described by the Concept • Role of person e.g. name of the Recording Observer is “Smith^Andrew^^Dr.” • TEXT - Free form textual expression of the concept (unlimited length) • Type of text e.g. procedure (GCS,H12) = PA and Lateral radiographs were …’ • IMAGE - UID references to Image SOP Instances • Reference = SOP Class 1.2.840.10008.. Instance UID 3.56.18.9... • CODE - Coded expression of the concept • Type of code e.g. ‘Conclusion(GCS H56) = ‘Possible Mass’ (ICD,XXX)

40. Value Types • NUM - Numeric value or measurement with associated units • Type of code e.g. “Diameter (GCS,H24) = 1.3 CM” • DATE - Calendar date of occurrence • Type of date e.g. “Time of Blood Pressure (GCS,H73) = March 3, 2000” • TIME - Time of day of occurrence • Type of time e.g. “Date of Blood Pressure (GCS,H73) = 8:30am” • DATETIME - Concentrated Date and Time of occurrence • Type of DateTime e.g. “Date and Time of Blood Pressure (GCS,H73) = March 3, 2000 at 8:30am” • WAVEFORM - UID references to Waveform SOP Instances • Reference = SOP Class 1.2.840.10008.. Instance UID 2.776.188.903..

41. Value Types • COMPOSITE - UID references to Composite SOP Instances that are not images or waveforms • Reference = SOP Class 1.2.840.10008.. SOP Instance UID 2.345.188.473.. • UIDREF- Unique Identifier identified by concept name • Type of UID e.g. “Study Instance UID of Evidence Directly Examined by RO (GCS,H92) = “3.6.889.12345….” • SCOORD - Spatial coordinates of a geometric ROI in Images • "CLOSED 1,1 5,10" {SELECTED FROM: IMAGE xx}. • TCOORD - Temporal coordinates of a ROI in Waveforms • SEGMENT 60-200mS" {SELECTED FROM: WAVEFORM xx}.

42. How are the Content Items linked together in the SR Tree? • Relationship Types

43. Root Content Item Content Item Content Item Content Item Content Item Source and Target Content Items Relationship Source Content Item Target Content Item

44. Relationship Types • Parent/Child relationship between Source and Target Target Content Item Source Content Item Relationship CODE“conclusions = Possible Mass” CONTAINER “Conclusions” contains IODs may specify constraints on relationships

45. Document Title‘Chest PA & LAT’ (GCS,T78) Recording Observer Name‘Smith^Andrew^^Dr’ Content Items and Relationship Has Obs. Context Has Obs. Context Observation Subject‘Jones^George’ Document Heading‘Procedures’ (GCS,H12) Contains Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’ Contains Contains Document Heading‘Findings’ (GCS,H34) Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’ Contains Contains Image ReferenceInstance UID=3.56.18.9 Document Heading‘Conclusions’ (GCS,H56) Inferred From Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’ Contains

46. Relationship Types • HAS OBS CONTEXT - Target conveying specialization of Observation Context needed for documentation of Source • CONTAINER: “Chest PA and Lateral” {HAS OBS CONTEXT: PNAME: Recording Observer = “Smith^Andrew^^Dr.”} • CONTAINS - Source contains Target • CONTAINER “Findings” {CONTAIN: TEXT “Findings(GCS,H34) = The PA demonstrates… A small opacity is visible in the base of lung in ...”}

47. Relationship Types • HAS CONCEPT MOD - Qualifies or describe the Concept Name of the Source; also used to quantify data greater than 64 characters • CODE: “Chest X-Ray” {HAS CONCEPT MOD: TEXT “View = PA and Lateral”} • HAS PROPERTIES - Description of properties of the Source • CODE: “Mass” {HAS PROPERTIES: CODE: “diameter”} • HAS ACQ CONTEXT - Target describes the condition present during data acquisition of the Source • IMAGE: “36” {HAS ACQ CONTEXT : CODE “contrast agent”}

48. Relationship Types • SELECTED FROM - Source Item conveys spatial or temporal coordinates selected from Target(s) • SCOORD: “CLOSED 1,1,5,10” {SELECTED FROM:IMAGE: “36”} • INFERRED FROM - Source conveys a measurement or other inference made from Target • CODE: “Malignancy” {INFERRED FROM: CODE: “Mass”}

49. Observation Context • Describes who or what is performing the interpretations • Whether the examination of evidence is direct or quoted • What procedure generated the evidence that is being interpreted • Who or what is the subject of the evidence that is being interpreted Observation Context is encoded in a Content Item

50. Document Title‘Chest PA & LAT’ (GCS,T78) Recording Observer Name‘Smith^Andrew^^Dr’ Content Items and Relationship Has Obs. Context Has Obs. Context Observation Subject‘Jones^George’ Document Heading‘Procedures’ (GCS,H12) Contains Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’ Contains Contains Document Heading‘Findings’ (GCS,H34) Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’ Contains Contains Image ReferenceInstance UID=3.56.18.9 Document Heading‘Conclusions’ (GCS,H56) Inferred From Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’ Contains