DICOM & IHE : An Update On -> the DICOM Standard -> the IHE Radiology Framework

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1 RADIOLOGY RESEARCH The DICOM Standard DICOM & IHE : An Update On -> the DICOM Standard -> the IHE Radiology Framework Michael Flynn, PhD mikef@rad.hfh.edu 2 DICOM Parts DICOM Review PS 3.1 Introduction and Overview PS 3.2 Conformance PS 3.3 Information Object Definitions PS 3.4 Service Class Specifications PS 3.5 Data Structures and Encoding PS 3.6 Data Dictionary PS 3.7 Message Exchange PS 3.8 Network Communication Support for Message Exchange PS 3.10 Media Storage and File Format for Data Interchange PS 3.11 Media Storage Application Profiles PS 3.12 Media Formats and Physical Media for Data Interchange PS 3.14 Grayscale Standard Display Function PS 3.15 Security Profiles PS 3.16 Content Mapping Resource PS 3.17 Explanatory Information PS 3.18 Web Access to DICOM Persistent Objects (WADO) 3 DICOM Utilizes an open standards development process that encourages the involvement and consensus of both vendors and users Specification of a conformance mechanism so that a user can decide whether or not devices are likely to interoperate 4 1

2 DICOM Review DICOM Standards Committee (DSC) DICOM Standards Committee (DSC) DICOM s executive body whose members are imaging equipment manufacturers, physician organizations, and others 26 manufacturer members 20 other members DICOM's activities are coordinated through a general secretariat at MITA formerly NEMA Development of DICOM Standard is done through committees termed Working Groups (WG) AAPM Members can participate in any WG to develop the Standard WG propose work items based on suggestions from members or at the direction of the DSC 5 6 DICOM WGs 1-6 DICOM WGs 7-12 WG # ** 6 Working Group Name Cardiac and Vascular Information Projection Radiography and Angiography Nuclear Medicine Compression Exchange Media Base Standard Relevance to Radiology Cardiovascular imaging, stress nuclear cardiology structured reporting Development of enhanced x-ray and angiography information objects Nuclear medicine and PET Application of data compression standards, such as JPEG 2000 and JPIP Distribution of images on CD-ROMs, DVDs, and USB flash drives Detailed technical evaluation of proposed additions or changes to the DICOM standard WG# Working Group Name 7 Radiotherapy 8 10 Structured Reporting Strategic Advisory 11 Display Function Standard 12 Ultrasound Relevance to Radiology Radiation therapy, including ion therapy Standardized vocabularies, encoding of structured reports, and integration with Long-range planning; coordination of DICOM with other international standards organizations Presentation and display of images on workstations, i.e., hanging protocols. Ultrasound imaging, including echocardiography; 3D/4D images ** Not currently active 7 8 2

3 DICOM WGs DICOM WGs WG# Working Group Name * Security Digital Mammography and CAD Magnetic Resonance 3D Clinical Trials and Education Relevance to Radiology Secure information exchange Breast imaging; structured reporting of computed-aided detection and diagnosis (CAD) results for mammography and CT colonography MRI Volumetric (multiframe) imaging modalities, including CT, MR, and ultrasound Application of imaging to clinical trials and medical education WG# Working Group Name Relevance to Radiology 19** Dermatology Standards Dermatology 20 Integration of Imaging and Information Systems 21** Computed Tomography CT imaging and dosimetry reporting 22 Dentistry Dentistry 23 Application Hosting DICOM in Surgery 25** Veterinary Applications 27 Pathology Web Technology Coordination of DICOM with Health Level Seven (HL7) standard for messaging between health information systems Develop specifications for interfaces between hosted application software Image-guided surgery and other surgical data Veterinary Pathology Applications Web service extensions * starting activity 9 ** Not currently active 10 DICOM workflow DICOM workflow Work items are divided into Supplements and Change Orders Supplements define new objects, content or structure Output of any work item is submitted to the Base Standards Working Group (WG6) for review throughout the process WG6 may request changes or clarification to the work item to ensure it complies with Standard Change Orders modify the existing Standard Once the work item is complete WG6 petitions the DSC to approve work item and send out for public comment

4 DICOM workflow Changes to Standard After public comment and all issues listed in the comments are responded to, the DSC authorizes the work item for letter ballot by DICOM members Change proposals do not require the same rigorous review process and are often batched for public comment and letter ballot, Some Change proposals can be instituted without comment or ballot if the change is required to reduce potential patient care issues or it is typographical or trivial in nature Currently over 100 approved Supplements incorporated into Standard Over 20 in progress or in comment stage Currently over 1000 Change Proposals incorporated into Standard Ongoing process with changes being reviewed at every WG6 meeting Recent DICOM Enhancements that are important to Medical Physicists Clinical Trial De-identification Profiles, Surface Segmentation Storage SOP Class, CT Radiation Dose Reporting (Dose SR), Tomosynthesis Image Storage SOP Class, JPEG 2000 Transfer Syntaxes and Interactive Protocol Enhanced CT and MR Image Storage SOP Class. A. De-Identification B. Surface Segmentation C. CT Dose Reporting D. Breast Tomosynthesis E. JPEG2000 & JPIP F. Enhanced CT/MR

5 A De-Identification Clinical Trial De-identification Profiles Working Group 18 Clinical Trials Supplement 142 Working draft 3, 2008 The existing confidentiality profile in PS 3.15 lists possible attributes that may cause identity leakage, without weighing the relative merits of their inclusion or replacement, or describing strategies to prioritize or selectively replace attribute values. WG 18 has determined that it is necessary to add additional confidentiality profiles to the DICOM Standard that are appropriate to specific types of trials, both to provide instruction for implementers, to assure compliance, and to provide guidance for sites and trial administrators that has been subject to expert review. A. De-Identification B. Surface Segmentation C. CT Dose Reporting D. Breast Tomosynthesis E. JPEG2000 & JPIP F. Enhanced CT/MR B Surface Segmentation B Surface Segmentation Polygonal Segmentation Storage SOP Class Working Group 17 (3D) & 24 (Surgery) Supplement 132 Standard, 2008 All images are stored as 2D frames If more than one image is acquired, and there is some information linking the images (e.g. cross sectional images, temporal images, etc.) the images can be stored as multi-frame objects The images are still single 2D frames The Supplement contains a new Common Surface Mesh Module that is used do encode the segmentation data. It is intended for composite data objects of any modality or clinical specialty

6 B Surface Segmentation B Surface Segmentation 3D reconstructions can be created from the multiframe objects Yet results can only be saved as snapshots of specific views (i.e. single- or multi-frame images) Surface renderings are commonly derived from polygonal surface primitives This supplement provides a method in DICOM to store these primitives instead of images 21 From Osirix 22 C CT Dose Reporting CT Radiation Dose Reporting (Dose SR) A. De-Identification B. Surface Segmentation C. CT Dose Reporting D. Breast Tomosynthesis E. JPEG2000 & JPIP F. Enhanced CT/MR Working Group 21 (CT) Supplement 127 Standard, 2007 The Computed Tomography X-Ray dose report is based on the SOP class of X-Ray Radiation Dose SR. Specific templates for the recording of the dose and the acquisition parameters in a CT environment have been developed. 23 The development of the CT Dose Report Template was accomplished by the DICOM WG 21 and by IEC SC62B MT30, which have defined a common set of dose-related information

7 C - SR Dose IOD C CT dose content CT SR Dose IOD Modules and Structure IE Module Reference Description Patient Patient C Describes the identity of patient Clinical Trial Subject C Identify clinical trial subject Describes the study performed upon Study General Study C patient Patient Study C Describes information about study Clinical Trial Study C Identify context of clinical trial Series SR Document Series C.17.1 Defines attributes of the SR document Clinical Trial Series C Identify context of clinical trial Frame of Synchronization C Synchronization to patient study Reference Equipment General Equipment C Attributes to identify the equipment Document SR Document General C.17.2 General context of SR document Specifies the attributes contained in the SR Document Content C.17.3 SR SOP Common C.12.1 DICOM basic for definition of object CT Accumulated Accumulated irradiation for an entire template Irradiation Dose Study examination CT Irradiation Event template 1 to n separate irradiation events 25 CT Acquisition Parameters The tube voltage and the tube current are stated. The effective exposure in mas is stated. The exposure time and the scanning length are stated. Acquisition parameters related to the volume acquisition are stated (collimation, pitch factor). For each CT Acquisition (irradiation event): The CITDIvol and DPL are stated. The corresponding CTDIfreeair is stated. The effective dose may be stated (optional). The parameters used are stated. The reference values for dose estimation and calculation are stated, e.g. calibration factor, effective dose type 26 D Breast Tomosynthesis Breast Tomosynthesis Image Storage SOP Class A. De-Identification B. Surface Segmentation C. CT Dose Reporting D. Breast Tomosynthesis E. JPEG2000 & JPIP F. Enhanced CT/MR Working Groups 2 (xray), 15 (mamm) Supplement 125 Standard, 2008 The scope of this Supplement is to customize the X- Ray multi-dimensional storage SOP Class.. to define the 3D volume or volumes created from digital breast tomosynthesis x-ray projections

8 B Breast Tomosynthesis UID Value UID Name Breast Tomosynthesis Image Storage UID Type SOP Class New object modules defined for Breast tomosynthesis contributing sources (Part 3 - C ) Breast tomosynthesis acquisition (Part 3 - C ) Part PS 3.4 A. De-Identification B. Surface Segmentation C. CT Dose Reporting D. Breast Tomosynthesis E. JPEG2000 & JPIP F. Enhanced CT/MR E JPEG2000 & JPIP E - JPIP: Implementations JPEG 2000 Interactive Protocol Working Group 4 (Compression) Supplement 106 Final Text, January 26, 2006 This Supplement extends the Pixel Data Module to allow reference to a JPIP URL to access pixel data, rather than encoding it in the image instance The use cases for this extension to the standard relate to an application's desire to gain access to a portion of DICOM pixel data without the need to wait for reception of all the pixel data. Examples are: 1) Stack Navigation of a large CT Study. 2) Large Single Image Navigation 3) Thumbnails Many PACS systems provide services for client access to images using proprietary progressive streaming technology. DICOM JPIP provides a standardized method that might have particular use in an open-source application. 4) Display by Dimension

9 Image Streaming GUIs JPIP facilitates advanced image viewing GUIs DICOM SUP 106 (2006), JPIP DICOM JPIP REFERENCED TRANSFER SYNTAX This Supplement extends the Pixel Data Module to allow reference to a JPIP URL to access pixel data, rather than encoding it in the image instance. Data Element (7FE0,0010) Pixel Data shall not be present, but rather pixel data shall be referenced via Data Element (0028,7FE0) Pixel Data Provider URL E - JPIP: Tag (0028,7FE0) E - JPIP: Informative Annex Supplement 106 establishes a JPIP transfer syntax and adds a tag that provides a URL to the image data that is used instead of the traditional pixel data tag (7FE0,0010). 35 Annex X JPIP Referenced Pixel Data Transfer Syntax Negotiation Case 1: AE1 and AE2 both support both a JPIP Referenced Pixel Data Transfer Syntax and a non-jpip Transfer Syntax AE1 makes a C-MOVE request to AE2 AE2 proposes two presentation contexts to AE1, one for with a JPIP Referenced Pixel Data Transfer Syntax, and the other with a non-jpip Transfer Syntax AE1 accepts both presentation contexts AE2 may choose either presentation context to send the object AE1 must be able to either receive the pixel data in the C- STORE message, or obtain it from the provider URL 36 9

10 DICOM with JPIP: Diagram A. De-Identification B. Surface Segmentation C. CT Dose Reporting D. Breast Tomosynthesis E. JPEG2000 & JPIP F. Enhanced CT/MR Weisfeiler, Dicom WG4, Feb F enhanced MR F - emr: Multiframe 24 Dynamic Functional Groups Enhanced MR Image Storage SOP Class Working Group 16 (MR) Supplement 49 Final Text, 26 March, 2002 The supplement describes 3 new IODs: 1. Enhanced MR Image 2. MR Spectroscopy 3. Raw Data A Multi-Frame concept is introduced which allows attributes grouped together to vary on a frame by frame base. This method is modality independent. 39 Pixel Measures MR Image Frame Type Frame Content MR Timing & Parameters Plane Position MR FOV/Geometry Plane Orientation MR Echo Referenced Image MR Modifier Derivation Image MR Image Modifier MR Receive Coil Cardiac Trigger MR Transmit Coil Frame Anatomy MR Diffusion Pixel value Transformation MR Averages Frame VOI LUT MR Spatial Saturation Real World Value Mapping MR Metabolite Map MR Velocity Encoding From Charles Parisot, May 5, 2002, Korean PACS Conference 40 10

11 F - emr: Multiframe 24 Dynamic Functional Groups For a Specific MR Image Instance : some Functional Groups are shared across all frames, some vary per frame Pixel Measures Frame Content Plane Position Plane Orientation Referenced Image Derivation Image Cardiac Trigger Frame Anatomy Pixel value Transformation Frame VOI LUT Real World Value Mapping MR Image Frame Type MR Timing & Related Parameters MR FOV/Geometry MR Echo MR Modifier MR Image Modifier MR Receive Coil MR Transmit Coil MR Diffusion MR Averages MR Spatial Saturation MR Metabolite Map MR Velocity Encoding From Charles Parisot, May 5, 2002, Korean PACS Conference MR Image Instance Shared Functional Groups Attributes For all frames Per Frame Functional Group Sequence Frame 1 attributes Frame 2 attributes 41 F - emr: Image Description Macro Supplement 49 proposes a reasonably orthogonal set of attributes for image type useful to reading applications: Image Type (0008,0008) values: 1: Original/Derived redefined 2: Primary/Secondary Only Primary valid for MR 3: Image Flavor the overall most important characteristic of this Image e.g. flow encoded, max-ip, Perfussion, Stress, T1, T2, etc. 4: Derived Contrast Diffusion aniso, Subtraction, Velocity, None generally an indication of post processing performed From Charles Parisot, May 5, 2002, Korean PACS Conference 42 F - emr: Image Description Macro F - emr: color, spectroscopy Other Image Types are separate attributes: Pixel Presentation (Palette) Color/Monochrome (color supported or not) Volumetric Properties Volume, Sampled, Distorted (used by Grx, 3D to determine image compatibility with the application) Volume Based Calculation Technique MAX_IP, MPR, Curved-MPR (used by Grx, 3D to determine image compatibility) Complex Image Component Magnitude, Phase, Real, Imaginary (standard MR transformations of the raw data) Acquisition Contrast T1, T2, Perfusion, Combination (MR acquisition contrast types) From Charles Parisot, May 5, 2002, Korean PACS Conference 43 From David Clunie, May 22, 2004, SCAR Hot 44 Color Spectroscopy 11

12 F - emr: mandatory tags A large percent of the new tags in the enhanced MR object are mandatory and are those in the enhannced CT object. F enhanced CT Enhanced CT Image Storage SOP Class Working Group 21 (CT) Supplement 58 Final Text, January 14, 2004 (Amended July 5, 2004).. it is necessary to create a new CT object to meet the needs of state of the art CT technology that has evolved substantially since the existing CT object was standardized in Furthermore, new applications such as cardiac CT, gated studies, perfusion CT, CT fluoroscopy, contrast tracking and post-processing are not supported by the current standard.... From David Clunie, May 22, 2004, SCAR Hot F - ect: Spiral Pitch F - ect: Acquisition Type 4 mandatory tags in the CT table Dynamics Macro are unambiguously defined in an informative paragraph. C Spiral Pitch Factor The formula for Spiral Pitch Factor (0018,9311) in terms of Table Feed per Rotation (0018,9310) and Total Collimation Width (0018,9307) is: Spiral Pitch Factor = (Table Feed per Rotation (mm)) / (Total Collimation Width (mm)) An example calculation of Spiral Pitch Factor (0018,9311) for a single slice spiral acquisition of an image with a Total Collimation Width of 2.5mm and a Table Feed per Rotation of 10mm is: Spiral Pitch Factor = (10 mm)/(2.5 mm) = 4.0 An example calculation of Spiral Pitch Factor (0018,9311) for a multiple slice spiral acquisition having a Total Collimation Width of 20mm and a Table Feed per Rotation of 10mm is: Spiral Pitch Factor = (10 mm)/(20 mm) = The Acquisition Type (0008,9303) contains a description of the method used during acquisition of the frame from a list of defined terms. C Acquisition Type Acquisition Type (0018,9302) has the following Defined Terms: SEQUENCED identifies that the acquisition was performed by acquiring single or multi detector data while rotating the source about the gantry while the table is not moving. Additional slices are acquired by incrementing the table position and again rotating the source about the gantry while the table is not moving. SPIRAL identifies that the acquisition was performed by acquiring data while rotating the source about the gantry while continuously moving the table. CONSTANT_ANGLE identifies that the acquisition was performed by holding the source at a constant angle and moving the table to obtain a projection image (e.g., a localizer image). STATIONARY identifies that the acquisition was performed by holding the table at a constant position and acquiring multiple slices over time at the same location. FREE identifies that the acquisition was performed while rotating the source about the gantry while the table movement is under direct control of a human operator or under the control of an analysis application (e.g., fluoroscopic image)

13 F - ect: Dynamic Contrast Conventional hanging protocols are rarely sophisticated enough to recognize multiple phases of contrast enhancement, e.g., during CT of liver Old DICOM objects have no standard information about contrast phase New objects name phases of contrast administration for each frame PRE-CONTRAST, POST-CONTRAST, IMMEDIATE, DYNAMIC, STEADY-STATE, DELAYED, ARTERIAL, CAPILLARY, VENOUS, PORTAL-VENOUS F - ect: Multi Frame Performance Reduced communication latency (delay) Opportunity for inter-slice (3D) compression From David Clunie, 2006, New DICOM Objects From David Clunie, 2006, New DICOM Objects F - emr & ect conformance Questions? The enhanced CT and MR objects were incorporated in the DICOM standard in 2003 and Implementation testing & demonstration June SCAR demonstration November RSNA InfoRAD demonstration Despite strong industry involvement in the development of the objects, support has not been available on commercial CT and MR systems? SOP Class UIDs Enhanced CT Enhanced MT

14 IHE 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 coordinated use of established standards such as DICOM and HL7 to address specific clinical need in support of optimal patient care. Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively IHE Member Organizations IHE Domains IHE: Member Organizations IHE: Active Domains 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 Cardiology Eye Care IT Infrastructure Laboratory Patient Care Coordination Patient Care Devices Quality Radiation Oncology Radiology Mammography Nuclear Medicine

15 Recent IHE Profiles Recent IHE Enhancements that are important to Medical Physicists IHE Profiles relevant to Medical Physics [NTPL-S] Normal Treatment Planning-Simple [MMR-RO] Multimodality Registration, Rad. Onc. [TRWF] RT Treatment Workflow [PWF] Post-Processing Workflow [NM] Nuclear Medicine Image [FUS] Image Fusion (in Trial) [REM] Radiation Exposure Monitoring [MAMMO] Mammography Image [PDI] Portable Data for Imaging 57 Radiation exposure monitoring (REM), Mammography acquisition workflow(mawf), Extensions to the Portable Data for Imaging (PDI) integration profile, Basic Image Review Profile (BIR), MR Diffusion Imaging (MDI), and CT/MR Perfusion Imaging with Contrast (PIC). 58 IHE - REM A. REM Rad. Exp. Monitoring B. MAWF Mamm. Acq. workflow C. PDI New Extensions D. BIR Basic Image Review E. MDI MR Diffusion imaging F. PIC CT/MR Perfusion imaging 59 This profile facilitates the collection and distribution of information about estimated patient radiation exposure resulting from imaging procedures

16 IHE REM Actors IHE REM Actors ACTORS Acquisition Modality - <Creates and stores Dose SR. Image Manager/Archive - <Accepts/Commits dose data and supports Q/R. Dose Information Consumer Responsible for supplemental handling of irradiation events, generally on an individual basis, e.g. display, analysis, or further processing. Dose Information Reporter Responsible for the aggregation, analysis, reporting and business logic related to irradiation events Dose Register Collates information about irradiation events from a number of facilities 61 The profile describes relevant transactions between actors. 62 IHE REM Use REM General Use Case IHE REM Q & A Q & A from the Trial Implimentation Draft, July Is there any need for translating the dose objects into an HL7 format? Answer: No needs could be identified at this time, but the possibility of sending data into HL7 was acknowledged. It will not be addressed now. Should we include dose from Radiotherapy procedures in the profile? Answer: Not yet. Focus on imaging initially. RT can be added later. Should we include dose from SPECT/PET procedures in the profile? Answer: Not yet. The dose SR work in DICOM does not exist for these modalities. When it does, they could be added. Should IHE make equipment identification details mandatory? Answer: Yes. A DICOM CP will be submitted to add the Enhanced Equipment Module (C.7.5.2) to the Radiation Dose IOD. (Manufacturer, model and serial number attributes would then be Type 1)

17 IHE REM Connectathon Every year, IHE conducts a connectathon to demonstate vendor implementations of new profiles. A. REM Rad. Exp. Monitoring B. MAWF Mamm. Acq. workflow C. PDI New Extensions D. BIR Basic Image Review E. MDI MR Diffusion imaging F. PIC CT/MR Perfusion imaging IHE - MAWF IHE exam type change Mammography Acquisition Workflow describes mechanisms to handle situation-specific exceptions to routine image acquisition scenarios based on the IHE Radiology Scheduled Workflow Integration Profile. The MAWF profile graphically illustrates the use cases considered. It defines how a Modality communicates ad-hoc procedure changes when supplemental images are taken or when the exam type changes. It defines interactions between Digital X-ray (FFDM) Modalities and systems managing departmental workflow when an examination is begun in one room and is finished in another room. It defines how corrections to view labels at the Modality are communicated to and used by an Image Archive

18 IHE MAWF Open Issue Open Issues (July 2008) While working on this Profile and finding technical solutions to its underlying use cases, the Technical Committee requested changes to the DICOM standard to realize needed Actor behavior. This includes one new attribute in MPPS and images, as well as code extensions to the Content Mapping Resource (see vol. 1, Appendix B). Corresponding Change Proposals to the DICOM Standards were submitted. This IHE Profile specification depends on these Change Proposals to be accepted and finalized. The IHE Radiology Technical Committee will stay in contact with the DICOM Committees and update this Profile as necessary based on the actions taken by DICOM. 69 A. REM Rad. Exp. Monitoring B. MAWF Mamm. Acq. workflow C. PDI New Extensions D. BIR Basic Image Review E. MDI MR Diffusion imaging F. PIC CT/MR Perfusion imaging 70 IHE PDI extensions June 21, 2009 Trial Implementation Draft This supplement adds options to the Portable Data for Imaging Integration Profile, To broaden from CD media only to include DVD and USB, To add support for lossless and lossy compression, To add an application on the media to decompress and decrypt the contents to send over the network. 71 A. REM Rad. Exp. Monitoring B. MAWF Mamm. Acq. workflow C. PDI New Extensions D. BIR Basic Image Review E. MDI MR Diffusion imaging F. PIC CT/MR Perfusion imaging 72 18

19 IHE PDI extensions IHE BIR objective June 10, 2009 Trial Implementation Draft Working closely with representatives of the American Medical Association and the American Association of Neurological Surgeons, the IHE Radiology Technical Committee has developed this profile to define the appropriate baseline functionality and behaviors for image viewing software on CD. 73 It is common practice for imaging facilities to distribute images on CDs, and for receiving physicians to review those images using a viewer included on the CD. Physicians have increasingly expressed frustration that frequently: viewers do not run successfully, viewers do not load the images successfully, the viewer loads too slowly, the viewer claims to be "not of diagnostic quality," functions critical to review are missing from the viewer or the various viewers encountered on CDs have unique graphical user interfaces that do not provide obvious access to basic functions. The impact is delayed care, inaccessible information, repeat examination and irradiation, and poor use of valuable clinician time. Creators of CDs may be unaware of the problems encountered by the physicians receiving the CDs and thus critical feedback about these issues is not communicated to the vendor of the system. 74 IHE BIR minimum computer IHE BIR mouse W/L functions Minimum hardware and software One x86 (Intel or AMD) processor or core Windows XP Home Edition and Windows Vista Home Basic Edition.NET 2.0 framework installed 512MB RAM for XP and 1024 MB RAM for Vista Graphics hardware and a single monitor of any type supported by Windows at 1024x768 resolution in 24 bit RGB color a mouse or other pointing device with a single button one drive that supports reading writable CD and DVD media a consumer-grade printer without requiring installation of, or permission to install, applications, frameworks (such as Java or other.net versions), libraries (such as DLLs or ActiveX controls), device or graphics drivers or software other than those shipped with the basic operating system without requiring the presence of a network connection (for download of software, licensing or registration or exchange of any other information whether via the Internet or local area network) 75 For grayscale images, a tool shall be provided to select the use of the mouse to window the images in all tiles of the currently selected viewport. This support shall include: a tool that selects windowing by mouse movement with the left (or only) mouse button held down acceleration of the rate of windowing by a keyboard modifier or detection of the rate of mouse movement Another tool is provided to toggle between two modes of windowing behavior, Center/Width and Clamped. When the Window tool is selected and the mode is Center/Width: horizontal movement of the mouse to the right will widen the window width (flatten the perceived contrast) vertical movement of the mouse upwards will lower the window center (increase the perceived brightness) When the Window tool is selected and the mode is Clamped: the bottom of the window shall be clamped to a rescaled pixel value of 0 vertical movement upward shall lower the upper limit of the window (increase the perceived brightness) 76 19

20 IHE BIR ICONS 37 standard icons are defined along and the function specifically delineated. Patient Selection B-W W-B Reversal Localizer Lines WL Mode A. REM Rad. Exp. Monitoring B. MAWF Mamm. Acq. workflow C. PDI New Extensions D. BIR Basic Image Review E. MDI MR Diffusion imaging F. PIC CT/MR Perfusion imaging Annotation CINE WL Default Values ZOOM IHE DIFF display IHE Diffusion display June 21, 2009 Trial Implementation Draft The MR Diffusion Imaging Integration Profile leverages enhanced MR diffusion images containing standard attributes for Diffusion B value, Diffusion gradient orientation and Diffusion image type. These objects are exchanged in an interoperable way allowing correct and convenient display. Applications using older single-frame DICOM image objects depended on knowledge of private attributes for this information.. 79 MR Diffusion Imaging creates stacks of images (slices) with different meaning and derived contrast by using techniques of MR Diffusion Weighted Imaging (DWI). This Integration Profile defines how a set of images resulting from a completed MR Diffusion exam are stored and archived into frames of one Enhanced MR DICOM (Multi-frame) object so that they can later be retrieved and displayed in an unambiguous way on image viewers supporting Enhanced MR DICOM objects. This enables widespread and adequate review and interpretation of b=0, ISOTROPIC and ADC diffusion frames by radiologists in an environment where all Actors support the Enhanced MR DICOM objects 80 20

21 IHE DIFF tags This profile requires certain DICOM tags be present in addition to mandatory enhanced MR tags. A. REM Rad. Exp. Monitoring B. MAWF Mamm. Acq. workflow C. PDI New Extensions D. BIR Basic Image Review E. MDI MR Diffusion imaging F. PIC CT/MR Perfusion imaging The values of these tags are used to establish the manner in which diffusion imaging sequences are stored in the multi-frame object IHE PERF display IHE Perfusion display June 21, 2009 Trial Implementation Draft The CT/MR Perfusion Imaging with Contrast Integration Profile facilitates the exchange of contrast enhanced images containing standard attributes for timing and position. The exchange of these attributes allow for correct and convenient display. Applications using the older single-frame DICOM image objects depended on proprietary assumptions about which timing attributes 75 were expected to be present, and were not generally interoperable. 83 CT/MR Perfusion Imaging with Contrast creates stacks of images at different timeslots, in order to demonstrate the uptake of a contrast agent over time. This Integration Profile defines how these perfusion images are stored and archived into frames of one Enhanced DICOM (Multi-frame) object so that they can later be retrieved and displayed in an unambiguous way on image viewers supporting Enhanced DICOM objects. This enables widespread and adequate review and interpretation of contrast-enhanced frames by radiologists in an IT environment where all Actors support the Enhanced CT or Enhanced MR DICOM objects

22 IHE PERF tags DICOM & IHE Similar to the DIFF profile, this profile requires certain tags to be used to facilitate perfusion images storage and display. DICOM Standards Committee & Integrating the Healthcare Enterprise (IHE) International Memorandum of Understanding Effective Date: May 15, 2009 The DSC will become a member of IHE International and appoint a liaison representative. Likewise, IHE International will become a member of the DSC and appoint one voting representative Each organization must execute the other s Intellectual Property Agreement Questions?? 87 22