genereaux thursday-fhir and dico mweb

FHIR and DICOMweb

Brad GenereauxFHIR Developer DaysNovember 17, 20169:45am - 10:25am

@integratorbrad #FHIRdevdays2016 #FHIR #dicomweb

Who am I?

Name: Brad Genereaux Company: Agfa HealthCare Background:

Product Manager, Agfa HealthCare Co-chair, HL7 Imaging Integration Co-chair, DICOM WG-20, Integration of Imaging and Information

Systems Co-chair, DICOM WG-27, Web Technologies In past lives - developer, architect, integrator, hospital IT in

Canada

@integratorbrad

Imaging/DICOM Track

Wednesday at 10:30Introduction to DICOM and DICOMweb

Thursday at 9:45FHIR and DICOMweb

Friday at 9:45FHIR Tools

Tutorial Objectives

You should: Know the FHIR resources that relate to imaging

and imaging workflows Understand the relationship between FHIR and

DICOMweb Understand how these technologies relate to IHE

and to real world use cases

Special Notes

I am covering planned content for STU3 I will skim over DICOM topics (covered

yesterday) – watch the taped presentation

RECAP: THE NEED FOR IMAGING EVERYWHERE

Worth 1,000 Words

“While written descriptions of lesions and infectious processes may be detailed, the visual presentation of these conditions is much more accurate and effective for diagnosis and treatment.” Imaging: New Electronic Tool For Clinicians,

2003 (Susan I. Reynolds)

Image-enable Everything Put the images in the EMR / EHR / reports Share them in collaborative workflows Generate quick previews using thumbnails Convey the patient condition in ways text just

can’t do

If I Can’t Find It, It Does Not Exist If imaging studies are not available, patients will

be re-imaged Increased risk → radiation Increased cost → unnecessary exams Increased delay for the patient Increased stress and discomfort for patients and their

families Increased delay for other patients (or need for additional

capacity)

DICOM is Imaging

Standard for handling, storing, printing, and transmitting information in medical imaging, and includes both a file structure and communication protocol

https://en.wikipedia.org/wiki/DICOM

Patient ;

Study 1

1Study x

Each patient has x studies, which has y series,

Instance 1

Instance z

Series 1

Series y

which has z instances… and could have f frames.

Image Hierarchy

Instance UID Height Width Position SOP Class UID …

Instance Series UID Modality Description Series Number Body Part …

Series Study UID Date of Study Description Refer Physician Accession …

Image Metadata

HOW DOES FHIR RELATE TO MEDICAL IMAGING?

HL7 II / DICOM WG-20

Joint effort between the two SDOs to ensure alignment within standards, eliminate duplication, and ensure respective needs are met in both communities HL7 - Imaging Integration DICOM WG-20 - Integration of Imaging and Information Systems

Why not just FHIR?

DICOM is one of the most widely deployed healthcare messaging standards in the world 100,000s of units, several 10’s of billions of

images archived, worldwide over decades It would be a Herculean effort without value,

need, or industry support to switch to a new standard One effort, MINT, was a precursor to what is now

known as DICOMweb

When to use which?

FHIR is used for information-centric workflows I.e., EMRs, EHRs - to discover available studies

and work with order- and report-centric metadata DICOM / DICOMweb is used for imaging-

centric workflows I.e., PACS, post-processing - to retrieve, process,

and parse the DICOM instances

IMAGINGSTUDY IN FHIR

Basic Imaging Workflow

Modality acquires images and transmits them to archive

Stores the images to a PACS (Picture Archive and Communication System)

Radiologist requests images for reading Radiologist creates the report

Imaging Workflow

DiagnosticRequestReferralRequest

CarePlanProcedureRequest

ProcedureDiagnosticReportImagingStudy

EncounterEpisodeOfCare

Visit Order Protocol

AcquireReportAccess

ImagingStudy

Study Date LinkAbdomen CT

Jan. 17, 2014

http://<url>

Chest CR Mar. 23, 2015

http://<url>

ImagingStudy Example

What studies do you have for John Doe?

GET ht

tp://s

erver.

com/fh

Imagin

gStudy

?subje

ct.nam

e=Doe%

2CJohn

The “Study” Part

DICOM Study UID EMR-assigned

Modalities (CT, MRI, etc)

Patient Reference

Date of study

Ordering physician

Performed Procedure –OR – Procedure Type

Free-text description

Encounter or visit

Reading radiologist

Reason for Exam

Children:• Series• StudyBaseLocation

The “Series” Part

DICOM Series UID

Modality for series

Series description

Part of body of series

Side of the body

Children:• Instance• SeriesBaseLocation

What is BaseLocation

Based on the type, the base URL can be combined with the UIDs to form a request for retrieval

Study Series

Type:• WADO-URI• WADO-RS

Base URL to the DICOMweb service

* May switch to EndPoint before STU3

The “Instance” Part

Type of Object

DICOM Instance UID

In Practice: Get a Study Thumbnail{ "resourceType": "ImagingStudy", "id": "example", "uid": "urn:oid:2.16.124.113543", "patient": { "reference": "Patient/12345" }, "started": "2011-01-01T11:01:20+03:00", “baseLocation” : [{“type”:”WADO-RS”, “url”:”https://server.com/wado”}], "series": [ { "uid": "urn:oid:2.16.124.113543.2", "number": 3, “baseLocation” : [{“type”:”WADO-RS”, “url”:”https://server.com/wado”}], "modality": { "system": "http://nema.org/dicom/dicm", "code": "CT" }, "description": "CT Surview 180", "bodySite": { "system": "http://snomed.info/sct", "code": "67734004", "display": "Upper Trunk Structure" }, "instance": [ { "uid": "urn:oid:2.16.124.113543.2.3", "number": 1, "sopClass": "urn:oid:1.2.840.10008.5.1.4.1.1.2" } ] } ] }

WADO-RS Call:GET https://server.com/wado/studies/2.16.124.113543/series/2.16.124.113543.2/instances/2.16.124.113543.2.3/rendered?viewport=50%2C50Accept: image/jpeg

Thumbnail

Web format

Caveats! In Practice: Get a Study Thumbnail Authentication Authorization Firewalls

That the thumbnail is relevant

IHE RADIOLOGY, FHIR AND DICOM

MHD-I Profile Mobile access to Health Documents for Imaging

Extends MHD (FHIR-driven Mobile Access to Health Documents) Discover and retrieve imaging studies published in a central registry /

repository (relates to XDS-I – next slide) Almost updated to use FHIR’s ImagingManifest

Cross-Enterprise Document Sharing

XDS-I (Cross-enterprise document sharing for imaging)

Describes publishing a KOS (Key Object Selection) to a repository

Which in turn describes the DICOM instances within and where to retrieve them

MHD-I can optionally be layered on XDS-I – enabling it for modern FHIR and DICOMweb technologies

ImagingManifest Similar to

ImagingStudy, but designed to be very lightweight and a comparable object to a KOS Manifest (that XDS-I uses)

Web-based Image Capture Uses DICOMweb’s

Store (STOW-RS) methods to enable acquisition of images using web services

WIC Profile

IID Profile

Invoke Image Display Connects user to a zero-footprint web viewer in a

standardized way to visualize an imaging study Solves an issue I highlighted earlier (top slice of a head

CT exam) - great method for embedding a viewer with an EMR

A DICOM viewer should be capable of handling advanced functionalities (like applying GSPS and appropriate contrasting)

REAL WORLD USE CASES

Image-Enabling Reports

FHIR® DICOMweb™

EMR Image Cache

Discover radiology reports as

Retrieve associated key images

Enabling Richer Worklists

FHIR® DICOMweb™

HIS Image Cache

Enrich with patient

metadata

Retrieve work list for

modality

CONCLUSIONS

FHIR and DICOM

Complementary services Built to meet the needs of

Patient-centric care Modern web-driven architectures Secured and protected Backward-compatible, forward-thinking

DICOM Standard http://dicom.nema.org

HL7 FHIR ImagingStudy http://hl7.org/fhir/imagingstudy.html

IHE Radiology https://www.ihe.net/Radiology/

Where do I find more information?

Get Involved in Imaging Standards Intersection of FHIR and DICOM is covered by

composite groups in both HL7 and DICOM Join WG-20 (DICOM) by e-mailing contact information

to the DICOM Secretariat: dicom@medicalimaging.org Join Imaging Integration (HL7) by joining II mailing lists

and teleconferences, find out more at: http://www.hl7.org/Special/committees/imagemgt/

Join IHE Radiology by visiting https://www.ihe.net/Radiology/

DICOM/Imaging Track

Wednesday at 10:30Introduction to DICOM and DICOMweb

Thursday at 9:45FHIR and DICOMweb

Friday at 9:45FHIR Tools

Special Thanks

HL7 International DICOM, NEMA, MITA IHE IT Infrastructure and Radiology Elliot Silver

Questions?

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