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Understanding the DICOM SR Supplement. DICOM Structured Reporting Workshop March 29 -30, 2000 Donald E. Van Syckle __________________________ DICOM WG 6 Chairman Director, MergeLink  Professional Services. DICOM Structured Reporting (SR). Results Management Get Prior Reports

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understanding the dicom sr supplement

Understanding theDICOM SR Supplement

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

dicom structured reporting sr
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 Enchanced
    • Complex Reporting
      • Comprehensive

How AboutDICOM Reporting?

today s reporting
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

dicom structured report
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

what is structured report
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

what isn t dicom sr

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!

key concepts and terms to learn
SR IOD

Query/Retrieve Model

Coded Entries

Content Items

Value Types

Relationship Types

Observation Context

Key Concepts and Terms to Learn!
not done yet key concepts and terms to learn
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
image information object definitions
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*

sr iods

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

sop instances linked
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

sr iod and query retrieve model
SR IOD and Query/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.
an illustration

Chest, PA & Lateral (GCS,T78)

Dr Andrew Smith…….

George Jones…...

An Illustration……...

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)

slide15

How do I build the

SR document?

  • Content Items
  • Relationships
content items and relationship

Recording Observer Name‘Smith^Andrew^^Dr’

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

Inferred From

Document Heading‘Conclusions’ (GCS,H56)

Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’

Contains

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

Has Obs. Context

Content Items and Relationship

sr document tree

Root Content Item

Content Item

Content Item

Content Item

Content Item

SR Document Tree
  • Single Root Content Item
  • Followed bynested Content Items
types of content items called value types
CONTAINER

TEXT

PNAME

DATETIME

DATE

TIME

NUM

IMAGE

WAVEFORM

COMPOSITE

UIDREF

SCOORD

TCOORD

CODE

Types of Content Items(called Value Types)
content items and relationship1

Document Heading‘Procedures’ (GCS,H12)

Contains

Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’

Contains

Contains

Document Heading‘Findings’ (GCS,H34)

Contains

Image ReferenceInstance UID=3.56.18.9

Document Heading‘Conclusions’ (GCS,H56)

Inferred From

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

Recording Observer Name‘Smith^Andrew^^Dr’

Has Obs. Context

Has Obs. Context

Observation Subject‘Jones^George’

Content Items and Relationship

Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’

Contains

Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’

Contains

the root content item and container value type
The Root Content Item and CONTAINER Value Type
  • 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’

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

slide22

How do I encodeCONTAINERS?

  • In a “Coded Entry” Sequence
    • Code Value
    • Code Scheme Designator
    • Code Meaning
coded entries triplet encoding
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

coded sequence used to define all codes
Coded SequenceUsed to Define All Codes

“Requested Procedure = Chest X-Ray”

dicom defines the ability to
DICOM Defines the Ability To:
  • More precisely define the Coding Scheme Designator
  • Extend existing Coding Schemes
  • Define “Private Coding Schemes”
content items and relationship2

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

Inferred From

Document Heading‘Conclusions’ (GCS,H56)

Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’

Contains

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

Recording Observer Name‘Smith^Andrew^^Dr’

Has Obs. Context

Has Obs. Context

Content Items and Relationship

pname value type
‘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

slide30

Recording Observer Name‘Smith^Andrew^^Dr’

Has Obs. Context

Observation Subject‘Jones^George’

Document Heading‘Procedures’ (GCS,H12)

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

Inferred From

Document Heading‘Conclusions’ (GCS,H56)

Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’

Contains

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

Has Obs. Context

Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’

Contains

text value type
‘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

slide33

Recording Observer Name‘Smith^Andrew^^Dr’

Has Obs. Context

Observation Subject‘Jones^George’

Document Heading‘Procedures’ (GCS,H12)

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

Document Heading‘Conclusions’ (GCS,H56)

Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’

Contains

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

Has Obs. Context

Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’

Contains

Image ReferenceInstance UID=3.56.18.9

Inferred From

image value type
‘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...’
code value type
‘CODE’ Value Type

CodeConclusions (GCS,H56)‘Possible Mass’ (ICD,XXX)’

  • Name/Value Pair
  • Concept Name Code Sequence =Conclusions
  • CODE = ‘Possible Mass’ (ICD,XXX)’
slide37

Recording Observer Name‘Smith^Andrew^^Dr’

Has Obs. Context

Observation Subject‘Jones^George’

Document Heading‘Procedures’ (GCS,H12)

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

Document Heading‘Conclusions’ (GCS,H56)

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

Has Obs. Context

Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’

Contains

Image ReferenceInstance UID=3.56.18.9

Inferred From

Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’

Contains

value types
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)
value types1
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. “Date of Blood Pressure (GCS,H73) = March 3, 2000”
  • TIME - Time of day of occurrence
    • Type of time e.g. “Time 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..
value types2
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}.
source and target content items

Root Content Item

Source Content

Item

Content Item

Content Item

Content Item

Content Item

Source and Target Content Items

Relationship

Target Content

Item

relationship types
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

slide45

Recording Observer Name‘Smith^Andrew^^Dr’

Has Obs. Context

Observation Subject‘Jones^George’

Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’

Contains

Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’

Contains

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

Has Obs. Context

Document Heading‘Procedures’ (GCS,H12)

Contains

Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’

Contains

Contains

Document Heading‘Findings’ (GCS,H34)

Contains

Image ReferenceInstance UID=3.56.18.9

Inferred From

Document Heading‘Conclusions’ (GCS,H56)

relationship types1
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 ...”}
relationship types2
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”}
relationship types3
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”}
observation context
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

slide50

Recording Observer Name‘Smith^Andrew^^Dr’

Has Obs. Context

Observation Subject‘Jones^George’

Text‘findings (GCS,H34) = The PA demonstrates… A small opacityis visible in the base of lung in lateral view. CT recommended.’

Contains

Code‘conclusions (GCS H56) = Possible Mass’ (ICD,XXX)’

Contains

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

Has Obs. Context

Document Heading‘Procedures’ (GCS,H12)

Contains

Text‘procedure (GCS,H12) = PA and Lateral radiographs were …….’

Contains

Contains

Document Heading‘Findings’ (GCS,H34)

Contains

Image ReferenceInstance UID=3.56.18.9

Inferred From

Document Heading‘Conclusions’ (GCS,H56)

initial observation context

Patient NamePatient ID

Patient Date of Birth

Patient Sex ...

Patient’s WeightReferring Physician's Name

Accession Number

Study Instance UID ...

…….

Initial Observation Context
  • Defined outside the SR Document Content Tree
  • Applies to all Content Items in SR tree

Patient Information

Study Information

Series Information

SR Document Information

inheritance rules in sr tree

Node 1

Node 3

Node 2

Contains

Contains

Has Obs Ctx

Has Obs Ctx

Has Obs Ctx

Node C2

Node C3

Node C1

Inheritance Rules in SR Tree
  • All inherit initial Ob. Co.
  • HAS OBS CTX adds to Ob. Co. of parent node
  • Node1 extended by NodeC1(e.g. Recording Observer)
  • Node2 inherits Ob. Co. of Node1
  • Node2 extended by NodesC2 & C3
inheritance rules

Node 1

Node 3

Node 2

Contains

Contains

Has Obs Ctx

Has Obs Ctx

Has Obs Ctx

Node C2

Node C3

Node C1

Inheritance Rules
  • HAS OBS CTX inherited by all by-value descendant nodes of parent regardless of relationship between parent and descendant
  • Node3 and its descendents inherits Node 2 (1, C1, C2, C3)
  • Ob. Ctx. is never replaced(i.e. tree of Content Items traversed top down from root)
  • Ob. Ctx. shall not be inherited across by-reference relationships

:

:

by reference content items

Code‘Findings (GCS H34) = Mass’ (ICD,XXX)’

Code‘conclusions (GCS H56) = Probable Malignancy (ICD,YYY)’

Inferred From

By Reference Content Items
  • Allows referencing to other Content Items
  • Document Relationship and Document Content Marcos are not included
  • For example: CODE: “Probable Malignancy” {INFERRED FROM: CODE: “Mass”}
reference content item identifier
Reference Content Item Identifier
  • Ordered set of integers
  • Root Content Item = 1
  • Each subsequent integer represents ordinal position of the Content Item in which Content Sequence it belongs
  • Walk through tree to determine ID

Root Content Item

Cont. Item ID01

Content Item

Content Item

Cont. Item ID01 02

Cont. Item ID01 01

Content Item

Content Item

Content Item

Cont. Item ID01 01 01

Cont. Item ID01 01 02

Cont. Item ID01 02 01

Not allowed for the simpleBasic and Enhanced SOP Classes

sr document general sr document content modules
SR Document General &SR Document Content Modules

How do I read the SR specific Modules?

  • Same as other DICOM Modules
  • Except new documentation convention called “Macros”
macros a new convention for dicom documentation
Macros - a new convention for DICOM documentation...

Easy way to document codes, measurements, spatial coordinates, image references, etc.

sr document general module
SR Document General Module
  • Attributes identify the SR Document and provide context for the entire document
  • Attributes are outside the SR Document Tree which simplifies Query access
  • See SR Supplement Table C.17-2
identification attributes
Identification Attributes
  • SOP Class UID and SOP Instance UID(from SOP Common)
  • Instance Number
  • Content Date (same attribute as Image Date)
  • Content Time (same attribute as Image Time)

All Type 1 Fields -

Date/Time important for managing reports

status and verifying attributes
Status and Verifying Attributes
  • Completion Flag - PARTIAL or COMPLETE
    • how to set the flag is open to implementation
  • Completion Flag Description - free form text
  • Verification Flag - UNVERIFIED or VERIFIED
  • Verifying Observer Sequence
    • identifies person(s) verifying the document and organization(s); required if flag = VERIFIED

Prevailing final version = most recentVerification DateTime, VERIFIED, COMPLETE

reference request sequence
Reference Request Sequence
  • Identifies Requested Procedure(s) being fulfilled by the SR document
    • Study Instance UID
    • Referenced Study Sequence
    • Requested Procedure ID, Accession Number
    • Requested and Performed Procedure Codes
    • ….

One SR document may cover multiple

Requested Procedures

related document object pointers
Related Document/Object Pointers
  • Predecessor Document Sequence
    • SRs whose content has been included into document (prior reports, amendments, etc.)
  • Current Requested Procedure Evidence Sequence
    • All Composite SOP Instances created to satisfy the current requested Procedure(s) being reported upon
  • Pertinent Other Evidence
    • All Other SOP Instances considered pertinent to document and not listed in “Cur. Req. Proc. Evid. Seq.”

Same SOP Instance cannot be inCurrent or Pertinent Sequences

identical documents sequence
Identical Documents Sequence
  • References all identical SR documents
  • Entire SR document is the same except for UIDs(i.e. Study Instance, Series Instance, SOP Instance)
  • When modifying an “Identical Document” the implementation must modify all “Identical Documents” or the new “modified” report is no longer an “Identical Document”

All “Identical” SR documents reference each other

three identical documents

Original Doc 1

Original Doc 3

Original Doc 2

Modified Doc 1

Modified Doc 3

Modified Doc 2

Identical Doc Seq.

Three Identical Documents

Identical Doc Seq.

Predecessor

Doc

Seq.

sr document content module
SR Document Content Module
  • Attributes convey content of the SR Document
  • Provides the “Root Content Item” (i.e. Document Title)
  • Nests Content Sequences for all other Content Items
  • See SR Supplement Table C.17.3
    • Document Relationship Macro
    • Document Content Macro
sr sop instance modification rules

Specimen Ident. Module

Patient Module

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

SR SOP Instance Modification Rules
  • New SOP Instance if modify:
    • SR Document General
    • SR Document Content
    • Series Instance UID
    • Study Instance UID
sr iods1
SR IODs
  • Basic Text SR IOD
    • Minimal usage of coded entries
    • Reference to SOP Instances restricted to leaves from text tree
    • No by-reference Content Items (i.e. by-value only)
  • Enhanced SR IOD
    • superset of Basic Text but extended to include spatial and temporal regions of interest
  • Comprehensive SR IOD
    • superset of Basic Text and Enhanced, references to leaves not restricted and includes by-reference Content Items
dicom structured reporting
DICOM Structured Reporting
  • Fits within the normal DICOM structure
  • New ideas such as Content Items and Relationships
  • Simple for Basic Text and Enhanced
  • More Complex for Comprehensive

Not just for Radiology and Cardiology

but can be used for all “ologies”