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FHIR and DICOMweb
Brad GenereauxFHIR Developer DaysNovember 17, 20169:45am - 10:25am
@integratorbrad #FHIRdevdays2016 #FHIR #dicomweb
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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
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Imaging/DICOM Track
Wednesday at 10:30Introduction to DICOM and DICOMweb
Thursday at 9:45FHIR and DICOMweb
Friday at 9:45FHIR Tools
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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
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Special Notes
I am covering planned content for STU3 I will skim over DICOM topics (covered
yesterday) – watch the taped presentation
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RECAP: THE NEED FOR IMAGING EVERYWHERE
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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)
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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
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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)
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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
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Patient ;
1
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
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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 …
Study
Image Metadata
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HOW DOES FHIR RELATE TO MEDICAL IMAGING?
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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
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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
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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
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IMAGINGSTUDY IN FHIR
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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
?
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Imaging Workflow
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DiagnosticRequestReferralRequest
CarePlanProcedureRequest
ProcedureDiagnosticReportImagingStudy
EncounterEpisodeOfCare
Visit Order Protocol
AcquireReportAccess
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ImagingStudy
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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
ir/
Imagin
gStudy
?subje
ct.nam
e=Doe%
2CJohn
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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
Order
Reading radiologist
Reason for Exam
Children:• Series• StudyBaseLocation
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The “Series” Part
DICOM Series UID
Modality for series
Series description
Part of body of series
Side of the body
Children:• Instance• SeriesBaseLocation
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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
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The “Instance” Part
Type of Object
DICOM Instance UID
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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
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Caveats! In Practice: Get a Study Thumbnail Authentication Authorization Firewalls
That the thumbnail is relevant
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IHE RADIOLOGY, FHIR AND DICOM
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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
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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
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ImagingManifest Similar to
ImagingStudy, but designed to be very lightweight and a comparable object to a KOS Manifest (that XDS-I uses)
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Web-based Image Capture Uses DICOMweb’s
Store (STOW-RS) methods to enable acquisition of images using web services
WIC Profile
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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)
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REAL WORLD USE CASES
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Image-Enabling Reports
FHIR® DICOMweb™
EMR Image Cache
Discover radiology reports as
CDA
Retrieve associated key images
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Enabling Richer Worklists
FHIR® DICOMweb™
HIS Image Cache
Enrich with patient
metadata
Retrieve work list for
modality
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CONCLUSIONS
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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
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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?
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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: [email protected] 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/
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DICOM/Imaging Track
Wednesday at 10:30Introduction to DICOM and DICOMweb
Thursday at 9:45FHIR and DICOMweb
Friday at 9:45FHIR Tools
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Special Thanks
HL7 International DICOM, NEMA, MITA IHE IT Infrastructure and Radiology Elliot Silver
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Questions?