Fred M. Behlen, Ph.D. Co-Chair, DICOM WG20 / HL7 IISIG Member, HL7 Structured Document TC

1. Fred M. Behlen, Ph.D. Co-Chair, DICOM WG20 / HL7 IISIGMember, HL7 Structured Document TC DICOM Working Group 10London, 23 June 2003Integrating Imaging and Reporting using DICOM SR and HL7 CDA LAItechnology Longitudinal Application Integration Solutions for Health Records

2. Report created in DICOM SR, transformed to CDA for export Report created in CDA, including image references and annotation DICOM evidence production requires input from external CDA documents Imaging application needs to present rendered CDA content Use Cases for CDA inDICOM Application Domains

3. SR Reporting application tightly integrated with image viewing and annotation application CDA document references SR source document Need: SR-to-CDA standards and tools Constraints on SR for reliable transformation Trial transformations of existing SR Templates Rules defining boundaries for new templates Robust CDA reference pointers to DICOM objects (WADO & DIMSE access) 1. Report created in SR, trans-formed to CDA for export

4. Image viewing and CDA reporting may be different applications, on the same or different platforms Reporting including image references and annotation is done in CDA document Reporting application may require access to DICOM SR evidence documents Potential encapsulation of CDA in DICOM for management with other DICOM objects? Need: Messaging between image viewing and CDA reporting application Robust CDA reference pointers to DICOM objects (WADO & DIMSE access) 2. Report created in CDA

5. CDA Structured content needs to be imported into DICOM application Requires a query and retrieve mechanism from DICOM appli-cation to CDA repository (crosses DICOM/HL7 boundary) May overlap with Relevant Patient Information Query CDA content may include image references Need: May not require additional standards work if RPIQ is used If RPIQ is not used, then need to define Q/R mechanism and possible encapsulation in DICOM environment Even if RPIQ is used, Query/display may be required Need to define templates for specific content extracts from CDA 3. Import CDA data for DICOM evidence production

6. CDA content not required in DICOM application Requires a query/display mechanism from DICOM application to CDA repository CDA content may include image references Need: Query facilities already planned as IHE CDA Query/Display Display may need to extract DICOM image reference and annotation from CDA document for rendering in diagnostic quality display 4. Display rendered CDA

7. Report created in DICOM SR, transformed to CDA for export Subspecialty domains only Report created in CDA, including image references and annotation DICOM evidence production requires input from external CDA documents May be served by RPIQ Imaging application needs to present rendered CDA content  No additional standards work required Use Cases for CDA

8. Create authenticated reports directly in target format CDA Release 2 (first committee ballot August 2003) has equivalent of DICOM SCOORD and image referencing Image viewing and reporting done in different appli-cations, on same or different (adjacent) platforms Network communications model serves both cases CDA Reporting Integration

9. CDA Reporting Integration Communications over TCP/IP(to server if Web-based) Image Viewing Application Reporting Application Measurements, Annotation Display control [optional] (User, Patient and Exam context)

10. CDA Reporting Integration Communications over TCP/IP(to server if Web-based) Image Viewing Application Reporting Application Measurements, Annotation Display control [optional] (User, Patient and Exam context) • Display control. • Use CCOW? • DICOM Normalized Services? • OLE automation? • Special-purpose XML messaging? • Measurements and Annotation • DICOM Application Event Notification Service (Supp. 66)? • HL7 V.3 Messaging? • Special-purpose XML messages?

11. CCOW Expensive High entry level DICOM Normalized Services New standards development Costly implementation Requires reporting vendor to adopt and support DICOM protocol stack and tools OLE Automation Microsoft Windows only May not work / security problems over network Special-purpose XML messaging? New to DICOM, but IHE audit trail uses similar approach Uses same connection as XML measurement/annotation Display control [optional]

12. DICOM Application Event Notification Service (Supp. 66)? Annotation in SR document fragments Costly implementation on reporting system end Requires reporting vendor to adopt and support DICOM protocol stack and tools HL7 V.3 Messages? Standards development required, not really HL7 application domain Special-purpose XML messaging? Annotation in CDA document fragments New to DICOM, but IHE audit trail uses similar approach Uses same connection as XML measurement/annotation Measurements & Annotation

13. Point-to-point TCP/IP socket connection Could be secured using TLS Record Layer Protocol if desired W3C XML Schema validation of messages Single Schema for messages in each direction Event notification function only, minimal protocol overhead Instance UID allows receiver to ignore duplicate sends, but otherwise no flow control Special-purpose XMLmessaging?

14. DICOM Normalized services Standards exist (Supp. 66) for event logging Standards development: SR root templates for annotation & measurements SR-to-CDA mapping for annotation & measurements CDA Diagnostic Imaging Report document specification Special-purpose XML protocol Standards development: XML message schemas for annotation & measurements Socket transport specification CDA Diagnostic Imaging Report document specification  More work for standards developers, less work for implementers Conclusion: Viable Protocols

15. If XML protocol, where would it go in the Standard? A new Part? An Annex? Where would the CDA Imaging Report document profile go? The IHE Technical Framework? An HL7 Informative Document? To become a balloted Template when (someday) HL7 Templates are available? A DICOM standard? Open Issues

16. A Possible Schedule

17. Accelerated Schedule