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DICOM Structured Reporting DICOM Structured Reporting DICOM Structured Reporting David A. Clunie PixelMed Publishing Bangor, Pennsylvania The author and publisher have taken care in the preparation of this book, but make no expressed or implied warranty of any kind, and assume no responsibility for errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of the use of the information contained herein. Copyright © 2000 by PixelMed Publishing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or trans- mitted, in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, with- out the prior written consent of the publisher. Library of Congress Card Number: 00-191700 ISBN 0-9701369-0-0 For Eleanor … Who This Book is For 21 Outline of This Book 22 Versions of the Standard 24 Conventions Used in this Book 24 Acknowledgements 26 Feedback 27 CHAPTER 1 Structured Reporting Concepts 29 Not Just Reports ... 30 Semantics not presentation 30 Constraints, IODs and Templates 31 Content 32 Trees and Relationships 33 Coded Concepts and Values 34 Living Without Codes 35 Report Management 36 Summary 38 CHAPTER 2 Codes and Controlled Terminology 39 Basic Concepts of Coded Entries 39 DICOM Encoding 40 Coding Scheme Designator and Version 42 Pros and Cons of Codes 43 Coding Schemes to Choose From 44 Codes for Structured Reporting 49 What does a Code Represent? 51 Code Meaning Revisited 53 Not Otherwise Specified 54 Context Groups and Mapping Resources 55 Context Groups and Synonyms 57 Beyond Triplets… Enhanced Encoding Mode 60 Private and Extended Coding Schemes and Mapping Resources 61 Summary 63 CHAPTER 3 Content Items: Concept Names and Values 65 Document Title 65 Headings 67 Encoding Headings 69 DICOM Structured Reporting 7 Value Types 70 Concept Names 71 Value Type CONTAINER 72 Continuity of Content 72 Value Type TEXT 73 Value Type CODE 75 Value Type NUM 76 Value Type PNAME 77 Value Types DATE, TIME and DATETIME 80 Reference Value Types 83 Value Type UIDREF 85 Value Type COMPOSITE 86 Value Type IMAGE 88 Value Type WAVEFORM 90 Coordinate Value Types 91 Value Type SCOORD 92 Value Type TCOORD 97 Purpose of Reference 100 Only Simple Types 102 Summary 103 CHAPTER 4 Encoding & Relationships: Building the Tree 105 Encoding a Tree 105 Relationships 110 Relationship Types 112 Contains Relationship Type 115 Has Properties Relationship Type 121 Inferred From Relationship Type 123 By-Reference Relationships 126 Referenced Content Item Identifiers 129 Selected From Relationship Type 130 Has Observation Context Relationship Type 130 Has Acquisition Context Relationship Type 131 Has Concept Modifier Relationship Type 131 Summary 136 CHAPTER 5 Images, Waveforms, and Voice Audio 137 Report+Images 137 The Limits of the Web Paradigm 138 Image References 139 Presentation States 141 8 DICOM Structured Reporting Spatial Coordinates 144 Temporal Coordinates 145 Waveforms 148 Living with Voice 149 Living With Paper 151 Scanned Documents 152 Scanned Images 152 Drawings 153 Forms 154 Acquisition Context 155 Acquisition Context in SR 158 Summary 160 CHAPTER 6 SOP Classes and Conformance 161 IODs, SOP Classes and Conformance 161 SR IODs and SOP Classes 162 What does conformance actually mean? 164 Conformance and Negation Related Issues 166 Negation using Pre-coordinated Concept Names 166 Negation using Concept Modifiers 167 Observation Context 168 Conformance and References to Other SOP Instances 168 Other Conformance Issues 169 Summary 169 CHAPTER 7 Context: Who did what to whom, when… 171 Observer Context 172 Subject Context 173 Procedure Context 174 Identification vs. Description 174 Encoding Observation Context 175 Inheritance of Observation Context 177 Initial Context 181 Quoted Content 182 Not Observation Context 185 Summary 185 DICOM Structured Reporting 9 CHAPTER 8 Document Management: SR in the Real World 187 Instances 187 Unique Identifiers 187 “Document” Paradigm: Persistence vs. Transience 189 Copies and Versions 191 States: Completion and Verification 195 Current and Other Evidence: References Revisited 198 Request and Procedure Information 202 SR Document General Module 203 Example of Management Information Encoding 203 SR Document Series Module 207 Query and Retrieval 208 Query Information Models 210 Query Keys: Matching and Return 212 Query Keys for SR 214 Workflow Management 218 Architectural Issues - Integrating the Health-care Enterprise 223 Architecture - Beyond DICOM 226 Electronic Medical Record 227 Summary 229 CHAPTER 9 Templates: Bringing order to chaos … 231 What is a Template? 231 Other Template Features 235 Templates and the Meaning of Codes 236 Template Authoring 236 Templates and Presentation 237 Template Proposals for Common Patterns 238 Diagnostic Imaging Report Outline 238 Classification of Procedures 239 Descriptions of Common Findings 240 Measurement Templates 242 Normal Ranges for Measurements 246 Negation Templates 246 Identifying Which Templates Are In Use 247 Summary 249 10 DICOM Structured Reporting CHAPTER 10 Internationalization and Localization 251 Basic Text Encoding: Single Byte Character Sets 252 Mixing and Matching: Code Extension Techniques 256 Multibyte Character Sets 260 Why not Unicode? 263 Character Sets and Conformance 264 Internationalization of Codes 265 Concept Modifiers and Languages 267 Identifying Languages 268 Designating Language of Names and Values 270 Equivalent Meanings 272 Reality Check - Codes and Languages in Practice 274 Summary 274 CHAPTER 11 Security: Privacy and Authenticity 277 What is “Security?” 277 DICOM and Security 278 TLS/SSL 279 TLS and Authentication of Individual Identity 280 TLS, Confidentiality and Integrity 283 Security Features Enabled by DICOM and TLS 283 Digital Signatures 284 Digital Certificates 285 Digital Signatures in DICOM 286 Validating Signatures and Bit Preservation 288 DICOM Media Security 289 Legal and Regulatory Issues 291 Summary 292 CHAPTER 12 Other Standards: HL7, MIME, XML, COAS 295 HL7 101 296 Encapsulation in HL7 Messages 298 MIME Encapsulation 299 E-mail 301 HTTP, MIME and DICOM 303 Transcoding and HL7 303 DICOM Structured Reporting 11 HL7 Clinical Document Architecture 305 XML: Beyond the Hype 306 What is XML? 307 Alternative XML Encoding Issues 309 A Standard XML SR Encoding? 310 XML and Presentation 312 HL7 CDA: Structure and Use of XML 313 CDA Coded Entries 315 Transcoding CDA and SR 316 Clinical Observations Access Service 320 Summary 323 CHAPTER 13 Trees, Traversal and Transformation 325 Tree Data Structures 325 Object Model 326 Document Object Model 328 SR Object Model 329 Using an SR Object Model 333 Iterators with Names 336 An Alternative Approach - Event Streams 337 Transformation 339 XSL-T 340 Using XSL-T with DICOM SR 341 Summary 342 ANNEX A Walking Through the Standard 345 Information Object Definitions 345 SOP Classes 347 Data Dictionary 347 Encoding 348 Files and Media 348 Network 349 Conformance 349 ANNEX B Basic Encoding Principles 351 Encoding 351 Transfer Syntaxes 353 12 DICOM Structured Reporting ANNEX C List of Codes 355 ANNEX D List of Attributes 363 Attributes Sorted by Tag 364 Attributes Sorted by Name 367 ANNEX E Structured Reporting Object Model 373 Java 373 Index 379 DICOM Structured Reporting 13 14 DICOM Structured Reporting Summary of Basic Code Sequence Macro 41 Coding Schemes listed in HL7, ASTM and/or DICOM 46 Summary of Enhanced Code Sequence Macro 61 Waveform IODs and Storage SOP Classes 148 Structured Reporting IODs and SOP Classes 163 Summary of SR SOP Class Specific Constraints 164 Mammography image module extract 232 Hypothetical template for mass characteristics 233 Hypothetical template that invokes mass characteristics as siblings 234 Hypothetical template that invokes mass characteristics as children 235 Hypothetical template with multiple nesting levels 235 Measurement units for distance, area and volume 245 Summary of Template Identification Macro 248 Sources of Single Byte Character Sets (with G0 ISO 646) 254 Correspondence between Languages and Latin Alphabets 255 Single Byte Character Sets with Code Extensions 259 Multibyte Character Sets with Code Extensions 260 SR Object Model - Interfaces 333 SR Object Model - Methods for Interface Node 335 Value Representations 352 List of Codes Used 355 List of Attributes used in Structured Reporting, Sorted by Tag. 364 List of Attributes used in Structured Reporting, Sorted by Name. 367 DICOM Structured Reporting 15 16 DICOM Structured Reporting FIGURE 1. Simple example of a DICOM Structured Report 30 FIGURE 2. An SR Tree with References (Directed Acyclic Graph) 33 FIGURE 3. Composite Objects Represent Multiple Entities 37 FIGURE 4. Humans see headings, computer scientists see trees … 68 FIGURE 5. Reference Value Types 84 FIGURE 6. Spatial Coordinates With Sub-Pixel Resolution 94 FIGURE 7. Spatial Coordinates for Distance Along a Line 95 FIGURE 8. Spatial Coordinates for Closed Objects 96 FIGURE 9. Spatial Coordinates for Angles Between Lines 96 FIGURE 10. Spatial Coordinates for Rectangles Including Rotation 97 FIGURE 11. Temporal Range Types for Temporal Coordinates 99 FIGURE 12. Purpose of Reference for Coordinates and Images 102 FIGURE 13. Example of a Simple SR Tree with One Level of Children 107 FIGURE 14. Implicit Numbering of Nodes in the SR Tree 108 FIGURE 15. Example of Nesting of Document Macros 109 FIGURE 16. Diagram Style to Illustrate SR Trees - Vertical 111 FIGURE 17. Diagram Style to Illustrate SR Trees - Horizontal 111 FIGURE 18. Diagram Style
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