State of the Standards Kevin O Donnell, MASc. Canon Medical Research

Transcription

1 State of the Standards 2018 Kevin O Donnell, MASc. Canon Medical Research

2 If you build it, they will come Yeah, right.

3 Draft & Publish Standard SDOs Implement & Release in Product Vendors Install & Use in Practice Users

4 IHE Secretariat: RSNA & HIMSS Scope: Profiling existing standards to address specific use cases in healthcare 13 Domains Radiology, Cardiology, IT Infrastructure, Lab/Pathology, Eyecare,

5 IHE Process Add Profiles to IHE Technical Frameworks Steps: (Annual Cycle) Profile Proposal Public Comment Trial Implementation Final Text

6 IHE Radiology What s New Recent TI Publications Management of Acquisition Protocols (MAP) Collect/Manage/Distribute CT Protocols Standardized Operational Log of Events (SOLE) Capture Operational Events related to Imaging Results Distribution (RD) Send Radiology Reports with key flags and metadata (Foundation for FUNC Follow-Up of Non-Critical actionable findings)

7 MAP Motivation One Scanner can have 100 or more protocols Quality of Care Good, consistent image quality depends on good protocols, used consistently Efficient Workflow Hanging Protocols, Image Processing, Reporting Workflow depends on consistent series names, procedure codes, etc. Dose Management Managing dose depends on managing protocols Analytics Summarizing data depends on consistent tagging

8 Management of Acquisition Protocols (MAP) Centralized, cross-vendor review and approval Upload protocols Periodically review & approve Modify (within limits) Re-distribute protocols and approvals Scanner A Scanner B Scanner C Protocol Manager (Workstation) Protocol Archive

9 MAP Technology DICOM CT Defined Procedure Protocol IOD Encodes a complete protocol (incl. private tags and constraints) DICOM Protocol Approval IOD Encodes list of protocols and associated approvals DICOMweb - NPI Service RESTful transactions to Store, Query, and Retrieve Non-patient Instances

10 SOLE Motivation Help sites solve operational problems; improve performance You can t manage what you don t measure Scope initially limited: Imaging departments that use orders and schedules. Activities between Order and Report. Build on SWIM, Syslog, DICOM Schema (like ATNA), REST Existing tooling, shared infrastructure

11 Use Case: Track Order to Ready-to-Read (Part I) * Courtesy Rob Horn

12 Use Case: Track Ready-to-Read to Report-Available (Part II) * Courtesy Rob Horn

13 Use Case: Bulk Analysis * Courtesy Rob Horn

14 Results Distribution (RD) Send reports to EMR (and external systems, e.g. for FUNC action) FOCUS! Existing infrastructure -> HL7 v2.x ORU Enable SOME structured, coded data to begin to move industry Useful gap solution, not end game Important baby steps towards computer processable data * Courtesy Teri Sippel, Vital Images

15 Profiled HL7 v2.5.1 ORU * Courtesy Teri Sippel, Vital Images

16 Profiled OBX Segments OBX DICOM Study Instance UID OBX Finding OBX Radiologist s Recommendation OBX Radiologist Requests Consultation OBX - Radiologist Requests Feedback OBX - Imaging Result Payload Note: OBX type indicated by LOINC Code in OBX-3 * Courtesy Teri Sippel, Vital Images

17 ACR Actionable Findings Categories Finding type ACR Actionable Finding Category Meaning Normal Normal As expected or unremarkable Non-actionable Non-Actionable Not quite normal, but no action to be taken (e.g., the spleen is slightly enlarged ) Non-critical ACR Category 3 Medical attention required within days to months; incidental (e.g., lung nodule) Urgent ACR Category 2 Medical attention required within hours (e.g., diverticulitis) Emergent ACR Category 1 Medical attention required within minutes (e.g., large pneumothorax) * Courtesy Teri Sippel, Vital Images

18 Standardized Mapping of Actionable Codes & Priority * Courtesy Teri Sippel, Vital Images

19 IHE Radiology What s Next Entering Trial Implementation Encounter-Based Imaging Workflow (EBIW) Part 1: Point-of-Care Ultrasound Web Image Access (WIA) Formerly MHD-I Entering Public Comment later this year (Sneak Preview) Import and Display of External Priors (IDEP) Proactively find and import priors over the network

20 What is Encounter-Based Imaging? Enterprise Imaging Encounter-based Imaging [PoCUS, Camera, iphone, ] (Dermatology, Wound Care, Burn Unit, ER, etc., etc., etc., etc.) Order-based Imaging [CT, MR, PET, XA, MG, Echo] (Radiology, Cardiology, etc.) EBI = imaging captured in the context of an encounter between a patient and a care-provider (typically without an imaging order)

21 So What s the Key?

22 Key Metadata To manage the images, and readily find & use them again Patient Metadata Name, Date of Birth, Age, MRN, Other IDs, Encounter Metadata Department, Specialty, Physician, Referring Physician, Admission ID, Admission Date/Time, Reason for Admission, Procedure Metadata Modality, Imaging Procedure, Body Part, Reason for Imaging, Accession #, Acquisition Date/Time, Device, Operator, Acquisition Parameters (more for PoCUS than cameras), Pixel Metadata Rows, Columns, Bit Depth, Pixel Size, Encoding,... turning a JPEG into a medical document

23 Encounter-Based Imaging Workflow (EBIW) Use Case 1: Point-of-Care Ultrasound (ER) Scan wristband [Gets metadata] Scan Patient [Adds metadata] [Stores Images] [Notifies EMR] Encounter Manager PoC US EMR, MPI, PAM, PDQ, etc. Get Imaging Context Notify (Patient ID, Visit ID, Acq. Time, Procedure Code, Accession #, Body Part, etc.) Result Aggregator Image Manager/ Archive EMR

24 IHE EBIW Actors & Transactions

25 DICOM Secretariat: MITA dicomstandard.org Scope: data and workflow compatibility between imaging systems and HIT systems diagnostic, therapeutic & associated data in medical disciplines that use digital images 31 Working Groups CT, MR, Dentistry, Physics, Web Technology, etc.

26 DICOM Process Add Supplements to DICOM Standard Steps: New Workitem Proposal Public Comment Letter Ballot Final Text

27 DICOM What s New (2017) Sup 189 Advanced Blending Presentation State Sup 190 Volume Rendering Presentation State Sup 191 Patient Radiation Dose Report Sup 192 Protocol Approval Sup 194 RESTful Non-Patient Instances Sup 197 Ophthalmic OCT Angiography Sup 200 Transform NCI AIM & DICOM SR Measures Sup 198 Retire WADO-WS Sup 201 Retire Radiation Dose from MPPS Patient Dose Surface

28 Advanced Blending Presentation State (Example) + Relative Opacity 0.6 Anatomical DTI (Relative Opacity 0.7) (Relative Opacity 0.3) Relative Opacity fmri (Relative Opacity 0.33) fmri (Relative Opacity 0.33) fmri (Relative Opacity 0.33) * Courtesy Wim Corbijn

29 Volume Rendering - Example 3D Voxel Data 2D Pixel Data Volumetric Graphic Annotation Projection Graphic Annotation VOI LUT Cropping Classification RGBA Volume Rendering P-Values or PCS-Values Graphics Layer P-Values or PCS-Values Cropping Specification Index value, Volume Cropping Render Display Render Geometry Render Shading * Courtesy WG-11

30 Patient Dose SR Modality FOR X-Ray Equipment Modality Image Radiation Dose SR Radiation Exposure Information - X-Ray exposure techniques - Table, Gantry Angle, Beam Geometry, collimation - Dose measure: CTDI, DAP,... Patient Dose Surface Patient Model FOR Equipment Information - Table dimension - Attenuating material, Organ Dose Reporter System Patient Dose Map Registration IOD Patient Dose SR Patient Model Patient Registration Information - Patient position on table - Fiducials - Registration of Patient FOR and Equipment FOR * Courtesy WG-28

31 Reactivated Working Groups WG-14 Security Common members with MITA Cybersecurity Ready to apply & extend DICOM WG-17 3D (Additive Manufacturing) Aligned with SME ( Society of Manufacturing Engineers ) WG-23 Application Hosting (Data APIs) APIs for query & data access appropriate to training AIs, and using AI to process a current study Machine Learning buzz continues at RSNA, HIMSS, SIIM

32 DICOM What s Next Sup 188 Multi-energy CT Image Sup 164 Contrast Administration SR Sup 183 Web Services Re-documentation Sup 193 REST Notifications Sup 203 DICOMweb Thumbnails

33 Multi-Energy CT 4 families Multi Energy Imaging Standard CT Image Objective Image Family Material Quantification Family Material Labeling Family Material Visualization Family many flavors Virtual Monoenergetic Image (VMI) Effective Atomic Number (Z) Image Electron Density Image Material- Specific Image Iodine Map; Bone Density Material- Removed Image Virt. Non- Contrast; Virt. Non-Ca; Proportional Map Image Discrete Labeling Image Probability Map Image Value based Map Image Gout crystals CT IOD Material- Modified Image Highlighted; Partially- Suppressed Other IOD Color Overlay Image Color Blending Image Color Map Image * Courtesy WG-21

34 Multi-Energy CT * Courtesy WG-11

35 Contrast Administration SR Performed Administration SR Contains Programmed at 1 injector device 1 Actually delivered by injector device Programmed Plan Delivered Plan 1-n 1-n Steps Steps Pressure Vs. Time Graphs Flow Rate Vs. Time Graphs 1-n 1-n Phases Phases

36 DICOM What s Next Sup 204 TLS Security Profiles (FT 2018) Sup 206 CRYPTREC TLS Profile Sup 205 STL Encapsulation for 3D Manufacturing (FT 2018) Sup 208 X3D Encapsulation for 3D Manufacturing Sup 147 Second Generation Radiotherapy Sup 175-9: 2nd Generation Radiotherapy Sup 202 Real Time Video Sup 207 Conformity Assessment 36

37 DICOM Realtime Video Sample Use Case: Automated OR Multi-display Tile multiple videos on one monitor Layout ( hanging protocol ) depends on procedure, metadata * Courtesy Working Group 13

38 QIBA Secretariat: RSNA Scope: Improve the value and practicality of quantitative biomarkers by reducing variability across devices, clinical sites and time 4 Coordination Committees (CT, MR, PET, US) Collaboration with Europe (EIBALL) and Japan

39 QIBA Industrializing Biomarkers Problem Analysis Solution? Treat Wait ±6 Sources of Variance Differences in: - Patient Handling - Acq. Protocols Measure = 7 ±6 - Reconstruction - Segmentation Goal... Protocol Reqs Recon Reqs Resolution Reqs Noise Reqs Segment. Reqs Patient Prep & Operation Reqs Segment. Reqs Calibration Reqs! Treat Wait When all participating actors conform Measure = 7±2 39

40 QIBA Process Add Profiles to QIBA Library Steps: Biomarker Proposal Groundwork Public Comment Consensus Technical Confirmation Claim Confirmation Clinical Confirmation

41 QIBA Recently Published Technically Confirmed CT Tumor Volumetry Claim: A true change in tumor volume occurred with 95% confidence if measured change is > 24% / 29% / 39% respectively for tumors with initial diameters of / / mm. FDG-PET/CT for Tumor Evaluation Claim: Tumor glycolytic activity (SUVmax) measurements have a within-subject coefficient of variation of 10-12%. Consensus CT Lung Small Nodule Screening SPECT I-123 Ioflupane for Dopamine Transporters in Neurodegenerative Disease

42 QIBA More Work Public Comment fmri BOLD for Pre-Op Mapping of Cortex PET Amyloid for Neurologic Disease MR DWI for Tumor Evaluation MR Elastography Work in Progress UL Shearwave for Liver Elastography MR Proton Density Fat Fraction CT Lung Density for COPD