DICOM Reporting Strategy – White Paper
I.
Purpose
Provide to the DICOM Community – Vendors and Users – strategic directions (or
guidelines) for the deployment of reporting mechanisms defined by standards: DICOM
SR and HL7 CDA.
There are some uncertainties associated with the two approaches:
 whether they are compatible or complimentary
 where do they differ in their areas of application
 what are the overlaps and how to harmonize them
 dependencies on clinical specialties, use cases and local practices or policies
In addressing these aspects DICOM also needs to account for providing users and
suppliers the flexibility to apply these standards according to their business needs.
There is no single universal solution to all questions/issues listed below, however
recommendations should be brought out based on typical/representative clinical
deployment scenarios.
The intention is to issue general strategic recommendations on behalf of WG-10 while
detailed use-cases should follow later and/or be identified in more details in specific
working groups (WG-06, WG-20, or other specialty oriented working groups).
While WG-10 should work on an overall “top-down” reporting strategy in DICOM, the
WG-20 will follow a “bottom-up” approach with its current CDA-SR mapping work
[1][2][3].
“From the standpoint of DICOM strategy, the key action is to encourage and continue
the efforts of WG-20” [4].
Additional implementation details could also be addressed in IHE (e.g. for Radiology,
Cardiology) based on the results of this DICOM work.
II. Open Issues & Questions
1. Different meanings of the term “Report” in different contexts.
2. When or where to use DICOM SR vs. HL CDA?
Analysis criteria: clinical specialties, scenarios, established practices, local policies,
use cases.
3. Scope of distribution of reporting information: consider different intended audiences
as well as distribution within and across departments and also within and across
enterprises.
4. Purpose of report, e.g.:
 for processing,
 for display only (e.g. PDF / text).
5. Encoding of report data:
 Structured data: DICOM SR, HL7 CDA,
 Unstructured data: PDF, text.
Consider when/how to transcode (transform) report data depending or based on
specific phases (steps) of report processing.
6. CDA – SR mapping:
6.1. Is a “full mapping / translation” useful or feasible? Most likely not.
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DICOM Reporting Strategy – White Paper
6.2. Identify a “meaningful” relevant subset(s) of “mappable” data (see current WG20 work).
7. When to use DICOM and when to use other means to access referenced images?
8. Storage / archiving of report information, e.g.: the “classical” PACS archive, IHE
XDS (EHR) type of registry/repository and also media (both digital and paper).
9. Use of references vs. encapsulating whole objects from “foreign domains”.
10. Do we need to re-activate WG-08 Structured Reporting to take on this work?
These issues and questions served as basis for several discussions (in meetings and
teleconferences) which led to a series of strategic insights and a proposal as outlined in
the following sections IV and V.
III. Approach
The main focus of the DICOM reporting strategy remains on the representation and
exchange of Imaging Reports.
Specialized
Diagnostics &
Intervention
Images
Evidence
Document
s
Imaging
Reports
• Mammography
• Ultrasound
• Cardiac
• Ophthalmology
Object reference
Use/create info content
Images
Images (incl. Presentation States) as created and processed within specialized diagnostic
and intervention facilities  Use of DICOM Objects.
Evidence Documents
Accompanying imaging information (Evidence Documents, Measurements, Protocols)
generated within specialized diagnostic and intervention facilities  Use of DICOM SR.
Imaging Reports
Imaging Reports are detailed representations (findings) of interpretations of imaging
procedures performed by specialized diagnostic and intervention facilities (e.g. in
Mammography, Cardiology, Ophthalmology, conventional Radiology).
Imaging Reports may contain references to pertinent images, evidence documents, etc.
Representation and exchange of Imaging Reports is the principal topic of the DICOM
reporting strategy.
Principles:
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

Provide users and suppliers the flexibility to apply standards (DICOM or
HL7) according to their business needs
Refrain from mandates such as:
o DICOM SR not suited for “final” Radiology reports
or
o CDA as THE only possible reporting output from Imaging / Radiology
Criteria:
 Common established practices:
o “Ophthalmologists have made a deep commitment to the use of DICOM
Structured Reporting” [4].
o Specialties such as “Mammography and Radiology are likely to be in
DICOM SR, while Endoscopy might be in CDA” [4].
 Additional implementation details could also be addressed in IHE
IV. Strategic Insights
1. Today in the clinical practice we hardly see any application of structured and coded
reporting beyond the evidence documents. The expectation and vision is that the need
for structured and coded reporting will emerge the coming years to facilitate decision
support, full integration in the patient’s EHR, data mining and analysis to improve the
theoretical foundation and practice of medicine.
2. The workload for creation of structured and coded reports is the most significant
acceptance criteria for the reporting clinician. There should be a direct link between
the guidelines and practice protocol and the template/document structure.
3. The expectation is that given the broad range of clinical domains, broad scope of the
use cases that need to be supported, and IT infrastructures and applications that are in
place today, there will be a coexistence of both DICOM SR and HL7 CDA for
encoding structured semantics.
4. Reporting use cases identified the need to exactly capture the report layout. This is
legally required in certain jurisdictions, and because of human perception and
readability, and business presentation and reimbursement. PDF is well suited to
support these requirements.
5. The assumption is that in (some) many reporting use cases the reference to the
evidence documents and images from the report is an important element in the report.
6. It is also assumed that the report and the referenced evidence documents and images
have to be incorporated in the patient's electronic health record.
7. Reaching agreement on clinical templates for specific applications is a significant
challenge to the adoption of structured and coded reporting, both for the professional
societies to generate them and for the IT infrastructure in the practice to be flexible
enough to deal with these.
V. Proposed Actions
1. In the DICOM community we need to find and document at least one typical clinical
use case where we believe DICOM SR is ideally suited to encode the structured
report, and efficiently supports the whole scope of the use case including the
verification, distribution and medical research.
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The DICOM standard has all the elements in place to support such an "all DICOM"
structured reporting use case (e.g. 1. Breast Imaging Report, 2. Echo).
2. DICOM should communicate to the IHE community it’s acceptance of the
coexistence of DICOM and HL7 constructs for the purpose of structured and coded
reports.
3. WG-20 is on the right track with the ongoing effort to harmonize the structured report
content between DICOM SR and HL7 CDA (diagrams below provide an overview of
the SR / CDA mapping [1]), because in practice it may well be that it is more the
hospital's IT and application infrastructure that is the decisive factor for the choice of
structured report encoding, rather than the clinical use case.
WG20 will be supported in their activity to define a Diagnostic Report template by
the activity defined in item 1 above.
Clinical
Document
Patient Medical
History / Relevant
Prior Documents
Clinical Summary
Report
Clinical
Document
HL7 Message
Inclusion into
*
Order
Specialized
Diagnostics/
Interventions
*
Image Data
Post-Processing
Derived
ObserImage
vations
Data
Image
Data
*
Evidence
Document
Evidence Doc Export SR -> CDA Rel.2
Transcoding
Interpretation
CCOW Access
* Convey relevant information
Observations
Conclusions
Diagnoses
of clinical document
HL7 CDA
Format: DICOM SR, HL7 CDA,
Text, PDF
DICOM SR
Imaging Report Export
Imaging
Report
Evidence Doc Import
On one or more
Imaging procedures
Clinical
Document
Order
Patient Medical
History / Relevant
Prior Documents
HL7 Order Message containing:
- Reference pointer to CDA document
or
- MIME encoded CDA document
Departmental Information System
e.g. Radiology Information System
DIS
Discussion of different options:
- MWL/GPWL: Reference Pointers to CDA Documents (Supp101)
- Transformation of meaningful parts of the clinical document: CDA -> DICOM SR
- DICOM Encapsulation of CDA and CDR (Supp 114)
- DICOM Encapsulation of PDF Documents (Supp104)
Modality/
Workstation
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4. Because DICOM has a method for encapsulating PDF, IHE is encouraged to
incorporate into the reporting workflow a mechanism by which DICOM SR is
complemented by an equivalent encoding of the report in PDF.
5. Advise to the DICOM Committee to set-up a liaison with Physician’s EHR Coalition
for the topic of clinical guidelines and the relationship to structured and coded
reporting
VI. References
All references listed herein are available at:
ftp://medical.nema.org/MEDICAL/Private/Dicom/WORKGRPS/Wg10/Reporting/
1. Overview SR / CDA Mapping Diagram –
Helmut Koenig (OverviewSR_CDA.ppt)
2. DICOM SR / CDA Rel.2 Mapping – San Antonio WGM, May 2006 –
Helmut Koenig (DicomSR_CDA_Mapping San Antonio.ppt)
3. Report Types & Templates –
WG-20 – Helmut Koenig (ReportTypesAndTemplates.xls)
4. Minutes DICOM Working Group Ten (Strategic Advisory) – April 10, 2006 –
Yokohama, Japan (WG-10_2006-04-10_Min.doc and SR_CDA_brainstorm.ppt)
5. Minutes DICOM Working Group Ten (Strategic Advisory) – June 14, 2006 –
Teleconference (WG-10_2006-04-10_Min.doc)
6. Integrating Imaging and Reporting using DICOM SR and HL7 CDA –
Fred M. Behlen, Ph.D. (Imaging Integration WG10 2004-09-02.04.ppt)
7. Integrating Imaging and Reporting using DICOM SR and HL7 CDA –
Fred M. Behlen, Ph.D. (Imaging Integration WG10 2004-04-06.00.doc)
8. Integrating Imaging and Reporting using DICOM SR and HL7 CDA –
Fred M. Behlen, Ph.D. (Imaging Integration WG10 2003-06-23.02.ppt)
9. Reporting Use Case Scenarios 3 and 4 –
WG-10 – Emmanuel Cordonnier (Scenarios 3 and 4 V2.1.ppt)
10. Reporting Use Case Scenarios 5 and 6 –
WG-10 – Niki Wirsz (Scenarios 5 and 6 V2.0.ppt)
11. Reporting Use Case Scenarios 56a –
Helmut Koenig (hkUseCase56a.ppt)
12. Reporting Use Case Scenarios 56b –
Helmut Koenig (hkUseCase56b.ppt)
13. Reporting Use Case Scenarios 7 & 8 –
WG-10 – Niki Wirsz (Scenarios 7 and 8 V1.0.ppt)
14. Reporting Use Case Scenarios 3, 4, 5, 6, 7, 8 –
WG-10 (Scenarios_all.ppt)
15. Reporting Needs Analysis –
WG.10 – July 11th T-Con (Reporting Model-V2.ppt)
16. DICOM Structured Reporting (SR) objects and XML – Extensible Markup Language,
HL7 V3.0 RIM – Reference Information Model, HL7 Clinical Document
Architecture – WG-10 – April 3rd, 2001 (SR in XML white paper 5.doc)
17. The Future of Radiology Reporting – Bruce I. Reiner, MD, Eliot L. Siegel, MD, and
Kaushal Shastri (chapter9.pdf)
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18. DICOM SR Meets XML - beyond the hype ... – NEMA SR Workshop 29th - 30th
March 2000 – David A. Clunie (srxml20000330.ppt)
19. Enterprise-Wide Reporting And The Continuity Of Care:
The Role Of DICOM SR And HL7 CDA –
DICOM Anniversary Conference and Workshop 2003 –
Helmut Koenig, Frank Krickhahn (P12_Koenig_Enterprise-Wide-Reporting.ppt)
20. Reporting Use Cases – Dr. David Channin
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