IT WORLD

DICOM: Key ConceptsPart I

Jeff Kabachinski
heres been a lot written about the Digital Imaging and Communications in Medicine Standard (DICOM) over the years. Its the standard that defines how medical instrumentation communicates on a network to transfer clinical information. In the usual IT World approach, well attempt to get at the main idea or basics of the DICOM approach. Its not as easy as it appears on the surface. DICOM is a complex standard as it endeavors to cover all the details that make up this kind of communication. DICOM allows for a lot of variability and flexibility to facilitate dependable data transfer among varying manufacturers. Its complex in that there is a lot of information in the standard and it can be initially confusing. There is a difference between complex and complicated however. The DICOM Standard is not complicated once you dig in deep enough and assemble all the reference materials. Each of the areas and aspects of DICOM are easily understood. There is so much material in the DICOM Standard that it could take 10 IT World columns to explore it all. A 10part column started now, we would not finish with DICOM until the end of 2007! I figure that wed probably lose a few readers along about part 7. However, we can get a good look at the basics of DICOM in just a two-part column. The intent of this two-part column is to investigate different parts of the DICOM Standard to get a sense of what DICOM is and how it works. In part 1, well cover some of the background and history of the Standard. Well also look into DICOMs main goals as well as some of the key aspects to see how DICOM gets its arms around this huge and complex problem of facilitating communication of different images among different manufacturers imaging systems. To do this well investigate service classes and the service object pair as well as the Information Object Definition (IOD). In part 2, well cover the Unique Identifier (UID), networking with DICOM, conformance, and conformance statements. The DICOM Standard has 16 sections. Well, actually 14
Jeff Kabachinski, MCNE, MS-T, is the training & development manager for GE HealthcareMultiVendor & Clinical Services located in Waukesha, WI. He holds MCNE certification, an MSc in Training and Development from Leicester University and a BS in engineering technology from the Milwaukee School of Engineering. He can be reached at Jeff.Kabachinski@ge.com Biomedical Instrumentation & Technology

as two of the sections are retired (see sidebar for a list of the sections). Each of the sections is a separate document and can be of a different revision level from the others. They can also be in a different state of approval. The good news is that the DICOM Standard divulges all the grim details allowing the user to make DICOM work for just about any kind of medical information communication need. The bad news is that DICOM has all the grim details and can be difficult to read and get through. For example, just the Conformance section (document # PS3.2-2004) is 285 pages in length! All of the sections are available in Adobe PDF format at http://medical.nema.org/.

History and Background

The need for a standard that describes a standardized method for transferring images and associated information between devices from various manufacturers was recognized in the 1970s with the advent of computed tomography (CT). By 1983, the American College of Radiology (ACR) and National Electrical Manufacturers Association (NEMA) had formed a joint committee to develop a standard that: promoted communication of digital image information between devices regardless of manufacturer; works with picture archiving and communications system (PACS) to interface with other hospital information systems; and allows the development of diagnostic information databases that can be cross-examined by a wide variety of distributed devices (in other words, via a computer network). The first ACR-NEMA standard was published in 1985 and went through a couple of revisions until in 1993 it was released under a new nameDICOM. DICOM included several enhancements that delivered on the promise of standardized communications. Prior to the standard, most devices stored images in a proprietary format. They also transferred files of these proprietary formats over a network or via removable media to perform image communication. The current DICOM release is the 3.0 version. The DICOM Standard nomenclature for the different sections is written as: PS3.1-2004. The first portion of the name is PS (Publication Standard) 3 (overall revision level), followed by the section number. This is followed by the year of release. DICOM is a cooperative standard in that the device manufacturers voluntarily follow it to facilitate crossOEM communication. (OEM stands for original equipPage Number

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DICOM: Key Concepts Part I

The DICOM Standard Contains 16 Parts

PS3.1: Introduction and Overviewdescribes the overall structure of the Standard. PS3.2: ConformanceSpecifies the general requirements, which must be met by implementations claiming conformance and defines contents of a Conformance Statement. PS3.3: Information Object DefinitionsSpecifies the structure and attributes of objects that are operated upon by Service Classes (PS3.4). These objects include images, studies, and patients. PS3.4: Service Class SpecificationsDefines the operations that can be performed on instances of Information Objects (PS3.3) to provide a specific service. These services include image storage, retrieval, and printing. PS3.5: Data Structure and Encoding PS3.6: Data DictionaryDefines the individual information attributes that represent the data content (PS3.3) of Information Objects PS3.7: Message ExchangeSpecifies the operations and protocol used to exchange messages. PS3.8: Network Communication Support for Message ExchangeDefines the services and protocols used to exchange messages (PS3.7) directly on OSI and TCP/IP networks. PS3.9: Retired (formerly Point-to-point Communication Support for Message Exchange) PS3.10: Media Storage and File Format for Data Interchange PS3.11: Media Storage Application Profiles PS3.12: Storage Functions and Media Formats for Data Interchange PS3.13: Retired (formerly Print Management Point-to-point Communication Support) PS3.14: Grayscale Standard Display Function PS3.15: Security ProfilesSpecifies a standardized method for secure communications and digital signatures. PS3.16: Content Mapping Resource Note: while the DICOM Standard parts are interdependent, each one is a separate document where revision level and approval status can differ.

ment manufacturer.) DICOM is found in just about every medical profession that uses images within the health care industry. These include cardiology, dentistry, endoscopy, mammography, ophthalmology, pathology, pediatrics, radiation therapy, and surgery, to name a few. The patients Electronic Health Record (EHR) is also affected by the DICOM Standard. It defines the network and media storage communication services allowing storage and access to these DICOM objects for EHR systems. DICOM is also global, it has been adopted by the Committee European de Normalization (CEN TC 251) and the Japanese Industry Association for Radiation Apparatus (JIRA). One of the coolest aspects of the DICOM charter is the mandate to stay current with specific needs of different modalities (as previously listed). DICOM is also designed to evolve to accommodate technological changes while being backward compatible.

Main Goals of DICOM

The Standard facilitates interoperability with devices that claim to adhere to it. As stated in PS3.1-2003, the goals of DICOM are: Addresses the semantics of Commands and associated data. To allow devices to communicate, there needs to be standards on how devices are expected to react to commandsbeyond just the information that is being passed. The original standard, before it became DICOM, addressed only the transfer of data. Addresses off-line communication aspects such as file service semantics and formats as well as information directories. This is also a quantum leap from the original standard where the physical media, file format, or logical file system was not specified. Addresses operation in a networked environment. The original standard was point-to-point operation only. Note that the two sections that defined point-to-point applications are now retired (see sidebar). Makes use of and adheres to any other existing standards. As mentioned earlier, the Standard is structured to accommodate the introduction of new services. Check out http://medical.nema.org to get an idea of whats being worked on now, look for The DICOM Standards Committee and Its Working Groups. The DICOM Standard identifies the operation of Service Classes beyond data transfer, and constructs a means for identifying Information Objects as they travel a network and are used by the devices on the network. It also stipulates a
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network protocol utilizing the transmission control protocol/Internet protocol (TCP/IP).

Service Classes and the Service Object Pair

Key concepts of DICOM are to identify who you are and what service you want as well as what service you can provide. Services are defined as service classes, which is nothing more than what you can do with the data. Service classes are things such as send, query, print, and store, among many others. In terms of who, DICOM uses the client/server model. The client or user of a service (service class) is called a Service Class User (SCU). The server or provider of a service (service class) is called a Service Class Provider (SCP). Someone provides the service and someone uses the service. Information Objects Definitions (PS3.3) defines what kind of data were dealing with. DICOM uses IODs as a way to encode real life information into an abstract definition applicable to communication of digital medical images and related information. This not only includes CT, x-ray, nuclear medicine, magnetic resonance, positron emission tomography, and ultrasound but also such things as waveforms, structured reports, and radiation therapy doses. This is an area that we can spend lots of time discussing. The section of the DICOM Standard that covers this (PS3.3) is 894 pages in length and if you really want to know, you can download this, and any of the sections of the standard at the DICOM Web site: http://medical. nema.org/. Click on The DICOM Standard in the PRODUCTS menu. Theyre all in pdf and are free. Section PS3.3 especially is a known antidote for insomnia! The combination of the Service Class and the Information Object Definition is called the Service Object Pair (SOP). This is the key for interoperability. Print X-Ray image, and send CT image are two examples of SOPs. Its all pretty obvious stuff. See Figure 1 for a snapshot of these definitions.
Figure 1. User and provider definitions

does not contain the values of the attributesjust which attributes will be included. Information Objects are defined in PS3.3 but includes other areas of the standard as well. Other areas of the Standard that affect the IOD are found in the conformance statement (see part 2 in the July/August 2005 issue of BI&T) and generally consist of: PS3.5the Data Structure and Semantics For example, this includes which image compression technique is used. This part also addresses the encoding rules necessary to construct the data stream (which in turn is made up of data elements). PS3.6the Data Dictionary This is the centralized registry of DICOM Data Elements. Each element is defined with things like a unique tag that includes a group and element number, an element name, a value representation (alpha, numeric), and how many values per attribute. Think of this as a lookup table for data types. PS3.14he Grayscale Standard Display Function Provides methods for calibrating a display system (monitor and print) to present grayscale images consistently. This part of the standard uses Bartens model of the human visual system. Another example of the important detail of the Standard. PS3.16Content Mapping Resource This part covers the templates and coded terms for DICOM information objects. This part also contains the glossary of terms and any country specific translations of coded terms.

The IOD
Information Objects are simply a way to classify data that is being transmitted via DICOM. It is a way to encode the physiological data so that it can be passed from device to device over a network. Typically this is digital image information and any related data (such as waveforms, formatted reports, radiation therapy dosage, etc.). Each Information Object Definition contains the description of its purpose and a list of the attributes that define it. The class itself
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Summary
In this issue and next, were investigating different sections of the DICOM Standard to get a grip on what its all about. The bottom line is to facilitate communication and DICOM addresses all the technical aspects to allow complying OEMs to talk to one another. In part 2, IT World completes its overview on DICOM by exploring UID, networking with DICOM, conformance, and conformance statements.
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