DICOM Anniversary Conference, Monday, September 22, 2003, 1:30

p.m.

The History and Future of

DICOM and HL7
1..1 1..1

Behlen^Fred^M^^PhD
American College of Radiology
Co-Chair, DICOM Working Group 20
Co-Chair, HL7 Imaging Integration SIG
President, LAI Technology, Homewood, IL
LAItechnology
 Today’s
• talk
History
– What is HL7?
– Other SDOs, early connections
• Now
– Comparative organizational structures
– Connections and collaborations
• Future
– Common information models
– Information objects and services
– CDA and reporting
– Congruence, not coalescence
 Diagnostic Imaging in the

Patient Care Process

Hospital Enterprise
Exam
context

Radiology
 Diagnostic Imaging in the

Patient Care Process

Hospital Enterprise
Exam
context
Results,
Images

Radiology
 Diagnostic Imaging in the

Patient Care Process

Hospital Enterprise
Exam
context
Results,
Images

Radiology $, £, ¥,
etc.
Sco
pe Scope of
Medical Informatics
of HL7

StanPatient ...
dar Bedside
Monitoring
Administrative
ds HIS/RIS Lab Data

...
Diagnostic
Imaging

Scope of
DICOM
Disagreements in
Healthcare
 Origin
s ANSI
SCAMC
HISPP (AMIA)
HL7 Harmonization
Sessions

ANSI
ACR/NEMA JWGDIC

ISIS
HISPP CEN
MSDS TC251
 DICOM-HL7
relationship
1996 IMSIG formed
1999 DICOM proposes joint WG
2000 DICOM WG20 formed, meets in
common with IMSIG (renamed IISIG)
2001 DICOM & HL7 execute Memorandum
of Understanding
2003 HL7 Version 2.5 Order Message for
Imaging (OMI)
 HL7
• ANSI-accredited standards development
organization, formed in 1987
• 16+ year old membership organization
– 512 organizations
2119 voting members
– 862 individual members (Nov. 2001)
• 14 Technical Committees (TCs)
• 17 Special Interest Groups (SIGs)
• 22 international affiliates
• A week of working group meetings 3 times
annually, about 400 people attending more than 25
parallel sessions and tutorials
 HL
7
• Special projects on drug information,
adverse event reporting, genomic
encoding, admin simplification, public
health surveillance, practice guidelines,
EHR and more
• Working relationships with ASTM, CEN,
DICOM, ebXML, GEHR, IEEE, LOINC,
OASIS, SNOMED, X12, W3C and others
DICOM HL7
Board of
Directors
1
DSC Work items
1

1 TSC Charters

1 1
n
WG6 Ballots
TCs Ballots
1
n 1

WGxx n

SIGs
 DICOM HL7
Board of
Directors Policy

Work items, 1
DSC 1
Policy
1 TSC Charters

1 1
n
WG6 Ballots
TCs Ballots

WGxx ... WG20

IISIG ... SIGs
 IISIG/WG20 Work Areas

• Version 2.5
– Order Message for Imaging (OMI)
• Version 3
– Representing DICOM Procedure Model
– Messages for imaging orders and reports
• Clinical Document Architecture (CDA)
– Transforming DICOM SR into CDA documents
– Diagnostic reporting in CDA format
 OMI Message Use Case

Order
Enterprise
Entry

OMI
message
Imaging Department used Imaging Department
Imaging Department Information System Information System

DICOM
Imaging Imaging Imaging
Modality Modality Modality
(Device) (Device) (Device)
 Hierarchy in OMI
Order
message
[ORC-2 Placer Order Number] – [ORC-3 Filler Order Number]
Imaging Service Request
[IPC-1 Accession Number]

Requested Procedure 1 Requested Procedure 2 Requested Procedure 3

[IPC-2 Requested [IPC-2 Requested [IPC-2 Requested Procedure ID]
Procedure ID] Procedure ID]
Procedure Step 1 Procedure Step 1 Procedure Procedure
[IPC-4 Requested [IPC-4 Requested Step 1 Step 2
Procedure Step ID] Procedure Step ID] [IPC-4 [IPC-4
Requested Requested
Procedure Procedure
Step ID] Step ID]
 HL7 Version
• 3 standard based on explicit information model
First HL7
(the “RIM”)
• Uses automated tooling to manage complexity
• Components
– Reference Information Model (RIM)
– Clinical Document Architecture (CDA)
– Version 3 Messaging
• Uses XML encoding
• High degree of compatibility with DICOM
• Extensive use of OIDs (cf. UIDs)
• Will change I.S. market as much as DICOM 3.0 changed
imaging market, mostly through CDA
Communicatio
n
dog
Communicatio
n
dog
 Patient

1 1
Study Content

Patient
makes has
Notification
1-n
1-n
1
Visit

& visit 1
describes

1
includes
1-n

Study

1 1-n
Comprised Comprised
of of
1-n 1-n

Study Modality Performed

Components Procedure Steps

Study &
1 1 1 1-n
includes includes contains See Note

1-n 1-n 1-n

0-n

acquisition Results
0-1 1-n
Frame of Spatially
Reference Defines
1
contains

1 1-n
Equipment creates

0-1 0-n
Series
Report Ammendment

1
contains

Stored 0-n 0-n 0-n

data 0-n
Stored
Print
0-n
Curve

0-n
Image

Radiotherapy Lookup
Objects Table Overlay
 Patient IOD

Patient 1

references
1

references Basic Study

Descriptor IOD
& visit 1-n
1-n
1
Visit IOD
IODs 1
describes

1
references
1-n

Study IOD

1 1-n
Comprised Comprised
Study & of
1-n
of
1-n

acquisition Study Component Modality Performed

IOD Proc. Step IOD
IODs
1 1 1 1-n
references references references See Note

0-n

Results IOD

0-n 0-n 0-n 1

Stored Stored Print IOD Standalone Modality Standalone Curve
references
See Figure 7.2b LUT IOD IOD
data 0-n 0-n 0-n 0-n 0-1

Radiotherapy IODs Standalone VOI LUT Standalone Overlay

IODs See Figure 7.2c IOD IOD Image IOD Interpretation IOD
 Message

age

M
s
es

es
sa
M

ge

Message
Message

age
M

s
es
es
sa

M
ge

Message
 Entity Role Participation Act
Entity 1 0..* Participation
Act Act_relationship
id : SET<II> Role Relationship_link type_ cd : C S
pla ys played_by is_source_f or has_source id : SET<II> type_cd : CS
class_cd : CS class_cd : CS effective_time : IVL<TS> time : IVL<TS>
mood_cd : CS inversion_ind : BL
Language_comm unication determiner_cd : CS effective_time : IVL<TS> 1 0..* type_cd : CS note_txt : ED is_source_for has_source
0 .. 1 0..* class_cd : CS sequence_nbr : INT
importance_status_txt : ED id : SET<II> signature_cd : CV
language_cd : CE txt : ED priority_nbr : INT
us ed_by c ommunic ates _with
qty : SET<PQ> status_cd : CS functi on_cd : CD 1 0..*
preference_ind : BL is_target_for has_target for has status_cd : CS pause_qty : PQ
telecom : SET<TEL> position_nbr : LIST<INT> awareness_ cd : C V
mode_c d : CV activity_time : GTS checkpoint_cd : CS
0 ..* 1 desc : ED qty : RTO signature_txt : ED
proficiency _level_cd : CV scopes is_scoped_by 0..* 1 effective_time : GTS split_cd : CS
status_cd : CS certificate_txt : ED encounter_a ccommod ation_cd : CV
confidentiality_cd : SET<CV> join_cd : CS
cd : CE addr : SET<AD> status_cd : CS
0 .. 1 0..* has_as_participant repeat_nbr : IVL<INT> is_target_for has_target negation_ind : BL
nm : SET<EN> telecom : SET<TEL> participates_in mode_cd : CV
interruptible_ind : BL conjunction_cd : CS
risk_cd : CE cd : CE seq uence_n br : INT 1
sends 1..1 priority_cd : SET<CV> 0..*
handling_cd : CE 0..*
1 independent_ind : BL
shall_receive 1..*
availability_time : TS
cd : CD
1..*
reason_cd : CV
originates_in_context_of
status_time : TS

Certified_practitioner
Living_subject Place board_certification_type_cd : CV
birth_ti me : TS Organization Material Role_heir recertification_time : TS
Entity_heir gps_txt : ST 0..*
deceased_ti me : TS standard_industry_class_cd : CE form_cd : CV position_txt : ED Resource_slot prov ides_context_f or
deceased_ind : BL addr : SET<AD> effective_time : IVL<TS> addr : AD slot _time : GTS
admi nis trative _gender_cd : CE directions_txt : ED Act_context Consent Financial_act
organ_do nor_ind : BL mobile_ind : BL Guarantor level_cd : CV
mul tipl e_bi rth_i nd : BL Patient Financial_contract net_qty : MO
credit_rating_cd : CV Qualified_practitioner lan guage_cd : CS Supply Observation
birth_order_nbr : INT confidentiality_cd : CV paym ent_terms_cd : C V
fellowship_field_cd : CE Substance_administration
very_important_person_cd : CV qty : PQ value : ANY
residency_field_cd : CE deri vation _expr : ST route_cd : CD
Manufactured_material Schedul able_resource Patient_encounter dose_qty : IVL<PQ>
method_cd : SET<CV>
expiration_time : TS slot_size_increment_qty : PQ discharge_disposition_cd : CV Referral rate_qty : IVL<PQ>
Working_list targ et_s ite_cd : SET<CD>
lot_nm : ST acuity_level_cd : CV authorized_visits _qty : R EAL interpretation_cd : SET<C S> dose_check_qty : SET<RTO>
birth_encounter_ind : BL desc : ED ownership_level_cd : CV
stability_time : IVL<TS> max_dose_qty : SET<RTO>
status_reason_cd : CV reason_txt : ED approach_site_cd : SET<CD>
Assigned_practitioner
valuables_desc : ED substitution_cd : CV Transportation
Covered_party position_cd : CV
Access pre_admit_test_ind : BL
Person gauge_qty : PQ
handicap_cd : CV primary_care_ind : BL referral_source_cd : CV Procedure
student_ind : BL special_courtesies_cd : CV
Di et
disability_cd : CE Non_Person_living_subject approach_site_cd : CD approach_site_cd : SET<CD>
target_site_cd : CD valuables_location_desc : ED energy_qty : PQ method_cd : SET<CV>
ethnic_group_cd : SET<CV>
taxon omic_class ification_cd : CE admission_source_cd : CV carbohydrate_qty : PQ target_site_cd : SET<CD> Device_task
race_cd : SET<CV>
breed_cd : CE accident_cd : CV Account
ambulatory_status_cd : CV Device p aram eter_value : LIST<ANY>
stra in_txt : ED Container urgency_cd : CV
education_level_cd : CV manufacturer_model_nm : ST allowed_ bala nce_qty : IVL<MO>
euthana sia_ ind : BL
living_arrangement_cd : CV last_cali brati on_tim e : TS capacity_qty : PQ currency_cd : C V
producti on_class_cd : CE height_qty : PQ
Employee Message_interaction
marital_status_cd : CV s oftware _nm : ST in terest_rate_qty : RTO
gen der_s tatus_cd : CE hazard_ exposu re_txt : ED Invoice_element
religious_affiliation_cd : CV loca l_remote_ control _state _cd : C E diameter_qty : PQ message_type_id : II nm : ST
addr : SET<AD> barrier_delta_qty : PQ job_class_cd : C V response_cd : CS item_nbr : REAL
a lert_ level_ cd : CE
special_accommodation_cd : SET<CV> bottom_delta_qty : PQ job_titl e_nm : ST Public_health_case item_qualifier_cd : CE
mothers_maiden_nm : ST separator_type_cd : CD prote ctive _equipme nt_txt : ED detection_method_cd : CE gross_qty : MO
cap_type_cd : CD salary_qty : MO 0 .. 1 transmission_mode_cd : CE coverage_source_cd : CE
salary_type_cd : C V is_com municated_as
Context_structure Diagnostic_image disease_imported_cd : CE
Inpatient_encounter unit_qty : RTO
job_cd : CE subject_orientation_cd : CV notify_subject_ind : BL
Financial_transaction
local_id : ST
le ngth _of_ stay_qty : PQ modifier_cd : CE payment_terms_cd : CV
Imaging_modality debit_exchange_rate_qty : RTO
factor_nbr : REAL
pixel_padding_qty : PQ c ontai ns points_nbr : REAL credit_exchange_rate_qty : RTO
pixel_intensity_relationship_cd : CV interest_rate_qty : RTO
0.. 1
spacial_resolution_qty : PQ Outbreak
time : IVL<TS>

Message Control

Batch File_of_batch
control_id : II Infrastructure (Structured documents)
con trol_ id : II
name : ST name : ST
0..1 creation_time : TS creation _tim e : TS Query_message_interaction
contains reference_control_id : II reference _control_id : II
sending_application_id : II send ing_ appl ica tion_id : II
is_contained_by 0..*
has_payload receiving_application_id : II receiving_application _id : II
0..* 0..*
security : ST is_contained_by contains Clinical_document 0..1 contains
0.. * security : ST Table is_contained_in
Message message_count : INT comp letion_cd : CV
h as_ re cipie nt 0..* file_batch_ count : INT rules : CS Entry
sending_application_id : II batch_totals : SET<INT> 0..1
file_co mment : SET<ST> s et_id : II cellspacing : ST
0..*
is_contained_in
0..* id : SET<II> batch_comment : SET<ST> s torage_cd : CV local_id : ST
cellpadding : ST
creation_time : TS vers ion_ nbr : INT Table_structure summary : ST
has_sender interaction_id : II copy_ti me : TS halign : CS width : ST
version_id : ST change_reason _cd : CV char : ST border : INT
profile_id : SET<OID> charoff : ST frame : CS
processing_cd : CV
Attention_line Query valign : CS
sequence_nbr : INT
can_include c an_ ac company key_word _txt : ST me ssage_qu ery_cd : CV local_id : ST
reply_to_com : TEL
Li nk_html
HEALTH LEVEL 7 receiving_application_id : SET<II>
processing_mode_cd : CV
1 0..* va lue : ST Sort_control
element_name : ST is_for has
id : II
pri ority : CV Local_attr title : ST
REFERENCE INFORMATION MODEL attachment_txt : ED
accept_ack_cd : CV
sequence_nbr : INT
0 .* 1
mo dify_i ndicator : C V
executi on_a nd_delivery_time : TS
name : ST name : ST
href : ED
direction_cd : CV value : ST
RIM_0110 application_ack_cd : CV in itia l_qty : PQ
res ponse_modality_cd : CV
rel : SET<CE>
rev : SET<CE>
return_eleme nt_g roup : SET<CV>
Version is basis for first committee-level ballots of Version 3. It Link
1 1
was released July 2001, and reflects RIM changes through has is _acknowl ed ged_b y Table_cell
Harmonization on 07/20/2001 rowspan : INT
colspan : INT Local_markup
Enitites Acts (Services) occurs_with acknowledges Table_column_structure
0..1 1..* Get_more_results abbr : ST ignore_cd : CS Character_data
axis : ST span : INT descriptor : ST
Acknowledgement query_id : II value : ST
headers : SET<ED> width : ST render : ST
type_cd : CV quantity : INT
scope : CS
Roles Acts (Financial) start_result_nbr : INT
note_txt : ED
error_detail_cd : CV
expected_sequence_nbr : INT Query_by_parameter Query_by_selection

Document Structures
Infrastructure (Structured Infrastructure (Message has 1
has_ex pression 1
documents) control) Query_ack
is_parameter_of
0..* id : II
Billboard produced by: Param eter query_status_cd : CV
has_left_side is_for 0..*
Rochester Outdoor Adv ertising is_part_of message_query_cd : CV
name : ST 1 Selection_expression result_count_total : INT
has_right_side
0..* 1 result_count_current : INT
result_count_remaining : INT

is_lhs_for is _rhs_for
0..* 0..*

may_contain
Logical_expression Rel ati onal_expressi on
0..1
A_parameter relational_conjunction_cd : CV element_name : ST
Parameter_list value : ST
value : ANY
relational_operator_cd : CV

Message Control
 Ima
ging
Ord
Act

Participationer

Role CMET R-
(Common Message
Element Type)
MI
M
Act Relationship

Entity
 The HL7 Clinical Document

• CDAArchitecture
header (CDA)
– RIM-derived
– Ground up compatibility with DICOM SR
• CDA Level One body
– Based on subset of XHTML, fits any report type
– Has image link, coded vocabulary
• CDA Release 2 body
– Permits data representation at various levels of
granularity
– Passed first Committee ballot August 2003
– Member ballot March 2004
 HL7 Clinical Document

• LevelArchitecture
1 (CDA)
– Coded header, text content with simple
formatting objects(section, paragraph, list,
table)
• Level 2
– Standard codes for Level 1 sections
• Level 3
– Full structured content derived from RIM
 HL7 Clinical Document
Architecture (CDA) Release
2 1
• Release
– Coded header, text content with simple
formatting objects(section, paragraph, list,
table)
• Release 2
– Standard codes for Level 1 sections

– Full structured content derived from RIM

 Release 2
• Release
CDA 2, Level One:
– alignment with current RIM, V3
methodology
– minor enhancements to CDA Header
– added functionality for CDA Body
• Region of interest (cf. DICOM SCOORD)
• Release 2, Levels Two and Three
– templates layered on basic XML spec
• Level Two: templates for headings
• Level Three: templates for contents
– enables detailed clinical encoding
 CDA
• Implementations
National & International
– PICNIC (European Union)
– SCIPHOX (Germany)
– HYGEIAnet/WebOnColl (Greece)
– NHS South Staffordshire (United Kingdom)
– Satakunta Macro Pilot (Finland)
– e-Claims Supporting Document Architecture (Canada)
• Local & Regional
– Mayo Clinic (USA)
– Buenos Aires project (Argentina)
– Dalhousie U, QEII Health Sci Ctr (Canada)
 HL7
• JointTem
project of Templates SIG, Structured
plat TC, Conformance SIG
Documents
• Openestemplate registry/repository
–will contain normative and non-normative
templates
• Tools for generating and validating
templates will be developed
• This will take a while
 A Number of
Connections
• WG20 / IISIG  Other HL7 groups
– Technical Committees
• Orders & Observations
• Vocabulary
• Structured Documents
• Laboratory Automation and Point of Care Testing
• Patient Care
• Control/Query
– Special Interest Groups
• Conformance
• Electronic Health Records (EHR)
• Security & Accountability
• Templates
 More
Connections
• WG14  SASIG  NEMA SPC
 IHE
• IHE  Conformance SIG
• DICOM  ISO @ HL7 venues
– WG10  TC215/WG2
– WADO  TC215/WG2
• Also WADO  Structured Documents TC
 A Rewarding
Partnership
• No big turf issues
– DICOM doesn’t want to define enterprise
communications
– HL7 has no ambition or bandwidth to model
specialty domain detail
• Each can learn from the other
– DICOM experience with persistent objects
– HL7 experience with modeling tools
• HL7 meetings are a good gathering place