DICOM Structured Reporting (SR) can greatly improve the efficiency and quality of radiology reports, especially for ultrasounds, by reducing unnecessary dictation.
Healthcare Information Technology (IT) departments often look for ways to enhance operational efficiency. They may consider implementing DICOM SR in-house through a ‘Do-It-Yourself’ (DIY) project using purchased software.
This article examines the challenges of internal projects versus leveraging specialized services, enabling organizations to determine the best ultrasound reporting software solution for their specific needs.
Summary: Although these projects may seem simple at first, mapping DICOM SR to radiology reporting templates can grow in complexity and present significant challenges, including:
- Hidden complexities of DICOM SR
- High Maintenance Costs
- Limitations of Available Tools
- Need for comprehensive expertise
Often, outsourcing this task to specialized vendors is a better solution.
The Objective: Optimized Data Flow and Enhanced Radiologist Throughput
The goal is clear: map measurements from imaging modalities, especially ultrasound and DEXA, into specific fields within report templates in Powerscribe, Fluency, or RadAI.
The objectives include increased radiologist productivity, improved quality through reduced dictation errors, and the generation of more consistent diagnostic reports for research or quality assurance initiatives.
The Rationale for In-House DICOM SR Projects
DICOM Structured Reporting (SR) enables the structured, machine-readable transmission of measurement data. Since digital imaging, DICOM, is already routed by IT, how hard can it be to map some code values (measurements)? It should be an easy opportunity to improve efficiency by reducing radiologist dictation load.
Internally developed solutions begin by assuming lower implementation costs. A common justification includes leveraging existing IT personnel and infrastructure.
DICOM SR Background Hints at Challenges
An examination of a DICOM SR file and specifications hints at challenges.
In a directory of DICOM images, the DICOM SR file is usually the smallest, typically ranging from 10 to 100 kilobytes, and is often the last file created by the modality.
Understanding DICOM SR: Core Concepts and Structure
DICOM SR is a structured document defined in PS3.3. It contains standard DICOM SR header modules such as:
- PatientName (0010,0010)
- StudyInstanceUID (0020,000D)
- Manufacturer Model Name (0008, 1090)
The rest of the content of an SR document is organized in a structured hierarchical tree structure. The tree base, or root content item, is built using Templates (from PS3.16) such as:
- TID 5003 OB-GYN Ultrasound Procedure Report
- TID 5100 Vascular Ultrasound Procedure Report
- TID 5200 Echocardiography Procedure Report
- Or a lot of custom stuff…
As there are no official templates for other procedures, vendors have shoehorned exams into one of the existing reports. For example, ‘TID 5100 – Vascular Ultrasound Procedure Report’ templates are used for thyroid, abdominal, and scrotal reports.
Additionally, all SR data types are ‘simple’ data types – so numeric measurements (ie, 9.3 mm) are not text strings but a composite of a distance and a unit content item. Content items are encoded in a hierarchical ‘Coded Concepts’ structure that describes all the structured information for measurements. Each manufacturer has a different cascading list of classifications and concepts before reaching the measurement.
| Manufacturer 1 | Manufacturer 2 | |||
| 121070 | Findings | T9900-01 | User-defined | |
| G-C0E3 | Finding Site | T9900-02 | Measurement | |
| G-0373 | Image Mode | T9900-04 | Label | |
| G-C171 | Laterality | G-C171 | Laterality | |
| 121206 | Distance | 121206 | Distance | |
To further complicate matters, the same manufacturer often uses different cascaded coding concept approaches between organ and lesion measurements.
Although Coded Concepts are unique identifiers that ensure clinical information is unambiguous and machine-readable, the standard was both incomplete and unconstrained for radiology, resulting in every manufacturer creating a unique data structure.
A surprise to most is how different each SR file is – let’s examine a series of SR documents.
Lack of Standard Mappings in DICOM SR for Radiology: A Hurdle for DIY Projects
Let’s compare sample documents from thyroid exams. The examples below are small parts of the entire document, for ease of illustration, omitting many additional concepts, such as units, status selection (e.g., mean, latest), value type (text, numeric), and other related concepts.
Generally, you will need to create a unique mapping for each ultrasound system, protocol, and measurement. It is not unusual for a site to have a couple of thousand measurements mapped.
| Vendor | Concept Code | Code Meaning | Value |
| Canon | G-C0E3 | Finding Site | Anatomic Structures |
| G-C171 | Laterality | Right | |
| T-B6000 | Thyroid | ||
| G-A220 | Width | 0.73 cm | |
| GE | GEU-1005-7 | Anatomy Label | Thyroid |
| 121206 | Distrance | 1.72 cm | |
| GEU-1005-5 | Measurement Label | RT LOBE H | |
| Philips | T9900-02/04 | Measurement/Label | LOBE H |
| G-C171 | Laterality | Left | |
| 121206 | Distance | 12.4 mm | |
Multiple DICOM SR Mappings for a Measurement: Implications for Ultrasound Reporting
Another common surprise is that there can be multiple ways of measuring the same organ.
For example, some sonographers choose the ‘length’ label to measure the major axis of the kidney, while others choose ‘height’. The DICOM SR ‘concept codes’ are different. Ultimately, both have to be mapped to the same output, as both labels will be used.
| Concept Code | Code Meaning | Value |
| G-C0E3 | Finding Site | Vascular Structure Of Kidney |
| G-C171 | Laterality | Right |
| G-0373 | Image Mode | 2D Mode |
| T-71000 | Kidney |
| 121207 | Height | 9.95cm |
| OR | ||
| G-A22A | Length | 9.95cm |
This example is likely the largest source of ‘missed’ mappings and is particular to one vendor. It is common to be in and out of Doppler mode performing abdominal measurements. In what seems like a manufacturer’s oversight, the state of the ultrasound measurement package software determines the path and, therefore, different mappings for the same specific values.
| Concept Code | Code Meaning | Value |
| G-C0E3 | Finding Site | Artery of Abdomen |
| G-0373 | Image Mode | 2D Mode |
| T-63000 | Gall Bladder | |
| GEU-1004-38 | Gall Bladder Wall | 2.9 mm |
| OR | ||
| G-0373 | Image Mode | Doppler Color Flow |
| T-63000 | Gall Bladder | |
| GEU-1004-38 | Gall Bladder Wall | 2.9 mm |
Ongoing Maintenance: The Hidden Burden of DIY DICOM SR Mapping
Imaging modality software undergoes frequent updates. These updates can alter the structure or contents of any module. The local ultrasound representatives are not familiar with whether a new software version has any DICOM SR changes. The consequence is that the IT staff must reinvestigate, remap, and revalidate the mapping from a software upgrade.
| Concept Code | Code Meaning | Value |
| Old | ||
| 121070/G-C0E3 | Finding Site | General Vascular |
| G-0373 | Image Mode | Doppler Pulsed |
| GEU-1005-7 | Anatomy Label | Aorta Iliac/Vessel_14 |
| New | ||
| GEU-1005-7 | Anatomy Label | Aorta Iliac/AORTA PSV |
| 11726-7 | Peak Systolic Velocity | 83.5 cm/s |
Software upgrades turn into an ongoing support issue.
Limitations of DIY DICOM SR Tools: When In-House Solutions Fall Short Some things can’t be done with DIY tools.
Historical DEXA
One example is capturing historical information from DEXA. The mapping is so complicated that DIY software just CANNOT extract it.
DEXA manufacturers, of course, do offer an option to send directly to the reporting package, which is an alternative if faced with DIY shortcomings. Purchasing the manufacturer’s solution would create another interface and software to manage.
Mapping Lesions
An issue that isn’t strictly SR is how to map lesions and masses to reporting templates. The value of SR is to eliminate the dictation of measurements. If a reporting template can’t handle one or multiple masses, it defeats a good portion of the value of DICOM SR.
A solution is to transfer more than the measurement and include spacing inside the ‘merge field/token’ as illustrated in this image.
I have seen alternatives with auto-text or pick lists for the number of lesions; in practice, these workarounds are abstract enough that many radiologists simply avoid and continue dictating.
Beyond Technicalities: Other Challenges in DICOM SR Implementation
Project Management and Clinical Decision Making
Although not technical DICOM SR issues, a time-consuming aspect of the project involves agreement on the measurements to be taken. These include image acquisition and measurement labelling decisions such as:
- Masses: 3 or 4 masses per lobe/organ
- Velocity: just mid, OR prox, mid, and distal.
- One, two, or three dimensions to measure a kidney
Each of these decisions is multiplied by the number of ultrasound vendors.
Ultrasound system configuration
Another time-consuming activity is configuring ultrasound systems. Most projects find:
- Manufacturer’s application person is the only person with expertise to configure the measurement package.
- Clear instructions to configure the agreed-upon measurements
- Software versions do matter
- Configure the ultrasound system to produce and send DICOM SR to a different destination than PACS.
A best practice is rewarding a local resource to become familiar with and resolve minor configuration issues.
Integrating Worksheets with DICOM SR: A Key for Comprehensive Reporting
DICOM SR transfers only quantitative (measurement) information. Implementing a DICOM SR efficiency project typically includes worksheets to record clinical observations.
Worksheets should provide.
- Qualitative information into reports: Single click for: Coarse echotexture, pain over the gallbladder, retroverted uterus, etc.
- Drawings with measurements: Help identify anatomical locations
- Calculators: Automatic volume and & percent (%) difference calculations
- Clinical decision support: Integrated TI-RADS and O-RADS
The ideal situation is that a technologist or sonographer selects radio buttons for qualitative observations, and the radiologist sees a complete findings section with both measurements and observations populated. DIY solutions are either ineffective or unable to accomplish these tasks.
The article Reporting Automation contains a more in-depth discussion of worksheets.
And for all the shortcomings, one still has to pay for DIY software
Enough said.
The Hidden Resource Drain: Why DIY DICOM SR Projects Underperform
What starts as a ‘simple DIY DICOM SR’ mapping project grows into a much larger effort requiring project management resources, clinical discussions, a crazy amount of DICOM mapping, and worksheet development.
Few healthcare institutions have the extra personnel with the skills and time to execute a DIY DICOM SR project to the satisfaction of Radiologists.
Specialized DICOM SR Solutions: The Strategic Alternative for Efficient Radiology and Ultrasound Reporting
Commercially available specialized DICOM SR solution providers, such as those from Imorgon Medical, have experience with the complexities discussed. They bring expertise in:
- Project Management and Schedules
- Expertise mapping any value/measurement
- Sample, customizable worksheets
- QC checking, including addressing typical problems
- Continued support for software upgrades or any problems
- Resources to develop customized solutions if necessary
Making an Informed Decision: Achieving DICOM SR Utility in Radiology
In conclusion, a DIY DICOM SR project may initially appear to be a cost-effective solution for enhancing radiology efficiency. However, the complexities of DICOM SR mapping, the necessity for continuous maintenance, and the absence of sophisticated features can lead to extended project durations, unfulfilled objectives, and dissatisfaction among radiologists…
Third-party DICOM SR solutions from companies like Imorgon Medical provide a strong alternative. They offer robust features, expert support, and enhance both operational efficiency and report quality. This improvement occurs without utilizing vital internal IT resources.
Summary: Critical Insights for Successful DICOM SR Implementation
- The Unseen Complexities of DICOM SR: True DICOM SR adoption, particularly for ultrasound and DEXA reporting, is far more complex than initially perceived due to the absence of universal mappings and the sheer volume of unique mapping requirements across various imaging vendors and protocols.
- High Maintenance Burden of DIY: Internal DICOM SR projects face continuous challenges from software upgrades that invalidate existing mappings, placing an unsustainable maintenance burden on IT departments and diverting resources from core institutional missions.
- Functional Limitations of DIY Tools: Many DIY DICOM SR software solutions lack advanced capabilities, such as handling historical DEXA data, accounting for masses and lesions, or integrating qualitative information from worksheets, thereby limiting the full potential of structured reporting.
- Beyond Technicalities: The Need for Holistic Expertise. Successful DICOM SR implementation requires not only technical proficiency but also robust project management, informed clinical decisions, and training in configuring ultrasound systems.
- The Strategic Advantage of Specialized Solution Providers: Third-party DICOM SR solution providers, such as Imorgon Medical, help mitigate the risks and challenges associated with handling everything in-house. They bring expertise and tailored solutions, allowing internal IT teams to focus on their primary tasks. This leads to better operational efficiency and higher-quality reports in radiology.
- Informed Decision-Making for Sustainable Utility: Institutions must thoroughly evaluate the actual long-term costs and resource implications of DIY projects versus a specialized solution to achieve sustainable and high-utility DICOM SR integration within their radiology workflow.
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