::

,, ,

x
; :

PACS Mini
5
Refresher Course
Introduction to the ACR-NEMA DICOM
StLfldard
w. Dean Bidgood, Jr, MD Steven
#{149} C. Horii MD

In 1982, the American College of Radiology (ACR) and the National Electri-
cal Manufacturers Association (NEMA) formed a committee to develop stan-
dards for the interconnection of digital imaging devices. Version 1 .0 of the
standard, published in 1985, specifies a hardware interface supporting
point-to-point (not network) image transmission, a data dictionary (a set of
rules for encoding information), and a set of commands to initiate transac-
tions. Version 2.0, published in 1988, also addresses point-to-point image
transmission and provides semantic rules by which messages (streams of bits
representing information in transit from one device to another) are orga-
: nized. Version 3.0, also referred to as DICOM (Digital Imaging and Commu-
. nications in Medicine), will be finalized in 1992. The DICOM standard en-
: courages open systems interconnection of imaging equipment over standard
networks, while maintaining compatibility with earlier point-to-point con-
nection standards. The DICOM standard conforms fully with the Interna-
tional Standards Organization reference model for network communications
(ISORM), addresses the issue of conformance, and incorporates the concept
of object-oriented design.

U INTRODUCTION

. Overview
In 1982, the American College of Radiology (ACR) and the National Electrical Manu-
facturers Association (NEMA) formed the ACR-NEMA committee to develop stan-
dards to promote a generic digital image communication format, facilitate the devel-

Abbreviations: ACR = American College of Radiology, ASCII = American Standard Code for Information Interchange,
DICOM = Digital Imaging and Communications in Medicine, ISO = International Standards Organization, ISORM = In.
temational Standards Organization reference model for network communications, NEMA = National Electrical Manufac.
turers Association, 051 = open systems interconnection, TCP.IP = transmission control protocol-internet protocol,
UID = unique identifier value

Index terms: Images, transmission Picture

#{149} archiving and communication system (PACS)

RadloGraphics 1992; 12:345-355

I From the Department of Radiology, University of Florida College of Medicine. BoxJ-374 JHMHC. 1600 SW Archer Rd.
Gainesville, FL 32610-0374 (W.D.B.); the Department of Radiology, Gainesville VA Medical Center. Gainesville. Fla
(W.D.B.); and the Department ofRadiology. Georgetown University hospital, Washington, DC (S.C.H.). From the 1991
RSNA scientific assembly. Received November 18, 1991; accepted November 19. Address reprint requests to W.I).B.
C 1992

See the article by Horii and Bidgood in the May 1992 issue.

345
 a. b.
Figure 1. Plain film from a barium enema examination, digitized for image processing. (a) In the digitized
image, the pixel value range has been restricted to 2 bits (four levels of intensity) to simulate the effect of
limiting the bit depth of the display memory. (b) Another digitized image, for which the gray scale has been
extended to 6 bits (64 levels of intensity). The pixels in a are no larger than those in b, but the intelligibility
of the former image suffers significantly due to poor rendering of the gray scale of the subject. (Courtesy of
Ken’ichiro Kajiwara, MD, Kurume University Hospital, Kurume, Japan.)

opment of picture archiving and com- . Fundamentals of Digital Imaging

munication systems (PACS), allow the cre- Computerized images make up a substantial
ation of diagnostic data bases for remote ac- fraction of routine diagnostic radiology exami-
cess, and help ensure the usability of new nations. Images are directly produced in digi-
equipment with existing systems (1). tal form in computed tomography, magnetic
Version 1 .0 of the ACR-NEMA standard was resonance (MR) imaging, ultrasound, nuclear
published in 1985. The document was then medicine, computed radiography, and digital
revised, new commands were added, other subtraction angiography. The remaining ra-
organizational changes were made, and yen- diologic images are in analog form. Conven-
sion 2.0 was published in 1988. Version 3.0 tional analog nadiographs can be scanned by
of the ACR-NEMA standard for Digital Im- film digitizers for entry into a computer.
aging and Communications in Medicine Whether initially created by a digital device or
(DICOM) will be circulated in draft form for converted by means of a film digitizer, any
comments in 1992. This is the first oftwo arti- nadiologic image can be translated into digital
des explaining the DICOM standard. The em- form with present technology. Once in digital
phasis of this article is on the format of data form, images can be enhanced, transferred,
messages that cross the interface. The com- and stoned by computers.
munications interface reference model of the Any digital image on a computer monitor
international Standards Organization (ISO) screen is basically an array of dots displayed in
and the fundamentals of object-oriented anal- rows and columns. Each dot makes up one
ysis are introduced as background informa- element of the image, called a picture ele-
tion for understanding the DICOM standard. ment (pixel). The computer keeps track of the
New features are illustrated by examples. precise location of each pixel by assigning
Other models for the representation of medi- each one an individual address in its display
cal information are highlighted to demon- memory area. At every address, the computer
strate the opportunities for cooperative stan- allocates a certain number of bits to hold the
dards development brought about by the intensity value of the corresponding pixel.
ISO-conformant framework of the DICOM The number of bits stored pen pixel typically
standard. In the next issue of RadioGraphics, ranges from 8 to 16 in nadiologic imaging de-
we will explain the hardware specifications of vices. Since memory chips are digital devices,
the interface, take a closer look at network each bit of stored data must be coded as ei-
protocols, and review the command set of the then one or zero. If 8 bits are available to rep-
ACR-NEMA DICOM standard. resent the brightness of a pixel, the number of
unique combinations of ones and zeros is
256. Thus, 256 different shades ofgray (from
full black to full white) are possible in an 8-bit
video display system (Fig 1).

346 U RadioGraphics U Bidgood and Horn Volume 12 Number 2

 STANDARD TEMPLATE

oo11o100111o1o1 ...- -Nowisthetimefor...

Figure 2. Standard and nonstandard tern-

NON-STANDARD TEMPLATE
plates. A stream of incoming bits is meaningless
to a computer unless it is aware of the syntax of
the data. If the templates (information models
and communications protocols) at both ends of
oo11o100111o1o1 ... - . - - *‘----‘-v#{248}-a- the circuit match precisely, information units
will be transferred accurately. The ACR-NEMA
standard serves the same put-pose as the stan-
dand template shown here, only on a larger
scale.

Nearly every computer has a built-in rou- cal industry, and present the industry’s views
tine for handling a stream of data to display to the government and other entities. NEMA
an image on its own monitor. Most computers is organized into divisions and subdivisions
even provide interfaces (such as serial and according to product lines. One of the associ-
parallel ports) to send messages over a cable. ation’s key functions is to provide an organi-
The operating system software and an addi- zational framework for cooperative nonpro-
tional communications (terminal) program prietary development of voluntary industrial
push the bits of the image to the outside standards and codes. NEMA provides meeting
world. The real challenge of image communi- rooms, administrative staff, and publications
cations lies not in the sending of data, but in support to achieve this goal. It is through the
making sense of the “foreign” bits streaming MED-PACS subdivision of the diagnostic imag-
in from another computer. The receiving ing and therapy systems division that NEMA
computer must have a template so that it can has worked jointly with the ACR to develop
decode the incoming bursts of ones and zeros the ACR-NEMA Digital Imaging and Communi-
into intelligible units of information. Given cations Standard (Table 1).
the right set of clues, the computer is able to
reconstruct an exact copy of the original im- U COMPONENTS OF THE ACR-NEMA
age and store it in its memory (Fig 2). STANDARD

U DOMESTIC STANDARDIZATION: . Version 1.0: Hardware Interface,

NEMA Data Dictionary, Commands
NEMA, formed in 1926, is a voluntary trade There are as many electronic systems to send
association of 630 companies (in 1990) that images as there are types of computers. The
manufacture a wide range of products used in ACR-NEMA committee was formed to explore
the generation, transmission, distribution, ways of standardizing the interconnection of
control, and use of electricity. The combined imaging devices. Version 1 .0 of the ACR-NEMA
value of product shipments by member com- Digital Imaging and Communications Stan-
panies in 1990 was nearly S 100 billion (2). As dard, published in 1985, established a reason-
the largest trade association in the United able common ground for users and vendors.
States for companies in the electrical products The original version specifies a hardware
industry, NEMA plays an important leadership interface, a data dictionary, and a set of com-
role. mands. A version 1.0 interface supports only
NEMA maintains and distributes industrial point-to-point message transmission. Connec-
statistics and other technologic, market, and
economic information. Staff members con-
duct educational forums, promote the electni-

March 1992 Bidgood and Horn U RadioGrapbics U 347

 tion to a network requires additional hard-
Table 1
ware and software. Between two version 1.0
Organizational Framework of NEMA
interface cards, bytes of data composed of 16
bits are sent oven a 50-wire cable at up to 8 Divisions of NEMA
Industrial automation
million bits/sec (1). An error-correction nou-
Electronics
tine ensures accuracy by requiring acknowl-
Building equipment
edgment of each byte prior to transmission of
Wine and cable
the next one. Lighting equipment
The data dictionary is a comprehensive ta- Industrial equipment
ble of rules for the encoding of information Insulating materials
associated with images; such information ac- Power equipment
companies the image pixel data in a file area Diagnostic imaging and therapy systems
called the header. An abbreviated header Extracorporeal lithotripsy
might contain the following information: pa- Nuclear medicine
tient name (encoded as a string of ASCII Ultrasound imaging
Magnetic resonance
[American Standard Code for Information
Radiation therapy
Interchange] text characters), patient identifi-
X-ray imaging products
cation number (a free-format string of ASCII
Medical picture archiving and communica-
text or numerals), and study date (a text tion systems (MED-PACS)
string having a defined format, for example,
yyyy.mm.dd) (Fig 3).
A minimal set of commands is provided to
initiate transactions over the interface. The Table 2
functions of the commands generally are re- Data Elemen ts ofGroup OO1OH: Patient
vealed by their names: SEND, GET, MOVE, Information
FIND, DIALOG, ECHO, and CANCEL. Each No. Element Name Type
command has a request form and a response
0010,0000 Group length 1
form. A protocol for message exchanges is
0010,0010 Patient name 2
defined. The success or failure of a command
0010,0020 Patient identification 2
request message is indicated by the value of a
number
status element within the command response 0010,0030 Patient birth date 2
message. (The ACR-NEMA command set will 0010,0040 Patient sex 2
be explained in more detail in our second 0010, 1000 Other patient identifica- 3
article in the next issue of RadioGraphics.) tion number
0010,1001 Other patient names 3
0010,1005 Patient’s maiden name 3
. Version 2.0: Message Structure 0010,1010 Patientage 3
The original standard was refined over the 0010,1020 Patientsize 3
years, resulting in the publication of version 0010,1030 Patient weight 3
2.0 in 1988. Ten years after the formation of 0010, 1040 Patient address 3
the ACR-NEMA committee, devices conform- 0010,1050 Insurance plan identifi- 3
ing to version 2.0 ofthe standard are widely cation number
0010, 1060 Patient’s mother’s 3
available.
maiden name
In the context of computer communica-
0010,4000 Comments 3
tions, a message is a stream of bits that repre-
sents information in transit from one device
to another. Messages conforming to the Se-
mantic rules ofthe version 2.0 ACR-NEMA ment combination is a unique identification
standard are composed of two parts: a com- tag for that piece of information. The version
mand segment and a data segment (Fig 4). 2.0 ACR-NEMA standard specifies that groups
Individual units of information, called data will be transmitted in ascending order, from
elements, are organized within the data dic- the lowest to the highest group number. Ele-
tionary into related groups (Fig 5). ments within each group likewise are sent in
Groups and elements are numbered. The ascending order. An element may be trans-
pair ofhexadecimal numbers (eg, OO1OH, mitted no more than once within a group.
0020H) that designates a given group-ele- Groups are sent only once per message. Table
2 lists the elements of the patient information
group (OO1OH).

348 U RadioGraphics U Bidgood and Horn Volume 12 Number 2

 Figure 3. Sample data dictionary
GROUP ELEMENT NAME VALUE entry. The data dictionary specifies
REPRESENTATION the unique group number and ele-
0028H O100H Bits Allocated BI ment number, element
name, value
representation, value
type, multi-
plicity, element (priority) type, de-
VALUE VALUE ELEMENT DEFAULT VALUE fault value (if assigned), and an cx-
TYPES MULTIPLICITY TYPE planatory definition for each entry.
HX S 1D 0016 B! = 16-bit binary, HX = any hexa-
decimal number, S = single value,
JD = required element with a de-
I- DEFINITION fault value defined.
I Maximum number of bits allocated for any pixel.

Figure 4. (a) Two-part message of

Tosndyoua version 2.0 standard. The groups
datast, I send are printed in the required order of
you a message transmission. A message is a stereo-
consIsting of two
general types of typed entity with predictable struc-
InformatIon... tune and variable length. The length
ofeach group is transmitted in its
first element. The total length of the
COMMAND DATA VALUES message also is sent as a cross
check. (b) Two-part message of ver-
sion 2.0 standard, in greater detail.
Group 0000 Groups 0008, 0010, 0018, 0020, 0028, 4000, Elements are sent in ascending nu-
6000, and 7FEO
merical order. Group number, dc-
ment number, element length, and
element value are sent for required
a elements, depending on the type
value. Default element values for
type 1 elements are assumed if not
More speclflcally...I send you ..and a set of data values. which are
a commend related with organized into standard groups sent. Ifa type 2 element value is
certain required elements... according to a previously agreed-upon unknown, the element must be sent
syntax. with length set to zero and nothing
in the value field. Type 3 elements
are entirely optional.
COMMAND DATA VALUES
Group 0000: Element. Element. Group 0008: Element, Element. ...Element;
...etc Group 0010: Element. Element. Element;
...etc

b.

r- GROUPNAME TYPICAL DATA ELEMENTS

Figure 5.
Straightforward group-
ing ofdata elements, according to
function. If these entities are not
0000H Command Command type, Message ID, Dataset type...
sufficient, users and manufacturers
0008H Identifying Date and time of study. Radiologist’s name... are permitted by the version 2.0
OO1OH Patient Patient’s name, ID numbers, birthdate... standard to define custom groups.
0018H Acquisition Contrast agent, slice thickness, radionuclide... These are called shadow groups
0020H Relationship Slice location, study #, series #, image # and are designated by tags 000 1H
0028H Image Presentation Rows, columns, pixel size, grey scale... higher than those of the regular
4000H Text Free-format ASCII text characters... groups. For example, the shadow
6000H Overlay Region of interest (ROI), overlay format... group for identifying data would be
7FEOH Pixel Data The actual image, pixel by pixel... number 0009H. ID = identification.

March 1992 Bidgood and Horn U RadioGraphics U 349

 Table 3
Overview of the DICOM Standard
Section Title Editor Description

Part 1: Introduction and Overview William C. Bennett Introduction, history, and future
directions; goals, rationale, and
technical description of the parts
of the standard
Part 2: Conformance William C. Bennett Requirements for functional, mes-
saging, encoding, and network
conformance; structure of a con-
fonmance claim
Pant 3: Information Objects James E. Steinke The set of information objects refer-
enced in service class specifica-
iions, attribute list, and semantics
of definitions
Part 4: Service Classes William C. Bennett Semantics ofa command as applied
to a data set in a given context,
definitions of associated set of
object attributes
Part 5: Data Interchange Formats Dwight Simon Details ofdata structure and seman-
tics, syntax, usage, compounding
of data sets, and basic and ad-
vanced functions
Part 6: Data Dictionary Steven C. Honii Attributes of information objects
classified by group and element
number, name, and parameters;
description of permitted values
Pant 7: Message Exchange Protocol James E. Steinke Examples ofcommand exchanges in
both point-to-point and ISO con-
texts, protocol for command en-
coding and status indication
Pant 8: Network Interface Specifica- Charles Parisot Definition of a generic upper-layer
iions service common to both OSI and
TCP-IP environments, supporting
standard networks
Part 9: Point-to-Point Interface Spec- Wayne DeJarnette Definition of 50-pin interface, physi-
ifications cal protocol, data link frame pro-
tocol, virtual channels, and ses-
sion layer services

Note.-OSI = open systems interconne ction, TCP-IP = transmissi on control protocol-internet protocol.

As it appears in a message, each individual ofversion 1.0 (Fig 3). In both versions, a type
data element consists of its group-element designation indicates the priority of each ele-
tag, its length, and its value. The length of ev- ment.
ery element and group is rounded to an even Group 0000H is the command group. Most
number to facilitate automatic error checking. of its elements are type 1 (required). The pni-
An odd length detected at the receiving end is ority designation of elements in the command
evidence of damage to the data set. When this group varies in a defined way, according to
occurs, the sending device is instructed to the type of command, since each command
repeat the transmission. performs a different function. ACR-NEMA yen-
From the user’s point of view, the element sion 2.0 commands are linked with three
values are the most essential part of the mes- classes of data sets: image, text, and graphics.
sage. Entries representing data values must be The standard defines the set of information
coded into proper syntax (ASCII text, ASCII elements that make up each class.
numerals, or binary). The version 2.0 data ForanMRimage(512 X 512 matrix, two
dictionary syntax rules are identical to those 8-bit bytes per pixel), the ratio of header in-
formation to image data is less than 1:1,000.
However, the proportion jumps to oyer 30%
when the same header is used for nuclear

350 U RadioGrapbic.s U Bidgood and Horn Volume 12 Number 2

 INFORMATiON HANDLING LAYERS

Level 7 APPLICATION Contains both the user interface software and the
President input/output routines of the generic communications
software. Establishes associations with peer application Figure 6. Seven-layer refer-
processes. Preserves the relationships between ence model for computer
Information units.
communications developed
Level 6 PRESENTATION Translates information units from the syntax of the
Sales manager Application layer to the transfer syntax negotiated with a by the ISO. Each layer re-
peer Presentation layer across the network. The size of ceives services from the layer
transferred information units is not constrained by the
Internal details of network function. immediately below it and pro-
vides services to the layer
DATA HANDLING LAYERS above it. The “job descnip-
tions’ ‘ in the middle column
Level 5 SESSION Establishes and controls connections. Segments the
are provided for clari&ation
Department head information units (of arbitrary size) provided by the
Presentation layer Into manageable dialogue units of data, only; they are not official ISO
the size of which is constrained only by the capabilities labels. Note the separation of
of the Transport service.
Provides reliable end-to-end transfer of Session dialogue the information-handling up-
Level 4 TRANSPORT
Supervisor units regardless of the type of Network employed. per layers and the data-han-
Ensures that speed, accuracy. and reliability meet levels dling lower layers. Although
specified by the Session layer.
Level 3 NEThOl< Routes and relays data units. Assigns virtual channels. functional flow here is de
Dispatcher Encapsulates data into packets and adds addresses and scribed only from the top
sequence numbers to each. Negotiates handoffs between
intermediate relay points to support the Transport layer.
down, the reciprocal occurs
Level 2 DATA LINK Frames each packet between a control word and a frame when data are received by the
Traffx cop check word. Facilitates error correction. Sends frames physical layer for delivery to
to the hardware of the Physical layer only upon receipt of the top. Each layer also open-
the proper status Indication.
Level 1 PHYSICAL Transmits frames created by the Data Unk layer by ates in tandem with its peer
Truck driver generating electrical or optical impulses, or other across the network (ie, appli-
signals, according to the timing. duration, and amplitude
protocols demanded by the type of network employed.
cation with application, pre-
sentation with presentation).

medicine dynamic images with a matrix size of of a vendor’s conformance clijpn. Conform-
32 x 32. This is an unacceptable amount of ance claims must be express#{235}tl in terms of
overhead, since version 2.0 requires a full specifically defined service classes, the func-
header to be sent with each image. tional units ofwhich are precisely described
with predefined terms. Vendors are free to
I Version 30: DICOM Standard implement any function in their software;
The incorporation of an object-oriented data however, if they claim to conform to the
model and the addition of support for ISO DICOM standard, they must state precisely
standard communications substantially which services are and which services are not
broaden the scope ofversion 3.0 ofthe ACR- supported by their product,
NEMA standard, DICOM. The draft document
of the standard is composed of nine parts. ISO Reference Model.-The DICOM stan-
Parts 1, 8, and 9 of the DICOM standard have dard conforms fully tothe ISO reference
been prepared for balloting in March 1992. model for netwoij communications (ISORM)
Parts 2-7 will be circulated for comment later (4, pp 13-129). Protocols based on the
in 1992. The modular design ofversion 3.0 ISORM control the process of information ex-
will facilitate future enhancements of the stan- change among dissimilar computer systems.
dard (Table 3) (3). The ISORM specifies a sequence of protocol
negotiations that mediate the differing abili-
Conformance Levels.-Missing from the ties and requirements of devices and software
early versions of the ACR-NEMA standard is a applications linked remotely by a network
rigorous treatment of the issue of conform- (Fig 6).
ance. Thus, the various interpretations of the ISO publications specify the requirements
earlier versions have been ambiguous. Trou- for conformance to the ISORM. These docu-
blesome incompatibilities have been noted by ments deal with the seemingly mundane but
users, particularly in the areas of unique iden- essential details of the structure of messages,
tification numbers, orientation coordinates of the negotiation of services among remote us-
cross-sectional images, and examination ens, and the resolution of errors and conflicts.
(study, acquisition, series, image) hierarchy.
The DICOM standard specifies levels of con-
formance and explicitly defines the structure

March 1992 Bidgood and Horn U RadioGrapbics U 351

 PEER
Figures 7, 8. (7) Cooperating peer service users
ENTITIES
linked transparently by a service provider. The physi-
cal layer forms the only real connection between the
two interoperating systems. However, peer entities IAPPLICATION . I JAPPLICATION
function
layers
as
below
if they
them
were
support
connected
their
directly,
virtual connection
since the
by
$ i I
providing appropriate services. The layers below any I
PRESENTATIONk - - PRESENTATIONI
given pair pass higher-layer protocol negotiation mes- I H I
sages back and forth, linking upper layer peers as if
they were wired with a direct hot-line. The transport,
I SESSION li#{248}- - - __SESSION

network, and datalink layers are grouped figuratively, 4 user j user

only to illustrate the net effect of their combined ser- provider provkier
vices on the layers above them; their peer interaction
TRANSPORT. NETWORK, DATALINK
is identical to that of the higher layers. Each layer has
a dual function: to perform its specialized services in PHYSICAL LAYER....Fiber, coaxial cable, twisted pair of wires
cooperation with its peer (Fig 6) and to transparently
7.
enable cooperation among all of the peer entity pairs
above it in the model. Dashed lines indicate the mdi-
rect flow of control information. Solid lines indicate
the direct flow of actual messages down and up
through the stacks of layers. (8) Three alternative
communications pathways supported by the DICOM
version 3.0 standard (arrows). Groups ofrelated soft-
ware layers are boxed together. Dotted lines repre-
sent new protocols developed for the DICOM stan-
dard. The generic upper layer service is designed to
allow systems to migrate from TCP-IP to OSI without
changes in the application message exchange proto-
col. A wide variety of standard network configura-
tions, as well as the original 50-pin ACR-NEMA point-
to-point connection, are supported.

A system called ASN . 1 (abstract syntax nota-

tion) catalogs all of the ISO standard repre-
sentations of data. It also is the standard glos-
sat-), of terms used in writing standards. ASN. 1
ensures mutual understanding among remote
8.
systems, which may vary widely in their inter-
nal representation ofdata (Fig 2). Network Connectivity Options.-The
Radiologic imaging software applications DICOM standard represents a major concep-
operate at level 7, with use of the top layer of tual departure from the limited point-to-point
the so-called ISO protocol stack. The user of communications goal ofversions 1.0 and 2.0.
the system interacts only with the application While maintaining compatibility with the 50-
program. Whether a graphic user interface or pin physical connector and the signaling pro-
a command-line interpreter is provided, the tocol of the original standard, the DICOM
application program is entirely responsible standard specifies means of alternative con-
for the ‘feel’ ‘ ‘ of the system. Commands on nections that simplify multipoint networking.
data entered by the initiating user are passed The DICOM standard simplifies network con-
down to the ISO software for transmission to nections by defining an upper layer service
the responding user, which may be a person that supports two widely used communica-
on a device. The application layer and presen- tions standards: the open systems intercon-
tation layer software entities are responsible nection (051) protocol and the transmission
for information handling. The lower layers are control protocol-internet protocol (TCP-IP)
concerned only with the reliable transmission (Fig 8).
of data. The ISORM incorporates the concept The new upper layer service supports
of cooperating peer service users linked trans- TCP-IP software, which can control communi-
parently by a service provider (Fig 7). cations between devices with use of inexpen-
sive and widely available Ethernet interface
cards (5,6). Versions ofTCP-IP are available
for essentially any hardware platform one is
likely to use today and for a broad range of
network configurations.

352 U RadioGrapbics U Bidgood and Horn Volume 12 Number 2

 Figure 9. Entity/relationship diagram modeling the associa-
tions among information object classes in radiology. Rectangles
represent the information object classes (Patient, Visit, etc); Di-
amond-shaped relationship operators (Makes, Has, Related to)
link the information object classes. The allowed multiplicity or
proportionality of relationships is indicated by the logical coefli-
cients 1, n, and m, which modify the relationship operators.
One patient makes any number (n) of visits. A visit may have
any number of studies. One study may have any number of im-
ages and any number (not necessarily the same number) of
graphics. Studies are related to results. A number (n) of studies
may be related to a different number (m) of results (reports).
For example, the results of three studies (a chest radiograph, a
radionuclide pulmonary perfusion study, and a pulmonary yen-
tilation study) might be consolidated into one interpretation.
However, the result of any one of the three studies also might
be reported separately. Thus, a result (report) could relate to
one or more studies, and the findings of a single study could
relate to multiple results (reports). Note also that results are
not related directly to images and graphics but are related to
them indirectly, through the study.

Folders and File Linking.-The Papyrus file standard were based. Tools of object-oriented
format developed at the University Hospital of analysis have been used to refine the standard
Geneva is a method for grouping associated data dictionary developed for versions 1.0
data sets into folders by value (containing ac- and 2.0 and to identify the characteristics of
tual images or other data) and folders by ref- key entities in the domain of medical imaging.
erence (containing only the memory ad- The purposes of an information model are
dresses of the actual data sets) (7). The folder to identify, classify, and abstract essential rela-
concept of Papyrus is blended with the ACR- tionships and to organize information into a
NEMA message structure by way of a user- formal structure. Similar ‘things, or instances,
‘

defined group 0041H, which contains the ad- are identified and abstracted as objects; char-
dresses of the related data sets. Future acteristics of these instances are abstracted as
versions of the DICOM standard will support attributes; and reliable associations between
ISO protocols for hierarchical directory struc- the instances are abstracted as relationships”
ture, remote use of storage resources, and (9).
selection of multiple files by logical “filters” Information modeling reduces redundancy
(4, pp 205-221; 8). and ambiguity by requiring that information
Version 3.0 of the DICOM standard will in- objects be defined only in terms of their most
corporate a mechanism for linking related fundamental and unchanging qualities or val-
images to a single identification header dur- ues-that is, their lowest common denomina-
ing transport. Working group 6 of the ACR- tors. Related but not identical types of entities
NEMA committee is considering proposals for are grouped into information object classes.
methods to eliminate repetition of identical Within an information object class, each mdi-
data elements. The reduction of redundancy vidual member is known as an instance of the
will be significant, particularly in nuclear class type. Properties of inheritance and hier-
medicine. archy determine the attributes of objects,
their superclasses, and subclasses.
U INFORMATION MODELING There is no overlap on duplication of at-
tributes among the superclass of normalized
. Object-oriented Analysis information object classes (Fig 9). However,
In the process of developing the DICOM stan- another superclass of composite information
dard, the ACR and NEMA have jointly taken objects is permitted to share some attributes
the difficult first steps toward the complete that may have identical group-element tags.
reorganization of the information model on
which versions 1.0 and 2.0 ofthe ACR-NEMA

March 1992 Bidgood and Horn U RadioGraphics U 353

 These objects have been defined to contain . Harmonization with Other
the imaging modality information found in Standards
the data dictionary ofversions 1.0 and 2.0. Several organizations have worked out de-
Examples of composite information object tailed information models for various aspects
classes include the MR image information ob- of medical data processing. Automatic com-
ject class and the ultrasound image informa- munication of results from laboratory equip-
tion object class. Their attributes are grouped ment is possible with use of specifications de-
in modules that are assembled in a generic veloped by the Association for Testing
manner. Their existence represents a logical Materials (ASTM). The Institute for Electrical
compromise made to provide upward com- and Electronics Engineers (IEEE) has devel-
patibility to systems still using ACR-NEMA oped the P1073 Medical Information Bus and
versions 1.0 or 2.0. Future versions of the Medical Data Interchange (MEDIX) protocols,
DICOM standard will migrate away from com- which are specifications for interfacing medi-
posite information objects toward normalized cal applications running on computers of dif-
information objects. ferent types (10). Health Level 7 (HL7) is an-
A unique identifier (UID) value is assigned other widely used voluntary standard for
to each class of information objects. The value “format and protocol for exchanges of certain
consists of a prefix assigned by an ISO mem- key sets of data among healthcare computer
ben organization and a suffix assigned by the application systems” (1 1). International coop-
local organization (ie, hospital, imaging cen- erative efforts involving the Japanese Medical
ten, or office). Each local organization is re- Image Processing System (MIPS) standard
sponsible for developing its own unique cod- (12) and the European CEN (Comit#{233} Eu-
ing system for UID suffixes. Standardization of nop#{233}ende Normalisation) Technical Commit-
object class enumeration is intended to en- tee 251 have been productive (13).
force compatibility among information mod-
els. UID values are also assigned by a similar U INTERNATIONAL
protocol to each individual instance of an in- STANDARDIZATION
formation object class. The prefix uniquely The ISO and the International Electrotechni-
identifies a particular organization. The suffix cal Commission (IEC) together form a system
is unique within that organization for a partic- for international standardization in conjunc-
ulan individual. The union of the two parts is a tion with national standards organizations
globally unique identification number (bar- from around the globe. The American Na-
ring coding errors). UID values for informa- tional Standards Institute (ANSI) is the largest
tion object class and information object in- of the member national organizations in
stance are carried in two new group 0008H North America. Because of the efforts of these
data elements defined for the DICOM stan- influential organizations, the ISO-IEC stan-
dard. dards are rapidly being adopted by several
Radiology has its own language. By careful nations, including the United States, as gov-
application of data modeling principles, one ernment network standards (10). The ACR-
can discover essential units of information NEMA committee is working toward the goal
and classify them into a precise structure. All of having the DICOM standard become an
communication across a computer interface international standard, part of the family of
to or from a radiology department obeys ei- ISO standards (3).
then explicit or implicit semantic rules and
involves an intentional choice of data syntax. Acknowledgments: We thank William C. Ben-
Mutual agreement on an information model is nett, chairman of working group 6 and editor of
the first step toward harmonization of two the DICOM document; David Best, cochairman of
different information-exchange standards. the ACR-NEMA committee; Bob G. Thompson,
Achieving this harmonization on a large scale chairman ofworking group 8; Charles Parisot, for
his contributions to our understanding of 051;
could strongly enhance the availability of din-
Fred W. Prior and James E. Steinke for their guid-
ical records for timely use in patient care.
ance in object-oriented analysis and service class
specifications; and Lee Bidgood for illustrations.

354 U RadioGraphics U Bidgood and Horn Volume 12 Number 2

 U REFERENCES ogy, open systems interconnection, common
1. ACR-NEMA Committee. Digital imaging and management information service definition.
communications. ACR-NEMA standards publi- Draft international standard (DIS) 95, publi-
cation no. 300-1988. Washington, DC: Na- cation no. ISO/IEC JTC 1 /SC 2 1 . New York:
tional Electrical Manufacturers Association, American National Standards Institute, 1990;
1989; iii. 3.
2. Annual report, 1990. Washington DC: Na- 9. Shlaer 5, Mellor SJ. Object-oriented systems
tional Electrical Manufacturers Association, analysis: modelling the world in data. Engle-
1990; 1. wood Cliffs, NJ: Yourdon, 1988; 6.
3. Bennett WC, ed. Part 1: introduction and 10. Spitzer P, Abelman A. HL7, MEDLX and the
overview. In: ACR-NEMA Committee. Digital pursuit ofthe unified standard. Computers in
imaging and communications in medicine Healthcare, November 1990; 19-24.
version 3.0. Draft 0.1. Washington, DC: Na- 1 1. Health industry level 7 interface standards:
tionalElectrical Manufacturers Association, version 2.1. Chicago: Health Level Seven,
1991; 2-6. 1990; I-i.
4. HenshallJ, Shaw S. 051 explained. 2nd ed. 12. Kimura M. Inter-vendor connection be-
New York: Ellis Horwood, 1990. tween components of a picture archiving and
5. Hancock B. Designing and implementing communication system (PACS) using the
Ethernet networks. 2nd ed. Wellesley, Mass: MIPS-87 image standard at Tokyo University
QED Information Sciences, 1988; 11-22. Hospital. Photocopy. Tsukuba University
6. FreerJR. Computer communications and Medical School, 1990.
networks. New York: Plenum, 1988; 152- 13. Minutes ofthe ACR-NEMA Committee work-
154. ing group VIII. Washington, DC: National
7. Ratib 0, Ligier Y, Hochstrasser D, SchenrerJR. Electrical Manufacturers Association, 1991;
Hospital integrated picture archiving and 141.
communication system (HIPACS) at the Uni-
versity Hospital ofGeneva. Proc SPIE 1991;
1446:330-340.
8. International Standards Organization, Inter-
national Electrotechnical Commission, Joint-
Technical Committee. Information technol.

March 1992 Bidgood and Horn U RadioGraphics U 355