Report on Japanese DICOM Activities

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                            ROSSLYN, VIRGINIA

                           1:00 P.M.

                            THURSDAY, JUNE 17, 1999
                            9:00 A.M.



Krishna Anedath             Konica Medical Imaging
David Best                  Eastman Kodak
David Clunie                Quintiles Intelligent Imaging Technologies
Emmanuel Cordonnier         ETIAM
Tim Cramer                  Picker International, Inc.
Bernard Hayes               Canon Research Center America
David Heaney*               ALI Technologies
Janet Keyes                 LORAD
Makoto Ogoda                Fuji Medical Systems USA, Inc.
Charles Parisot             GE Medical Systems
Hidenori Shinoda            Toshiba
Dwight Simon                Merge Technologies Inc.
Kees Smedema                Philips Medical Systems
Csaba Titton (Proxy)        DeJarnette Research
Nikolaus Wirsz              Siemens Medical Systems


Dean Bidgood                American College of Radiology
Joel Chabriais              Societe Francaise de Radiologie
Brent Dove                  America Dental Association
                                                              EXHIBIT A
Lloyd Hildebrand                              American Academy of Ophthalmology
Joseph Kvedar +                               American Academy of Dermatology
Alan Rowberg                                  American College of Radiology


Robert Britain                                NEMA
Isao Ohbayashi                                JIRA
Edward Staabs                                 NCI, NIH
Loren Zaremba+                                Food and Drug Administration



Alvin Belden                                  Shared Medical Systems Corp.#
Geert Clays                                   AGFA
Keith Klassy                                  Camtronics Medical Systems
Ed Schieffer                                  Sterling Diagnostic Imaging#
Doug Sluis                                    ATL, Inc.
Todd Treiber                                  StorCOMM, Inc.#
John Vengroski                                Nikon#
Rainer Waedlich                               IFA Systems Group
Bill Yaeger                                   Infimed, Inc.

# Do not count toward the quorum at meeting


Ulysses Balis                                 College of American Pathologists
Michel Berg                                   American Academy of Neurology
Steven Horii                                  American College of Radiology
Louis Korman                                  American Society for Gastrointestinal Endoscopy
Carolyn Lanham                                American College of Cardiology#
Johan HC Reiber                               European Society of Cardiology
Ruediger Simon                                European Society of Cardiology

#Do not count toward the quorum at meeting


Sun Kim                                       Korean PACS Standard Committee
Laura Sato                                    Canadian Institute for Health Informatics#

# Do not count toward a quorum at the meeting

                                                                              EXHIBIT A
Jay Gaeta (Speaker phone)+                  Merge Technologies
Shun Kabata*                                Hitachi Medical Co.
Thomas Kennedy*                             Camtronics Medical Systems
Bisharah Libbus+                            NIH
Eric Martin*                                Picker International
Kathleen Rattell                            Booze-Allen & Hamilton
Charles Showalter*                          ACR Staff
David Snavely                               NEMA Staff/DICOM Comte. Secretary

* Attended Wednesday only + Attended Thursday only

                                            MR. DAVID BEST, CO-CHAIRMEN


       The minutes of the DICOM Standards Committee meeting held March 10 - 11, 1999 were
reviewed. Under Working Group 12, “ISUS” should be “ISIS.” Under Time and Place of Next Meeting,
the meeting in San Francisco should be “August 27, 1999” not “September 27, 1999.” The minutes were
then approved as amended. It should be noted that the meeting in Japan will be in conjunction with the
JMCP in Yokohama, Japan.


       There was one application for membership on the DICOM Standards Committee in the vendor
category. The application was from ETIAM, a vendor of cooperative medical imaging products. The
motion was made and passed to approve the membership of ETIAM on the DICOM Standards


       There were four requests to be on working groups and have official voting status. The requests
were from Martin Kernberg, MD, University of California at San Francisco and Charles Thomas,
Heartlab to be on WG 1 and Eric Goodall, IBM Corporation, and Andrei Leontiev, IDX System
Corporation to be on WG 6. All four requests were approved.



        Thomas Kennedy, Chairman of WG 1 submitted a written report (Exhibit A) which was e-mailed
to members before the meeting. The draft IVUS IOD is well along and Waveform is completed for
submission to WG 6 with the request to go to letter ballot. Work has started on DICOM „2000 which will
feature the Integrated Cardiac Record. WG 1 is developing SR requirements for the Cath Lab.
                                                                           EXHIBIT A
       WG 1 submitted a Work Item for the development of the intravascular ultrasound (IVUS) IOD
and Application profile. Tom Kennedy reported that the review time for WG 6 should not be that much
and that WG 1 expects to submit the IVUS IOD to WG 6 at their September or October meeting. The
motion was made and approved to accept the Work Item with the addition of the dates for submittal to
WG 6.


        Brent Dove, Chairman of WG 2, distributed a written report at the meeting (Exhibit B). He
reported that Supplement 32 is widely accepted. WG 2 is not working on anything at the present time.


       No written report was submitted. No report was present at the meeting.


         Alan Rowberg, Chairman of WG 4 submitted a written report (Exhibit C) which was e-mailed to
members before the meeting. He reported that WG 4 is working only by teleconference. David Clunie and
Kathleen Rattell are the WG 4 liaison to JPEG 2000. The JPEG Committee is doing the compression
evaluations on opaque paper but WG 4 is willing to coordinate the medical evaluations. The plan is to use
the flicker technique. The next meeting of the JPEG Committee is in Vancouver, BC, July 12 - 16, 1999.

       WG 4 will also send to WG 6 a Change Proposal to include JPEG-LS in DICOM. The question
was raised whether some of the 16 forms of JPEG should be retired. Alan Rowberg agreed that WG 4
would review the 16 forms for retirement consideration.


        David Clunie, Chairman of WG 5, prepared a written report (Exhibit D) which was e-mailed to
members before the meeting. He reported that Supplement 40 went out for public comment but no
comments were received. WG 5 believes it is not realistic to ballot Supplement 40 at this time. However,
there is interest in experimenting with the DVD media available (DVD-R and DVD-RAM). WG 5 will
present to WG 6 a proposal to freeze Supplement 40 with variable parameters and specify DVD-R and
DVD-RAM with UDF 1.5 for trial implementations. Tom Kennedy, Co-Chairman of WG 1 stated that
WG 1 would just as soon wait for WG 5 to make a recommendation.


       Don Van Syckle, Chairman of WG 6, prepared a written report (Exhibit E) which was e-mailed to
members before the meeting. In the absence of the Chairman, Dwight Simon gave the report. He
reviewed the supplement status and reported that WG 6 members made presentations at the May 3 -5,
1999 IHE meeting. WG 6 discussed the decision by the DICOM Standards Committee that the DICOM
Standard be published every year with the new material included. WG 6 requested the DICOM Standards
Committee to reconsider that decision and to publish every two years. A straw poll of the Committee

                                                                             EXHIBIT A
indicated 21 in favor of yearly publication, 1 in favor of publication every two years, and one didn‟t care.
Consequently, the decision of the Committee for a yearly publication remains.

        WG 6 proposed a work item for Interpretation Work List with an early draft in September.
Members then discussed the priority list for WG 6 that WG 10 developed. There were six levels with
Interpretation Worklist having the lowest priority. It was suggested that the priority of Interpretation
Worklist could be raised if an Ad Hoc Group was formed to work on it which didn‟t take resources away
from WG 6. Dwight Simon felt the Chairman of WG 6 would create an Ad Hoc Group. A motion was
made and passed to accept the priorities presented by WG 10 as the priority that WG 6 should be working
on. The priorities are as follows:

Priority 1

Correction Proposals

Priority 2

Presentation State (Almost completed)
Waveform (Almost completed)

Priority 3


Priority 4

Yearly publication of the Standard
Retirement of Sections
Revisiting of Sections (Parts 1 & 2)

Priority 5

Multiframe VL
Advanced MR
Intravascular US
Stress Echo
DICOM Mime type
UDF Media

Priority 6
                                                                               EXHIBIT A
Interpretation Worklist (Status could be raised by formation of an Ad Hoc Group)

       The motion was made and passed to approve the work item on Interpretation Worklist.


        David Murray, Chairman of WG 7, prepared a written report (Exhibit F) which was e-mailed to
members before the meeting. In the absence of the WG 7 Chairman, Charles Parisot provided a short
report There are presently two activities of WG 7, Change Proposals and Demonstrations. WG 7 is
lacking support on the professional side to try to publicize the Standard.


        No written report was submitted. Dean Bidgood, Chairman of WG 8, reported that a draft of
Structured Reporting was discussed at the March 9 - 10, 1999 WG 10 meeting. On March 22, 1999 WG 6
spent a lot of time on SR and froze the draft. On April 8, 1999 WG 9 (Ophthalmology) meet to discuss
the use of SR. On April 13 - 14, 1999 WG 1 strongly endorsed SR and will feature SR in the ACC „2000
trade show.


       Lloyd Hildebrand, Chairman of WG 9, prepared a written report (Exhibit G) which was e-mailed
to members before the meeting. He reported that WG 9 meet April 9, 1999 in Seattle. They are working
with CAP with respect to the terminology that they need but it has been a problem. Interest has been
generated with respect to VL in the user community. WG 9 is working on a network demonstration.


        Kees Smedema, Co-Chairman of WG 10, presented the report on the WG 10 meeting held June
15 - 16, 1999 (Exhibit H). A proposal was made in the WG 10 meeting to request a DICOM MIME type
and a DICOM file extension. This proposal may be approved by WG 10 at the next WG 10 meeting. This
would not be a part of DICOM. Members also discussed the scope of DICOM and how DICOM needs to
evolve in a changing world.

        A presentation was provided of what is happening for the IHE for both year 1 and year 2. IHE
will provide WG 6 with its wish list. Dean Bidgood provided a summary of the latest draft of SR. WG 10
recommended that WG 6 place a high priority on SR. The HL7 reply to the DICOM Standards
Committee letter asking for a joint working group and that the IMSIG be raised to the Technical
Committee level was discussed. HL7 replied that it was not necessary for the IMSIG to be given
Technical Committee status in order to achieve the objectives put forth by the DICOM Standards
Committee. In light of this, WG 10 recommended that a new working group be formed with HL7 with
co-chairs, one Co-Chair from the DICOM Standards Committee the other Co-Chair from HL7.

        Priorities for WG 6 were recommended to the DICOM Standards Committee by WG 10. WG 10
will produce a draft on Workflow and also a draft Strategic Planning Document. WG 10 discussed the
                                                                            EXHIBIT A
issues on the rights and royalties of SNOMED and whether the medical part is still royalty free. WG 10
has asked David Clunie and Dean Bidgood to contact CAP to get the original proposal to NEMA. They
are to determine if the proposal is still in place and if implementers can use the terms royalty free as
described in the letter..


        No written report was submitted. In the absence of the Co-Chairmen, David Clunie gave a short
report. Letter ballot text was prepared for Supplement 33 - Soft Copy Presentation Storage for WG 6 to
review at their June meeting. There will be a demonstration of Soft Copy Presentation Storage for RSNA
„99 and it will include print vendors. WG 11 is working in a very early stage on Structured Display and
Advanced Presentation and is doing work with WG 17 on 3D.


      David Heaney, Chairman of WG 12, prepared a written report (Exhibit I) which was e-mailed to
members before the meeting. He reviewed the work that WG 12 is doing. He was not aware that the 3D
Working Group is dealing with acquisition sets. He will report this to WG 12 members. WG 12 is only
working on multiframe not single frame. They are presently deciding between MPEG 1 and MPEG 2.


       Lloyd Hildebrand, Co-Chairman of WG 13 provided a written report (Exhibit J). He reported that
the working group is waiting for the results of the letter ballot of Supplement 15 - Visible Light (Single
Frame). The multiframe part was split out and made Supplement 47 Multiframe VL. It does not need a
work item since it was approved when it was part of the initial VL proposal. No work has started on
Supplement 47.


       Lawrence Tarbox, Chairman of WG 14 (Security), prepared a written report (Exhibit K). In the
absence of the Chairman, Dwight Simon reported that no progress has been made since the last DICOM
Standards Committee meeting. The Network Security Supplement is almost ready for ballot.


        David Clunie, Co-Chairman of WG 15, prepared a written report (Exhibit L) which was e-mailed
before the meeting. He reported that WG 15 has considered a proposal to develop an extension to
DICOM to standardize the reporting of Computer Assisted Detection (CAD) results for mammography.
WG 15 has no other work at the present time. A proposal for a Mammography CAD Work Item was
present to the DICOM Standards Committee for approval. The CAD work item was approved by motion.

                                                                              EXHIBIT A
        Matthias Drobnitzky, Chairman of WG 16, prepared a written report (Exhibit M) which was
distributed at the meeting. In the absence of the Chairman, Nikolaus Wirsz presented the report. He
summarized the previous activities of WG 16 and their planned schedule. He then presented a work item
for the development of a new MR Object supplement. The New MR Object work item was approved by

       WORKING GROUP 17 (3D)

        Doug Sluis, Chairman of WG 17, prepared a written report (Exhibit N) which was e-mailed
before the meeting. It was pointed out that the new Chairman of WG 17 was Doug Sluis.


       A. Working Group on Clinical Trials and Education

        A proposal to form a new working group on Clinical Trials and Education was e-mailed to
members before the meeting (Exhibit O). The National Cancer Institute agreed to serve as Secretariat. The
motion was made and passed to approve the formation of a working group on Clinical Trials and
Education with the National Cancer Institute as Secretariat. David Clunie and Curtis Langlotz will
convene the first meeting. NEMA staff will send out a letter informing of the new working group and
inviting participation. This will be WG 18.

       B. Working Group on Dermatologic Standards

        A proposal to form a new working group on Dermatologic Standards was e-mailed to members
before the meeting (Exhibit P). Joseph Kvedar explained that their need for DICOM included the
cataloging of slides and to view remotely to give advice. They do not have a vendor community but use
off-the-self equipment. The motion was made and passed with one opposed to approve the formation of a
working group on Dermatology with the American Academy of Dermatology as Secretariat. NEMA staff
will send out a letter informing of the new working group and inviting participation. This will be WG 19.

       C. Working Group on Integration of Imaging and Information Systems

       WG 10 proposed a new working group on Integration of Imaging and Information Systems.
Members discussed the proposal and suggested changing bullet 6 to read: Meetings should be held in
conjunction with HL7, DICOM, and other related meetings. The estimated number of meeting days is 10
days per year. It was recommended that bullet 7 should be deleted and a new bullet added reading: The
Co-Chairs shall report to the DICOM Standards Committee and to the HL7 Technical Steering
                                                                             EXHIBIT A
Committee. Also added was that the DICOM members of the Working Group should be considered as
full HL7 members for this Working Group/SIG and vice versa and that the proposal will be sent to the
HL7 Board of Directors. The revised proposal is attached (Exhibit Q). The motion was made and passed
to approve the formation of the new working group on Integration of Imaging and Information Systems.
Since the formation of this working group was not on the agenda a thirty day ballot confirming the motion
will be sent to members of the DICOM Standards Committee. NEMA has agreed to serve as Secretariat
for the working group until another Secretariat is found. This will be WG 20.


        Kees Smedema presented a report on current DICOM Activities in Europe (Exhibit R). He stated
that DICOM WG meetings in Europe have exceeded the number expected and the program to represent
DICOM as an International Standard is well under way. Europeans will not see the DICOM Standards
Committee as an American Committee. In addition they are working very hard to have IHE like activities
in Europe. There is no additional relationship between DICOM and CEN. The status quo seems
acceptable. The ISO TC215 Task Force was satisfied with the DICOM Standards Committee as a Class A
liaison with TC215.


      Hidenori Shinoda distributed a written report on current Japanese DICOM activities (Exhibit S).
He summarized the report through a series of slides.


        NEMA staff reported that Ballot 32 Supplement 15 - Visible Light passed with 24 ballots
received, 21 approval, 1 disapproval, and 2 abstentions. There were a number of comments received with
the ballots. Ballot 31 DICOM CP 5 expires June 22, 1999. At the present time 13 ballots have been

     The NEMA server has been changed back to permit ftp but Vicki Schofield would prefer
members still use http.


        Charles Parisot reported that ISO TC215 met for the second time in Europe to organize TC215.
Work items were discussed but most were not approved. Joel Chabriais as Chairman of the Ad Hoc group
reported their recommendation that an imaging working group not be formed. The US delegation objected
to not forming an imaging working group on the basis that they felt the DICOM Standards Committee
was not open enough and did not communicate with other standards groups. Charles Parisot pointed out
the DICOM Standards Committee relationship with HL7, JIRA, and other standards groups and that the
DICOM Standards Committee was accepted as a category A liaison with TC215. The US delegation
agreed to proceed without an imaging working group. A TC 215 Ad Hoc group composed of Nick
Brown, Joel Chabriais, and Ed Hammond with Nick Brown as Chairman was formed to serve as the
TC215 liaison to the DICOM Standards Committee.

                                                                             EXHIBIT A
        With regard to getting DICOM approved as an ISO Standard there are two approaches that could
be used. One is for the DICOM Standards Committee to become recognized as a peer standardization
group. As a peer group, DICOM could be proposed as an ISO standard with a vote up or down. The other
approach is to propose DICOM as an international standard to TC215 with one round of voting with
comments. The DICOM Standards Committee is open on how to proceed but does not want to reballot
the Standard.

        Charles Parisot stressed to the DICOM Standards Committee members the need to build the
category A liaison with ISO. Charles Parisot was assigned to lead the DICOM liaison coordination. He
stressed that DICOM should have a liaison representative at every TC 215 meeting and give a 15 minute


        Charles Parisot stated that he felt the workshop was useful. There was no DICOM representation
at the VA workshop which was held after the IHE/DICOM workshop. The VA did promote the second
day of the IHE/DICOM workshop.


       Lloyd Hildebrand made suggestions of what should be represented in the DICOM Logo. These

  Want to bring out word DICOM
  Want to give the global effect
  Want to give the technical effect
  Need a tag line
  Need to give image of healthcare
      With regard to the use of the word DICOM, the Committee has made the statement that
companies can use DICOM in product name as long as they don‟t trademark it.


        Jay Gaeta joined the DICOM Standards Committee meeting by speaker phone and provided a
written report (Exhibit T). He pointed out the procedures used by the Committee for the Advancement of
DICOM and what manufacturers get from demonstrations. This includes software and the visibility they
receive by having their name on a list of participants. He asked for suggestions to improve the process
from the DICOM Standards Committee. It was suggested that a point of contact was needed with fields
other than radiology. Specialty groups should identify a champion within who has good contact with


        Lloyd Hildebrand reported that in talking to the appropriate people at the University of Oklahoma
he was told that they can not give away resources of the State. What was considered in the cost of setting
up a ftp site for DICOM was a public and private area and backup. The cost would be approximately
                                                                                EXHIBIT A
        Bob Britain stated that NEMA has purchased a dedicated server for DICOM only. The NEMA IS
staff now thinks the problem with the down time of the server is a Microsoft problem. NEMA has a 24
hour monitoring service with Microsoft to hopefully find the problem and fix it.

        Bob Britain also reported that he is making a report to the NEMA Board of Governors on the
placing of the draft DICOM Standard on the server. There have been 25,000 successful hits.

        Members recommended to hold off on an alternate site for the ftp site and to put the University of
Oklahoma offer on hold. The motion was made and passed to dissolve the DICOM FTP Task Force. The
motion was made and passed to dissolve the Task Force On Publishing DICOM. It was suggested that in
the future the working group reports be put at the end of the agenda and that a one day meeting be


        Bob Britain reported that NEMA will reimburse COCIR $10,000 for this year and $10,000 for the
year 2000. For the year 2001 there will probable be less money from COCIR and NEMA. The DICOM
Standards Committee will need to address this. Any increase in activity in Europe will require an increase
in dues or other means for funding. The need to consider reducing expenses was stressed.

       The revised DICOM Operating Procedures approved in December 1998 were written for
acceptance by ANSI. The DICOM Executive Committee agreed that the application for accreditation
should be submitted. NEMA staff will target submittal by July 31, 1999.


       A nominating committee was appointed for the vendor co-chair composed of Dave Best, Lloyd
Hildebrand, and Tim Cramer with Dave Best as Chairman. They will report a slate of candidates at the
August DICOM Standards Committee meeting.


         Members identified three topics at this time for the August meeting. These were:

     Additional DICOM Advancement Reports
     ANSI Accreditation
     DICOM Committee Logo


       The next meeting of the DICOM Standards Committee is planned for Friday, August 27, 1999,
9:00 a.m. - 6:00 p.m. in San Francisco. Following meetings are planned for December 2, 1999, 9:00 a.m. -
5:00 p.m. in conjunction with the RSNA meeting in Chicago. Meetings in 2000 are planned in April in
Yokohama or Tokyo, Japan in conjunction with JMCP, in June in Baltimore, Maryland in conjunction
                                                                             EXHIBIT A
with SCAR, in September in Europe, and in December in Chicago in conjunction with the RSNA


      The meeting was adjourned at 5:00 p.m. on Wednesday and at 12:15 p.m. on Thursday.

                                          REPORTED BY:
                                          DAVID SNAVELY
                                          SECRETARY, DICOM STANDARDS COMTE.

Attachments: Exhibit A - Working Group 1 - Cardiac and Vascular Information
             Exhibit B - Digital X-ray Working Group Report
             Exhibit C - Working Group 4 (Compression) Report
             Exhibit D - DICOM WG 5 Interchange Media Report
             Exhibit E - DICOM WG 6 Status Report (Base Standard)
             Exhibit F - DICOM WG 7 (Radiotherapy) Report
             Exhibit G - WG 9 Report
             Exhibit H - Report of Working Group 10 Meeting, June 17, 1999
             Exhibit I - WG 12 Report for DICOM Committee
             Exhibit J - WG 13 - Visible Light
             Exhibit K - WG 14 Report
             Exhibit L- DICOM WG 15 Digital Mammography Report
             Exhibit M - Report from DICOM WG 16 (MR Enhancements) Activities
             Exhibit N - WG 17 Status Report
             Exhibit O - DICOM WG on Clinical Trials Report
             Exhibit P - Proposal to Create a Working Group on Dermatologic Standards
             Exhibit Q - New DICOM Working Group: Integration of Imaging and Information
             Exhibit R - Report on European DICOM Activities
             Exhibit S - Report on Japanese DICOM Activities
             Exhibit T - MII Committee for the Advancement of DICOM Report to the DI


                                                                        EXHIBIT A
To:     DICOM Standards Committee

From: Working Group I – Cardiac and Vascular                        Information
      Thomas Kennedy, Ph.D. Co-chair
      Steven Nissen, M.D. Co-chair

Date: June 7, 1999

Re:     WG1 Report

I.     Work Item Authorization Request
      WG1 requests work authorization to complete development of the intravascular ultrasound
      (IVUS) IOD and Application profile. IVUS is a key imaging modality in the cardiac cath lab,
      and in clinical practice, the IVUS images are closely linked to the cardiac x-ray angiographic
      images for diagnosis of coronary artery disease and evaluation of intravascular therapy. IVUS
      is a key component of the digital integrated record for the cardiac cath lab under development by
      WG1 (incorporates waveforms – audio, and structured reporting – procedure log). Agreement
      has been reached with WG12 (Ultrasound) that the IVUS modality is distinct from the
      ultrasound or echocardiographic modalities that the IOD development should proceed under
      WG1. Further, WG1 has essentially completed an IVUS clinical requirements specification,
      and drafts of the IVUS IOD and Application Profile have been developed.

II.   Supplement 30 – Waveform Interchange
              WG1 has completed development of Supplement 30 and changes based on public
      comments have completed. In particular, recommendations from WG 6 have been incorporated
      into the supplement and will be reviewed at the June WG6 meeting.

       III.            Digital Integrated Cardiac Record
      WG1, in collaboration with the American College of Cardiology (ACC) and the European
      Society of Cardiology (ESC) developed a multi-media (CD-based) presentation of the
      ACC/ESC/DICOM vision for the integrated cardiac patient record at the ACC scientific Session
      in March, 1999. In the presentation, an actual patient was followed through an entire post-MI
      cardiac workup. Multi-modality (x-ray angiography, IVUS, and nuclear medicine) images,
      waveforms, and clinical reports were presented. The clinical and economic benefits of the
      digital integrated record were also clearly described in the presentation. As part of the vision
      statement, and to highlight the benefits of the digital record, conference attendees were given a
      set of the traditional paper records for the same patient. The vision of the digital integrated
      cardiac record and the role of standards, particularly DICOM, in enabling the vision were well

      At the ACC Scientific Sessions in March, 1999, WG1 solicited increased support from the ACC
      for development of the DICOM-based integrated cardiac record. Specifically a proposal was put
      forth to the ACC Database Committee for expert physician input on clinical reporting
      requirements (see attached). WG1 was particularly interested in harmonizing efforts between
      WG1 and the Database Committee. Subsequent to the proposal, the ACC confirmed their
      support for WG1‟s efforts, and the ACC Cath Committee will represent the ACC‟s interests.
                                                                        EXHIBIT A
IV.    Structured Reporting
              WG 1 is in the process of developing requirement specifications for key elements of the
      cardiac catheterization lab procedure and clinical reports:
         -            Quantitative measurements (QCA, QVA, etc.)
         -            Hemodynamic measurements
         -            Laboratory reports
         -            ECG interpretation reports
         -            Outcomes core data – ACC National Cardiovascular Database Registry (NCDR)
         -            Patient history and physical report
         -            Clinical Summary reports

              WG1 has developed a clinical informatics model to describe the cardiac catheterization
      event, and the model is generalizable to other cardiology specializations. The clinical model has
      been developed in close cooperation with Dean Bidgood, and the model will be used to develop
      templates based on Supplement 23.

             It is expected that a structured reporting demonstration for the cardiac cath lab will be
      developed for the ACC 2000 Scientific Sessions.

From:  Cardiac and Vascular Working Group 1, DICOM
          Thomas Kennedy, Ph.D.                     Co-Chair
          Martin E. Kernberg, MD (UCSF):     SR DICOM Clinical
          Harry Solomon:                       SR DICOM Standard
For:   ACC Database Committee
Date: March 10, 1999
Subject: DICOM Integration of the ACC Database, Data Structure, And
       Data Model for Interchange of Structured Reporting In The
       Cardiac Catheterization Laboratory.

I.      Summary:

        The interchange of cardiac x-ray angiographic data is supported
        by specially developed extensions to the DICOM 3.1 (Digital
        Image Communication in Medicine) standard; parallel support is
        necessary   for    the   interchange    of   textual  information
        (annotations,   hemodynamics,    electrocardiography,  pathologic
        findings, procedure log, complications, catheterization reports,
        and clinical summaries) to provide complete data interchange for
        diagnostic    interpretation    and   interventional   decisions.
        Integration of the American College of Cardiology database
        (National Cardiovascular Database Registry), data structure
        (clinical organization of the NCDR), and data model (ACC Digital
        Integrated Cardiac Record) for cardiac catheterization sets the
        clinical requirements and specifications for the implementation
                                                                            EXHIBIT A
       of DICOM structured reporting for cardiac catheterization.
       Supplements 23 and 46 of the DICOM standard provide the
       governing parameters for the implementation of and support for
       the structured reporting interchange standard for the cardiac
       catheterization laboratory. Content requirements and structure
       follow the ACC standard development process.

II.    Background

        The ACC/ESC/DICOM exchange standard was adopted in 1995 as a result of an initiative by
the American College of Cardiology to define a standard digital medium for the inter-facility exchange
of x-ray angiographic exams. The College recognized that a variety of clinically inferior media were
finding their way into practice as a replacement for cine-film in labs that had converted to filmless
operation. Use of analog recording media, with SVHS tape as an example, often resulted in patient re-
catheterization because of the diagnostic image quality of the replacement recording medium.

        The American College of Cardiology (ACC) and the European Society of Cardiology (ESC), in
conjunction with representatives from the National Electrical Manufacturers Association (NEMA),
selected CD-R (Recordable Compact Disc) as the standard digital medium for exchange of
angiographic exams. This committee also developed a format for writing patient demographic
information and angiographic images to the digital medium. Similar standards were also developed for
the exchange of echocardiographic and cardiac nuclear medicine exams.

        The media-based exchange standards are an extension of the basic DICOM (Digital Image
Communication in Medicine) standard. The DICOM standard was originally developed for exchange
of digital radiology images over a communication network. The standard specifies protocols and
services for the exchange of images and related patient information between interconnected devices
such as workstations, printers, and archive units. Today, the ACC/NEMA DICOM exchange standard
for x-ray angiographic images is well accepted and CD-R‟s are routinely used to exchange patient
exams between physicians and hospitals. Network-based cardiac archive and review systems based on
the DICOM x-ray angiography definitions have also been introduced.

        The success of the ACC/NEMA DICOM exchange standard is a direct result of close
collaboration between the American College of Cardiology and the medical equipment manufacturers.
 Expert physician input was essential for establishing the clinical requirements and performance
expectations for interchange. Engineers were able to incorporate these requirements into DICOM
extensions for cardiology. The rapid adoption of the exchange standard is also the result of a very
active education program supported by the ACC , ESC, and the DICOM cardiology working group –
particularly with demonstrations at the annual ACC and ESC Scientific Sessions.

III.  The Next Step – The Integrated Cardiac Record
      Angiographic image data represents only a fraction of the useful clinical information describing
a catheterization event in any individual patient.       Intravascular ultrasound images (IVUS),
                                                                           EXHIBIT A
hemodynamic waveform data and measurements, the procedure log, and physician reports all combine
to provide the complete clinical perspective for a catheterization exam. Unfortunately, as with the
earlier problem of angiographic interchange, no standards exits for communication of these multiple
data types. According, the DICOM Standards Committee formed Working Group I in 1997 to address
the problem of cardiovascular information interchange for the catheterization exam. As the DICOM
standard moved beyond angiography, WG1 solicited additional physician and manufacturer expertise
to address each of the various cath lab data types.

IV.    Current Status of WG I ICR Efforts

         A.    Creation of the Waveform Information Object

       DICOM support for waveforms (hemodynamic and electrophysiologic) is nearly complete.
The DICOM waveform extension is general enough to describe any type of waveform; including multi-
channel ECG, hemodynamic, and audio signals. In addition, the Waveform Standard provides a
method to describe the acquisition context of the waveform. For example, the waveform standard not
only describes the temporal characteristics for the waveform, but also specific measurement locations
and derived parameters such as pressure gradients.

         B.    Creation of the IVUS Information Object

        The IVUS modality represents a unique set of problems within the catheterization laboratory.
IVUS images cannot be properly interpreted without knowledge of the imaging catheter location in the
cardiac arterial structure. Fluoroscopic imaging must be utilized to document IVUS catheter
positioning. In today‟s IVUS equipment, an audio dictation track is recorded with the IVUS images to
provide some direction, but correlation to other data sources in the catheterization laboratory has been
limited. Like waveform data, IVUS image data requires a method within DICOM to describe the
acquisition context. Taxonomy for the native and grafted vessels must be created to provide an
adequate method of communicating acquisition context for IVUS images. This approach relies on the
evolving DICOM paradigm for structured reporting and will require expert clinical input.

         C.    Reporting and Procedure Log

     DICOM Structured Reporting (SR) is a method for structuring and
encoding observations and findings associated with medical imaging
procedures. It also allows for the encoding of a variety of analytic
data, and provides a method for linking measurements and observations
to images or waveforms. Structured Reporting provides the framework
for describing and interchanging critical cath lab patient history
and physical reports, laboratory reports, procedure logs, and
quantitative measurements. Structured reporting also makes extensive
use   of    controlled   vocabularies    to   facilitate    universal
interchangeability.   The vocabulary dictionaries are maintained in
databases by experts outside of DICOM (e.g., SNOMED), although
provisions   exist  for   use   of  locally-developed   dictionaries.
Importantly, the ACC database elements will provide a subset of these
vocabularies, and thus enabling their interchange for clinical
information, quality assurance, or research.

                                                                            EXHIBIT A
     In large measure, Structured Reporting is the final, critical
element in the development of a DICOM-based integrated cardiac
catheterization record.      SR will allow physicians to link
angiographic images, IVUS images, waveforms, and procedure notes for
a single cath exam.    Objective measurements as well as physician
reports will be included in the electronic interchange (DICOM) file.

V.     Information Model for Cardiac Catheterization

The DICOM Cardiac Catheterization Structured Report (or Object),
illustrated in the 1999 ACC CD-ROM demonstration of the Digital
Integrated  Cardiac  Record,  contains  the   following sections

    Entries   in   Bold   Face:   explicitly   defined  ACC   National
     Cardiovascular Database Registry (NCDR) database
    Entries in Plain Text: delineated in the ACC DICR data model,
     reflecting the database structure.
    Entries in Underlined Text: DICOM standard in draft, frozen draft,
     or completed form.

1. Demographics
2. Clinical Indications
   2.1.    XA
   2.2.    PTCA
3. Clinical Presentation
   3.1.    History of Present Illness
   3.2.    Past Medical History
      3.2.1.    Cardiac Risk Factors
      3.2.2.    Other Past Medical History
   3.3.    Physical Examination
   3.4.    Electrocardiography
   3.5.    Laboratory
4. Operator(s)
5. Pre-Procedure Protocol
   5.1.    Laboratory
   5.2.    Informed Consent
6. Procedure
   6.1.    Diagnostic Procedure
   6.2.    PTCA Procedure
   6.3.    IVUS Procedure
   6.4.    Site Complications
   6.5.    In Lab Complications
   6.6.    In Lab Medications
   6.7.    Hemodynamic Data
7. Findings
                                                       EXHIBIT A
   7.1.   Laboratory Data
   7.2.   Summary Coronary Anatomy
   7.3.   Lesion Description
   7.4.   Other Coronary Angiographic Findings
8. Conclusion

                                                 EXHIBIT A

The Cardiac and Vascular Working Group 1, comprised of ACC and NEMA
representatives, will support    the complete set of ACC lexicons,
databases, reporting standards, and clinical protocols within the
DICOM interchange standard. Each of the proposed DICOM reports and
corresponding sections (and subsections) will reflect the ACC
database, data structure, and data model, as the latter three evolve
under the direction of the associated ACC Committees, particularly
the Database Research and Development and Cardiac Catheterization

The proposed DICOM SR standard for cardiology fundamentally involves three types of data:
 clinical information (current symptoms, historical data, and physical examination)
 cardiology studies (diagnostic evaluation, monitoring, and imaging dependent on special
   equipment), and
 therapy (including medical management, interventional cardiology, and related cardiovascular
   surgical procedures).

Applying this tripartite division to the cardiac catheterization
report yields the following set of sections (DICOM objects or
modules) requiring detailed templates for reporting:

1. Clinical Information
   1.1.       Clinical Presentation
      1.1.1.        Coronary Artery Disease
      1.1.2.        Acute Coronary Syndromes
   1.2.       History of Present Illness
   1.3.       Review of Systems (Cardiovascular)
   1.4.       Past Medical History
      1.4.1.        Cardiac Risk Factors
   1.5.       Past Imaging History
      1.5.1.        Nuclear Cardiology
      1.5.2.        Diagnostic Angiography
   1.6.       Past Interventional History
      1.6.1.        Cardiac Interventional Procedures
      1.6.2.        Peripheral Vascular Procedures
   1.7.       Past Cardiovascular Surgical History
   1.8.       Medications
      1.8.1.        Cardiovascular
      1.8.2.        Non-Cardiovascular
   1.9.       Social History
   1.10. Family History
   1.11. Physical Examination

2. Diagnostic Studies
   2.1.   Laboratory
   2.2.   ECG
   2.3.   Cardiac Imaging
                                                                     EXHIBIT A
      2.3.1.    Nuclear Cardiology
      2.3.2.    Cardiovascular MR
      2.3.3.    EBCT
      2.3.4.    Echocardiography
      2.3.5.    ICE
      2.3.6.    TEE
   2.4.    Coronary Angiography
3. Therapy:
   3.1.    Cardiovascular Medications
   3.2.    Interventional Procedures
      3.2.1.    PTCA
      3.2.2.    IVUS
      3.2.3.    Stents
      3.2.4.    EPS

VII.   Summary
         WG I Seeks the support of the American College of Cardiology and the Database Research
and Development Committee to provide the clinical expertise necessary to complete the proposed
DICOM Standard for Structured Reporting of the cardiac catheterization event. The collaborative
model established by the ACC and WG1 for development of the x-ray angiography, waveform, and
IVUS DICOM Exchange Standards must be continued to ensure success of the proposed Structured
Reporting extensions. WG1 also seeks the guidance of the ACC in securing the continued support
of the European Society of Cardiology and the Japanese College of Cardiology in development of
structured reporting for the cardiac catheterization environment. International participation has
been fundamental to the success of the DICOM exchange standard for cardiology.

                             DICOM Standards Committee
                        Digital X-ray Working Group Report
                                                                       EXHIBIT A
                Submitted by S. Brent Dove, Chairman
                            June 16, 1999

Since the approval of the Digital X-ray Supplement to the DICOM
Standard in August 1998, there has been considerable acceptance of
the supplement. A large demonstration of the DX Supplement at the
American Dental Association annual meeting has established the DICOM
Standard as “the” imaging standard for all of dental imaging. I am
proud to inform you that virtually all vendors in the industry are
implementing the DICOM Standard in their new products. There has
also been significant acceptance of the DX Mammography extensions in
the field of general purpose mammography as well.

As chairman of the working group, I would like to thank each of the
members of Working Group 2 and all the members of the DICOM Standards
Committee for making this significant contribution to health care.

No new action items have been proposed. No meetings of this working
group have been scheduled. No action is requested of the committee
at this time.

                                                   EXHIBIT E
Working Group 4 (Compression) Report
June 8, 1999
Alan Rowberg, Chair

Working Group 4 (Compression) held teleconferences on March 29 and
June 3, 1999.

David Clunie represented DICOM meeting of JPEG 2000 is in Seoul,
Korea during March 15-19. He reviewed the importance of compression
in medical imaging, and underscored the need to process medical
images with the proposed algorithms. During this meeting the
committee converged on a single Validation Model, and made progress
on the working draft. There is still a plan to have a Committee
Draft of the standard by December, but not later than March. He also
attended the parallel US national body meeting for NCITS May 17-21 in
Savannah, GA.

Kathleen Rattell, the JPEG 2000 liaison to DICOM, also attended both

We are attempting to get the critical features, such as 16 bits per
pixel capability, in the baseline standard while not contributing to
feature creep in other areas, such as security.

During the June 3 teleconference, we reviewed the existing plan to
print original and compressed images onto high-resolution film, and
then make paper positive prints, for all of the JPEG 2000 test
images. Alan Chien of Kodak has said this will be done at the
levels of 0.25 bpp, 0.125 bpp, and 0.0625 bpp. We agreed that we
would like to have this done for the DICOM images also, but we will
also provide the images to the Kodak/Mallinckrodt/Henry Ford
consortium for evaluation using their flicker technique, as described
at RSNA (IDA9730 Demonstration of JPEG and JPEG 2000 Compression for
Medical Images by Slone, Foos, Young, Whiting, Muka, and Kohm). The
evaluation will be rank ordering but not observer preference or ROC
analysis. This evaluation will be done in St. Louis at no cost to
DICOM. .Compression will be requested at three compression levels,
different from the ones which will be used for the JPEG 2000 images.

The visible light images may be viewed on hardcopy, although the
flicker technique can also be used on color images. Because
ophthalmologists usually deal with 35mm slides rather
than reflective hardcopy, we will explore other output methods to
make it easier for experienced fundus photography readers to
evaluate the ophthalmic images.

David Clunie will also represent DICOM at the next JPEG 2000 meeting
July 12-16, 1999 in Vancouver, BC

The next meeting of WG 4 will be by teleconference July 30, 1999.

                                                   EXHIBIT C
WG4 has also reviewed a CP to propose the inclusion of JPEG-LS (ISO
14495-1) in
DICOM, now that it is officially an ISO and ITU standard. The CP will
be referred to WG6.

                                                   EXHIBIT E
DICOM WG 5 Interchange Media Report (for June 1999 DICOM Committee Meeting)

The only current work item for WG 5 is to add DVD media to the standard.

Supplement 40 - DVD Media Using UDF has recently been through the public comment
phase. No comments were received. At its June meeting, the working group decided
not to aim for letter ballot in 1999 but rather to produce a "draft for trial
implementation" in order to allow implementors to experiment with the proposed
technology. The current intent (subject to WG 6's approval), is to define in the
draft supplement both those media types currently available (DVD-R and DVD-RAM)
for experiments with UDF 1.5 to begin. The modality specific groups (in particular
1 and 12)will be consulted as to whether or not they wish to use only one media
for the experiments for their profiles, or whether to experiment with both (as is
proposed for the general purpose profile).

This strategy has been suggested in order to proceed with experiments using what
technology is already available, while reducing the risk created by the
considerable confusion in the optical media industry over competing proposals for
writable and rewritable DVD formats.

No action by the committee is requested at this time.

David A. Clunie                   
Director, Medical Imaging Technologies
Quintiles Intelligent Imaging    
521 Plymouth Rd #115                   Work 610-238-0572 Fax -0578
Plymouth Meeting PA 19462              Home 570-897-7123 Fax –5117

                                                              EXHIBIT D
          DICOM WG 6 Status Report (Base Standard)
                        June 9, 1999
1.0   Scope of WG 6 - Base Standard Working Group

WG 6 is responsible for the overall consistency and maintenance of
the DICOM standard. WG 6 provides technical guidance to all DICOM
working groups and serves as the technical coordination point. It
also develops extensions (Supplements) to DICOM typically related to
overall systems enhancements. Some of responsibilities are as

     Execute the DICOM Maintenance Process (Correction Proposals).
       This process is used to make “corrections and minor changes”
      to the current versions of the Standard. Any corrections made
      are processed using the normal Letter Ballot procedures as
      defined by NEMA.
     Provide technical coordination and guidance for all WGs. This
      includes review and official approval before the Public
      Comment, Letter Ballot, and Final Text draft releases of all
     Develop Supplements to the standard related to Print, Image
      Management, etc.
     Coordinate joint development efforts with CEN, JIRA, and Medis
     Coordination with NEMA for the publication of DICOM.

1.1 WG 6 Meetings Held

     March 1999

1.1 Specific Deliverables for 1999

 DICOM Maintenance Process

         Various Correction Proposals have been processed and CP Item
          packet 5 was sent to the DICOM Committee for Letter Ballot.

         Visit the NEMA web site for the Correction Proposal Log     and

 Supplements Currently Being Developed by WG 6

         The DICOM committee has asked WG 6 to retire Part 9 of
          DICOM. As part of this, WG 6 is looking at other portions
          of the Standard and will make additional retirement
          recommendations for the next DICOM committee.

          The following process was defined by WG 6 for retiring Parts
          and Sections from DICOM. The DICOM committee is invited to
          review and comment.

          1- Create work item for retirement which list WG 6 as the
                                                         EXHIBIT E
         responsible working group (WG 6 believes this has already
         been accomplished as part of Part 9 retirement process).
         2- Package retirement items providing the topic and
         rationale for retirement prepared for Public Comment.
         3- Comments will be analyzed by WG 6.
         4- Retirement package containing the rationale for
         retirement and the required editing of the Standard for each
         item prepared by WG 6 with the help of other working groups
         (Items will be listed separately so each may be voted on
         5- Vote by WG 6 - Each member may pull any item and delay
         action on the item by 9 months

        6- What has not been pulled from the package goes to Letter
         Ballot by the DICOM Standards Committee.
         7- Pulled items resubmitted after 9 months for ballot will
         be WG 6 with a two-thirds majority required for submittal
         for ballot by the DICOM Standards Committee.

        See the attach document for supplement status information.

 Review and Approve Supplement from Other WGs (see individual
  reports for details)

        Supplement 15: VL (Single Frame) passed WG 6 approval and
         was sent to the DICOM Committee for Letter Ballot.

        Supplement 23 and Supplement 46 have been incorporated into
         Supplement 23:Structured Reporting and no longer exists as a
         separate supplement. Members made many comments.

        Supplement 29: RT Treatment Record IOD passed DICOM Letter
         Ballot by the DICOM Committee. Final Text was written with
         technical changes, therefore, it has been resent to the
         committee for further ballot.

        Supplement 30: Waveform Interchange was discussed and many
         comments were made to WG 1. The goal is to release this
         supplement for Letter Ballot after the June WG 6 meeting.

        See the attach document for supplement status information.

     Please see other WG reports for details.

        The Letter Ballot of many supplements from other WGs and WG
         6 will account for much of the agenda in June. Please don’t
         forget, if the documents are not formatted using the new
         DICOM supplement template they will not be reviewed by WG 6
         and a WG member must be present.

 Miscellaneous

        The need for a DICOM workshop related to Image Management
         Services (Modality Worklist, Modality Performed Procedure
         Step, and Storage Commitment) was discussed. It was
                                                        EXHIBIT E
         suggested that this effort should be coordinated with the
         planned IHE and VA workshops. It occurred (May 3-5) and
         members Charles Parisot and Don Van Syckle represented WG 6.

         Miscellaneous technical discussions related to DICOM image
         management and IHE occurred.

 DICOM Publication

        WG 6 was asked by the DICOM Committee to produce a new
         version of the DICOM standard "DICOM 1999". This request
         was discussed and members were about evenly divided related
         to its support.

         The supporters wish to go ahead as they feel it's important
         to print new supplements and correction proposals in the
         published standard as soon as possible. The non-supporters
         feel that printing these updates so quickly makes it
         difficult for customers of the standard (i.e. I just ordered
         and paid an old copy?).

         WG 6 wishes the DICOM committee re-discuss these pros and
         cons and make the final decision for when the standard
         should be published.

 New Work Items

        Members discussed models for the creation of a new work item
         related to Interpretation Worklist. The scope of the
         supplement will be determined by the basic questions that a
         "physician using a workstation" will need to ask focussed
         upon the goal of creating a diagnostic report. Such as:
         What to do today, and what to do next? What information do I
         need to do the task, and where is that information? How to
         compile and structure the results of the tasks?

         Ideas were discussed to define the "high-level" scope of the
         work item. Member, Cor Loef, has written a new work item
         for the DICOM Committee. (See work item).

Respectfully submitted by:

Donald E. Van Syckle
Chairman, DICOM WG 6

                                                        EXHIBIT E
              DICOM Supplement Status Overview - WG 6
                         March 25, 1999

The following table is a status overview of the various DICOM
supplements and is formatted as follows:

Column 1 - Supplement Number, Column 2 - Supplement Name,
Column 3 - Parts Affected
Column 4 - Status of the supplement
           Preliminary (effort in progress, but no early
           Early Draft
           Released for Public Comment , Public Comment
           Frozen for Purpose of Trial Implementations
             (Frozen Draft)
           Released for Letter Ballot, Passed Letter Ballot
           Final Text Created (waiting for Publication)
           DICOM (date) - DICOM Standard where Supplement has
             been published. (Ex. DICOM 1996)
Column 5 - Comments

NEMA Server Address - ,

The format of the supplement names are as follows:
supNN_VV.doc   where:

   NN is the supplement number
   VV is the version number, ie:
           01 for draft number 1
           99 for draft number 99
           pc for public comment
           lb for letter ballot
           fz for frozen draft for trial use
           ft for final text

Donald E. Van Syckle
Chairman, DICOM Committee WG 6

                                                        EXHIBIT E
Suppleme   Supplement Name                   Parts      Status       Comments
nt #                                         Affected
0          Print Management Point-to-Point   13         DICOM 1995
           Communication Support
1          Media Storage and File Format     3,4,6,10   DICOM 1996
           For Media Interchange
2          Media Storage Application         2,11       DICOM 1996
3          Media Format and Physical Media   12         DICOM 1996
4          X-Ray Angiographic Image          3,4,6,11   DICOM 1996
           Objects and Media Storage
5          Ultrasound Application Profile    3,4,5,6,   DICOM 1996
           IOD and Transfer Syntax           11
6          X-Ray Fluoroscopic Image Object   3,4,6      DICOM 1996
7          Nuclear Medicine Image Object     3,4,6      DICOM 1996
8          Storage Commitment Service        3,4,6      DICOM 1996
9          Multi-byte Character Set          2,3,4,5,   DICOM 1996
           Support                           6
10         Basic Worklist Management         3,4,6      DICOM 1996
11         Radio Therapy IODs Phase 1        3,4,6      DICOM 1998
12         PET Image Object                  3,4,6      DICOM 1998
13         Queue Management                  3,4,6      DICOM 1998
           (Print Queue SOP Class)
14         Unknown Value Representation      2,5        DICOM 1998
15         Visible Light Image (Single       3,4,6      Released     Goal to be released for
           Frame)                                       for Letter   Final Text July 1999
16         PostScript Print Management       3,4,6      Canceled
Suppleme   Supplement Name                   Parts      Status       Comments

                                                     EXHIBIT E
nt   #                                    Affected
17       Modality Performed Procedure     3,4,6      DICOM 1998
         Step SOP Class
18       Media Storage Application        11         DICOM 1998
         Profile for CT and MR Images
19       General Purpose CD-R             11         DICOM 1998
         Interchange Profile
20       X-ray Cardiac (1024) Media       11         DICOM 1998
         Application Profile
21       Nuclear Medicine Media           11         Canceled      Will be solved by using the
         Application Profile                                       General Purpose CD-R
                                                                   (Supplement 19).
22       Presentation LUT (Print)         3,4,6      DICOM 1998
23       Structured Reporting             3,4,6      Frozen        Continued to be frozen, see
                                                     Draft         supplement 46 for future
24       Stored Print related SOP         3,4,6      DICOM 1998
25       Ultrasound Application Profile   11         DICOM 1998
         Media Extensions
26       Ultrasound Application Profile   3,4,6      Preliminary
         Structured Interpretation
27       Media Formats and Physical       12         DICOM 1998
         Media for Data Interchange
28       Grayscale Standard Display       14         DICOM 1998
29       RT Treatment Record IOD          3,4,6      Final Text    Waiting for Publication
                                                     upon          upon approval of the DICOM
                                                     approval of   committee.
30       Wave form Interchange            3,4,6      Public        Goal to Release for Letter

                                                  EXHIBIT E
                                                        Comment       Ballot July 99.
Suppleme   Supplement Name                   Parts      Status        Comments
nt #                                         Affected
31         Security Enhancements One         2,3,8,15   Public        Goal to Release for Letter
                                                        Comment       Ballot mid 99.
32         Digital X-Ray                     3,4,6      Final Text    Waiting for Publication
33         Soft Copy Presentation Storage    3,4,6      Public        Goal to Release for Letter
                                                        Comment       Ballot mid/late 99.
34         Non-Preformatted Print Storage    3,4,6      Canceled      Withdrawn by the champion
           SOP Class                                                  and consensus was obtained
                                                                      to cancel.
35         Retiring Referenced Print         3,4,6      Final Text    Waiting for Publication
36         Codes and Controlled              3,4,6      Final Text    Waiting for Publication
           Terminology                                  Created
37         Printer Configuration SOP Class   3,4,6      Final Text    Waiting for Publication
38         New Basic Image Overlay Box SOP   3,4,6      Final Text    Waiting for Publication
           Class                                        Created
39         Stored Print Media Storage        3,4,10     Final Text    Waiting for Publication
40         DVD using UDF Media               10,11,12   Early Draft   Public Comment in January
41         Security Enhancements Two                    Preliminary
42         MPEG Transfer Syntaxes and        5          Preliminary
43         3D (multi-dimensional)            3,4,6,10   Preliminary
           Ultrasound IODs and SOP Classes
44         Part 9 Retirement                 9          Initial       Public Comment July 1999

                                                      EXHIBIT E
45   Ultrasound Protocol Support       3, 6        Initial
46   Simplified Structured Reporting   3, 4, 6     Early Draft   Public Comment July 1999
47   Multi-frame Visible Light Image   3,4,6       Late Draft

                                                 EXHIBIT E
DICOM WG7 (Radiotherapy) Report

WG7 (radiotherapy) has been working primarily on Supplement 29
(RT Treatment Record Objects). This work has been undertaken using the WG7
newsgroup and teleconferences. Supplement 29 was presented to WG6 at the
March meeting, and was approved as final text subject to distribution of a
letter outlining some modifications made after letter ballot. This letter
was sent with no comments received during the two week period, and
Supplement 29 is now ready to become part of DICOM.

In addition, a number of Change Proposals (six) have been developed by WG7,
mostly clarifying interpretation of the standard following
Implementations of Supplement 11 objects. These CP's were reviewed by WG6
at the March meeting and will be reviewed again at the June meeting in

A number of important RT trade shows (e.g. AAPM, ASTRO, IFOMP) take place
in the coming months. Work is beginning to decide upon appropriate
DICOM RT demonstrations and/or workshops at these trade shows. It may be
possible to organize a WG7 at one of these shows to discuss future
directions for Dicom RT.

             David Murray
             Chairman, WG

                                                             EXHIBIT F
WG 9 - Ophthalmology Report:

The Working Group met in Seattle in association with the American
Society of Cataract and Refractive Surgery on April 9, 199. The following
issues and work items are being addressed:

1. Preparation for WG 9 presentation at the Joint AAO/PAAO meeting in
Orlando October 24-27 Vendors had positive feedback about the DICOM WG 9
presentation at the Technology center of the American Academy of
Ophthalmology in New Orleans and the participants of the New Orleans
presentation committed to participate in another DICOM presentation in
Orlando. Several possibilities will be considered including:

      - Integration of more instruments
      - Collaboration with other workgroups with the goal of adapting
        other standards
      - Creation of a project similar to IHE (Integrated Healthcare
        Enterprise) for ophthalmology (IEE=Integrated Eyecare

2. A specific request for the AAO user community to develop reporting
templates for major ophthalmic conditions was requested. The existing PPP
structure (Preferred Practice Patterns) developed by the AAO will
be the platform for proposals of standard templates. The AAO has agreed
to produce templates beginning with these major clinical conditions:

      -   Diabetic retinopathy
      -   Glaucoma
      -   Cataract
      -   Refraction/Refractive Surgery

3. The Integrated Eyecare Enterprise An invitation will be extended to the
industry for to assist in creating an IEE project (Integrated Eyecare
Enterprise) similar to the IHE project.

4. Recruitment for New Working Groups The AAO will continue to recruit
participation from vendors within the field of perimetry, corneal
topography and ultrasound to participate within a dedicated subgroup of WG
9 for researching existing standards within DICOM and defining specific
needs for additional standard sets.

5. Next meetings The next meeting is planned in Europe. Alternatives are
the SOE in Stockholm or the DOG (Deutsche Ophthalmologische Gesellschaft)
in Berlin (as in 1998). The next WG 9 meeting in the US is planned in the
conjunction with the annual AAO meeting in Orlando (Friday, 22. October


Lloyd Hildebrand
Co-Chair, Working Group 9

                                                             EXHIBIT G
Report Working Group 10 meeting, 16 June 1999
The Working Group agreed with the proposal of Emmanuel Cordonnier to request a DICOM MIME
type and a file extension.

DICOM Strategic Document
A discussion was held about the future of DICOM. Based on this
discussion, Eric Martin has offered to make a first version of
a strategic document.

Charles Parisot and Kees Smedema reported on the progress of
the IHE demonstration for year 1 and the preparations for year
2. The IHE will inform WG 6 before their next meeting about
the priorities from IHE’s point of view for completion of
certain parts of the DICOM standard. The IHE assumes that
supplements that do not go to letter ballot before March 2000
cannot be used in IHE year 2.

Structured Reporting
Dean Bidgood gave an update, reviewed Annex A and distributed the “Blue Book”. WG 10 thanked Dean
Bidgood for all the work he did and does for SR. WG 10 recommends to the DICOM Committee that WG 6
gives now a very high priority to the completion of SR.

Terminology and Codes
Some years ago DICOM got the agreement from CAP to use the terminology of SNOMED in DICOM SR.
However, SNOMED has evolved and the question is whether this agreement is still valid in the current
circumstances. The Working Group decides to ask Dave Clunie and Dean Bidgood to investigate the current
situation with the CAP as soon as possible and come up with an answer whether the codes are under any
royalties or not. This is required before SR goes to letter ballot.

Relation with HL7
It was proposed to go ahead with making IMSIG a full DICOM Working Group. It was suggested that merging
this new Working Group with WG 8 would probably be very beneficial. There should be 2 co-chairs, one from
DICOM and one from HL7. Meetings should not only be held in conjunction with HL7 meetings, but also with
relevant DICOM meetings.

Priorities for WG6
WG 10 recommends the following priorities for supplements etc:

1       Change Proposals
2       Presentation State
2       Waveform
2       Security-Communication
3      SR
4      Retirement of Sections
4      Re-visiting Part 1 and Part 2
5       Security- Digital Signatures
5       3D
5       Multiframe VL
5       MR

                                                                                     EXHIBIT H
5    US: MPEG, Intravascular, Stress Echo
5    Optomology
5    DVD-UDF Media
5    DICOM MME type
6    Interprestation Worklist
It was suggested that if WG 6 would want to work on the Interpretaion
Worklist, a special Ad-hoc group should be set-up that would not delay
other work.

                                                             EXHIBIT H
Report on Working Group 12, Ultrasound
June 7, 1999
David Heaney

WG 12 continues to follow the progress of the Structured Reporting
Ultrasound will adopt this Supplements for use in conveying
Ultrasound measurement and observation data. At this time plan on using
'generic' or 'general' SOP Classes rather than Ultrasound specific SOP

Progress continues in the development of the Stress Echo Supplement. We
hope to soon present it Working Group VI for review. Final discussions
involve mapping of Protocol Stages to the DICOM model. i.e. is each
Protocol Stage a Scheduled Procedure Step etc?

The progress on the development of the IVUS Supplement by Working Goup I
continues to be followed. We have reviewed the initial Requirements and
hope to assist in it development.

The Work Group continues to compile and review list of measurements for
inclusion in LOINC.

Work has begun on creating a Supplement for adding MPEG compression for
Ultrasound cine images. This is planned to take the form of a new Transfer
Syntax and additional encoding rules for MPEG data in the existing pixel
data element.

The new 3D Group will be developing rules for encoding multi-dimensional
Data sets. They will not however address encoding issues for acquisition
sets which are used to derive the 3D data. For this reason Working Group 12
is reviewing the existing Ultrasound IODs to determine if any changes or
new IODs and SOP Classes are required.

A decision will be made on whether to end the formal disk exchange tests
and create a final report for the ultrasound and DICOM communities.

                                                             EXHIBIT I
WG 13 - Visible Light

WG 13 has not met since the last DICOM Standards Committee meeting. The
group is awaiting the final ballot results on the VL supplement 15
   (Single Frame). Supplement 47 (Multi Frame) work item has not yet been
addressed since it has been segregated from the initial VL proposal.

Lloyd Hildebrand
Co-chair, WG 13

                                                             EXHIBIT J
WG 14 Report -- 17 June 1999

WG 14 held two teleconferences since the last DICOM Committee Meeting.   The
main effort was to send out, then evaluate responses to a Request
For Proposals (RFP) for a demonstration of DICOM Digital Signatures
at an upcoming conference. This RFP was coordinated through the
Committee for the Advancement of DICOM. The target conference for the
demonstration was RSNA 1999, with either SPIE 2000 as a fallback date.   We
had one response to the RFP from OTech, which the Working Group deemed
acceptable. Based on that response, the WG submitted a proposal for a
booth at InfoRad.

About the same time, Vicki Schofield sent out requests to NEMA members for
voluntary contributions to support the RFP. Unfortunately, the
last report Vicki gave to the WG was that only two parties came forward
with a combined commitment of $6000, which falls far short of the $22,500
requested by the OTech/OFFIS development team. In light of this, Vicki
indicated that the RFP probably could not move forward.

Due to delays for which the Chair takes full responsibility, the WG 14
meeting originally scheduled for May was postponed to August in San
Francisco. The intention is to hold a full day meeting to address
finalization of Supplement 31, future steps for Supplement 41, the
potential support for a Digital Signature demonstration, and future issues
suggested by WG 10. Based on that last discussion, WG 14 could possibly
submit new work proposals to the DICOM committee.

L. Tarbox

                                                             EXHIBIT K
DICOM WG 15 Digital Mammography Report (for June 1999 DICOM
Committee Meeting)

WG 15 has considered a proposal to develop an extension to DICOM to
standardize the reporting of Computer Assisted Detection (CAD)
results for mammography. There is sufficient interest in this
subject by members of the working group (which includes several
CAD vendors) to support this development effort. This effort will
take advantage of the BIRADS standard from the ACR for mammography

WG 15 has no other work items on its agenda at the present time.

Action requested: Approval of the attached work item for a Mammography
CAD extension to DICOM.

   -- end report --

   -- begin proposal --

Proposal for Mammography CAD Work Item


The DICOM Mammography WG 15 has determined that it is necessary to
develop an extension to DICOM to standardize the reporting of
Computer Assisted Detection (CAD) results for mammography.

It is proposed that the DICOM Committee approve a Work Item
for the development of a Mammo CAD supplement, and
request the WG 6 staff to assign a supplement number.

Limitations of Current Standard.

The existing standard contains only overlay or curve objects that
may be used to indicate regions of interest on an image that may
pertain to CAD output. These convey no semantics and are not
sufficient to adequately represent the information CAD algorithms
may generate. At present, CAD results are used only in a
proprietary manner, without the opportunity to share results between
implementations or with general purpose (non-CAD specialized) workstations.

                Description of Proposal.

It is therefore proposed that a Mammo CAD supplement be developed,

- makes use of the structure and framework defined by proposed Sup 23
  structured reporting to encode CAD results
- makes use of terminology and structure defined in the ACR BIRADS
  standard for mammographic reporting

Parts of Standard Affected.

Part 3   will require a new SR Mammo CAD IOD.
Part 4   will require a new SR Mammo CAD SOP Class.
Part 6   may require an extended data dictionary of Mammo CAD elements.
SNOMED   will require the addition of terms for mapping BIRADS

                                                               EXHIBIT L
It is not proposed to add new services, messaging or encoding.


The Mammo WG 15 consists of members from the general vendor, digital
mammography and CAD community, as well as clinical and research
radiologists, medical physicist and scientists, representatives of
regulatory authorities and research institutions, as well as ACR staff
involved in mammography.

The meetings do not consume significant bandwidth of other DICOM working
group members, apart from the involvement of some individuals concerned
with structured reporting. The secretariat is ACR and most of the meetings
have been in the USA. There is a high level of interest by many members,
particularly vendors, for the early adoption and implementation
Of a Mammo CAD reporting standard.

At the present time it is not expected that other CAD applications will
need to be considered in this supplement, since the state of the art in
mammography is further advanced, as is the commercialization of the
technology, hence the need for a standard.

It is anticipated that development of the supplement will take 12 months
and that meetings will be held on a three monthly basis, with much of the
work of document preparation and editing done by the exchange of email.
Many of the meetings will be held in conjunction with major scientific
meetings (such as SBI and AAPM).

Six hours of WG 6 meeting time on two occasions during early
and mid 2000 are expected to be consumed for the review and approval of
public comment and letter ballot text.

             -- end proposal --

David A. Clunie                   
Director, Medical Imaging Technologies
Quintiles Intelligent Imaging    
521 Plymouth Rd #115                   Work 610-238-0572 Fax -0578
Plymouth Meeting PA 19462              Home 570-897-7123 Fax -5117

                                                              EXHIBIT L
Report from DICOM WG 16 (MR enhancements) activities
Matthias Drobnitzky

List of previous meetings

   september 16 and 17, 1998, during ESMRMB ’98 in Geneva
   january 12 and 13, 1999, at NNI in Delft
   april 15 and 16, 1999, at NEMA in Washington

List of future meetings

   june 20 and 21, 1999, before CARS ’99 in Paris
   september 14 and 15, 1999, before ESMRMB ’99 in Sevilla
   december 13 and 14, 1999 at NEMA in Washington

List of action items defined through novel MR applications

   work on multi-frame image module
   work on novel descriptive attributes for pulse sequences
   work on spectroscopy data representation
   work on MR specific modality LUT, color in MR applications, calibration,
    description of stimuli used in functional MR imaging, operations between images
    (wrt. original and derived MR images)
   discussion about MR rawdata representation

List of short-term goals

   based on feedback of WG 6 on a draft of a new MR multiframe object members
    are revisiting their ideas trying to reach a pragmatic solution
   finding consensus on vendor-independent nomenclature of advanced pulse
    sequence techniques and attributes
   drafting of proposed work items for presentation to the DICOM comittee
   have a joint meeting together with WG 17 (3D) to clarify common
    interests/syngergies (before ESMRMB ’99 in Sevilla)

Action requested from the DICOM committee

 consider a draft of a WG 16 scope for review by DICOM committee (was sent
Matthias Drobnitzky, WG 16
                                                                    EXHIBIT M
The scope of DICOM WG 16 – a proposal for the DICOM Committee

Proposal for New MR SOP Class Work Item


The DICOM MR WG 16 has determined that it is necessary to create a
new MR object to meet the needs of state of the art MR technology that
has evolved substantially since the existing MR object was standardized
in 1993.

It is proposed that the DICOM Committee approve a Work Item for the
development of a New MR Object supplement, and request the WG 6
staff to assign a supplement number.

Limitations of Current Standard:

It is not possible without the use of extensive collections of private
elements to describe modern MR pulse sequences using the current
standard, hence interoperability of annotation and advanced annotation
are hampered by the current standard.

Furthermore, new applications such as functional MR and MR
fluoroscopy, as well as the non-imaging application MR spectroscopy,
are not supported by the current standard. Not only are technique
attributes insufficient, but the organization of increasingly large datasets
as single frame objects is awkward, and limitations of the existing
definitions of spatial and temporal attributes are apparent.

The MR WG believes that adding new optional elements to the existing
MR object would not be sufficient to meet the needs of modern MR

                                                              EXHIBIT M
Description of Proposal:

It is therefore proposed that a new MR object be developed, that:
 contains a more extensive set of descriptive attributes
 makes use of the multiframe mechanisms and variants thereof (as
    originally introduced by the nuclear medicine, ultrasound and x-ray
    angiography objects)

Parts of Standard Affected:

Part 3 will require a new MR IOD.
Part 4 will require a new MR Storage SOP Class.
Part 6 will require an extended data dictionary of MR elements.

It is not proposed to add new services, messaging or encoding.


The MR WG 16 has been meeting regularly since it was established in
1998, and its members are drawn mostly from the MR community. Until
now meetings do not consume significant bandwidth or other DICOM
working group members. The secretariat is now COCIR/NNI and most
of the meetings have been in Europe. This situation avoids the need for
NEMA staff to travel to staff all the meetings. The working group
includes members from the majority of MR equipment vendors as well
as interested users, mostly from the scientific community. The level of
interest by vendors bodes well for the early adoption and
implementation of a new MR object.

It is anticipated that development of the supplement will take 12-18
months and that meetings will be held on a three monthly basis, with
much of the work of document preparation and editing done by the
exchange of email. Many of the meetings are held in conjunction with
major MR scientific meetings (such as ESMRMB and ISMRM).

Six hours of WG 6 meeting time on two occasions during early and mid
2000 are expected to be consumed for the review and approval of public
comment and letter ballot text.

                                                           EXHIBIT M
A close liaison with the DICOM 3D WG 17 is expected, since some
commonality in the form and description of spatially and temporally
varying multiframe acquisition objects is expected. Proposals have been
made to hold joint or overlapping 3D and MR WG meetings when

It is suggested that this commitment of time and resources is
considered to be well justified, considering that the exchange of MR
images is one of the oldest, highest volume and most mature
applications of DICOM, yet is one of the most rapidly evolving.

Matthias Drobnitzky, WG16

                                                           EXHIBIT M
WG17 Status Report

WG17 convened its third meeting at NEMA May 18-19.

WG17 produced a draft set of requirements. A copy accompanies this report.
Concerned Working Groups should review this document at their next meetings
and provide feedback to WG17 regarding the adequacy, completeness, and any
other comments. Also attached to this report is a summary of WG17 mission
and activity intended for distribution to Working Groups or others that may
have interest in participating.

WG17 requests submissions that describe anticipated data types intended for
eventual support by the Standard. A directory on the NEMA ftp site holds
submitted white paper, minutes and other documentation.

There are two primary requirements classifications:
- reconstructed and modality native data; and
- annotation and presentation.

The former requirements are the current priority. WG17 will work with WG11
to refine the presentations related requirements. WG17 and WG11 will
interact to evolve the definition of these requirements and to partition
the responsibilities. As yet, there is no schedule for the effort.

WG17 is pursuing a *structured node* approach for the representation of
multi-dimensional data. The approach is a representation based on
hierarchical nodes. Primitive data types form the building blocks of
progressively more complex data types. The approach is extensible and
should meet all the requirements discussed thus far. Volunteers are
submitting use cases and white paper to develop and evaluate alternatives.

Volunteers are also evaluating how to leverage existing multi-dimensional
standards such as OpenGL, Fahrenheit, and SMIL.
The intent is to choose parameter definitions and terminology
consistent with that of these standards.

Doug Sluis
Chair WG17

                                                             EXHIBIT N
                Requirements for N-Dimensional Data Sets
                             WG17 Draft
                           May 24, 1999
This draft is a summary of requirements gleaned from the first
two meetings and submitted white paper. The requirements are
separated into two categories:
 requirements for data from acquisition through the
   reconstruction stages
 presentation data or the specifications by which to derive
        Acquisition and Reconstruction
1. Data sets can be of any order of dimensionality: 1D, 2D, 3D,
   … Dimensions may be space, time, physiological phase,
   detector energy, or other acquisition defined dimensions.
2. Resampled, reconstructed data sets (such as a 3D voxel
   arrays); sequences of lower dimension data types (such as
   modality native 2D image frames) used to derive the
   reconstructed objects.
3. Sampling rates can vary along each dimension. That is, the
   spacing in each dimension may differ. Voxels may be non-
   cubic and pixels not square.
4. The sampling relationships between the data sets within a
   particular dimension may be regular or irregular. Regular
   relationships are the common case of pixels or voxels
   equally spaced along an axis. An example of irregular
   sampling is cine loops with missing frames or non-uniform
   frame intervals.
5. The sequence of data sets is not constrained. That is the
   organization of the binary data portion of the data set (and
   reflected in the organization of the nodes) is
   unconstrained. For example a modality may export a four
   dimensional data set with either space or time as the
   highest order dimension. Similarly, a modality may
   interleave the data sets of multiple sample components at
   any level: pixel, frame or as separate volumes.
6. The data set relationships may be non-orthogonal and can
   have arbitrary spatial relationships (both orientation and
   translation). In this case, the relationship between the
   data sets must include the direction cosines to define the
   data set’s projection onto its child data sets. In this way
   it is possible to describe the 3D spatial relationships of
   frames acquired in any geometric acquisition protocol
   including, for example, free hand ultrasound.
7. Data sets may have multiple components (or channels). For
   example, ultrasound may have an echo component as well as
   doppler components; MR may have T1, T2 and functional
8. Data sets of different components may have different
   dimension sizes or sampling rates. For example, the data

                                                           EXHIBIT N
   sets of the power doppler component may be a sub-volume or
9. Data set components may have different dimension order
   within the same root data set. For example, one dimensional
   audio or physiological data sets may be correlated with two
   dimensional frames.
10.Data sets have relationships describable in the Standard.
   These are local (within the same root data set), or they can
   be external, that is references to a reference coordinate
   system defined externally. The relationships include
   spatial, temporal, trigger delay relationships.
11.Data sets may have additional data to describe modality
   specific acquisition data. This enables the modality to
   specify any data useful to downstream clinical applications.
12.Data sets can be binary “shutter” volumes that define
   volume masks. Data sets may have an enumeration of data
   types. For example, an enumeration may encode segmented
   tissue classifications such as: bone, muscle, fat, etc..

Presntation Requirements
3D attributes that correspond to WG 11 Base Presentation
State.      These are simple extensions of what is already
standardized in Base Presentation State.

   Graphics Annotations
   Points
   Lines
   Graphics
   Text
   Shutter

                                                    EXHIBIT P
New 3D attributes not handled via extension of Base Presentation State
These are not done in Base Presentation State, but items that
are sensible extensions.

   Camera viewpoint, angle, path in time
   cutting planes
   types of rendering used
       volume rendering (opacity based, MIP, etc)
       surface renderings (marching cubes, isosurface, etc)
   intent of rendering, i.e. clinical protocol (Circle of
    Willis, CTA, etc)
   segmentation
       bitmap
       probablistic
       multivalue (different colors for different types, etc)
    leaf “structured nodes” used to generate the visualization
   polygonal structures (external objects, like biospy gun,
    radiation treatment beam, etc).

Complete description of Rendering State
This is to exactly specify (and thus) standardize the methods
used for the visualization.

   Exact rendering method (volume, opacity, alpha blending, IW,
    transparency, lighting, shading, etc).
   Parameters to rendering method
   Image processing

                                                          EXHIBIT N


     This is a summary of DICOM Work Group 17 activities,
provided as information to other DICOM Work Groups concerned
with 3D imaging or other multi-dimensional data needs. The
mission, status and current activities are set forth.

     Accelerating activity in 3D diagnostic imaging
applications has given rise to the need for representation of
3D diagnostic image data in DICOM. This need is relevant to
multiple modalities and DICOM Working Groups. To avoid
independent and divergent efforts in multiple Working Groups,
the DICOM Standards Committee commissioned WG 17 to develop a
common framework for multi-dimensional data sets, extensible
to any modality and clinical specialty.

     The purpose of this paper is to inform other interested
Work Groups of WG 17’s direction, and to invite input and
collaboration toward the Standard’s development. The Work
Group convened its first meeting on Friday, December 4, 1998,
and has held subsequent meetings on February 25, 1999 and on
May 18-19, 1999. The next meeting will be held on September
15-16, 1999 in Seville, Spain. The morning of September 15
will be devoted to a joint meeting with Work Group 16 (MR).


     At the first meeting, the WG set forth the mission. The
Standard must support dimensions of any type, including space,
time, spectral or other. WG 17 identified the following
general of requirements:

- Acquisition:
     - Native modality objects
     - Resampled objects such as 3D reconstructed volumes
- Presentation
     - Derived presentation objects such as 2D images
renderied from 3D objects
     - Annotation related requirements

     Data types and characteristics of the data sets may

- Aggregate correlated data sets within multi-dimensional
     -multiple signal types
     -varying dimensionality
- Relationships to external objects and frames of reference

                                                     EXHIBIT N
- Binary or enumerated volumes such as shutter masks,
segmented volumes
- Fiducials for data fusion, registration and synchronizing

     WG17 identified examples of clinical applications the
Standard should support. Representative of these are:

-Diagnostic visualization: surface, volumetric, virtual
endoscopy, stereo projections
-Computer Aided Diagnosis
-Treatment planning and simulation
-Intra-operative: Image Guided Therapy
- Clinical specialties: cardiac; vascular; oncology;
obstetrics, dental; reconstructive surgery, pathology,


WG17 is giving priority to the problem of modality export vs.
presentation related issues. WG17 and WG11 will interact to
evolve the definition of these requirements and the
responsibility for.

                                                   EXHIBIT P
WG17 is pursuing a “structured node” approach. Primitive data
types form the building blocks of progressively more complex
data types. Volunteers are submitting use cases and white
paper to develop and evaluate alternatives. The following
items are now under investigation:

-Identifying and defining the fundamental node types
-Rules for constructing tree structures, dimension nesting,
and context inheritance
-Encoding recurring and non-recurring events
-Investigating what leverage, if any, is possible from
standards such as OpenGL, SMIL


     WG 17 is seeking from each affected modality and clinical
specialty, requirements statements, descriptions, or examples
of anticipated needs to ensure that the Standard will fully
meet the needs of the DICOM community. Thus far, WG17 has
received input from Ultrasound, Nuclear Medicine, and Working
Group 11.

Integrating the differing requirements of various modalities
is a daunting task. The members of WG 17 urge that your
Working Group incorporate multi-dimensional issues into its
agendas. We encourage your input into our development process.
Whenever possible feasible, WG17 will arrange joint meetings
with other work groups to deal with common issues. One such
meeting was held with WG12, the Ultrasound Working Group. A
joint meeting with WG 16 (MR) is another step consistent with
this strategy.

     If you have further questions, please feel free to
contact Richard Eaton, Industry Manager at NEMA, by telephone
at (703) 841 - 3248, fax at (703) 841 - 3348 or e-mail at

                                                   EXHIBIT N
DICOM WG on Clinical Trials Report (for June 1999 DICOM Committee

At the last DICOM Committee meeting in March in Vienna, a WG on Clinical
Trials was approved, pending acceptance of the Secretariat by the ACR.

In the interim, the NCI has been proposed as an alternative secretariat.
Discussions with the NCI representatives indicate a probable favorable
response, but this has not yet been formally confirmed.

Also, it has been suggested that the scope of the proposed WG might be
extended to include the use of DICOM in educational roles (e.g. the storage
of images for educational purposes), since there are many commonalties
(such as anonymization of patient identifying information).

The proposed WG has not yet met.

Action requested: That the committee approve NCI as the secretariat,
pending their acceptance.

Action requested: That the committee approve naming the proposed group
the Clinical Trials and Education WG, pending a formal charter and
scope to be developed by the group members, once convened.

David A. Clunie                   
Director, Medical Imaging Technologies
Quintiles Intelligent Imaging    
521 Plymouth Rd #115                   Work 610-238-0572 Fax -0578
Plymouth Meeting PA 19462              Home 570-897-7123 Fax –5117

                                                              EXHIBIT O

The American Academy of Dermatology convened an open organizational meeting for a new
Working Group on Dermatology Standards to focus on issues related to standards for
dermatologic imaging and digital communications. The Academy believes that the interests
and needs of industry, dermatologists and their patients are best served by establishing global
standards governing the communication of images and data. A digital imaging standard
permits users to communicate readily, no matter what specific technology they use. The
Digital Imaging and Communications in Medicine (DICOM) standard is recognized
throughout the world as the medical imaging standard. To date, however, there has been
little interface of dermatologists with this standard. The establishment of this Working
Group provides a formal mechanism for input into and creation of standards that are
responsive to the needs of industry, users and patients.

The group will be focusing on the standards development
activities related to digital imaging and terminology in
caring for diseases and conditions of the skin.

Accordingly, it is proposed that a new Working Group be
established to address this subject reporting, as appropriate,
to the Structured Reporting Working Group (Working Group 8)
and the Visible Light Working Group (Working Group 13)

Formation and Review:

       The formation (and later disbandment) requires approval
       by a majority vote of the DICOM and appropriate notice to
       those who have interest in the activities of DICOM. The
       scope and duties delegated, as a working group shall be
       approved at the time it is formed. Subsequent changes in
       scope or duties shall also require DICOM Committee


       Like all DICOM Working Groups, membership and meetings would be open to all,
       but it is likely members would include:

       Members of the AAD interested in the application of DICOM
       to dermatology.
       Major research institutions
       Other industrial partners


       Members and the Sponsoring Organizations of this working group will be appointed
       by DICOM.

                                                                             EXHIBIT P
     A request for membership shall be addressed to the
Secretariat, and shall indicate:
     a) The applicant’s direct and material interest in the
DICOM Committee’s work;
     b) The applicant’s qualifications and willingness to
participate actively;

                                                   EXHIBIT P
     c) The interest category of the applicant (vendors, bio-
     medical professional organizations, vendor associations,
     standards developing organizations, government agencies);
     d) The name of the representative (and alternate, if

Maintenance of Membership:

    If any member or alternate of the working group is not
    present for three consecutive meetings of the working
    group, membership will cease. After the second
    consecutive meeting not attended, the secretariat shall
    notify the member that membership in the working group
    will cease after the next meeting, if the member is not
    present. Membership may be reinstated by action of

Membership Roster:

    The secretariat shall maintain a current and accurate roster and shall distribute it to the
    members at least annually, and otherwise on request. The roster shall include: the
    name, chair, Sponsoring Organizations, and names and addresses of all members.

    Individuals active in the formation of this Working Group

            Joseph C. Kvedar, MD, Chair
            Timothy Chartier, MD
            Armand Cognetta, MD
            Marta Petersen, MD
            Robert Schosser, MD
            William Stoecker, MD


    Meetings will be held on a semi-annual basis, usually in conjunction with the semi-
    annual meetings of the American Academy of Dermatology.

Calling of Meetings

     Meetings may be held as decided upon by the members or
the chair.
     Meetings shall be open to all members and others having a
     direct and material interest.

Prohibition of Commercial Topics:

    No commercial topics shall be acted upon or even considered. To avoid the most
    sensitive areas, there shall never be a discussion of the following at meetings:
                                                                            EXHIBIT P
    current or future prices or components thereof, including discounts, rebates, and credit
    terms; price lists or procedures for coordinating price changes; sales or production
    quotas; allocation or division of territories of customers among manufacturers,
    distributors or retailers; boycotting any party or denying any party access to markets,
    products, product inputs, or information; identified individual company statistics,
    market shares, inventories or merchandising methods; commercial practices,
    warranties, guarantees, or the particular terms and conditions of sales, including
    credit, shipping and transportation arrangements; or anything dealing with “arm-
    twisting,”, trade abuses, or excluding or controlling competition.

Conduct of Meetings

    All meetings shall be conducted in such a manner that all members are afforded an
    adequate opportunity to present their views. All opinions shall be considered before
    actions are voted upon. The chairperson(s) shall undertake this responsibility with the
    assistance of the secretariat‟s staff.

    Discussions shall be confined to technical, clinical, and
    safety factors. Commercial considerations (warranties,
    guarantees, etc.) are not proper factors and shall not be
    considered. Since the DICOM Standard is voluntary, there
    must be no agreement to adhere to it or any discussions
    as to when members will begin to offer products
    conforming to DICOM.

    The secretariat shall ensure that minutes of all meetings
    are clear, complete and accurate with regard to the
    actions that were taken and the justification for those

    There shall be no conversations off the record at the
    meeting. If comments are not appropriate for recording,
    they shall not be brought up at meetings.

    Meetings shall be adjourned when it is over in all
    respects and not simply in name. Informal rump sessions
    are not part of meetings and should not be held.


    The American Academy of Dermatology will act as secretariat performing
    administrative functions, coordinating meetings and meeting the requirements of the
    DICOM procedures for Working Groups.

Responsibilities of the Secretariat:

    Work closely with NEMA (National Electrical
    Manufacturers’ Association) for proper conduct and
    documentation of subgroup activities, and coordinate with
    other standard-setting bodies as appropriate;
                                                                          EXHIBIT P
Oversee the subgroup’s compliance with the procedures of
the DICOM Standards Committee;

Provide a secretary to perform administrative work including: meeting arrangements,
notices, agendas, minutes and other records;

                                                                  EXHIBIT P
    Perform other administrative functions as required; and

    Following the meeting procedures of the DICOM Standards

Proposed Work Items:

      Create and maintain a SOP Class for dermatology

    Develop definitive content specifically related to
    dermatologic imaging and image-related information (such
    as reports) applications in the DICOM standard;

    The extension of the DICOM standard with respect to
    dermatologic imaging applications of visible light,
    ultrasound, and infrared imaging of the skin;

    Assisting DICOM on technical, engineering, quality
    assurance and safety issues related to imaging of the
    skin as required;

    Development of a standard terminology and interaction
    with groups such as SNOMED; and

    Demonstrations of the DICOM standards in dermatologic
    imaging standards for visible light, ultrasound,
    structured reporting and use of these standards in
    telemedicine applications.

                                                        EXHIBIT P
Proposal to start a new Working Group
   New DICOM Working Group: Integration of Imaging and Information Systems.
   The scope of the working group is:
   The development of DICOM and HL7 standards for image-related information for areas where the
    consistent use of HL7 and DICOM is of prime concern.
   The coordination and mutual education and understanding between the HL7 and the DICOM organizations
    and their technical committees/working groups
   All current members of IMSIG will be invited to become member.
   The combination of WG 8 with this new working group may be explored in view of the substantial common
    interests and the efficient organization of the DICOM work.
   The NEMA has agreed to be the secretariat. This maybe taken over by a professional organization.
   Meetings may be held in conjunction with HL7 meetings, DICOM Working Group meetings and other
    related meetings. The estimated number of meeting days is 10 days per year.
   The co-chairs shall report to the DICOM Standards Committee and to the HL7 Technical Steering
   The DICOM members of the Working Group should be considered as full HL7 members for this Working
    Group/SIG and vice versa.
   This proposal will be sent to the HL7 Board of Directors.

Agreed in the DICOM Standards Committee Meeting of 17 June 1999

                                                                                     EXHIBIT Q
Report of the European DICOM secretariat

The European DICOM secretariat has been more successful than
was anticipated: more DICOM meetings were held in Europe than
we budgeted for.
The European DICOM secretariat is held by the Dutch Standards
Organization (NNI), under the auspices of the COCIR.

The following meetings were held or are planned for 1999:

Jan., 12-13                                Working Group 16    Delft,

March, 9-10                                Working Group 10    Vienna,
March, 10-11                               DICOM Standards Committee
           Vienna, Austria

June, 21-22                                Working group 16    Paris,
June. 23   COCIR IT Committee              Paris, France      (not
June, 28-July, 1                           Working Group 6     Paris,

Aug. 30    Working Group 1                 Barcelona, Spain
Sept. 14   Working group 16                Sevilla, Spain
Sept. 15-16                                Working Groups 16, 17
           Sevilla, Spain

The increasing number of meetings in Europe has certainly
enhanced the international image of DICOM. It has raised the
attendance from European companies, professional societies and
standards bodies to meetings held in Europe.

So far we have not been very successful in getting additional
membership from European professional societies, apart from
the French Society of Radiologists. We will continue our
efforts to increase membership in Europe.

The presentation state demonstration at the ECR in March in
Vienna was a success. Many people visited the demo in the
“Compurad”. The COCIR made an excellent brochure about DICOM
which was distributed at the ECR and beyond. There was also an
information booth about DICOM sponsored by the French Society
of Radiology.

                                                           EXHIBIT R
The COCIR is trying to raise awareness and funds to start an
IHE-like 1 demo in Europe. The initial plan was favorably
received by the European Union.

Kees Smedema

                                                   EXHIBIT P
                 Report on Japanese DICOM Activities
                                                         H. Shinoda
                                                          S. Kabata
                                                       I. Ohbayashi

JIRA and MEDIS-DC mainly perform DICOM related activities in
Japan. JIRA is an industrial association and has several
departments, one of which is for medical imaging systems.
MEDIS-DC is an organization supported by MITI, Ministry of
International Trade and Industry, and Ministry of Health and
Welfare. The department of JIRA is organized by people from
medical equipment manufacturers and has several committees
like DICOM Committee, ISO Committee, CRT Diagnosis Committee,
etc. under the department. JIRA’s DICOM committee is formed
with members from 30 companies and four advisors from
universities. The committee has meetings regularly and
sometimes forms a working group to discuss specific subjects.
The major mission of the committee is interpreting DICOM
standards, adapting the standards to Japanese circumstances,
and educating them to Japanese users. For example, we proposed
the multi-byte character set and using ISCL for the security.

Japanese committee currently focuses the interface between
HIS/RIS and PACS/modality, or worklist management and
performed procedure step. The information needed to operation
in the radiology department in Japan is slightly different
from that in the United States. For example, Japanese law
requires recording operating conditions like electric voltages
and currents to X-ray tubes in both cases of taking
fluoroscopy and radiography. We, therefore, have formed a
working group under JIRA’s DICOM committee and are extensively
discussing what kind of information or data should be
maintained for the practical operation. The working group is
lead by Dr. Kimura, professor of Hamamatsu University of
School of Medicine, and run by JIRA and JAHIS. JAHIS, Japanese
Industries Association of Healthcare Information Systems, is
another industrial association whose members are from
healthcare information systems manufacturers. After the
discussion has been completed, we will propose to correct the
supplement 10 and 17.

Education about DICOM to Japanese users is another area of
activities where the committee devotes. We have lectures on
DICOM at JMCP that is annual exhibition of radiological
equipment and systems and at academic conferences.
We have a regular meeting with JRS, Japan Radiological
Society, and JSRT, Japan Society of Radiological Technology.
They are the largest user groups of the standards in Japan. We
discuss issues on standards, operation in the radiology
department, regulations we all are interested in, etc.
                                                   EXHIBIT S
Regarding biomedical imaging standard, which was discussed at
ISO/TC215, we formed a working group with JRS and JSRT.
We plan to demonstrate an integrating system of HIS, RIS,
PACS, and modalities at the next JMCP.

MEDIS-DC, Medical Information System Development Center, is
another standard discussing organization in healthcare
informatics. They have a committee, which is called IS&C
Committee and currently focuses to the discussion about
storage media and on-line security. A medium called IS&C,
Image Save and Carry, is now standardized as an archiving
medium for the medical image data. The standardization was
done after the discussion with DICOM Standards Committee. They
are now discussing the next generation media and

                                                   EXHIBIT P
trying to find the way to harmonize DICOM standards. The
discussion is carried at working groups whose members are from
medical equipment and information systems manufactures and
academic societies. Another emphasized subject is on-line
security. The discussion is being shared with DICOM WG14.

The Ministry of Health and Welfare recently issued an official notice that said Japanese government would
approve healthcare facilities to archive any medical datum in electronic format. The facilities have been allowed
to archive only medical image data on IS&C media before the notice. Now they can archive any medical datum
in electronic format on certain media under proper operational rules and systems that would be defined by each
facility. JIRA, JAHIS, and MEDIS-DC are now discussing how we interpret the notice and what the proper systems
should be.

                                                                                            EXHIBIT S


The Committee for the Advancement of DICOM utilizes an e-mail
Distribution list and telephone conferences, scheduled as needed, to
organize activities. It was established as an ad-hoc committee by the NEMA
Medical Imaging Informatics (MII) section, and meets infrequently,
typically once a year during the MII section meeting at RSNA. The chairman
of the Committee for the Advancement of DICOM has asked committee members
and MII section members on many occasions if they wish to have face-to-face
meetings or become more active. The consensus has always been that e-mail
and telephone conferences work well, and that there are too many DICOM-
related meetings anyhow.

The funding for activities supported by the Committee for the Advancement
of DICOM comes primarily from voluntary contributions from MII section
member companies, supplemented occasionally with money that has accumulated
from two public NEMA-organized DICOM workshops. The activities sponsored
by the Committee for the Advancement of DICOM have historically coincided
with RSNA.

NEMA and the MII section have established and maintained a cordial
relationship with RSNA. NEMA has requested RSNA support for various
activities or demonstrations in the past. On some occasions RSNA
has requested support from the vendor community represented by the
MII section at NEMA (which typically exhibits products at RSNA). For
example, the MII section, at the request of RSNA was instrumental in
obtaining initial support from diagnostic imaging vendors for the RSNA-
HIMSS Integrating the Healthcare Environment (IHE) initiative. RSNA has
supported DICOM activities starting with the first DICOM demonstration in
1992. RSNA feels strongly that demonstrations need to be planned and
influenced by the vendor community that NEMA represents.


The Medical Imaging Informatics, Committee for the Advancement of DICOM was
asked at the DICOM Committee Meeting in Vienna, to solicit support for two
demonstrations for RSNA 1999:

      1) Softcopy Display/ Hardcopy Output Consistency Demonstration
      2) Security Demonstration (DICOM and Digital Signatures)

The process that was followed by the Committee for the Advancement of DICOM
in support of these requests is similar to what has been done in
the past and is described below as an illustration.

A telephone conference was scheduled by the Committee for the Advancement
of DICOM to discuss the two suggested demonstrations, and to discuss
various organizational issues with respect to the MII section, and the
Committee for the Advancement of DICOM. Minutes of the telephone meeting
are available from NEMA staff (Vicki Schofield).

RFPs to support the proposed demonstrations were generated by the
corresponding DICOM working groups and were distributed by NEMA
Staff, on behalf of the Committee for the Advancement of DICOM.

                                                             EXHIBIT T
Solicitations for voluntary contributions to support the proposed
demonstrations were also distributed by NEMA staff. RSNA was informally
contacted to request support (assuming the necessary funding was obtained),
and a champion representing the corresponding working groups was

The proposals received to support the demonstrations were evaluated by the
Committee for the Advancement of DICOM (to make sure they met
NEMA open participation guidelines), and the respective DICOM working group
(for technical merit, and to determine if it met the RFP
requirements). This was done using a combination of e-mail messages and
telephone conferences, and working group meetings.

A timeline to gather the necessary information needed to obtain formal
support from RSNA was established. RSNA ECC meets each year in early June,
at which time such proposed projects are approved or disapproved;
from past experience, it is known that if that deadline is not met, it is
difficult or perhaps impossible to obtain RSNA support. Resource/ Budget/
and Space allocations are directly influenced as a result of the RSNA ECC

RSNA has expressed a strong interest in supporting the consistency
demonstration and will provide the space requested, provide educational
forums (theater access), etc.. Per the request of the Committee
for the Advancement of DICOM an RSNA ECC "champion" was identified to
help plan the demonstration and create educational and marketing materials.

The IHE demonstration planned for RSNA 1999 is proving to be very
costly for participating vendors. This makes it particularly challenging
to obtain voluntary contributions for additional demonstration at RSNA.
Unfortunately the security demonstration did not receive sufficient
funding, it will need to be postponed. Approximately 70% of the funding
for the consistency demonstration has been raised so far, therefore we will
continue to move forward with the plans, using contingency funds
accumulated from past DICOM workshops to fill in the gaps if necessary.
NEMA staff is issuing the contract to support the accepted consistency
demonstration proposal.

The committee for the advancement of DICOM request assistance from DICOM
Committee members to obtain additional voluntary contributions to support
the consistency demonstration.

The committee also requests advice from the DICOM Committee with respect to
the security demonstration. Should a demonstration be planned for ECR 2000
(Austria), or JMCP (Japan), or perhaps some other venue?

The following individuals will coordinate additional activities
Associated with the consistency demonstration (probably using e-mail):

     Jay Gaeta, chairman committee for the advancement of DICOM
     Herman Oosterwick, consistency demonstration project manager
     Brad Hemminger, WG 11 champion
     David Channin M.D., RSNA ECC champion
     Vicki Schofield, NEMA staff
     Steve Drew, RSNA staff

                                                             EXHIBIT T
There are a large number of educational and marketing activities that need to
be defined and planned between now and RSNA...


The process followed to support RSNA demonstration is well understood by the
Committee for the Advancement of DICOM. It is usually similar to
what has been described above but always requires a fair amount of
flexibility depending on circumstances. The committee would welcome
suggestions from the DICOM Committee for improving "the process".

The DICOM Committee recently suggested that the committee for the
advancement of DICOM sponsor workshops to raise funds to support
international standardization activities (i.e. COCIR, JIRA). The
committee will explore this idea as long as such workshops are not in
conflict with activities that may be already provided commercially. Perhaps
workshops that concentrate on new DICOM aspects, or emerging trends that
require a workshop setting for investigation might be appropriate. The DICOM
Committee should suggest specific workshop ideas for investigation.


The chairman of the committee for the advancement of DICOM feels that it is
difficult to establish relationships similar to NEMA and RSNA
with other trade shows and scientific exhibits, particularly outside the
United States. It requires additional active involvement from other MII
section and committee members.

It has been suggested in the past that COCIR members, for example, take a more
active role to support European demonstration activities (i.e. ECR) and JIRA
members help coordinate activities in Japan (i.e. JMCP).
This is particularly important in establishing initial contacts and
defining "a process" that might be followed in future years.


Jay Gaeta <>   Tel: +1 (414) 475-4507
Chairman, Committee for the Advancement of DICOM

                                                       DICOM Standards Committee,
                                                       Diagnostic Imaging & Therapy
                                                                Systems Division (09)
                                     305                           June 16 - 17, 1999