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Owning work group name

Imaging Integration

Committee Approval Date:


Contributing or Reviewing Work Groups

FHIR Resource Development Project Insight ID

Project ID 1315.

Scope of coverage

A reference to a set of DICOM images, frames, segments or observations along with contextual information describing the nature of the collection. A single ImagingReference resource only references items within a single DICOM Study and Series.

This is necessary for the following use cases:

  • Referencing a specific image or frame in a DiagnosticReport or an Observation
  • Referencing the set of images or frames constituting a volume in a DiagnosticReport or an Observation
  • Referencing the set of image coordinates that relate to a measurement in an Observation resource
  • Linking an observation in a DICOM Structured Report tree to an Observation resource
  • Specifying key images in an ImagingStudy
  • Providing additional context to imaging applications in a context-sharing environment

RIM scope


Resource appropriateness

Does the resource meet the following characteristics?


  • Represents a well understood, "important" concept in the business of healthcare 
  • Represents a concept expected to be tracked with distinct, reliable, unique ids
  • Reasonable for the resource to be independently created, queried and maintained


  • Declared interest in need for standardization of data exchange
  • Resource is expected to contain an appropriate number of "core" (non-extension) data elements (in most cases, somewhere in the range of 20-50)
  • Have the characteristics of high cohesion & low coupling – need to explore whether coupling is good some places, not elsewhere – layers from Bo’s document

Expected implementations

  • PACS / Enterprise Imaging systems
  • Imaging AI systems
  • Advanced Visualization (3D / 4D) systems
  • FHIRcast synchronized applications

Content sources

  • FHIRcast
  • IHE Radiology
    • Relates to AI Result profile

Example Scenarios

  • Link to a specific set of images / frames in a DiagnosticReport or Observation
    • e.g. relate a measurement to a specific image rather than just an ImagingStudy
  • Link to a set of coordinates within an image
    • e.g. specify the source of an image measurement
  • Link to an observation within a DICOM SR
    • e.g. relate a measurement extracted from a DICOM SR to the specific SR document and node within the SR tree
  • FHIRcast
    • Communicate image sets to be loaded / image sets currently displayed in given view-ports
    • Communicate key image information to reporting application
  • Store key image note 

Resource Relationships

  • subject: Patient
  • performer: Practitioner | Practitioner Role | Device | Organization | Patient | RelatedPerson
  • derivedFrom: ImagingStudy
  • endpoint: Endpoint

Resource Boundaries

  • Primary source of confusing likely to be with ImagingStudy
  • Two resources are sufficiently distinct, both in content and in use cases
    • ImagingStudy expected to represent complete available study
      • Including all series and instances
    • ImagingStudy contains no frame, observation, coordinate information 
    • ImagingReference limited to images / frames within a single series
  • Trying to use ImagingStudy to cover both sets of use cases likely to result in user confusion
    • ImagingStudy resources must be parsed to determine which are 'full studies' and which are subsets


Jira Users

  • jwhitby
  • lindop

When Resource Proposal Is Complete

When you have completed your proposal, please send an email to

FMG Notes

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