The MIRCdocument Schema

1 Introduction

This article describes the XML schema for indexable documents on sites using the RSNA MIRC software. It is intended for engineers implementing MIRC sites and authoring tools as well as for administrators and MIRCdocument authors who wish to exploit the full capabilities of their sites. The article assumes a basic understanding of XML. For more information on XML, see the XML Primer.

The MIRCdocument schema includes all the MIRC-specific elements and attributes that can be included in a document on a MIRC site running the RSNA MIRC software. Where noted below, HTML elements may also be included as well.

All elements in the schema include a visible attribute that allows the author to instruct a MIRC site's display software whether to render the contents of the element. Except where noted, the default value of the visible attribute is yes. The rendering behavior described inthis article is that provided by the RSNA MIRC software when MIRCdocuments are accessed by a browser (via an HTTP GET). In all cases, if a parent element's visible attribute is no, none of its children are rendered, and if a parent element's visible attribute is yes, only children whose visible attributes are yes are rendered.

2 The MIRCdocument Element

The MIRCdocument element is the root element of all MIRCdocuments. It encloses all the content of a MIRCdocument:

<MIRCdocument>
    …content…
</MIRCdocument>

2.1 The docref Attribute

When a user selects a MIRCdocument for display, the user's browser is directed either to the MIRCdocument itself or to another document. The optional docref attribute provides the link. To understand its use, it is helpful to understand the MIRC search mechanism.

A user accesses a MIRC Query Service from a web browser. The Query Service provides an HTML form into which the user inserts the search criteria. Upon completion of the form, the browser posts it to the Query Service, which then constructs a query from the form data and posts it to the MIRC Storage Services identified in the form. The query is an XML object in a format defined by the MIRCquery schema. Each Storage Service searches its content for documents matching the search criteria, encodes the list of matching documents in an XML object in a format defined by the MIRCqueryresult schema, and sends the list to the Query Service. In the MIRCqueryresult schema, each document that matches the search criteria is identified by a URL. The Query Service compiles the results from all the Storage Services polled and sends the consolidated results to the user's browser. The consolidated results are constructed as an HTML ordered list, where each item in the list describes one document matching the search criteria and provides a link to the document iself. When the user selects an item in the list, the browser obtains the document identified by the link. In the RSNA MIRC implementation, the docref attribute is used to construct the URL that provides that link.

Some MIRCdocuments contain a complete document, allowing them to be self-indexing. Other MIRCdocuments serve as indexable documents describing information in other formats. To accommodate these different kinds of MIRCdocuments on sites using the RSNA MIRC software, the docref attribute may be coded in several ways.

• If the docref attribute is not included in the MIRCdocument element, the RSNA MIRC Storage Service provides a link to the file containing the MIRCdocument. This technique is used when the MIRCdocument element contains a complete document. For example, a teaching file case can be constructed as a MIRCdocument and indexed by a Storage Service. When a user selects the document from a list of search results, the link takes the user to the document itself. In this case, the MIRCdocument element is defined without a docref attribute:

<MIRCdocument>
    …content…
</MIRCdocument>

• If the docref attribute contains the name of a document with no path information, the RSNA MIRC Storage Service provides a link to the named document in the same directory on the Storage Service as the MIRCdocument. This technique is used when the MIRCdocument is only a means to index another kind of content. For example, when the actual content of interest is a presentation in PowerPoint format, it can be indexed by creating a short MIRCdocument containing the title, the authors, and an abstract. This MIRCdocument, called an "index card", is only useful during the user's search for the document, so the docref attribute is set to point to the presentation file itself, and the Storage Service stores the presentation file and the index file in the same directory.

<MIRCdocument docref="presentationfilename">
    …content…
</MIRCdocument>

• If the docref attribute contains the name of a document with path information, the RSNA MIRC Storage Service provides a link to the named document. This technique is a more general example of the previous case. It is used when the actual document of interest is not stored in the same directory on the Storage Service as the MIRCdocument that indexes it. Since authors generally do not control the actual storage locations of their documents, this mechanism is infrequently used, and then only by MIRC administrators.

This is an example of an index card referencing a presentation stored by a MIRC administrator in a common "presentations" directory under the "MIRCdocuments" directory of the server root:

<MIRCdocument docref="/MIRCdocuments/presentations/filename">
    …content…
</MIRCdocument>

• If the docref attribute contains the name of a document with a fully qualified path, the RSNA MIRC Storage Service provides a link to the named document. This technique is a more general example of the previous case. It is used when the actual content of interest is a document not stored on the same Storage Service as the MIRCdocument that indexes it. This mechanism can be used to index the contents of a webserver on a MIRC Storage Service without storing the documents on the Storage Service itself.

This is an example of an index card referencing a document stored somewhere on the web:

<MIRCdocument docref="http://www.somewhere.edu/filename">
    …content…
</MIRCdocument>

2.1.1 Important Note for MIRC Site Implementers

The description in the section above applies to MIRCdocuments stored on MIRC sites using the RSNA MIRC software. It is important not to confuse the flexibility in the use of the docref attribute described here with the inflexible requirement that a Storage Service provide a fully qualified URL for each document in its MIRCqueryresult reply to a Query Service.

The MIRCqueryresult schema uses the MIRCdocument element to describe each document meeting the search criteria it received in a MIRCquery. A detailed description of the MIRCqueryresult schema is included in a separate article. Briefly, a MIRCqueryresult has the following form:

<MIRCqueryresult>
    <MIRCdocument docref="http://www.somewhere.edu/filename">
        …title, author, abstract content…
    </MIRCdocument>
    …additional <MIRCdocument> elements – one for each query match…
</MIRCqueryresult>

In the MIRCqueryresult schema, each MIRCdocument element is required to provide a fully qualified URL pointing to the document. On sites using the RSNA MIRC software, that URL is generated automatically by the Storage Service as described in the section above for documents with a missing docref attribute or with one that contains a less than fully qualified URL.

2.2 The display Attribute

The MIRCdocument element also supports the optional display attribute, which can be used to instruct the MIRC rendering software on how the author intended the document to be displayed. The RSNA MIRC rendering software supports three values of the display attribute:

• page instructs the rendering software to display the document in a linear, sequential fashion as a normal document would appear. This is the default value.
• tab instructs the rendering software to display the document with each section appearing as a separate tab.
• mstf instructs the rendering software to display the document in a standardized teaching file format oriented toward residents. For compatibility with previous releases, mirctf is a synonym for mstf.

2.3 The first-tab Attribute

The first-tab attribute of the MIRCdocument element instructs the rendering software which tab to display first. This attribute is used in the tab and mstf display formats. It is ignored in the page display format. The default value of the first-tab attribute is 2.

2.4 The show-empty-tabs Attribute

The show-empty-tabs attribute of the MIRCdocument element instructs the rendering software whether to display sections that have no content. This attribute is used in the tab and mstf display formats. It is ignored in the page display format. The possible values are yes and no. The default value of the show-empty-tabs attribute is no.

2.5 The background Attribute

The background attribute of the MIRCdocument element defines the background color of the document when it is displayed. The possible values are light and dark. The default is light.

2.6 The path Attribute

The path attribute of the MIRCdocument element is dynamically generated by the RSNA MIRC software when a MIRCdocument is exported from a storage service. It is used to provide third-party, client-side authoring tools the relative path to the document on the server.

2.7 The as-mode Attribute

The as-mode attribute of the MIRCdocument element is automatically generated by the Author Service when an author edits the MIRCdocument. It defines whether technical elements are displayed in the editor. Its possible values are true and false.

2.8 The visible Attribute

The visible attribute of the MIRCdocument element is ignored by the RSNA MIRC software.

3 Document Structure Elements

Certain first-generation child elements of the MIRCdocument element are used to provide structure for a document, encapsulating titles, authors, abstracts, keywords, and the various content sections of the document. They are used both to encode key information to be matched against search criteria and to organize the entire document for display.

The RSNA MIRC software only displays MIRCdocument content which appears within one of these elements. Information included for indexing purposes only can be placed as text value or child elements of the MIRCdocument element or in a section element with the visible attribute set to no.

3.1 title

The title element contains the title of the document. The title element and the alternative-title element determine the title displayed when the document is rendered or when it appears in a list of search results. See the next section, alternative-title, for details. HTML should not be embedded in the title element.

<MIRCdocument>
    <title>This is the Title</title>
    …content…
</MIRCdocument>

The RSNA MIRC software ignores the value of the visible attribute of the title element.

3.2 alternative-title

The optional alternative-title element provides a title which is used when the document is requested to be displayed as an unknown case.

HTML should not be embedded in the alternative-title element.

The RSNA MIRC software ignores the the visible attribute of the <alternative-title> element.

When the Storage Service receives a query requesting the results as unknowns, it substitutes the contents of the alternative-title element for the title element when constructing the list of query results. If the alternative-title element is missing, the Storage Service generates a title as described in the section on the category element.

The Storage Service similarly substitutes the contents of the alternative-title element when it is requested to display the document as an unknown.

3.3 author

The optional author element contains information for a single author. When a document has multiple authors, multiple author elements are used.

Within the author element are three optional child elements containing the author's name, affiliation, and contact information.

HTML should not be embedded in the author element or its children.

<MIRCdocument>
    <title>This is the Title</title>
    <author>
        <name>John Author</name>
        <affiliation>Organization of John Author</affiliation>
        <contact>Email address of John Author</contact>
        <contact>Post address of John Author – line 1</contact>
        <contact>Post address of John Author – line 2</contact>
    </author>
    <author>
        <name>Mary Author</name>
        <affiliation>Organization of Mary Author</affiliation>
        <contact>Email address of Mary Author</contact>
    </author>
    …content…
</MIRCdocument>

The RSNA MIRC software ignores the value of the visible attribute of the author element and its children.

3.3.1 name

The name element contains the author's name. No provision is made for identifying the given name, surname, or titles. The value of each <name> element appears in the search result list.

3.3.2 affiliation

The affiliation element contains one line of the name of an organization with which the author is affiliated. If multiple lines are required, or if the author is affiliated with multiple organizations, multiple affiliation elements are used. No provision is made for separating multiple organizations.

3.3.3 contact

The contact element contains one line of information on how to contact the author. If multiple lines are required, multiple contact elements are used. No provision is made for identifying the kind of contact information (phone, email, post, etc.) contained in the element.

3.4 abstract

The abstract element contains the abstract of the document. The abstract element and the alternative-abstract element determine the abstract displayed when the document is rendered or when it appears in a list of search results. See the next section, alternative-abstract, for details.

HTML may be used for formatting; in particular, HTML paragraph elements must be used to identify the paragraphs.

<MIRCdocument>
    …content…
    <abstract>
        <p>
            First <b>paragraph</b> of the abstract.
        </p>
        <p>
            Second <b>paragraph</b> of the abstract.
        </p>
    </abstract>
    …content…
</MIRCdocument>

The RSNA MIRC software ignores the value of the visible attribute of the <abstract element.

3.5 alternative-abstract

The alternative-abstract element provides an alternative abstract which is used when the document is requested to be displayed as an unknown case.

HTML may be used for formatting as in the abstract element.

The RSNA MIRC software ignores the visible attribute of the alternative-abstract element.

When the Storage Service receives a query requesting the results as unknowns, it substitutes the contents of the alternative-abstract element for the abstract element when constructing the list of query results. If the alternative-abstract element is missing, the Storage Service generates no abstract element.

For MIRCdocuments with the display attribute set to page, the Storage Service similarly substitutes the contents of the alternative-abstract element when it is requested to display the document as an unknown. (The abstract element is used in MIRCdocuments with the display attribute set to tab or mstf. In these documents, the abstract is included in the first tab and the first tab displayed is typically the second tab, thus concealing the content of the abstract until the user wants to see it.)

3.6 keywords

The optional keywords element contains a list of words under which the document should be indexed. Although all words in a document are indexed, the keywords element makes it also possible to query for only those words explicitly identified as keywords.

HTML should not be embedded in the keywords element.

<MIRCdocument>
    …content…
    <keywords>word1 word2 word3</keywords>
    …content…
</MIRCdocument>

The RSNA MIRC software ignores the value of the visible attribute of the keywords element.

3.7 section

The optional section element is used to identify separate parts of a MIRCdocument. It contains one attribute, heading, that is used to contain the heading applied to the section when the MIRCdocument is rendered by a browser. The value of the section element is the content of the section. HTML may be used for formatting; in particular, HTML paragraph elements should generally be used to identify paragraphs. (The rendering software can display content not contained in paragraphs, and certain third-party authoring software sometimes creates documents in this way, but the Author Service is more strict than the display software, so it is necessary to use HTML paragraphs if the Author Service is to be used to edit the document.)

<MIRCdocument>
    …content…
    <section heading="Method">
        …Method section contents…
    </section>
    <section heading="Results">
        …Results section contents…
    </section>
    …more content…
</MIRCdocument>

MIRCdocuments used as index cards generally do not have section elements since index cards are only displayed as query results. For all other applications of the MIRCdocument schema, however, the section element provides the way for the author to group related parts of the document together. This grouping instructs the RSNA MIRC software on how to handle the parts of the document when it is displayed. For example, in tab display mode, the RSNA MIRC software creates a separate tab for each section, using the heading attribute as the title of the tab.

The default value of the visible attribute is yes.

3.8 image-section

The optional image-section element is used to collect groups of related images. The image-section element supports the heading attribute in the page and tab display modes. The heading attribute provides a label for the section containing the images.

The image-section element supports the image-pane-width attribute, which instructs the RSNA rendering software how much space to allocate for image display in the right pane in the tab and mstf display modes. The default value of the image-pane-width attribute is 700. The RSNA rendering software enforces a minimum width of 512.

The RSNA MIRC software ignores the value of the visible attribute of the image-section element.

3.9 references

The optional references element encapsulates a set of reference elements in the MIRCdocument. The RSNA MIRC software generates a separate section entitled "References" when the MIRCdocument is displayed. The software automatically generates an ordered list of the reference child elements.

<MIRCdocument>
    …content…
    <references>
        <reference>
            …text of the first reference…
        </reference>
        <reference>
            …text of the second reference…
        </reference>
        …additional references…
    </references>
    …content…
</MIRCdocument>

The RSNA MIRC software ignores the value of the visible attribute of the references element.

3.9.1 reference

The reference element is a simple container identifying the enclosed content as a reference to a publication. It has no internal formatting, although this is an area open to extension. Numbering of the reference elements is generated automatically by the references element when the MIRCdocument is rendered. HTML may be embedded in the reference element.

The RSNA MIRC software ignores the value of the visible attribute of the reference element.

3.10 rights and publication-date

If the rights element and/or the publication-date element appear as direct children of the MIRCdocument element, the RSNA MIRC software displays their values at the end of the document. If they appear within a section element, they are displayed as part of the section.

See the section below for information about the elements and their contents.

4 Special Purpose Elements

The schema includes many element which identify specific kinds of information. The RSNA MIRC software renders these elements only when they appear within a section element. Each element may appear multiple times in a section element. These elements can also be used to encode non-displayed information for indexing purposes by placing the elements as direct child elements of the MIRCdocument element.

4.1 history

The optional <history> element allows content to be identified as a patient history for use in specialized searches. The default value of the visible attribute is yes. <findings> The optional <findings> element allows content to be identified as the patient's history for use in specialized searches. The default value of the visible attribute is yes. <diagnosis> The optional <diagnosis> element allows content to be identified as a diagnosis for use in specialized searches. The text value of the <diagnosis> element contains the diagnosis. It may also contain one or more elements to capture diagnostic coding information. In addition, it may contain a <confirmation> element to describe how the diagnosis was confirmed. The default value of the visible attribute is yes.

<diagnosis>text of diagnosis</diagnosis> This is an example of a more complex <diagnosis> element:

<diagnosis> At <confirmation>autopsy</confirmation>, the patient was determined to have … . 12345.67890 </diagnosis> 4.3.1.1 <confirmation> The <confirmation> element describes how a diagnosis was confirmed. The default value of the visible attribute is yes. <differential-diagnosis> The optional <differential-diagnosis> element allows all or part of a part of a section to be identified as the differential diagnosis of the current case for use in specialized searches. The default value of the visible attribute is yes. <discussion> The optional <discussion> element allows all or part of a part of a section to be identified as case discussion for use in specialized searches. The default value of the visible attribute is yes. <pathology> The optional <pathology> element allows all or part of a part of a section to be identified as pathology relating to the case for use in specialized searches. The default value of the visible attribute is yes. <anatomy> The optional <anatomy> element allows all or part of a part of a section to be identified as anatomy relating to the case for use in specialized searches. The default value of the visible attribute is yes. <organ-system> The optional <organ-system> element allows all or part of a part of a section to be identified as anatomy relating to the case for use in specialized searches. The default value of the visible attribute is yes. <a> The <a> element inserts a hyperlink into a MIRCdocument. The <a> element is taken directly from HTML, with the addition of the format attribute: • href contains the address of the document to which the value text is linked. • format contains a description of the format of the document to be found at href. The value text contains the text that is rendered in the MIRCdocument and used as the hyperlink. The format attribute is optional and is not displayed in the MIRCdocument. This is an example of the use of an <a> element to link to a PowerPoint presentation:

This a reference to a <a href="http://www.somewhere.edu/mypresentation.ppt" format="PPT">resource</a>. From this code, the RSNA MIRC site generates HTML that is rendered by a browser as: This is a reference to a resource. The word resource appears as a hyperlink to the object at: http://www.somewhere.edu/mypresentation.ppt. The RSNA MIRC software ignores the value of the visible attribute of the <a> element and applies instead the visible attribute of its parent.

Note In version 8.0 of the schema, the <link> element was used as a synonym of the <a> element, but only the <link> element had the format attribute. To eliminate any confusion with the HTML <link> element, subsequent versions deprecate the <link> element and add the format attribute to the <a> element. The element contains information related to a medical code. The element has one attribute and value text: • coding-system contains the name of the code, e.g., CPT. • the value text contains the code value itself. The element can optionally contain a <meaning> element. The default value of the visible attribute is yes. When rendered by the RSNA MIRC software, the element is displayed as: [coding-system attribute value]:[ element value] ([meaning element value]).

For example, the following element:

12345.67890 will be displayed by the RSNA MIRC software as: MyCode:12345.67890 4.3.1.2 <meaning> The <meaning> element is used to encapsulate the human language meaning of the code value. The default value of the visible attribute is "yes". For example, the following element:

12345.67890 <meaning visible="yes">normal variant</meaning> will be displayed by the RSNA MIRC software as: MyCode:12345.67890 (normal variant) <modality> The optional <modality> element contains a list of the modalities related to the document. If contained within an <image> element, it identifies the modality of the image. The default value of the visible attribute is yes. <patient> The <patient> element is used to encapsulate elements describing specific parameters of a patient. The default value of the visible attribute is yes. The subsections below describe the child elements unique to the <patient> element. Here is an example using some of the child elements:

<patient> <pt-name>John Doe</pt-name> <pt-id>7654321</pt-id> <pt-mrn>1234567</pt-id> <pt-age> <years>3</years> </pt-age> <pt-sex>male</pt-sex> <pt-race>caucasian</pt-race> </patient> 4.3.1.3 <pt-name> The <pt-name> element may be used to identify a patient. It is intended for use in clinical situations where access to the patient's protected health information is restricted by the computer system on which the MIRCdocument resides. It should be omitted in situations where access to the document could compromise the privacy of the patient. 4.3.1.4 <pt-id> The <pt-id> element may also be used to identify a patient. It is intended for use in clinical situations where access to the patient's protected health information is restricted by the computer system on which the MIRCdocument resides. It should be omitted in situations where access to the document could compromise the privacy of the patient. 4.3.1.5 <pt-mrn> The <pt-mrn> element may be used to identify the medical record number of a patient. It is intended for use in clinical situations where access to the patient's protected health information is restricted by the computer system on which the MIRCdocument resides. It should be omitted in situations where access to the document could compromise the privacy of the patient. 4.3.1.6 <pt-age> The <pt-age> element encapsulates one of the following child elements: <years>, <months>, <weeks>, or <days>. 4.3.1.6.1 <years> The <years> element contains the patient age if expressed in years. 4.3.1.6.2 <months> The <months> element contains the patient age if expressed in months. 4.3.1.6.3 <weeks> The <weeks> element contains the patient age if expressed in weeks. 4.3.1.6.4 <days> The <days> element contains the patient age if expressed in days. 4.3.1.7 <pt-sex> The <pt-sex> element contains one of the values male or female (or neutered in veterinary medicine applications). 4.3.1.8 <pt-race> The <pt-race> element contains the name of the race of the patient. 4.3.1.9 <pt-species> The <pt-species> element contains the name of the species of the patient. This element is intended for use in veterinary medicine and paleontology. 4.3.1.10 <pt-breed> The <pt-breed> element contains the name of the breed of the patient. This element is intended for use in veterinary medicine. <image> The <image> element is used to reference an image either for display or as the target of a hyperlink. It has two attributes that are used to determine whether to display the image directly or to generate a hyperlink to the image: • src contains the address of the image to be displayed. • href contains the address of the image referenced. If src is present, the image is displayed when the page is loaded. If src is not present and href is present, then the value of the <image> element is used as the hyperlink for display and href references the image that is the destination of the hyperlink. If src is present, the <image> element also has the width and height attributes of the HTML <img> element. These are passed to the browser to set the displayed width and height of the image; they do not refer to the actual size of the image in the file on the server. The value of an <image> element may be empty or it may contain text, another <image> element, and optionally <patient>, <diagnosis>, <anatomy>, <pathology>, and elements to associate the parameters of the patient and/or the diagnosis with the image. It may also contain the <modality>, <format> and <compression> elements to encode parameters of the image itself. The RSNA MIRC software ignores the value of the visible attribute of the <image> element and applies instead the visible attribute of its parent. The following example shows the use of an <image> element to produce a text link to a JPEG image. … This <image href=”http://www.somewhere.edu/images/image1.jpeg"> image </image> displays the relevant anatomy. … From this code, the RSNA MIRC software generates HTML that is rendered by a browser as: This image displays the relevant anatomy. The word, image, appears as a hyperlink to the object at: http://www.somewhere.edu/images/image1.jpeg. Note that this image would not be discovered in a query for JPEG images because the format of the image was not explicitly encoded. To do so, the element would be written as:

… This <image href=”http://www.somewhere.edu/images/image1.jpeg"> <format>jpeg</format> image </image> displays the relevant anatomy. … The following example shows the use of an <image> element to include a JPEG image directly in the rendered document.

<image src="http://www.abc.edu/images/image1.jpeg"> <format>jpeg</format> </image> The image appears in sequence with the rest of the text value of the element in which the <image> element is contained. The following example shows the use of <image> elements to include a JPEG image directly in the rendered document, with a link to a DICOM image.

<image href="http://www.abc.edu/images/image1.dcm"> <image src="http://www.abc.edu/images/image1.jpeg" /> </image> The JPEG image appears in sequence with the rest of the text value of the element in which the <image> element is contained, but the image is displayed with a border indicating that it is a hyperlink. Clicking the image causes the browser to attempt to load the DICOM image. If a DICOM viewer has been configured into the browser, it may display the image; if not, the browser will allow the user to download the image to the local computer. The following more complex coding of the previous example shows the use of multiple child elements within an <image> element.

<image href="http://www.abc.edu/images/image1.dcm"> <format visible=”no”>DICOM</format> <compression visible=”no”>original</compression> <modality visible=”no”>CT</modality> <anatomy visible=”no”>abdomen</anatomy> <pathology visible=”no”>renal carcinoma</pathology> <patient visible=”no”> <pt-age> <years>86</years> </pt-age> <pt-sex>male</pt-sex> </patient> <diagnosis visible=”no”> renal carcinoma <confirmation>pathology</confirmation> 1234.5678 </diagnosis> <image src="http://www.abc.edu/images/image1.jpeg"> <format>JPEG</format> </image> </image> The following example shows the use of <a> and <image> elements to connect an image to a PowerPoint presentation file.

<a href="http://www. abc.edu/mypresentation.ppt" <image src="http://www.abc.edu/images/image1.jpeg"> <format>="JPEG</format> </image> </a> 4.3.1.11 <format> The <format> element is used to identify the storage format of an image. The <format> element has four enumerated values: • DICOM • JPEG • PNG • GIF The default value of the visible attribute is yes. 4.3.1.12 <compression> The <compression> element is used to identify the compression history of an image. The <compression> element has four enumerated values: • original • reversible • non-reversible • unknown A value at any level in the list above implies that the compression history of the image does not include a version at a lower level. Thus, a value of reversible implies that the image in question is not simply a reversibly compressed version of an image that was non-reversibly compressed. The default value of the visible attribute is yes. 4.3.1.13 <alternative-image> The <alternative-image> element identifies a version of the parent <image> element intended to be used for a specific purpose. The <alternative-image> element has two required attributes. • src contains the address of the <alternative-image>. • role identifies the purpose of the <alternative-image>. The role attribute has four enumerated values: • icon identifies the <alternative-image> as a small image intended for use as an icon link to the parent image. • annotation identifies the <alternative-image> as annotations for the parent image. • original-format identifies the <alternative-image> as the original image acquired by the modality (except for changes required for anonymization). • original-dimensions identifies the <alternative-image> as a version of the parent image having the same dimensions as the original-format image. The <alternative-image> element with role=”annotation” has one additional attribute, type, that describes the format of the annotation data. The type attribute has three enumerated values: • image (default) identifies the annotation data as an image that is to replace the primary image when annotations are to be displayed. • overlay identifies the annotation data as an image that is to overlay the primary image when annotations are to be displayed. The overlay image is expected to be a GIF with a transparent background. • svg identifies the annotation data as scalar vector graphics instructions for displaying the annotations overlaid on the primary image when annotations are to be displayed. The <alternative-image> element may optionally contain the width and height attributes of the HTML <img> element. The <alternative-image> element is used by the RSNA MIRC software only in the MIRC standard teaching file display mode, and its visible attribute and those of all its children are ignored. 4.3.1.13.1 <format> The <alternative-image> element may contain a <format> child element with the same enumerated values as defined in 4.3.12.1. 4.3.1.13.2 <compression> The <alternative-image> element may contain a <compression> child element with the same enumerated values as defined in 4.3.12.2. <quiz> The <quiz> element is used to contain a quiz that is displayed by the RSNA MIRC software within a <section> of the MIRCdocument. Multiple <quiz> elements may appear within one <section> element. Multiple <section> elements may contain <quiz> elements. A <quiz> has the following structure:

<quiz id="…"> <quiz-context> …content defining the context of the quiz… </quiz-context> <question> <question-body> …content defining the question… </question-body> <answer correct="yes|no"> <answer-body> …content shown to the user as a possible selection… </answer-body> <response> …content shown to the user if the answer is selected… </response> </answer> …additional <answer> elements… </question> …additional <question> elements… </quiz> The <quiz> element has an id attribute that is intended to allow a CME interface to distinguish all the quizzes in a document. The value of the id attribute should be unique within the <MIRCdocument>. HTML and MIRC elements are permitted in all the child elements. Numbering of the questions and answers is generated automatically by the RSNA MIRC software. Within a single <quiz> element, there is no limit to the number of <question> elements. The RSNA MIRC software ignores the visible attribute of the <quiz> element and all its children. 4.3.1.14 <quiz-context> The optional <quiz-context> element contains any description required to provide a context for the questions to follow. 4.3.1.15 <question> The <question> element contains the body of a quiz question and its possible answers. Within a single <question> element, there is no limit to the number of <answer> elements. 4.3.1.15.1 <question-body> The <question-body> element contains the content of a quiz question. 4.3.1.15.2 <answer> The <answer> element contains the body of the answer to a quiz question and the response which will be provided if the user selects the answer. The <answer> element may contain a correct attribute indicating whether the answer is correct (yes) or not (no). At least one answer to a question must be identified as being correct. Multiple answers to a single question may be identified as being correct. The default value of the correct attribute is no. 4.3.1.15.2.1 <answer-body> The <answer-body> element contains the body of the answer to a quiz question. 4.3.1.15.2.2 <response> The optional <response> element contains the response which the browser will display if the user selects the answer. <show> The <show> element is a special purpose display command to the RSNA MIRC software. In the MIRC Standard Teaching File format (display=”mirctf”), the <show> element generates a button that allows the user to cause a specific image to be displayed. The show element has two possible attributes, only one of which may be present in any specific element: • image=”n” is used to cause the button to display the image corresponding to the src attribute of the n-th <image> element in the <image-section> • annotation=”n” is used to cause the button to display the image corresponding to the src attribute of the <alternative-image role=”annotation”> child element of the n-th <image> element in the <image-section> The <show> element is ignored in page and tab display modes. The <show> element contains no text of element children. The proper usage is:

<show image="3"/> or <show annotation="2"/> 4.4 Document Description Elements The elements described in this section are used to describe certain parameters of the document. They typically appear as children of the <MIRCdocument> element and are therefore not displayed. However, they may also appear within <section> elements if display is desired. With the exception of the <rights> element, HTML should not be used in these elements. <phi> The <phi> element identifies the protected health information (PHI) that is contained in the document. Absence of the element is interpreted to mean that the document contains no PHI. If the document contains PHI, the <phi> element contains one or more <study> child elements, each identifying one patient study referenced in the document. The contents of the PHI element and its children are not rendered by the RSNA MIRC implementation; it is used only to provide access logging information required by HIPAA. 4.4.1.1 <study> The <study> element encapsulates the PHI for one patient study. If the document contains PHI for multiple studies, multiple <study> elements must be present. 4.4.1.1.1 <si-uid> The <si-uid> element contains the Study Instance UID of the study whose images or patient identifying information are contained in the document. 4.4.1.1.2 <pt-id> The <pt-id> element contains the identifier of the patient corresponding to the study. 4.4.1.1.3 <pt-name> The <pt-name> element contains the name of the patient corresponding to the study. <document-type> The optional <document-type> element identifies the document as one of the following types: • radiologic teaching file a teaching file, which may be a single case or a collection of cases in a single MIRCdocument • radiologic collection a document containing references to multiple radiologic teaching files; a course; a conference • research dataset a MIRCdocument describing and containing a link to a research dataset • educational document an educational document, e.g. a presentation or course • technical document a technical document Since the MIRCdocument schema permits the construction of complex documents combining characteristics of all the listed document types, multiple types may be listed within the element. The default value of the visible attribute is yes. The following unlikely example code fragment could be imagined:

This document provides a link to the <document-type> research dataset </document-type> of all MR images for the image analysis project. <category> The optional <category> element identifies the document as belonging to one of the American Board of Radiology categories: • Musculoskeletal • Pulmonary • Cardiovascular • Gastrointestinal • Genitourinary • Neuro • Vascular and Interventional • Nuclear • Ultrasound • Pediatric • Breast When searching for teaching file documents, a user may request that query results be displayed as unknowns. In this case, if the document does not contain an <alternative-title> element, the RSNA MIRC Storage Service generates a title in the form "Unknown - <category>". <level> The optional <level> element indicates the degree of difficulty of the document. It is intended to allow teaching files to be graded for difficulty, allowing students to search for teaching files corresponding to their level. The level element contains one of: • primary • intermediate • advanced The default value of the visible attribute is yes. The following even more unlikely example code fragment could be imagined:

This document is an <level visible="yes> intermediate </level> <document-type visible="yes"> radiologic teaching file </document-type> for the neuroscience curriculum. <lexicon> The optional <lexicon> element identifies the name of the lexicon used in the document. The default value of the visible attribute is yes. <access> The optional <access> element indicates whether a document is accessible: • public accessable by anyone • restricted accessible only by certain authenticated users • owner accessible only by the owner of the document The default value of the visible attribute is yes. This element is automatically generated by the RSNA MIRC site software from the contents of the <authorization> element. <authorization> The optional <authorization> element controls access to the document for various purposes. 4.4.1.2 <owner> The optional <owner> element defines the owner of the document. The value of the element is specific to the server hosting the document. The RSNA MIRC software uses the element to contain a comma or whitespace delimited list of usernames to be granted all privileges (read, update, export, delete). 4.4.1.3 <read> The optional <read> element defines the individuals or groups who are authorized to view the the document. The value of the element is specific to the server hosting the document. The RSNA MIRC software uses the element to contain a list of roles that are authorized to read the document. Individual users can be granted the read privilege by including their usernames in the list enclosed in square brackets as in this example:

<read>resident staff [drjones] [drjohnson] technologist</read> If the <read> element is missing, or if the value of the element contains “*”, all users are granted read access. 4.4.1.4 <update> The optional <update> element defines the individuals or groups who are authorized to modify the document. The value of the element is specific to the server hosting the document. The RSNA MIRC software uses the element to contain a list of roles that are authorized to access the document through the author service and store modifications back on the server. Individual users can be granted the update privilege by including their usernames in the list enclosed in square brackets as in the example above. If the <update> element is missing, updates are not authorized. If the value of the element contains “*”, all users are granted update privileges. 4.4.1.5 <export> The optional <export> element defines the individuals or groups who are authorized to export the document from the server to their browser in the source format. The value of the element is specific to the server hosting the document. The RSNA MIRC software uses the element to contain a list of roles that are authorized to receive the standard MIRC zip file containing the document’x XML file and all its local references. Individual users can be granted the export privilege by including their usernames in the list enclosed in square brackets as in the example above. If the <export> element is missing, or if the value of the element contains “*”, all users are granted export privileges. <peer-review > The optional <peer-review> element contains information about the peer-review status of the document. If the <peer-review> element is missing, the document is assumed not to have been peer-reviewed. If the element is present, it must contain child elements identifying the reviewing authority and the status of the peer-review. The default value of the visible attribute is yes. If the <peer-review> element is displayed, all its children are displayed. 4.4.1.6 <approval-date> The <approval-date> element represents the date on which the document was approved by the reviewing authority. The date must be coded in accordance with ISO 8601 (e.g., yyyy-mm-dd). 4.4.1.7 <expiration-date> The optional <expiration-date> element represents the date on which the reviewing authority's approval of the document will expire. The date must be coded in accordance with ISO 8601 (e.g., yyyy-mm-dd). 4.4.1.8 <reviewing-authority> The <reviewing-authority> element contains the name of the institution or organization responsible for providing the independent peer review before publication. 4.4.1.9 <reviewer > The optional <reviewer> element contains the name of the reviewer. <language> The optional <language> element specifies the language in which the document is written. The <language> element has a required code attribute specifying the ISO 639:1988(E) two-letter code for the language, as defined as in http://ftp.ics.uci.edu/pub/ietf/http/related/iso639.txt. The default value of the visible attribute is yes. The following code fragment

<language code="en">English</language> generates the word "English". The RSNA MIRC software does not enforce the correspondence between the value of the code attribute and the value of the element. Query searches on language (when they are implemented in the MIRCquery schema) will use the value of the code attribute, so the following fragment will possibly produce unexpected results:

<language code="en">French</language> <creator> The optional <creator> element identifies the application program that was used to create the document. The default value of the visible attribute is yes. <document-id> The optional <document-id> element is intended to provide a place to store a unique identifier for the document. This element is not used by the RSNA MIRC software. The default value of the visible attribute is yes. <publication-date> The optional <publication-date> element contains the date associated with the document, coded in accordance with ISO 8601 (e.g., yyyy-mm-dd). The default value of the visible attribute is yes. <revision-history> The optional <revision-history> element encapsulates a set of <revision> elements, one for each revision of the document. The default value of the visible attribute is yes. If the <revision-history> element is displayed, all its children are displayed. 4.4.1.10 <revision> The optional <revision> element encapsulates a set of elements that define the author of the revision, the date, and a description of the revision. When present, it must contain the child elements <revision-author>, <revision-date>, and <revision-description>. 4.4.1.10.1 <revision-author> The <revision-author> element contains the name of the person who authored or revised the document. 4.4.1.10.2 <revision-date> The <revision-date> element contains the release date of the revision. The date must be coded in accordance with ISO 8601 (e.g., yyyy-mm-dd). 4.4.1.10.3 <revision-description> The <revision-description> element contains a description of the changes made in the revision. <rights> The optional <rights> element can contain any text describing the rights held to the document. HTML may be used to format the presentation of the rights text. The default value of the visible attribute is yes. When the <rights> element is not contained within a <section> element, the RSNA MIRC software automatically displays the contents of the <rights> element at the end of a MIRCdocument. This is the only instance where a document description element is displayed when it is not contained within a document structure element. 4.5 Template Elements The elements described in this section are not formally part of the MIRCdocument schema used to identify the meaning of data in a document. They are instead used to control the generation and updating of MIRCdocuments by the clinical trial service in the RSNA MIRC software. <text> The <text> element is an encapsulating element whose contents are rendered as if they were part of the element’s parent element. Its function has been overtaken by the development of the T25 version of the author service. It merely instructs the author service to provide a block for editing. <text-caption> The <text-caption> element instructs the author service to provide a block for editing. It is used to embed a centered caption between images in a <section> element. The <text-caption> element has an optional display attribute with possible values always and normal. The default is normal. The <text-caption> element also has an optional jump-buttons attribute with possible values yes and no. The default is no. The <text-caption> element also has an optional show-button attribute with possible values yes and no. The default is no. The rendering of the <text-caption> element depends on its contents and on the values of the display, jump-buttons and show-button attributes: • If the <text-caption> element contains only whitespace text, the entire element is ignored when the MIRCdocument is rendered unless the display attribute is present with the value “always”, in which case the element is always rendered. • If the <text-caption> element contains any non-whitespace text, the text contents are displayed; otherwise, the text contents of the element is not rendered. • If the jump-buttons attribute has the value yes, the rendering software inserts two HTML buttons with the values “<<<” and “>>>”. The buttons allow the user to jump up or down to the previous or next caption. • If the the show-button attribute has the value yes and the text content of the caption is non-whitespace, then the text content of the caption is initially hidden when the document is rendered and an HTML button with the value “Show Caption” is inserted between the “<<<” and “>>>” buttons, allowing the user to reveal the caption after examining the images. <GxxxxEyyyy> DICOM Elements

DICOM elements in a template instruct the clinical trial service to insert the values of elements from the header of a DICOM object into a MIRCdocument. DICOM elements are of the form <GxxxxEyyyy/>. The elements have no child elements or text values. The group (G) and element (E) identifiers (xxxx and yyyy) are 4-place hexadecimal numbers. Upper case and lower case may be mixed anywhere within the element name. The format of the content inserted into a MIRCdocument for a specific element depends on whether the DICOM element is found within an HTML

element. The operation of the MIRCdocument generator is described in the Clinical Trial Service section of the MIRC Site Software Release installation and configuration document. <insert-kin> The <insert-kin> element contains text and other template elements to instruct the MIRCdocument generator to insert DICOM elements from a DICOM Key Image Note into a MIRCdocument. <insert-note> The <insert-note> element allows a user to insert a note into a document, with logging of the authenticated username and the date and time. <insert-image> The <insert-image> element instructs the clinical trial service or the author service to insert a reference to an image. The creation and insertion of images into a MIRCdocument is explained in the separate document on creating templates, available on the RSNA MIRC site. The <insert-image> element appears within a <section> element. The <insert image> element supports the width attribute, which specifies the maximum width of the JPEG image to be created. The default value of the width attribute is 700. The <insert image> element also supports the optional caption attribute, which specifies whether a <text-caption> element is to be generated after the image reference. The value of the caption attribute must be numeric. The <insert image> element also supports the optional jump-buttons attribute, which indicates whether a <text-caption> element is to be generated with a jump-buttons attribute. The possible values of the next-button attribute are yes and no. The <insert image> element also supports the optional show-button attribute, which indicates whether a <text-caption> element is to be generated with a show-button attribute. The possible values of the next-button attribute are yes and no. The <insert-image> element has no child elements or text value. <insert-megasave> The <insert-megasave> element instructs the clinical trial service or the author service to insert a reference to a megasave image group. The creation and insertion of images into a MIRCdocument is explained in the separate document on creating templates, available on the RSNA MIRC site. The <insert-megasave> element appears within an <image-section> element. The <insert megasave> element supports the width attribute, which specifies the width of the primary JPEG image to be created for initial display of the image. The default value of the width attribute is 700. The <insert-megasave> element has no child elements or text value. <insert-dataset> The <insert dataset> element instructs the clinical trial service to create a folder hierarchy within the document’s directory and store a copy of a DICOM image within it. The <insert-dataset> element appears as a first-generation child of the <MIRCdocument> root element. The <insert dataset> element supports the phi attribute, which specifies whether the stored DICOM instance is to contain protected healthcare information. The possible values of the phi attribute are yes and no. The <insert dataset phi=”yes”/> element creates a folder named phi. Instances are stored unmodified in subdirectories named for the Series Description (if present), the Series Number (if present), or the Series Instance UID. The <insert dataset phi=”no”/> element creates a folder named no-phi. Instances are first de-identified using the storage service’s anonymization rules and then stored in subdirectories named as described above. When MIRCdocuments containing <insert dataset> elements are displayed, links are provided allowing for the export of a zip file containing the requested dataset. <metadata-refs> The <metadata-refs> element instructs the clinical trial service to insert a reference to a metadata file. The <metadata-refs> element may appear anywhere within a <section> element. It is rendered by the RSNA MIRC software as a table, with the values of the <type> elements serving as links to the files. The RSNA MIRC software ignores the visible attribute of the <metadata-refs> element and all its children. 4.5.1.1 <metadata> The <metadata> element identifies a reference to a single data file. It has one required attribute, href, which provides the URL of the data file. There are three child elements. 4.5.1.1.1 <type> The <type> element identifies the type of the metadata file. The clinical trial service automatically parses received files and fills this element with the class name of the file. The clinical trial service defines four classes: • DicomObject: a DICOM file (image, KOS, or SR) • XmlObject: an XML file of any kind • ZipObject: a zip file with any contents • FileObject: any file not meeting the criteria above. 4.5.1.1.2 <date> The <date> element identifies the date associated with the metadata file. The clinical trial service attempts to get the date from the file, and if it fails, uses the last modified date of the file (typically the date the file was received by the clinical trial service). 4.5.1.1.3 <desc> The <desc> element describes the metadata file. The clinical trial service attempts to get the description from the file, and if it fails, inserts an empty element.