Sunday, June 22, 2014

There Was A Time When Doctors Were Doctors

By James Ong, M.D., via

There was a time when doctors were doctors. There was a time when young men and women sacrificed the best years of their youth, learning to treat patients and conquer diseases, not to become typists, paper pushers, data-entry clerks, or to have hospitals, insurance companies, and the federal government dictate to us how to practice medicine.

There was a time when doctors were trusted. There was a time when we were not guilty until proven otherwise, as viewed by blood-thirsty bounty hunters like the wild dogs of the recovery audit contractor (RAC) unleashed by our ruthless federal government.

There was a time when doctor’s orders were meant to be orders. There was a time when our orders were not subject to endless scrutiny and nonsensical denials by HMOs, pharmacists, hospital formularies, insurance companies, and the federal government.

There was a time when doctor’s opinions were valued and recommendations were followed. There was a time when we were not routinely challenged by our patients, their families, their neighbors, hospital case managers, hospital administrators, medical officers of HMOs, or some random doctors on the other end of the phone 3,000 miles away.

There was a time when doctor’s progress note held useful information. There was a time when our writing contained constructive and consequential discussions on patient’s medical conditions, not a mere memo to be attached to the chart and artificially beefed up with worthless numbers, reports, graphs, and other meaningless rubbish created in anticipation of Medicare audit.

There was a time when doctor’s consultation note was a work of literary art — succinctly crafted and beautifully articulated to efficiently describe the patients and their diseases, and to effectively convey to the reader the well thought-through recommendations of its author.

There was a time when the reader of a medical chart did not have to scroll through 10 pages of repetitious, auto-filled, and computer-generated garbage mandated by the feds, the hospitals, and Joint Commission (JCAHO), only to get to an anemic, malnourished, and anticlimactic — albeit the most important — final section of “discussion and recommendation.”

There was a time when doctors actually wrote orders. There was a time when we did not have to go through 10 steps and 22 keystrokes on a hospital computer just to place a simple order like NPO, which would have otherwise taken 2 seconds with a pen.

There was a time when doctors actually saw patients. There was a time when we spent more time with our patients than with our computers — more time on listening to them than on training Dragon Dictation, typing notes, keeping up with meaningful use, writing rebuttals to RAC, drafting appeals to PPOs, filling out forms, updating problem lists, and reconciling medications on hospital EHR.

There was a time when doctors were welcomed by the hospitals and the communities they served. There was a time when hospitals assigned more parking spaces to doctors than to their own administrators. There was a time when there were no padlocks on the refrigerator in the doctor’s lounge.

There was a time when doctors actually utilized their brains at work. There was a time when practicing medicine was not just about completing forms, checking boxes, navigating pathways, meeting core measures, and predicting — before patients actually arrive at the hospital — whether they would be inpatient or outpatient according to Medicare rules.

There was a time when doctors spent more time thinking about patient care than pushing papers. There was a time when we did not have to sign more documents for a simple outpatient procedure than what is required on a home mortgage application.

There was a time when HMO was still a three-letter word. There was a time when JCAHO was still a five-letter word. There was a time when Obamacare was not a four-letter word.

There was a time when private health insurance was considered good insurance. There was a time when the acronym PPO was not used for blasphemy.

There was a time when patients actually paid their bills. There was a time when the words co-pay, deductible, and coinsurance meant what they truly meant, not some random numbers subject to inventive negotiation and crafty blackmail tactics by some patients.

There was a time when doctors were judged by their credentials and by their professional peers. There was a time when our medical school diploma meant more than the reviews on certain online social media intended for rating restaurants, plumbers, and prostitutes.

There was a time when young men and women went to medical school because having “M.D.” behind our names was the most honorable and respectable thing to do. There was a time when professional gratification for physicians was not an oxymoron.

There was a time when doctors were doctors, physicians, and surgeons. There was a time when we were not referred to as contractors, providers, or whatever other denigrating and demoralizing monikers insurance and government bodies choose to confer on all of us who have dedicated our lives to this once prestigious and highly respected profession.

There was a time when doctors were real doctors.

James Ong is a cardiologist.

Saturday, June 14, 2014

Orphan Radiopharmaceuticals And Other Libations

It has been a few years since I've made it to the Society of Nuclear Medicine annual meeting, so long actually that the Society has since changed its name, and is now called the Society of Nuclear Medicine and Molecular Imaging, I personally think this was prompted by the unfortunate amusement among the puerile (like yours truly) related to the original title's initials. SNMMI just doesn't have the same ring to it, but they don't ask me about these things. 

The exhibit hall is about 1/50th the size of the massive trade show at the RSNA, but most of the big players have a presence.

Herr Großkopf, the huge animated head, graced the Siemens booth, touting Amyvid. My new Intevo SPECT/CT was perpetually scanning a rather eerie half of a patient, also created by the geniuses of Legacy Effects. (By the way, if you want to see more on the production of Herr Großkopf, try this YouTube video:

It is a humbling experience to sit in the educational sessions presented by those quite a bit smarter than I am, and realize just how much I don't know. But somehow, we average rads/NM physicians do manage to muddle through. We can't all be the best of the best, but I'm grateful to those who are the best for their willingness to share their expertise with the rest of us.

I'm often asked how Nuclear Medicine differs from Radiology. The simple answer is that with the latter, we somehow externally energize the body, or pass energy through it; an X-ray is taken by passing the beam of radiation through the body and detecting what is blocked and what is transmitted. With MRI we spin your molecules, and with Ultrasound, we bounce sound waves off your tissue interfaces. You get the idea. 

Nuclear Medicine is different. Here, we inject some radioactive stuff (in the case of PET, we use honest-to-God antimatter) into your body, or make you drink or eat it, breathe it in, or in some cases instill it into places God did not intend us to instill things. We then use very sensitive detectors to see where the stuff went, how long it takes to go away, and so on. In the proper doses, some of the agents can be used for therapy as well. The stuff we give you is called colloquially a radiopharmaceutical, basically a drug with a radioactive atom attached to it, or in the case of radioiodine, the radioactive isotope of the element itself, delivered as sodium iodide, is given to scan, treat, or even ablate the thyroid, which gobbles up iodine, radioactive or not. 

The bottle of wine above isn't really a radiopharmaceutical, but I found it amusing as the term MUGA refers to a Nuclear Medicine heart scan, generically known as a Multiple Gated Acquisition. There were dozens and dozens of new scanning agents being discussed at this meeting, and at least some of them will be approved eventually for general use. Hopefully. That process takes a long, long time, and I'm told new drugs require a $4 BILLION investment each. Given this, you would think that a successful product would be celebrated and propagated.  You would be wrong.

One of the big areas of research in diagnosis and therapy involves labelled monoclonal antibodies, basically a radioactive atom attached to a natural molecule that targets some particular tissue. These so-called magic bullets have been somewhat disappointing overall, not quite magic after all. But some have worked, and in particular, a couple of these compounds, Zevalin and Bexxar, directed at treatments of some forms of lymphoma have really performed quite well. The antibody seeks out the tumor (actually a particular protein on the tumor surface) and the radioactive atom blasts away. For once, the term "cure" can be tossed around for patients who had failed other regimens. Zevalin uses yttrium-90, while Bexxar uses iodine-131 as its nuclear bomb, so to speak. 

I've administered both of these therapies. They are horrendously expensive, with pricetag of the pharmaceutical alone exceeding $26,000. Medicare paid us perhaps $15-17k, so there is a potential loss on every dose which much be made up by charging those with other coverage upwards of $100,000.  I've had more experience with Bexxar, and that experience has been good. We've achieved a number of complete remissions and we had no deaths that could be attributed directly to Bexxar. Our one Zevalin patient did not survive, but that is most likely due to the fact that this therapy wasn't applied until that particular patient was at death's door. Another shop in town did quite a few of these therapies, ending several years ago; some of the patients are now coming back with white cell depletion, a known complication when you are placing radioactive stuff right in the marrow. It's a problem, but one that they wouldn't have had without this therapy because they would most likely be dead.

One of the lectures this week at SNMMI touted the virtues of Bexxar, noting that as compared to Zevalin, its administration offers at least an attempt at radiation dosimetry. We give tiny doses to see where it goes and how fast it is eliminated, and base the final dose on that data. It's not complete, but it takes an army of physicists to do better, and out in the field, this is pretty advanced stuff.

Sadly, Bexxar, a very good treatment, is being pulled off the market. Why? Because the $100,000 per dose radiopharmaceutical couldn't turn a profit.

Jamie Reno, a Bexxar patient himself, writing in The International Business Times, bemoans the loss:
The discontinuation of Bexxar is an extreme example of a lifesaving drug being eliminated due to its relatively low profitability. In most cases, when a pharmaceutical company concludes that a niche drug is not making enough money, the product is sold to another, smaller company which continues to make it available. But continued availability is left to the discretion of the company (or companies) that owns the rights to the drug, which is how pharmaceutical companies can withhold potentially lifesaving experimental drugs that have not yet been approved by the FDA -- often, due to concerns that a potential problem resulting from such use could jeopardize the drug's ultimate approval.
Luke Timmerman, on, traces Bexxar's history:
Bexxar, developed in the late ‘90s by South San Francisco-based Coulter Pharmaceutical and acquired in 2000 by Seattle-based Corixa, had a lot going for it. The drug was aimed at a protein marker called CD20, which was already a validated molecular target for cancer, based on the success a couple years earlier of a so-called “naked” antibody from Genentech and Idec Pharmaceuticals, rituximab (Rituxan). Corixa had a well-respected CEO in Steve Gillis who attracted scientific talent, and raised lots of cash. It had a Big Pharma partner in Glaxo to help it manufacture and market the drug to the fullest.


Corixa, unable to turn Bexxar into a profit center, ended up being acquired by GlaxoSmithKline in 2005.
Without boring you with reams of positive data, suffice it to say that Bexxar worked, and worked well. There was talk of using it as a secondary or even a primary therapeutic agent, rather than a last-ditch hail-Mary for those who had failed all other regimens. But it was not to be. Timmerman continues:
But there was a catch. Oncologists who saw these non-Hodgkin’s lymphoma patients could prescribe rituximab at an infusion center, along with chemotherapy. These doctors made money on every patient that went through their infusion center. Prescribing Bexxar meant they’d have to forgo that revenue stream, and refer the patient to a nuclear medicine pharmacy or radiation oncologist who could handle Bexxar or Zevalin.

“There were complicated logistics with having oncologists refer to another part of the healthcare system they normally didn’t interact with,” Rivera says. “We couldn’t get them to change their habits. The doctor would usually say ‘Oh, I’ll give the patient another course of R-CHOP’ (Rituxan plus a specific chemo regimen) instead.”

Younes, the chair of lymphoma at Memorial Sloan-Kettering, has heard the story about oncologists rejecting Bexxar because they didn’t want to refer patients to medical centers that might be seen as competitors. He says that point is “exaggerated” and notes that oncologists refer patients to other specialists all the time. He points to other problems with Bexxar’s commercialization. “It’s almost a comedy of errors,” he says.
Are we to believe that the very people who were supposed to be saving patients walked away from a cure over profit? I'm trying hard not to... There were other factors, though:
There was a muddled clinical trial strategy, Younes said. Multiple trials were opened up to expand Bexxar usage, which may have been well-intended, but the plan ended up confusing physicians about where the drug was most useful, Younes said. A lot of clinical trials were sponsored, making it possible for many patients who might have paid to get the drug to instead get it for free. Then at one point, Glaxo abruptly shut down all the trials, Younes said.

“They ended up pissing off a lot of people,” he said.

There were headaches in manufacturing an antibody that was linked to radiation. The radioactive piece of the drug came from a supplier in Canada, and the occasional snowstorm would throw the whole supply chain out of whack, causing patients infusions to be delayed, Rivera said. That was a big inconvenience for some patients who sometimes had to drive hours for a scheduled infusion at a big academic medical center, Rivera said.
So what constitutes bad sales? Reno gives us the numbers:
While Bexxar saved this writer’s life in a clinical trial in 1999 with virtually no side effects and has saved many other lives, sales of the drug did not meet GSK’s expectation. Catalina Loveman, GSK’s director of U.S. external communications, oncology, told IBTimes that total sales of Bexxar in 2012 in the U.S. and Canada were approximately $1 million; for comparison, the blockbuster drug Viagra earned Pfizer a reported $2.05 billion in sales in 2012.
Everything is relative.  I guess it didn't occur to GSK that those who survive lymphoma might eventually become Viagra customers. Oh, well. I guess a few thousand lives pale in comparison to a few million...well, need I say it?

Zevalin will remain on the market because its owner has a different outlook:
Like Bexxar, Zevalin has also struggled in the marketplace. In the third quarter 2013, Zevalin’s profits were $8 million. But unlike GSK, Spectrum Pharmaceuticals, makers of Zevalin, is committed to keeping this drug on the market.

“What is happening with Bexxar is virtually unprecedented,” said Spectrum’s chief operating officer, Ken Keller, who came to Spectrum a year and a half ago from California-based Amgen, the world's largest independent biotech company. “I do not know of a single example of a drug company that has walked away from a drug that is this effective. Typically, when a company gives up on a treatment that works this well, they will a find a smaller company to sell it.”

Keller acknowledged that neither Bexxar nor Zevalin has been able to break through and become the blockbuster drugs that he says they both should be.

“I’ll be honest: We don’t gain a lot of value from Zevalin,” he said. “We have the data that shows how well it works, but it has still not caught on with many doctors. However, Spectrum will continue to manufacture Zevalin because our CEO [Raj Shrotriya] is on a mission to make RIT the standard of care for lymphoma in the U.S.. If this were only about finances, it could lead to different decision. But this treatment saves lives, and we believe we have an obligation to cancer patients. They deserve to have access to it.”
Why was Bexxar quashed? Only GSK really knows for sure. Maybe their Board of Directors all own stock in Spectrum. Information from a friend of a friend of a friend of a cousin of a sister of a guy who knows something indicates that the move was deliberate and based purely on profit or the lack thereof. Maybe someone looked into the zillion pages of ObamaCare as currently morphed and decided GSK would NEVER see any profit, let a break-even point, on Bexxar.

It occurs to me that this whole episode (put very nicely) represents a complete disservice to our patients. We have in Bexxar a VERY good treatment, a lifesaving treatment, and it was scuttled because oncologists wouldn't use it, and they wouldn't use it because they couldn't make money on it, so neither could GSK. Does anyone else find this sickening?

But I'm prompted to think outside the box.

I've become mildly addicted to Kickstarter and Indiegogo, crowd-funding sites that promote anything from researching burritos to sending people on a one-way trip to Mars. (I've personally helped fund a couple of smart-watches that haven't come to fruition and probably won't, and a few other frivolous items.)

I don't know IF GSK would consider selling the rights to Bexxar, and if they would, I don't know how much they might want for something they buried in their corporate backyard. If the price was reasonable, I would buy the rights myself and find a way to get Bexxar back on the market. Assuming the price tag is a bit above my weekly allowance, the next step might be a Kickstarter campaign for interested parties to pick up the tab. This would include not only people like me who want Bexxar to be available, in my case as a physician, but also patients and their families as well. It would, of course, be critical to attract folks who have connections in the pharmaceutical industry who could actually put Bexxar back into production.

To my knowledge, this has not happened before. We've all heard of orphan drugs, but I can't think of any/many that were actually completely suppressed in this manner. Nor have I ever heard of a consortium of the type I propose above rescuing a valid treatment from oblivion. But this needs to be done, and I challenge you to join me to do it.

GSK? Docs? Patients? Family members? Are you listening?

Sunday, May 04, 2014

Beauty and the Asp

Dear Readers:  The following story is fictional. Any resemblance to anyone real, living, dead, or otherwise, is purely in the warped mind of the beholder.

Once upon a time, a phrase that amuses physicists no end, there was a King and Queen who lived in a modest but nicely-furnished castle in the Land of Iodine. They were what one might call enlightened. They ruled their little nation with as much kindness and wisdom as they could muster, and their subjects prospered.

The royal couple had a beautiful little daughter, Princess Xela, upon whom they doted and fussed, and due to their ministrations, or perhaps in spite of them, she grew to be a beautiful and wise woman, beloved by everyone she met. Xela's love of animals was known throughout the kingdom, and it was clear to all that she would one day become a world renowned veterinarian. And so it was.

Xela attended the finest veterinary schools in the land, and studied very, very hard. After all, there is much knowledge to be acquired to care for the multitude of God's creatures. She learnt it all, or tried to, anyway, and was celebrated by her mentors as one of the finest students they had seen in years. Of course, the very proud King and Queen made it possible for her to study in relative luxury. Her little hut on the grounds of the school wasn't particularly posh, but it was hers. This did make Xela somewhat uncomfortable, as many of her classmates were living in hovels, and selling their hair and other unmentionable body-parts to the enchantresses at neighboring schools of magic, just to eat. Princess Xela told no one of her heritage, so as not to make them jealous. If asked how she could live so well and keep her hair, she would mumble something about being lucky at rolling the bones, and change the subject.

Princess Xela of course did quite well in all her subjects. But it was during the courses of herpetology that she first encountered the Asp. The legless being saw in Xela, well, something. We of warm-blood and calm disposition probably will never understand just what it is the predator sees in the prey. The Asp wanted Xela for his own nefarious purposes. (Such has it been since our first female ancestor Eve, who was also the object of desire of a serpent, one who offered her knowledge in return for the fall of Mankind from Paradise.) By instinct, Xela shunned the Asp, for he was scaly, weird-looking, and poisonous, toxic to mankind. But the Asp, being cold-hearted but incredibly cunning, continued his gentle but relentless pursuit. He brought offerings, sacrifices he managed to catch in his fangs, and spoke endlessly of his knowledge of all things herpetic, and even pertaining to the treatment of all animals, all the while telling Princess Xela how wonderful she smelt, and how much he would love to be her companion. And gradually, ever-so-slowly, she began to think that perhaps the Asp wasn't so bad after all. Ultimately, she took him home with her, and established a place in her bed for him, so she could warm him at night; otherwise the poor Asp might freeze to death, being cold-blooded and all.

This rather unusual situation went on for quite a while, months, years. The King and Queen were of course beside themselves. Princess Xela had let them play with the Asp once or twice, not telling them just what species he was, but the monarchs were not stupid, and they rather quickly realized just what they were dealing with. Xela had grown to love the Asp, and that's all that mattered to her. She wanted to take it everywhere with here. She was taken aback when her friends and the other townspeople would shrink away in horror and fright when she drew the Asp from her pack, and she soon realized the wisdom of leaving him at home when she went to market or out to visit. But still, she longed for the day when all would accept her love for the Asp, and accept him for the wonderful being only she could see.

Xela had a brief flash of insight toward the end of her schooling. Her toxicology class had a long unit about the reptilian poisons, and she realized, ever-so-briefly, that the Asp was dangerous to her. She ran home to the palace, and, sobbing, regaled the King and Queen for hours about how close she had come to tragedy, having on multiple occasions stroked the Asp on his head while he bared his fangs in delight. She swore to put him back in his cage and never pick him up again.

But alas, Princess Xela had a kind heart, and even after her oath, she happened to pass by the Herpetorie one day, and was again drawn to the call of the Asp. And she succumbed. She tried to hide her recidivism from the King and Queen, but they happened to see the Asp peek his head out of her pack one day, and the situation was clear.

Things went downhill from there. The Princess was a modern girl, not afraid in the least of the King and Queen, and staunchly declared that she loved her "Aspie" as she now called the Asp, that she would never return him to his cage, certainly not on the orders of her old fuddy-duddy parents. She declared that she, the preeminent veterinarian-to-be, was wrong about the Asp after all, that he was really a completely different, non-poisonous species. The King and Queen were, of course, devastated, seeing imminent danger for their beloved daughter, but unable to convince her of this. Ultimately, the King even threatened to throw himself on his sword, which prompted Xela to embrace the Asp even tighter. Of course, the Asp understood none of this with his brilliant but limited reptilian mind, but he did realize that Xela was drawn to him by some strange bond, and that's all he really cared about.

The King and Queen went about the business of running the kingdom, but their broken hearts were no longer in the task, and the courtiers and regents could certainly tell that something was wrong, although they did not know just what it could be. Kings don't have the luxury, generally, of taking a prolonged period to mourn such things. All the while, the King was dealing with several crises in the kingdom. There was a failure of magic throughout the land one one occasion, wherein things that were etched in stone suddenly were not after all, and vice-versa as well. There was a drought which affected the bremsstrahlung crop, and the wealthier among the members of the court were terrified that they could no longer maintain their castles properly, not to mention their Albion-crafted chariots.

I wish I could tell you that, as in other fairy tales, all lived happily ever after. Sadly, I cannot. All I can say is that the King and Queen are doing their best to plod along through the remainder of their lives, expecting daily the messenger bearing the news that the Asp has finally done what Asps do, and poisoned their beloved Princess Xela.

The End

Thursday, April 17, 2014

Accelarad Nuance Makes It Official

Dear Accelarad customer,You should have received an email from me on Monday of this week, when I provided our customers an early insight into the announcement that Accelarad is now a part of Nuance Communications. At this time, I wanted to provide you some additional information and invite you to learn more.

You can read the full press release here: (Nuance Unveils PowerShare – April 17,2014)As discussed, this new union brings together our cloud-based medical image sharing technology and Nuance’s PowerScribe radiology reporting and communication platform. The partnership will give you, our valued customer, access to Nuance’s expansive healthcare technology and professional services, while continuing to provide you with the proven software and solid relationships you have come to expect from Accelarad. With this partnership, Accelarad’s SeeMyRadiology solution has been rebranded to align with the Nuance diagnostic brand, and will be part of the Nuance PowerShare Network. To learn more about PowerShare | Image Sharing, sign up to join one of our webinars.

Most importantly, know that the products and people you have come to rely on will not change. Accelarad's leadership team and valued employees will be deeply involved in creating a smooth transition for our customers, and our focus remains on making sure you continue to receive the excellent service you deserve.

Thank you again for your support and confidence in us. We will keep you informed about any incremental changes along the way and are open to your feedback.


Willie Tillery, CEO, Accelarad 

Rodney Hawkins, General Manager, Diagnostic Solutions, Nuance
For your viewing pleasure, here is the press release:

Nuance PowerShare Network Unveiled for Cloud-Based Medical Imaging and Report Exchange
Industry’s Largest Medical Imaging Network Helps Providers and Patients Coordinate Care and Share Information Across Distances and Disparate Healthcare Systems

BURLINGTON, Mass., – April 17, 2014 – Nuance Communications, Inc. (NASDAQ: NUAN) announced today the immediate availability of Nuance PowerShare™ Network, the industry’s largest cloud-based network for securely connecting physicians, patients, government agencies, specialty medical societies and others to share essential medical images and reports as simply as people exchange information using social networks. Nuance PowerShare Network promotes informed and connected physicians and patients who can instantly view, share and collaborate while addressing patients’ healthcare needs.

“Organizations are being tasked to communicate efficiently both in and out of their networks to provide clinical insight to physicians beyond one person or office to a much broader team involved in the continuum of care,” said Keith Dreyer, DO, PhD, FACR, vice chairman of radiology at Massachusetts General Hospital and Chair of the American College of Radiology (ACR) IT and Informatics Committee. “Nuance PowerShare Network addresses the information sharing challenge physicians face today with a network that supports things we’ve dreamed of doing for years,” he adds.

Fully Connected Patients & Providers
Nuance PowerShare Network is already used by more than 1,900 provider organizations for sharing images via the cloud using open standards. Made possible through the acquisition of Accelarad, this medical imaging exchange eliminates the costly and insecure process of managing images on CDs and removes silos of information in healthcare that inhibit providers from optimizing the efficiency and quality of care they provide. Anyone can join the network regardless of IT systems in place to instantly view and manage images needed to consult, diagnose or treat patients, enabling clinicians to more seamlessly evaluate and deliver care for patients who transition between facilities or care settings.

Nuance is already used by more than 500,000 clinicians and is a critical component within the radiology workflow and a trusted partner for 1,600+ provider organizations that rely on Nuance PowerScribe for radiology reporting and communications. Healthcare organizations that use Nuance PowerScribe, a group that produces more that 50 percent of all radiology reports in the U.S., can immediately leverage their existing investment and begin sharing radiology reports along with images, such as X-rays, MRIs, CT scans, EKGs, wound care images, dermatology images or any other type of image. This simplifies secure health information exchange between multiple providers, patients and disparate systems without costly and time-consuming interfaces, CD production or the need to install additional third-party systems.

“The challenge of sharing images with interpretive reports is something we’ve heard about consistently from our customers and EHR partners, and we know Nuance PowerShare Network will overcome this major obstacle, helping physicians treat patients more efficiently and effectively,” said Peter Durlach, senior vice president of marketing and strategy, Nuance Communications. “This nationwide network, one that is fully integrated into the EHR workflow and already connected to approximately half of all clinicians producing diagnostic imaging information, is a ground-breaking solution that delivers immediate benefits at an unprecedented scale to our healthcare system.”

“Integrated image and report sharing helps us deliver quality care and drive down costs especially when patients transfer from one facility to another. Whether at their desktop or on their mobile device, our physicians can see the study that was done along with the interpretive report, which provides the information they need to treat the patient and avoid duplicate testing,” says Deborah Gash, vice president and CIO, Saint. Luke’s Health System in Kansas City. “By integrating this with our EHR, PowerShare will enable physicians to manage inbound imaging through one point of access and login. Physicians in our 11 hospitals and 100-mile radius referral network see this cutting-edge technology as a way to deliver the highest level of patient care,” she adds.

To learn more about the PowerShare Network and the new image sharing solution, visit to join one of our webinars. Connect with Nuance on social media through the healthcare blog, What’s next, as well as Twitter and Facebook.
Definitely an interesting constellation of services! I wonder where this might lead. Ironically, Rodney is also an old friend from the AMICAS days...

Saturday, April 12, 2014

Film at Eleven...But I Need It NOW!!!
A Bigger Share Of Image Sharing

A long time ago (November, 2005 to be exact), sitting in a radiology department far, far away from most of you, I bemoaned the problem of the "Portable Patient" in one of my early articles:
Of the thousand daily frustrations I experience as a radiologist, perhaps the most painful is that of the "portable patient." You see, patients migrate from hospital to hospital, from clinic to clinic, and from office to office. They may be searching for a second opinion, a superspecialist, someone who will give them the particular answer they seek (some want to hear good news, some prefer bad news), convenience, drugs, or some combination of the above.

As often as not, they acquire a mountain of imaging studies along the way. When asked why they had a particular study at a particular site, the answer is invariably, "My doctor told me to have it there."

Add to that the dependence on our ERs for emergent (or maybe just impatient care, as I like to call it), and the ER's love of imaging studies. Put them together and you've got a collection of the patient's imaging studies spread across a city or even a state.
I was pretty smart back then, identifying a problem that many folks far wiser than I have been trying to solve since. And last year, I authored a follow-up article:
I've introduced you to a portable patient, and you can see what happened to her because no one knew about the examinations she had already undergone. She was irradiated, magnetized (probably less of a problem), and scared to death (arguably more damaging than radiation) because we have no way to connect the dots of her various studies.

Well, that isn't quite true. We do have ways -- we just aren't using them... Many years ago, when our old PACS needed replacing, I suggested to the IT types that the three hospital systems in our average town in the South combine efforts to create a single citywide PACS to serve all three hospitals and, particularly, all of their patients. I was told by the illustrious chief information officer that we couldn't even think of working with one of the other hospitals because it was "suing us" (which wasn't quite a lie ... they were challenging a certificate of need application). Millions of dollars and patient welfare down the toilet over C-suite egos.

There were and are other approaches. As an alternative to a central repository, connecting one PACS to another isn't that hard. The best way to do this -- and fulfill all HIPAA requirements in the process -- is to use an image-sharing system such as lifeImage (my personal favorite by a mile).

Don't even bother to suggest that CD-ROMs solve anything. They don't. They get lost, they get broken, they don't always load, the patient forgets to bring the disk, or the original imaging site forgets to send it, and darn, they're closed today...

At one of the clinics we staff, the clinicians come at me at least twice a day, every day, with an outside CD. After three years, I finally was able to convince the powers that be to load the damn things into PACS and merge the data with local exams. But the clinicians don't want to bother with waiting for the disks to load -- they want results now. In my opinion, CDs aren't even worthy of being drink coasters, given that huge hole in the middle. (And their older PACS rejects a significant percentage of the disks anyway.)


Here's where I'm going to anger a lot of people, and this is of course why you like to read my rantings. The following is something that needs to be said, however, and I'm going to say it.

Given that ...
  • Not knowing that the patient has had prior studies leads to unnecessary imaging
  • Unnecessary imaging may expose the patient to unnecessary radiation, costs, and anxiety
  • Unnecessary radiation is bad for you, as is anxiety
  • We have ways to share prior studies
... then it stands to reason that today, in the 21st century, shirking our responsibilities to the patient in this aspect of medical imaging is malpractice. Yes, I used the "M" word. But that's exactly what it is. We are not doing what we should -- and what we must -- for patient care. It is high time to apply technology that has been around for a long time to unify patients' records, imaging and otherwise.

We are harming our patients out of ignorance, out of hubris (why would they go to any doctor/hospital/clinic other than me/mine?), and out of greed (I get the revenue if I repeat the study!). This is completely unacceptable...
Forgive the massive regurgitation of the last post, but you must acquire (or reacquire) the mindset of the necessity of image-sharing.

If you wondered if exams were really repeated under the "portable patient" scenario, let me assure you that they are.

A study from western New York showed:
(A)pproximately 90% of duplicate and potentially unnecessary CT scans were ordered by physicians who have little to no usage of the HIE when combining slices of users with less than 500 queries in 18 months. An opportunity therefore exists to reduce the number of duplicate CT scans if the physician is utilizing HEALTHeLINK to look up information and recent test results on their patients prior to ordering more tests. In addition, this also highlights a need to get more physicians participating and using the HIE in a meaningful way as more than 70% of duplicate CT scans were ordered by physicians who did not query HEALTHeLINK.
Another study from the University of Michigan found:

In our sample there were 20,139 repeat CTs (representing 14.7% of those cases with CT in the index visit), 13,060 repeat ultrasounds (20.7% of ultrasound cases), and 29,703 repeat chest x-rays (19.5% of x-ray cases). HIE was associated with reduced probability of repeat ED imaging in all 3 modalities: -8.7 percentage points for CT [95% confidence interval (CI): -14.7, -2.7], -9.1 percentage points for ultrasound (95% CI: -17.2, -1.1), and -13.0 percentage points for chest x-ray (95% CI: -18.3, -7.7), reflecting reductions of 44%-67% relative to sample means.

HIE was associated with reduced repeat imaging in EDs. This study is among the first to find empirical support for this anticipated benefit of HIE.
That's a lot of repeat studies. And a lot of excess radiation. We can wait for the study to be delivered from the outside place, or the outside CD to be loaded ("Film at Eleven") or we can redo the study. None of these choices are optimal. We can all see that.

So...Now that you've gone through the indoctrination, we can proceed.

I've known Hamid Tabatabaie for many years, starting back when he was CEO of AMICAS. (I guess that dates me. Like Mrs. Dalai's grandfather who died at 93 after having outlived 5 of his internists, I've gone through two subsequent AMICAS CEO's and I'm on my second or third Merge CEO. Justin, you'd better hope I get out of this business soon!) Hamid is one of the visionaries behind web-based PACS, of which AMICAS Merge PACS is still one of the best examples. Today, he heads lifeIMAGE, my favorite among the image sharing companies out there.

The story is making the rounds that Nuance, one of my least favorite companies, is diving into this arena, with the purchase of Accelarad. From Hamid's blog (I guess everyone has one now):
I spoke with a friend today who is now the sixth person to have heard rumors about Nuance entering the image sharing market. He thinks it will announce the acquisition of a small Atlanta-based company imminently. I know the target company rather well, think highly of the founders, and I’m happy to see them finally reap some benefit from their 15-year-old startup odyssey. They started out as a small PACS company and then carved out a niche by selling data center based teleradiology PACS, which I think delivers the great majority of its $6M or so annual sales.
This little company is apparently Accelarad. More on them in a moment. Back to Hamid:
We (lifeIMAGE) started out working with innovators and early adopters who believed in our cause. We believe in eliminating duplication of imaging, avoiding delays in care and excessive radiation, and improving quality of care for patients. To realize our goal, we build software that helps make medical images part of a patient’s record and helps physicians access imaging histories conveniently, from any setting. We’ll soon announce our fifth anniversary as a well funded, privately held company, with many remarkable results that make our team very proud...

..(I)mage sharing for serving radiology, with 25,000 or so US radiologists, where Nuance has its major presence, has been around for a long time. Innovations in teleradiology are well past their prime, so, we at lifeIMAGE do not see a disruptive opportunity to innovate in that area. We are focused on the far broader need, which exists among large health systems that need to avoid the cost and problems associated with repeat imaging orders. Their ordering physicians, our end-users, are non-radiology image intensive specialists who need access to patients’ imaging histories in order to reduce the rate of repeat exams. 
The cure for the portable patient indeed.
Recently, I’ve been fascinated with what professor Everett Rogers called “the law of diffusion of innovation.” It basically spells out that there is a point at which an innovation reaches critical mass. “The categories of adopters are: innovators, early adopters, early majority, late majority, and laggards.[1]” The early majority buy into a technology when it’s been well vetted by innovators and early adopters first. Every innovative and disruptive company looks for the sign that its technology has started to be adopted by the “early majority.” Nuance’s entrance into the image sharing market is an indication for me that the market is getting ready for broad adoption, validating what we already see in the lifeIMAGE customer statistics. Professor Rogers suggests that once 16% of the market has signed up for a technology, that’s when the early majority starts to adopt. Current lifeIMAGE customers represent nearly 16% of all US physicians...

lifeIMAGE is the most utilized image sharing network, designed for use by physicians across a wide range of clinical disciplines—neurology, orthopedics, cardiology, oncology, surgery, etc. Our position is unique in that our engine of innovation is fueled by this population of doctors, who encounter patients with outside imaging histories on daily basis. We also help providers with patient engagement strategies and lead the way in providing access to patients who can in turn share their imaging records with providers of their choice. So, indeed new market forces may very well validate the market and expedite adoption of our disruptive and expansive technology, innovation for which is guided by multi-disciplinary specialists, including radiologists....

When I was CEO of AMICAS, our team spent some time studying the concepts around disruptive technology. Its definition in Wikipedia is, “A disruptive innovation is an innovation that helps create a new market and value network, and eventually disrupts an existing market and value network (over a few years or decades), displacing an earlier technology.” That is what our web-based PACS was back in 1999.
To me, being rather more concrete than some, a "disruptive" technology is one that interrupts my workflow, and nothing could fit that definition better than what Nuance is really known for: Speech Recognition, also incorrectly known as Voice Recognition. Here we have a technology that displaces the human transcriptionist, freeing the hospital from the tyranny of employing said human and paying their salary and benefits. It dumps the work of transcribing and editing onto the radiologist with no increase in pay for the effort. And it barely works. A friend who is totally enamored with SR tried to show me how wonderful it functions in his enterprise. I watched him focus his entire attention onto the report screen, which was three monitors away from the radiographic image he was supposed to be interpreting. Yah, this is great and wonderful stuff. Now it does speed things along. My friend claims to be able to read 300 exams in 8 hours with <1% error-rate because of his beloved SR. I'll simply say that it wouldn't work that well in my hands.

I'm digressing, but for a reason. Nuance and the other SR vendors have made inroads into hospitals and other imaging emporiums with their disruptive technology. They ride in on the white horse of decreased turn-around time (TAT) which warms the cockles of the administrative types who live and die by picayune metrics like that. In addition, they convince these folks that it's CHEAPER to have the computer do the job than a cadre of benefit-sucking humans, and that's all they need to say.

I'm sure Nuance wouldn't enter the image-sharing market if they didn't think it would be lucrative. Few in this business (including me) do things for free out of the goodness of their hearts. As Hamid implies, Nuance's entrance to this space validates the concept, and I think validates lifeIMAGE as well, which I maintain does it better than anyone.

Accelarad seems to have the basics down, and Nuance has apparently made the GE-like choice of buying the technology en bloc rather than developing its own. Fine with me. Here's their description:

Our medical imaging solution combines the ease of social networking with the clinical precision and security that medicine demands, making medical image sharing with patients, colleagues and other organizations easier than ever. Accelarad allows you to quickly and securely upload, access, manage and share medical images from any Internet-connected computer, mobile device or via our app. So you have images and reports from any originating institution, physician or system at your fingertips from a single portal, allowing you to focus on what you do best–delivering patient care.

They say all the right things, and I'm sure the product does what it says it does. However, I'm equally sure that lifeIMAGE does it better:


Don't just take my word for it. Look at their website and arrange a demo.

In many ways, Nuance's entry presents an opportunity for lifeIMAGE to get its foot into (or back into) doors that might otherwise be closed. I've tried to become a lifeIMAGE customer. I believe in their system, and I know most of their people, many of whom brought me AMICAS years ago. But I cannot convince those that control the purse strings that image sharing is a critical necessity. They see that lifeIMAGE has a cost associated to it, nominal per patient though it is, which can be eliminated by someone sticking the CD-ROM that came taped to the trauma patient into a workstation. IF it works. IF it came at all. But happily, if there wasn't a CD-ROM to be found, well, gee, we'll just have to rescan the patient and CHARGE for the privilege. In other words, image sharing LOSES them money on both ends. But it is still best for the patient, and I'll stick to my inflammatory statement above: it is malpractice NOT to utilize it.

It may be that with Nuance pushing the concept using the sales force that sold the bean-counters on SR, proper consideration will finally be given to image sharing at places that shunned it before. Then, we can have the real discussion as to which company does it best. I've had many an argument with those who say only the large PACS companies will survive. In the image sharing space, there are no large companies as yet, although Merge's iConnect and Honeycomb are good starts. The entry of Nuance into the field could be a game changer...for the company that does it right. We'll see. Film at Eleven.


I am without a doubt getting old and I'm not completely on my game, the game of paranoia, that is. Normally, I would have seen this possibility, but it took a friend to analyze the data and inform me of the consequences. Here is what he said (he wishes to remain anonymous for obvious reasons...):

I pushed hard for an "outside study" solution. We were regular victims of Philips PACS non-DICOM CD's every night from a particular hospital. We looked at both lifeIMAGE and Accelarad, and went with the latter and it works well for us. However, the Nuance purchase suggests to me that they want to be a complete 3rd party reading group, and replace groups like Optimal. Once they can share images well, dictate reports and disseminate results, they become a radiology department for anyone. I'll bet they start advertising over-reads/consults by big institution names before it's all over.

It just looks to me like they are assembling the pieces of the puzzle to become "Uber Radiology". The video mentions/shows a graphic for telemedicine; that screams 3rd party. Any site can be set up to just put their system as a destination on each modality. Boom, you send them your images, they can be read. It's not even a "PACS to PACS transfer" but a replacement PACS. No onsite storage is needed, just the Nuance cloud.. oops until the internet is down and you don't have your images anywhere...
Hey, just because you're paranoid doesn't mean they aren't out to get you...

And Yet Another ADDENDUM

Interesting coincidence...Nuance just hired someone to "document, share and use" clinical information per their recent press release:
BURLINGTON, Mass., – April 7, 2014 – Nuance Communications, Inc., (NASDAQ: NUAN) today announced that it has named Trace Devanny as president of Nuance’s Healthcare business. Mr. Devanny will oversee Nuance’s largest division and lead its efforts to deliver a more seamless approach for healthcare professionals to document, share and use clinical information. He will report to Paul Ricci, Nuance chairman and CEO.

“Our healthcare business presents a significant opportunity for innovation, leadership and growth in today’s dynamic healthcare environment,” said Paul Ricci, chairman and CEO of Nuance. “As a healthcare technology industry veteran, Trace brings a powerful skillset that combines operational excellence, team development, customer engagement and a strategic vision. I look forward to working with him to lead Nuance and our healthcare business through its next phase of growth.”

Mr. Devanny has more than 30 years of executive leadership experience in the healthcare IT industry, having held executive leadership roles in multi-billion dollar, international healthcare organizations. He joins Nuance from TriZetto Corporation, where he served as chairman and CEO. At TriZetto, he drove revenue and bookings growth in excess of 20 percent and led the organization through a business and sales model transition. Previously, he held several executive roles at Cerner Corporation, most recently as president, over an eleven year period where he was instrumental in growing the company and revenues from a $340 million business in 1999 to a $1.8 billion healthcare IT leader. Earlier in his career, Devanny was president and COO of ADAC Healthcare Information Systems and held a series of executive positions with IBM and its healthcare business. He holds a BA degree from the University of the South.

“Improving quality of care while driving down healthcare costs is one of the most significant challenges that providers face today. Nuance is advancing these initiatives through innovative solutions that make it easier for providers to deliver patient care,” said Trace Devanny. “I look forward to working with this talented and ambitious organization to build on our momentum and make an even greater impact on the healthcare system at this important point in its history.”
Only the paranoid would put this together with my friend's speculation and see anything interesting...  What? Me? Paranoid? NEVER!

Tuesday, April 01, 2014


Courtesy Wikipedia

You may recall my earlier post declaring my retirement within two years.


I had attempted to start my retirement clock, and we had some long discussions on the topic. In the course of the discourse, various factors were mentioned, introduced, revealed, discovered, or otherwise made to appear which had not been present before. The cost for officially entering the short-term glide-path became more onerous than I thought it should.

Therefore, my request is now withdrawn. When my numbers and the stars align properly, I'll be giving my 90 day notice. That might be tomorrow, or it might be 10 years from now. So much for a heads-up to allow for planning, hiring, etc.

And this time, you may disregard the date of the post.

Friday, February 21, 2014

Merge Announces...

In my daily barrage of email came this announcement from Merge, which you can also find on Yahoo Finance:
CHICAGO, Feb. 21, 2014 (GLOBE NEWSWIRE) -- Merge Healthcare Incorporated (MRGE), a leading provider of innovative enterprise imaging, interoperability and clinical systems that seek to advance healthcare, today announced that its Board of Directors has appointed William J. Devers Jr., president of Devers Group Inc, as a director, effective immediately.

"We are very fortunate to have a new director with such a considerable amount of business and software experience added to the Merge Board of Directors," said Merge Chairman Dennis Brown. "Bill's knowledge and vision will make him a significant contributor to helping Merge execute the business plan it has formulated to increase its market position in enterprise imaging and interoperability. We believe that his strategic insights and guidance will be critical as we look to increase shareholder value."

Devers was the CEO of Trans Union Credit Information Company. He left Trans Union in 1983 and started Devers Group as a vehicle for his private investments. Devers group began with an acquisition strategy, acquiring software companies in various vertical markets. Prior to divestitures, Devers Group had revenues of approximately $100 million and employed approximately 700 people.

Over the past 30 years, Mr. Devers has bought and sold over 20 software concerns, including sales to EDS, Klopotek (Berlin, Germany), DBS Systems and others. Currently, Mr. Devers manages DGI Private Equity Ventures, LLC, serves on the Board of Directors of Ryan Specialty Group, Lurie Children's Hospital of Chicago, the Big Shoulders Fund and is a less than 3% non-voting shareholder of Merrick Ventures. In addition, Mr. Devers serves on an Advisory Board at the University of Notre Dame and is a Trustee of the Museum of Science and Industry in Chicago.
Italics are mine. Mr. Devers sounds like an excellent addition to the Merge team. But I'm a little intrigued by the mention of the buying and selling of software concerns. Are we announcing more than we are announcing?

Hat tip: TOAOPM