Saturday, May 23, 2015

A Note To GE PACS Service

Image courtesy


I don't believe I've had the opportunity to meet any of you, but I am one of the radiologists who provide imaging interpretation at a site using GE PACS. I have some familiarity with PACS in general as well, and so I wanted to touch base with you on the issues we are having with the Universal Viewer. I was very disappointed to learn that GE would not have someone on site today; we had rearranged the schedule so I could be here to work with you. Since that is the case, I wanted to outline some of the difficulties we are facing with the new UV software in lieu of a personal meeting,   While UV represents a significant improvement over the old Centricity PACS/RA-600, we have encountered several problems with the software, some with severe enough impact upon patient care that we must request a patch on an emergency basis.

The most serious problem we face is the inability to save annotations (measurements, etc.) placed on an image. In the clinical oncology setting, it is absolutely critical that we have the ability to follow a lesion from scan to scan, and if the measurements are not preserved, the lesion on a comparison study must be remeasured, taking additional time and leading to possible inaccuracies.

An equally serious defect leads to one or more slices of a CT series simply dropping out, leaving a blank screen within the viewport showing only the text "0% loaded". Closing and reopening the study may reveal the missing slice, but usually this requires multiple attempts and sometimes causes other slices to disappear. Clearly, we cannot interpret what we cannot see.

At least one of us is experiencing intermittent zooming of slices when scrolling through a CT series. This is an unnecessary distraction at best which could lead to inability to visualize structures beyond the aberrant field of view.

On at least one occasion, and probably several others, a prior study does not appear to have been properly retrieved. I believe the most glaring case has been submitted to GE. The report from the prior study (multiple priors in this particular case) refer to images that are not present. Is there some reslicing taking place on the stored prior exams, particularly if they were performed on the old CT's which have since been replaced?

There are other lesser but still annoying and potentially dangerous glitches in UV. Scrolling though the prior report with the mouse wheel is disabled once the user clicks back into a viewport. The report can still be scrolled with the left mouse button using the cursor to drag the side-bar control. The Navigator window is hidden initially by the exam information window. To retrieve it, we must press "N" twice. I suspect both of these are state problems stemming from the use of Internet Explorer intermixed with your ActiveX viewer. Perhaps this legacy from Dynamic Imaging isn't playing well with the newer code?

We had high hopes of using UV for reading PET/CT scans. As it stands today, this cannot be done. Synchronization is not possible (at least on some patients) between the PET and a prior CT only exam. Perhaps this could be fixed with a new hanging protocol, but I haven't been able to make this work consistently. We are unable to get SUV readings, without which we cannot interpret a PET exam. In addition, the fusion function does not work correctly. Proper PET/CT fusion requires an "alpha" control which varies the contribution of the PET and the CT slice to the fused image. The only control you have on the fusion pane is for PET intensity, and this does not yield a usable image. This is properly executed on our old Advantage Workstation, and I would refer you to this display to see how fusion should work.

Finally, the search function of the worklist perpetuates the rather annoying requirement that ONLY GE has insisted upon for years and years, the placement of a space after the comma when searching for a patient by name. Yours is the only software out there that does not simply parse the input for the comma. Yes, it's a minor thing, but for those of us who have to bounce back and forth between multiple PACS systems, this uniqueness is really not appreciated.

I should add that the new Zero Footprint Viewer does work much better than the old Centricity Web client, which was truly one of the worst pieces of PACS software ever created. I had anticipated being able to utilize the full UV client remotely; I had thought it to be a zero-footprint product itself rather than an ActiveX app. I assume UV could be used remotely, but apparently our site is not allowing it to be distributed beyond the DMZ as we are doing elsewhere with Merge and Agfa clients. But that's another topic for another day.

The problems above that affect the display of the images, particularly the image drop-out and the inability to save annotations, represent impediments to patient care. I would urge GE to patch these as quickly as possible.

Thank you.



Tuesday, May 12, 2015

Watching The Apple Watch

My birthday present from Mrs. Dalai arrived yesterday, just a few months past the event itself. The much ballyhooed Apple Watch now rests comfortably on my wrist, wresting my restless attention from the rest of what I'm supposed to be doing. (Mrs. Dalai is getting a complete kitchen redo for her birthday...I think she wins.)

I won't go into much detail on its function and so forth, as that is available ad nauseum on the internet. Suffice it to say, I'm happy with my present, and I think it has a great future. When you read some of the reviews out there, you'll think this little gem is nothing more than a flash in the pan, because quite a few of the IT pundits out there have panned it rather mercilessly. As Mike Cannavo, The One and Only PACSMan once put it:
A lot of these folks making the postings suffer from a disease known as LDS, and I'm not talking about the The Church of Jesus Christ of the Latter Day Saints either. It's Little D*ck Syndrome- where you have to make up for your "shortcomings" somehow so you mock on the first person who seems to know what the hell they are talking about. I live it every day.
Absolutely NONE of the Commie Windows-Loving Apple-Hating nay-sayers out there on the net, in the Twitter-verse, or anywhere else in the electronic or print media could envision, let alone put together, something like the Apple Watch. Or an iPhone. Or a Mac. Or even a PC. Well, maybe a PC. Of course, I've done my share of panning of PACS products, but I really could make a better PACS. If I ever got around to it. Which I will. Someday. Eventually. I promise. Really.

Like PACS, a smartwatch is something you have to play with yourself to see how well you interface with the interface. What works for some won't feel right to others in both venues. But since the Apple Watch only works with the iPhone, its users are essentially guaranteed to be well-versed in, and generally lovers of, the way things are done in the Apple Universe. The Watch GUI fits right in with the rest of the toys.

Being a bleeding-edger can cause some minor cuts and bruises. So far, though, the only physical injury I've endured is a few snagged hairs, mostly grey, which were caught in the tightly-woven steel Milanese band. Said band actually looks good, and the magnetic tab closes securely. Functionally, I've had some minor hiccoughs. Upon first activating the Watch, it is supposed to put something on the screen to automate pairing with one's iPhone. It never did show whatever it was supposed to show, and I had to pair "manually" which involved entering a 6-digit number into the phone. Big deal. I've seen some minor stuttering when shifting between apps, but that's really the extent of the difficulties.

It took me about 30 minutes to become familiar with the three controls and what they do. The screen itself is a touch-screen, with Apple's new Taptic Engine yielding haptic feedback to your taps. There's also Force Touch which senses how much pressure you are putting on the screen and acts accordingly. The digital crown turns, of course, but it is also a button that can be pushed. There's a side button as well.  The whole package is quite nicely finished, worthy of a piece of daily-wear jewelry.

The software and interface work fine as far as I'm concerned. The ability to answer the phone from the watch itself, and to engage in limited texting go well beyond the capabilities of my old Kickstarter Version Black Pebble. (I might just start an essay contest for those who would like to be the proud owner of Dalai's Pebble...Dalai Junior doesn't want it...)  If I could request one change in apps or functionality at this early date, it would be something that lets me add my own images to the watch faces. There are already quite a few permutations built-in, but I still like to use my own pictures, something the Pebble could do, although the image had to be downgraded to a 1-bit dithered black-and-white facsimile.

My friends and loyal readers (all three of you) knew I couldn't resist buying an Apple Watch. Such are the joys of being a fan-boy, I guess. You might ask if the Watch is right for you. I'm not sure I can answer that, beyond saying that if you like the other iOS products, you'll most likely appreciate this one as well. Keep in mind the usual caveats...this is the first generation of a very unique product. It WILL change yearly. I'm hoping that new functionality in years to come will be applicable in retrograde fashion to the older models, and Apple is usually pretty good about doing so.

But spare me from the endless carping I've seen on the web from the nay-sayers. No one is holding a gun to anyone's head to buy the darn thing. If you don't wear a watch, you don't like watches, you think watches are a Commie plot, then by all means, DON'T buy the Apple Watch! The rest of the world doesn't really care if you don't get one or if I do. Hate to break it to you, but Steve Jobs won't be spinning in his grave either way.

You'll find a number of articles released in the past few days saying things like, "I've beta-tested the Apple Watch so you don't have to" and "I've got buyer's remorse" and "The Apple Watch sucks" and so forth. And there are one or two positive reviews as well. The main theme of those who've received their Watch in the same shipping dump that brought me mine seems to be that it doesn't meet expectations. I'm sorry, folks, but just what DID you expect? The basics of the thing have been out there since Tim Cook tried his hand at the "Oh, and one more thing" thing. Lots of whining but little if any productive talk about just what would have satisfied the whiners. Really, some of them sound like a kid at Christmas who had been pining for some popular toy and then realized that playing with the box was more fun. As Spock might say, the wanting for some is more fun than the having. (Apologies to the writers of Amok Time).

I'm thinking what the milquetoasts really wanted but couldn't seem to vocalize was a porn-app that utilized the taptic engine to its full potential. They might need to attach a much smaller watch band.

In the meantime, I am hoping at least one of my friends gets an Apple Watch so I can send them my heartbeat to confirm that I'm alive. Lub Dup!

Tuesday, April 28, 2015

Enterprise Imaging: To Boldly Radiograph What No Man Has Radiographed Before
Well, Actually, ONCE Before...

Few images are more iconic than the Starship Enterprise flying around the galaxy. One could argue that the ship herself was the real star of Star Trek. Of course, there was never an actual Enterprise, right?

Wrong. These are the voyages of the model ship that in a very real sense was the Enterprise itself, its 50 year mission, to delight and amaze fans and Trekkies of all ages, to boldly pretend to go, well, you get the idea.

Back in the days before computer generated imaging (CGI), to make a ship fly through space, one needed a model of the ship, which was filmed in front of a green-screen or starry-sky backdrop. Perspective and such was adjusted to make the model look like the real thing. Today, a computer-generated model (such as this by Doug Drexler, master Trek designer) looks more real than a real ship:

But back to the solid version. The physical model we all know and love was delivered to the studio on December 29, 1964. That would be over 50 years ago. Damn, I must be getting old.

The 11-foot model was based on a design by Matt Jefferies and built by Richard Datin, Mel Keys and Vern Sions. (Image courtesy
Once the series wrapped in 1969, the poor model was crated and warehoused in some dark corner at Paramount Studios until it was donated to the Smithsonian in 1974.

Spaceship in a box

You can see it wasn't in good shape, and extensive renovation was required before it could be put on display. In fact, the model was restored multiple times, the first upon receipt by the Smithsonian in 1974, then again in 1984 and 1991.  Until 2000, the model was hung by wires (which was not what it had been designed to do) in an upstairs gallery of Air and Space. The earlier renovations are discussed in this article from the museum. (Most of the photos on this post are from the Smithsonian as well.)

In the course of the renovations, the Enterprise was X-Rayed to reveal its underlying structure and to show the various stresses and damages from the rather improper display.

June 22, 1999, the starship underwent X-Ray analysis at QC Laboratories, Inc., in Aberdeen, Maryland, Frank H. Winter, Photographer.

X-Ray of the back of main hull...note the (gulp) metal tacks and the fancy light bulb! 

The model was moved from a real flight gallery to the basement of the gift shop, where it stayed from 2000 through 2014:

The USS Enterprise in the Air and Space Gift Shop Basement

We now get to the exciting part of the story, and with some information that justifies my telling this tale on a PACS blog.

The model is to be given a more prominent place in the museum, at the forefront of the renovated Boeing Milestones of Flight Hall, opening in 2016, and it is to be renovated/conserved yet again. But before that happens, the Enterprise will undergo a complete analysis, including a full radiographic examination. From the Smithsonian's description of the latest efforts:

Notably, conserving the Star Trek starship Enterprise studio model has allowed some wonderful cooperation between different branches of the Smithsonian institution. In December 2014 and again in January 2015, Tangara Cross of the National Zoological Park arranged for Marilyn Small and Peter Flowers, two National Zoo registered veterinary technicians (and Star Trek fans), to come to the Steven F. Udvar-Hazy Center in Chantilly, Virginia, to examine the model used in filming of the original Star Trek television series (1966–1969).

To give the Museum’s conservators a look inside the Enterprise model, Marilyn and Peter brought a portable radiography (x-ray) machine to the Emil Buehler Conservation Laboratory, which is a behind-the-scenes work space at the Museum’s Steven F. Udvar-Hazy Center near Washington Dulles International Airport. Consisting of three pieces, the apparatus has an x-ray emitter that exposes a special digital photographic plate, which in turn communicates with a computer enabled with its own independent WiFi. But what really made it special was that this technology has also been used to examine zoo animals, even panda sensation, Bao Bao. (Talk about breaking the Internet! Consider combining the web power of Bao Bao and Star Trek!)

To organize the data, the radiology technicians/Star Trek fans first created a record for the “patient:”

ID: NCC-1701

Birthday: 1964

Sex: Other

Saucer as the “skull”

Secondary hull as the “body”

Nacelles as the “legs”

The x-ray apparatus produced images in a special format called “dicom” (which Peter explained, “makes a jpeg look like a pencil sketch”). To get each image, Peter and Marilyn worked with Engen Conservation Chair Malcolm Collum and Museum photographer Dane Penland to line up the radiography machine on one side of the artifact with the photographic plate positioned exactly opposite on the other side. They planned the overlapping images to provide a complete tricorder-like diagnostic of the model’s interior. As each image was shot, the digital plate communicated via WiFi with the laptop, capturing the image. To avoid a magnification effect, they positioned the plate as close to the body of the model as possible. They got the perfect exposure on the first try, based on Peter and Marilyn’s expert calculations comparing the probable density of the model versus the known density of biological specimens.

Working slowly, the participants planned the exposures to allow the images to be “stitched” together so conservators can get a more complete picture of the artifact. Our photographer, Dane, advised on how best to overlap the images so that they could be matched once the images had been taken back to a zoo computer to be processed. The composite image of the left nacelle shown here has been put back together by Museum conservator Ariel O’Connor. When printed at full size, it gives the conservators a clear map of the interior of the model, without disturbing any of the original structure. It’s worth noting how much the technology has improved since the last time the Enterprise model was x-rayed in the 1990s.

The x-ray process involved a lot of back and forth—literally. Marilyn, Peter, and Malcolm wore lead shielding to protect themselves during the x-ray shooting. For the rest of us, after backing away during each shot to avoid being unshielded inside the scatter range of the x-rays, we all rushed back to the monitor as the image appeared to see what was revealed. Immediately, we could see the light bulbs inside the model as well as finishing nails, electronics, and wiring. Some of the images were so clear that we could see the grain in the wood used to build the model! The results will help the conservation team to make clear decisions about next steps when assessing the structure of the model.

Radiographing the Enterprise for the 2015 restoration

Here's a video of the current restoration efforts:

So it seems the 50 year-old mostly wooden Enterprise model will live long and prosper, thanks in part to DICOM and advanced imaging techniques.  I'm rather amused at the complexity assigned to something we do dozens of times every hour of every day.

I wish the Enterprise Godspeed for her next 50 year mission!

Sunday, April 26, 2015

Dalai's Shipboard Standup Routine
Or, Why I'm Keeping My Day Job...

Earlier this year, Mrs. Dalai and I spent a week on a Princess Cruise ship, meeting up with some good friends who were escaping the horrid weather in the Northeast. (Our weather here in the Deep South wasn't so wonderful either: we had a pipe freeze and then rupture, spewing a waterfall from the ceiling by our back door. Thus, this phase of my retirement is devoted to helping Mrs. Dalai redo the kitchen.)

I'm guessing just about everyone has been on a cruise at some time or other. Most of them are rather similar. A few shore excursions to tropical beaches punctuating over-indulgences in food and drink. Buffet lines to beat the band, and on our ship of 3,000 souls (or in some cases soul-less souls) there was a significant wait for the tenders to shore. In St. Thomas, of all places! This was apparently caused by someone jumping off of a Carnival ship which caused delays and complicated the docking schedule for the rest of us.  How rude.

But speaking of rude, our ship had a Passenger Talent Show at the end of the run, and I was sorely tempted to sign on. Fortunately for me and my bodily integrity, Mrs. Dalai put a quick end to those aspirations. I do believe she had visions of me walking the plank, and she was afraid she might approve of that after hearing my act.

Since I was too chicken (or cautious) to go out and debase myself in front of a live audience, I'll do it here for my loyal readers, and pray that at least a few of you continue to read my rantings after this.

The act consists of my observations of humanity as confined to this rather nice floating tin can. (I've since thrown in some material based on some of the folks I met on the rivers in France as well.) If you see yourself in my babbling, well, I'll apologize in advance. No offense is intended, but if we can't laugh at ourselves, then we shouldn't act in ways that prompt rogues like me to take notice.

Curtain, please...

Ladies and Gentlemen, Princess Cruises presents with some degree of shame, our former passenger, Dr. Dalai!

(One drunk claps in the back of the room, then passes out again.)

Good evening, fellow travelers! My name is Dr. Dalai, and yes, I'm a real doctor! No, madam, I don't have a remedy for your Montezuma's Revenge, I'm a radiologist. I look at the pictures of your insides. Yeah, I'm the one who gives barium. Why, did you want some?

I am working only part time these days, which allows me to go on trips like this. I'm trying to decide if I should quit completely and join the comedy circuit, and this is my first foray into that area. So I'll need all of you to tell me honestly if I should keep my day job.

As a physician, I like to keep an eye on my fellow passengers. It's just a professional thing, and lucky for you, I don't charge for it! I've got to tell you guys something sad, though, and remember, I'm a doctor and I know what I'm talking about. The condition of some of you is absolutely deplorable. I'm talking really, really bad. In fact, some of our fellow passengers are just about at death's door. The good news is, they won't fit through! I won't point fingers, but there are some folks here who would tip the scales. At the truck-stop. This is serious, folks. Do you ever think of your health?

Look, I've battled with my waistline just about my entire life. I like food as much as the next glutton, but come on! If you don't want to be overweight, eat less and exercise more. Lifting your plate and your fork don't count as exercise, by the way. I've seen some of you down at the lunch buffet. You've got to be kidding me! There are two modes of attack on that line. Some folks just stop and examine every little thing like it's their last meal and they want only the best morsels for their very own. The rest just go through like a bulldozer, scraping everything not nailed down onto their tray and going back for seconds. And thirds.

What I find even more troublesome is that some of these steam-shovellers are plying their trade from a motorized scooter, just barely avoiding plowing the other bipeds out of the way. Now trust me, since I am a doctor, I have full sympathy for those who can't ambulate (that means walk for those of you who didn't complete your education) but still, you have to wonder. Which came first, Jabba the Hutt's barge on wheels, or Jabba the Hutt? In other words, are these folks scooting around because they have become too large to move under their own power anymore, or were they confined to the skateboard at a young age, and left with oral cravings as the only thing they can still gratify? I'm not going to ask, as they might run me over and then whip me with a rasher of bacon as they pass my broken body. I don't mean to sound unsympathetic, but at some point, we can't simply blame hormones. If you don't like being as you are, there ARE things you can do about it! Just ask your own doctor! Seriously!

If I were to put on my psychiatrist hat, I would have to think there is some degree of anal retention going on here. Or maybe these folks have some genetic memory of starvation. But the grabbiness, the unsaid declaration of "MINE!" may indicate some deeper problem. You've seen some of these folks on airplanes. You might BE one of them in spite of normal girth. You know who you are. You, sir...didn't I ask you if you would trade seats so I could sit with my wife? Remember your answer? "No, No, NO! This seat is MINE!" Thanks a lot. And you, ma'am...weren't you the one taking about 20 minutes to stuff your oversized bag in the overhead bin? It wasn't a pretty sight, and the 157 people behind you were about ready to help you join your bag up there. My gosh! Can't you anal retentives part with any of your possessions for the short duration of the flight? Or are you just too damn cheap to pay the $25 fee after paying $1000 for your ticket?

What's that sir? Yes, you in the back. It's nice to have you back among the living. What's that? Oh, no, I'm sorry, that's anatomically impossible. You know, I was about to suggest a CAT scan for your head, but I'm afraid we wouldn't find anything in there.

Let's get back on board this vessel. You'll notice I'm one of the younger people on board. I've always thought we have this retirement thing all wrong. We should be able to cruise and do fun stuff while we're young, and then when we get old and decrepit, we should be restricted to going to work. Now don't get me wrong, I want be old and decrepit someday although I've left strict instructions with my kids that once I cross the line of not knowing who or where I am, they are to give me a very large dose of valium with a vodka chaser. Goodnight, sweet prince, and all that. So now I have them taste any drink they hand me before I touch it. But with all the respect I do have for my elders (I really do!), I can't help but feel that some of you are a little too far along the path to be gallivanting here in the Caribbean. Let's be real, you aren't having a lot of fun digging in the sand, and unless you have the deluxe version, those bloody scooters don't do well on the dunes. Yeah, us old guys like to look at the cuties in bikinis on the beach, but let's face it, we've forgotten why.

Now the few young'uns on board who wear their bikinis to the beaches or the pool on the top deck who SHOULD be wearing them seem to think that tattoos all over their bodies are a good thing. But trust this ol' country doc, ladies, there is no greater turnoff than a big red eagle plastered on your chest rising out of your d├ęcolletage. It's gross! Just how drunk or stoned did you have to get before that sounded like a good idea? Did anyone tell you it doesn't wash off? Yuck. I feel dirty just looking at this pagan display. And it's painful when Mrs. Dalai sees me looking and bats me on the head.

Speaking of feeling dirty, have you noticed how the crew has been very diligent in getting everyone to use hand sanitizer at every opportunity? Are they telling us we are filthy, germ-laden dirt-balls? Well, they're right. I'll tell you why.  I had to use one of the public restrooms near the main dining room on formal night. While I was washing my hands (very, very diligently) there came the sound of anything but music from one of the stalls.  I'm talking a noisy production. I'll spare you the medical terminology, but suffice it to say there was every form of matter but plasma being produced in there. After a while, the gentleman walked out of the stall, adjusted his cummerbund, slicked back his hair, admired himself in the mirror, and went back to the dining room. And he DIDN'T WASH HIS GODDAM HANDS!!!  Thank Heavens he wasn't at my table. I subsequently used up the entire container of sanitizer and I think I drank some too. So, yes, the crew is right to assume we are dirty dogs indeed.

You have to wonder what the crew really does think of us. The tipping policy on board this ship does inspire them to endear themselves to us. If they are nice to us, they get more money. I wish my job worked that way. I have to do mean things to people, make them drink foul potions and shoot radiation through their bodies, and only then do I get my $10.97 from Medicare. After taxes, and other pains in the butt, I might clear $5, and the patient doesn't even know who I am. In fact, when patients find out nothing is wrong, they get mad and want their money back. Of course, if I miss something on the Xray, the patient's lawyer is going to come find me, and that's never any fun. But hey, I'm rich! I've got five whole bucks in my pocket! Maybe I'll see if the ship will take me on as a room steward. I wanna see the world, one stateroom bathroom at a time. The tips have got to be better!

There are those who see the world one selfie at a time, and at the risk of angering half the world's population, I've got to say a few words about our friends from China. Yes, all 2 billion of you, who decided to see the world all at the same time. Love the Chinese, mean it. I do hope to visit their great nation someday. But having been in France recently with all 2 billion Chinese tromping through Versalles at the same time, I've got to tell you they can be annoying. Pushing, shoving, dominating the place for their endless photos like a bunch of Yankees with funny accents and haircuts and nice cameras. And that's just in the line for the bathroom! At least they seem to wash their hands. Some of our Chinese friends don't have the best of manners, though. The guides at Versalles were lamenting the fact that some were spitting on the floor. Hey, when I go to China, I'm going to find out what's offensive in their culture and be sure NOT to do it! But then when you hold the mortgage on most of the world, I guess the rules don't quite count the same as for the rest of us.

Well, my red light is flashing, or is that a laser tracer pointed in my direction? Hey, sorry, this is all in fun, right? You don't believe I meant any of this, do you? I was just kidding, folks. I love you all, really. Even you in the back, sir. Stop by the hospital after the cruise for a free CAT scan of your head. I promise we won't find anything. Nothing at all.

Safe travels home!

Wednesday, April 01, 2015

Last Mango In Paris

My primary goal for retirement was to hit the road with Mrs. Dalai and travel the world. I'm happy to report that we have begun our journey into journeying. Whilst I havent been writing prolifically about it, or anything else, we have averaged a trip out of the US every month for the preceding three: Curacao in January, and the Caribbean earlier this month. Right now I am typing away on a bus carrying us from Paris to Lyon, having just left a cruise of the Seine River, and headed to a second on the Rhone in southern France.

I have to tell you we made this trip with some trepidation.  The Charlie Hebdo and HyperCasher slaughters happened here all too recently, and as Jews we were quite concerned for our safety. But we did ultimately proceed, and I'm glad we did. 

Paris and the Normandy area are truly beautiful, and the French people are very warm and welcoming. Yes, you read that right, and the statement is not l'April Fools joke. We were prepared for the stereotypical nasty French treatment of Americans (which Mrs. Dalai experiened over years of French classes, explaining why she doesn't remember any of her French). But the reality was completely different. We saw absolutely no sign of the condescending, arrogant treatment so often attributed to Parisian waiters and so on. On the contrary, we were treated far better by every single Frenchman and woman we met than we were by the surly gate agents in Delta livery working the gate in Atlanta for our Delta code-share Air France flight over. (Air France, by the way, still believes in hiring young, happy, and energetic flight attendants, unlike Delta where an AARP card is mandatory for most of the cabin crew.) Most everyone here speaks English, although they all seem to appreciate our feeble attempts to communicate in French, and are kind enough to suppress their laughter at our horrific mangling of the language. 

Let me speak briefly of the Normandy Beach visit.

Today, the various little towns along the D-Day landing sites are placid and picturesque. You would never know of the terror and bloodshed that occurred here 71 years ago (could it really have happened that long ago?) on June 6, 1944. Thousands upon thousands of brave Allied soldiers stormed these beaches, knowing they would probably not survive the attempt. Thousands died, and many were laid to rest in the cemetary at Omaha Beach. Row upon row upon row of crosses, with the occasional Star of David, occupy this sacred patch of land. I cannot begin to convey the intensity of feeling inspired by the knowledge of how these ordinary men became heroes. In a very real sense, each and every one helped to save the world from tyranny. Without them, you might be speaking German, and I might not be here at all. Sadly, the understanding of what happened here has not penetrated to some politicians who have also stood on this hallowed ground, thinking it a photo-op and not a moment to reflect, but that's OK. We get it. And the heroes buried here, who certainly are looking down upon us, get it as well. I will thank them for the rest of my life.

At Versailles, we toured the amazing palace as best we could while being trampled by hordes of folks from China whose concept of personal space differs greatly from mine. 

Dalai at Versailles. It's good to be the king, but where's the pissboy?

Our guide gave us an alternative interpretation of the classic Marie Antoinette line, "Let them eat cake..." Some say she was attempting to distribute the contents of the royal storehouses to the starving. We will, of course, never know for sure, but it just goes to show that things you thought were etched in stone still deserve inquiry. 

But back to the future.

First connected by Aunt Minnie, I have been communicating for a while with a French radiologist named Denis, and he graciously invited me to visit his clinic near Notre Dame in central Paris. He picked me up at my hotel, and gracefully navigated the treacherous morning traffic, finding a parking space only two blocks from the hospital, a lucky break since there is no parking for physicians at the hospital itself. All morning, we discussed the state of French medicine in general, and radiology and PACS in particular. Things are different over here, as you might imagine.  As we see in many other nations, there is a mixture of private and public care, with heavy governmental regulation. There is a bit of a physician shortage in France, though, because the government in its infinite wisdom decided years ago that the way to save healthcare Euros was to cut back on the number of physicians. (Somehow that never happens with lawyers.) So it was mandated that doctors retire at age 62. And now there aren't enough doctors, surprise, surprise. The age of retirement has been raised to 72, which won't help much for a long time. It's so bad that in Provence, for example, where we are now headed, and to which Denis commutes to practice periodically, the only available ophthalmologist is a young physician from Morocco, who is flown in every two weeks. Right. Also, it had been declared that none of the nations's smaller hospitals would have radiologists. So much for getting a summer job on the Rivera.

Anyway, as is often the case with people of incredibly high calibre and capability, Denis, and his partner, Jean Noel, treated me as an equal, a colleague come to visit from afar. Indeed, I had no idea of the rarified air I was breathing. Denis mentioned almost in passing that he had been deeply involved with GE, and was responsible for parts of the Advantage Workstation ". . .which I hear the Dalai doesn't like! Ah, but this is OK, I agree with you!"  The more we talked, the more it became clear that Denis was a far more important figure in PACS and radiology than I had imagined. In fact, if I am the Dalai of PACS, Denis should be the Pope of PACS, and David Clunie could then be High Priest. (I'll stop with the religious allusions now before I get stoned.) Denis has had such a significant involvement with the development of PACS he said, without trace of regret, "Had I been in America, I would have been a millionaire by now, but I would far rather be in France." Denis keeps his hand in the business today, working with a smallish company that has captured much of the French PACS market, Global Imaging. I had the chance to see him use the product he has helped design in the production environment. It functioned well even on an older Windows workstation, with a better-than-average GUI that hid unnecessary buttons. Perhaps I'll get the chance to play with a demonstration version in the future.

I had to leave all too soon to get back to the hotel where Mrs. Dalai was waiting, but before I left, Jean Noel asked me to stop by his office to see the book he has co-authored. It turns out to be one of THE authorative texts on pelvic imaging. Again, I had no idea of the brilliance of these gentlemen who instantly accepted me as a friend from afar. Jean Noel is now working on the second edition. "I will try to do at least a little better than I did on the first version." I'm not sure that would be possible...the first edition is a masterpiece. 

One very interesting aspect of their practice is their direct involvement with the patients. Both Denis and Jean Noel speak with the patients presenting for MRI or CT before their exam, and then directly protocol each study. When the exam is finished and interpreted, they review the whole thing with the patient. As Jean Noel put it, "I can't make a report without seeing the patient." It is a very different paradigm than ours, and it has great merit.

Since I have limited broadband (and none on our bus now leaving Dijon en route to Lyon), I'm going to have to postpone the post about my discussion with Denis about server-side rendering and who owns what patents for it. More to come on that very interesting topic, which I think will literally dictate the future of PACS.

In the meantime, I raise my glass of local Chardonnay to my new friends in Paris, and to all of you, and wish you Bon Appetite! And yes, despite the date, I am really in France!

Saturday, March 28, 2015

How To Kill A Doctor

From the HealthCareBlog:

How To Kill a Doctor

flying cadeuciiIt’s really quite easy to kill a doctor. Here’s a step-by-step process guaranteed to succeed at least 400 times a year:

Start early.

Be sure to denigrate medical students whenever possible. Even if they’ve come to the profession later in life and have accomplished all kinds of amazing things personally and professionally (which don’t count, of course, since those are other professions) they don’t know squat about medicine and you do. Make sure to emphasize their ignorance and inexperience at every turn, because it’s the only way to prove that you know more than they do, which of course means that you’re a better person than they are. The fact that as a group they’re all at the very top of their peer group in motivation and intelligence is irrelevant.

Tell them they’re lazy when they say they’re tired after being up for 36 hours (since they’re not residents, they don’t have work hour restrictions). Tell them they smell of formaldehyde from the anatomy lab and make amusing gagging noises whenever you see them. If all else fails and they are actually able to competently work up a patient, plus answer the most esoteric questions you can think of, impugn their sexuality or tell them they dress weird. Don’t worry about being judgmental; patients are the only ones deserving of your respect. And other doctors, of course; well, the ones ahead of you in training at any rate. But only in your own specialty.

Don’t let up once they graduate from medical school.

The first year of residency training is a great time to kill doctors. They’re foundering around desperately trying to figure out how to function in their new roles. Most of them are also drowning in debt and watching as their non-medical friends (if they still have any) get married, buy houses, and have kids; you know, have lives. Yell at them for everything that goes wrong with their patients, whether it was their fault or not. Tell them it builds character.

Hospital administrators have an important role.

Make sure the physicians you hire understand how important it is that they show up for their shifts, but don’t give them any input into the schedule. Ignore their scheduling requests, but tell them they were lost; better yet, imply that they were never sent. Same with messages, committee meetings, and other administrative responsibilities. Make sure there are enough of these to make it impossible for doctors to take care of the patients. Otherwise the patients may actually think it was the doctors, and not your wonderful hospital (or hospital system) responsible for their recoveries.

If you’re not a particularly affluent institution, make sure that the food, decor, and customer service at your institution is as bare-bones as you can, but lump everything under “Medical care” in your patient satisfaction questionnaires so the doctors get blamed. Then tie their payments to those satisfaction scores. Win-win, for you.

Be sure to switch up your EMR annually at least, but call it “Upgrading” and label any doctors who complain as “disruptive.” It helps if the main hospital, Emergency department, and Radiology departments all run separate systems that don’t interact. Make sure each system requires different passwords, and require that they be changed at different intervals. Forbid physicians to write them down. Security, you know.

Don’t stop once you’re in practice.

Pick on your younger colleagues for their inexperience. Whatever you do, never tell them they’re doing a good job. Stick them with as much holiday and weekend call as you can. After all, you’ve paid your dues; now it’s their turn. (Tell them that.) Don’t listen to your older colleagues either. They’re just old farts whose knowledge is waning. Who cares about their decades of experience? Just tune them out when they start talking to you, then nod condescendingly and walk away.

Practice that condescending look and use it at hospital staff events. Make it a point to ignore newcomers. Concentrate on talking just with your friends and laughing at inside jokes, especially when others are around. Don’t return their calls, and don’t take their calls if you can possibly help it. If you accidentally wind up on the phone with the patient’s primary physician, just tell them you’ve got it all under control, and that he (and the patient) are so lucky you got involved when you did.

Target your efforts.

None of the above actions in and of themselves is likely to drive a doctor to suicide. However if you manage to select individuals with a personal or family history of depression, those with poor social supports or self esteem issues, you can greatly increase your chances of killing a doctor. Concentrating on certain specialties where there may be easier access to more lethal means, like anesthesiology and surgery, may also raise your yield. Don’t despair, though. Intensively applying all the strategies above and more (you know what to do; much of it has been done to you over the years, and may still be occurring as we speak) to doctors in any specialty represent proven ways to kill them.

Now you know how to kill a doctor.

It’s really not that hard. The question is: Why would you want to?

Lucy Hornstein, MD is a contributing blogger for THCB. She blogs regularly at Musings of a Dinosaur, where this post first appeared.

Friday, February 27, 2015

A Case Of MergDR...Merge Buys DR Systems

I guess my fingers are not quite as firmly placed on the pulse of PACS as I might have thought. I was completely blindsided by today's announcement of the acquisition of DR Systems by Merge. Oh, well, life is full of surprises.

February 27, 2015 -- One of the oldest names in imaging informatics is going by the wayside as PACS firm DR Systems has been acquired by Merge Healthcare. While the DR Systems name will be retired as part of the deal, founder and CEO Dr. Murray Reicher has been named chief medical officer (CMO) of Merge.

The deal unites two midlevel PACS providers and gives Merge additional scale to compete with larger multinational firms in the imaging informatics space. It also expands Merge's geographic footprint to DR Systems' core market in the Western U.S., while broadening the combined company's portfolio of intellectual property.

The deal was finalized on February 25, according to Michael Klozotsky, vice president of marketing at Merge.

Founded in 1992

DR Systems was founded in 1992 by neuroradiologist Reicher along with another brain imaging specialist, Dr. Evan Fram. Reicher and Fram said they founded the company out of dissatisfaction with existing PACS software available at the time.

The closely held company charted its own course over the years, remaining fiercely independent even as the rest of the radiology industry consolidated. The company gained a reputation for high levels of customer satisfaction, as evidenced by a string of top rankings in KLAS reports, as well as for its aggressive defense of its patents for PACS software.

Through the years, Reicher maintained his active role with the San Diego firm, serving as a frequent speaker at industry events and publishing peer-reviewed articles on imaging informatics. He assumed the position of CEO again earlier this year after the retirement of longtime chief executive Rick Porritt.

In announcing the acquisition, Merge cited the broad array of healthcare information technology software that will be offered by the combined firm, including DR Systems' eMix image-sharing service, RIS software, and cardiology and pathology offerings. Both companies also offer traditional PACS and RIS/PACS software and, indeed, have long been competitors in the acute care and ambulatory markets, Klozotsky said.

Merge cited the high customer satisfaction ratings of the combined entity, with No. 1 ratings according to KLAS surveys for cardiovascular information systems, hemodynamic monitoring software, and RIS software. Merge also plans to offer its iConnect Network services, including exam preauthorization, through DR Systems' installed base.

In addition to adding Reicher as CMO, Merge said it plans to keep DR Systems' San Diego headquarters open as its West Coast regional office. DR Systems employs some 180 people, according to Wikipedia. Merge will also maintain support for DR Systems' core software platform, continue with current implementations, and support and advance all product lines, the company said.

Merge expects the deal to be accretive to earnings per share under nongenerally accepted accounting principles (GAAP) in 2015 and future years. Merge financed the deal through a combination of $20 million in cash on hand and $50 million in cash raised from the sale of shares of recently issued preferred stock.

The deal is the latest in a long string of acquisitions that Merge has made over the years as it grew from a niche firm offering data connectivity software to perhaps the largest independent PACS firm. Other acquisitions have included Amicas, Cedara Software, Confirma, RIS Logic, and eFilm Medical.

Merge's most recent acquisition is designed to give the combined entity the heft to move forward in a healthcare industry where size increasingly matters.

"As healthcare continues to consolidate, scale is very, very important," Klozotsky. "This allows Merge to really operate on an entirely different level of scale."
I've met Dr. Reicher one one occasion, and he is a perfect choice for CMO. He is very well spoken, and truly a pioneer in this business.  In fact, DR holds quite a few core patents in PACS, as some other companies have painfully discovered.

It remains to be seen just how the DR products will be incorporated into the Merge palate. Will Merge PACS have a Catapult for the techs? We shall see...

Live Long and Prosper...And Boldly Go Where All Men Someday Will...

Leonard Nimoy, Star Trek's Mr. Spock to generations of fans, died today at age 83. Nimoy died peacefully at home from complications of COPD, chronic obstructive pulmonary disease, caused by cigarette smoking in his younger years. How illogical.

I think the eulogy given by William Shatner as Captain Kirk in the second Star Trek movie, The Wrath of Khan, says it all:
We are assembled here today to pay final respects to our honored dead. And yet it should be noted that in the midst of our sorrow, this death takes place in the shadow of new life, the sunrise of a new world; a world that our beloved comrade gave his life to protect and nourish. He did not feel this sacrifice a vain or empty one, and we will not debate his profound wisdom at these proceedings. Of my friend, I can only say this: of all the souls I have encountered in my travels, his was the most... human.
Star Trek gave us hope of new worlds, of new ideas, in the midst of the strife of the 1960's. We need this encouragement even more today.

Spock was at once of us and foreign to us, half-human and half-Vulcan. Similarly, Nimoy, growing up an Orthodox Jew in Boston, probably felt something of the same dichotomy. When a Star Trek script called for Spock to make an "alien gesture," Nimoy reached back into his Jewish heritage, and used the Orthodox priestly blessing as the "Live Long and Prosper" sign we know so well:

I spent about 10 seconds in the presence of Messrs. Nimoy and Shatner at the Star Trek convention in 2004. We were not quite on a first-name basis, although at one point I was one of William Shatner's 5,000 Facebook friends. Still, like millions of fans today, I feel like I've lost a close friend; these actors and their characters have been part of our lives, well, for most of our lives.

But as DeForrest Kelley's Dr. McCoy said at the end of The Wrath of Khan, "He's not really gone as long as we find a way to remember him." Perhaps not completely logical, but true nonetheless.

Godspeed, Leonard.

I have to add one little thing on this, the day of Mr. Nimoy's funeral. I was searching the Official Leonard Nimoy Online Shop ( for something he had touched or otherwise autographed. I came upon his signed self-portraits in the photography section, housed by R. Michelson Galleries, and ultimately found this one for sale:

It's called "Self-Portrait with MRI".  Well, even Spock made a mistake here and there... The signed versions may be a little pricey, but this is priceless. I'm waiting on a quote...