Saturday, February 06, 2016

The Measure Of A Company

The measure of a man cannot be whether he ever makes mistakes, because he will make mistakes. It's what he does in response to his mistakes. The same is true of companies. We have to apologize, we have to fix the problem, and we have to learn from our mistakes.

Wil Shipley

Software, being written by humans (until Watson gets the hang of it, I suppose) is going to contain errors. When the program has something to do with the medical field, those glitches could cause devastating effects.

Now being human as well, and having made my share of mistakes in interpreting images over the years, I'm not really trying to throw stones at the software folks. But when a glitch is found, there are ways to deal with it, and ways NOT to deal with it.

The latter is easy to recognize. Say one has a shiny new PACS system that skips CT slices intermittently. Telling the customer that it's an issue with the code, and the next fix will come roughly a year after the software went online is probably NOT the best approach. Having a PACS that sometimes doesn't inform the user that there are prior issues, and spending lots and lots of time backpedalling and outlining how the issue was bounced back and forth and back again within the corporate structure is definitely NOT how I want things handled.

So how should our friends in the medical software market do their mea culpa's? An excellent question. Here is how Merge Healthcare did it with two recent letters to their customers.

These two notices arrived January 27, 2016:

Recall #2016-012
January 27, 2016
Dear Radiology Manager or PACS Administrator,
This is to inform you of a product recall involving:
Merge PACS™ V6.0.2.0 MR2 and earlier. We shipped these products May 2006 through June 2010, or earlier from Amicas. 
This recall has been initiated due to an issue in which the patient name in the Halo title bar may not update to match the name on displayed images due to the JAVA running out of memory.
Potential Harm:
Use of this product may result in a mismatch of the displayed patient name on the Halo title bar and the displayed images. 
Product Containment:
A software update has been released which adds a warning message to the user interface for the user to close some viewers whenever the Java memory usage size exceeds 97%. The use of Merge PACS does not need to be discontinued.
An upgrade for Merge PACS is available for this issue. Call Merge Customer Service at (REDACTED) to schedule the upgrade. 
If you decide to decline this maintenance release, please complete (REDACTED)
Please ensure that all users of the product are provided with this notification. Your assistance is appreciated and necessary to prevent patient harm.
If you may have further distributed this product, please identify your customers and notify them at once of this product recall. Your notification to your customers may be enhanced by including a copy of this recall notification letter.
Merge Healthcare is committed to improve efficiencies and enhancing the quality of healthcare worldwide. If you have any additional questions, call Merge Customer Service (REDACTED)
This recall is being made with knowledge of the Food and Drug Administration.


Recall #2016-012
January 27, 2016
Dear Radiology Manager or PACS Administrator,
This is to inform you of a product recall involving:
Merge PACS™ V6.0.2.0 MR2 and earlier. We shipped these products May 2006 through June 2010, or earlier from Amicas. 
This recall has been initiated due to an issue in which the patient name in the Halo title bar may not update to match the name on displayed images due to the JAVA running out of memory.
Potential Harm:
Use of this product may result in a mismatch of the displayed patient name on the Halo title bar and the displayed images. 
Product Containment:
A software update has been released which adds a warning message to the user interface for the user to close some viewers whenever the Java memory usage size exceeds 97%. The use of Merge PACS does not need to be discontinued.
An upgrade for Merge PACS is available for this issue. Call Merge Customer Service at (REDACTED) to schedule the upgrade. Reference this recall #2016-012.
If you decide to decline this maintenance release, please (REDACTED)
Please ensure that all users of the product are provided with this notification. Your assistance is appreciated and necessary to prevent patient harm.
If you may have further distributed this product, please identify your customers and notify them at once of this product recall. Your notification to your customers may be enhanced by including a copy of this recall notification letter.
Merge Healthcare is committed to improve efficiencies and enhancing the quality of healthcare worldwide. If you have any additional questions, call Merge Customer Service at (REDACTED)
This recall is being made with knowledge of the Food and Drug Administration.

You get my drift. Face up to the glitches, let the customers who haven't yet found them know they exist, and FIX them. Sounds like a plan. A plan other vendors need to follow a bit more religiously.

Monday, January 25, 2016

Reporting In

A few weeks ago, I received this message from one of the top Merge execs (emphasis mine):

Notification of Enhanced FDA Reporting Methodology

Dear Valued Customer,

As part of our commitment to ensure compliance and driven by our objective to deliver high-quality medical devices, we want to inform you of a change in our quality management processes to provide greater transparency to our customers and raise the bar on delivering quality in the medical device industry. I also want to take this opportunity to reiterate Merge Healthcare's commitment to implementing corrective actions to ensure compliance with the Federal Food, Drug, and Cosmetic Act and all regulatory requirements. Merge's executive management team takes the FDA’s observations seriously, and we have been fully cooperating with the FDA to resolve any questions or concerns expressed by the FDA.

Merge Healthcare has enhanced its FDA reporting methodology to report to the FDA product corrections and removals including those that may be classified by the FDA as Class III recalls. For clarity, Class III recalls signify the lowest potential risk situations, representing minimal impact to patient care. In this context 'recall' can be a form of communication and should not be interpreted as always requiring an update to a product. This change in policy will also increase transparency and notification to the FDA of Corrections and Removals associated with our medical devices. As a result, it is very possible that you will see an increased number of reported events on the FDA website. You will also see an increased number of messages from us, explaining the details around the event and any required action that may need to be taken.

So what does this mean to you? It means that we will continue to provide timely and comprehensive communication and information about the use of our products and overall product quality. It also means we will continue to deliver solutions you can trust and that help you provide the best patient care possible. And lastly, it means we will continue to provide world class support of those solutions and provide the opportunity for you to take advantage of our latest product advancements.

Merge Healthcare intends to advance the delivery of quality, patient-centric solutions in healthcare. We thank you for your continued partnership with Merge Healthcare and look forward to continuing to serve you for your current and future needs.

If you have any questions or would like to discuss this matter further, please feel free to reach out to me at your convenience.

I am gratified to read this; it is an upstanding and even courageous stance.

Software, being written by human beings, always contains some mistake or glitch or something. The PACS created by Merge, and its predecessor AMICAS, are no exceptions. THIS LINK takes you to the 11 complaints I could find about Merge PACS. THIS LINK shows a few more, older complaints when AMICAS ran things.

By the way, MAUDE in the list of problems stands for: "Manufacturer and User Facility Device Experience". I guess that could be positive or negative.

Having a problem? Your government is here to help you. Search for it at:

Friday, January 08, 2016


If you didn't know, I'm semi-retired, working only 26 weeks of the year. That would be half of the year for those uncomfortable with mathematics. The ultimate plan is to do this for another 12-18 months (one to one and one half years if you need the conversion factor) and then goodbye to the joys of private practice.

Of course, my ultimate plan lacks some ultimate planning. Being relatively young, and in relatively good health, I've got to do something with all that free time beyond writing blog posts few read, and lurking around Facebook and

A friend knew people who were going to create a flying hospital within an old 747 some airline was going to donate to them. I found this a fascinating concept, and I was forwarding suggestions as to which scanners and PACS and so on might be critical for such a project. Sadly, this has yet to get off the ground, so to speak.

A Merge Healthcare newsletter, however, revealed their partnership with RAD-AID, a world-wide Radiology project that IS active, and in fact has done quite a lot of good already in many far flung places.
Chicago, IL, 10 Sep 2015

Merge Healthcare (NASDAQ: MRGE) today announced a new global collaboration with the nonprofit organization, RAD-AID International, (US Registered 501c3) to bring vital radiology and health information technologies to medically underserved and poor regions of the world. The collaboration—RAD-AID Merge International Imaging Informatics Initiative (RMI4)—leverages Merge’s leadership in radiology information technologies with RAD-AID’s global health outreach network, including 3,500 volunteers, 14 country-outreach programs, 33 university-based chapters and affiliation with the United Nations’ World Health Organization (WHO).

WHO reports that nearly half the world has little or no radiology services. Moreover, most of these low and middle-income countries have no access to health information technologies, such as Picture Archiving and Communication Systems (PACS), Electronic Health Records (EHR), Radiology Information Systems (RIS), Hospital Information Systems and other life-saving health informatics platforms for storing, retrieving and interpreting patient data. In collaboration with Merge’s charitable contributions of software, technical resources and expertise in radiology image-management, RAD-AID will implement these health information technologies at the nonprofit’s partnered international sites along with RAD-AID’s ongoing delivery of clinical education, on-site training and radiology assistance to comprehensively support poor and resource-limited countries.

“This collaboration between RAD-AID and Merge represents a major step forward in bridging charitable outreach and health technologies for the mission of improving global health,” said Dan Mollura, chief executive officer, RAD-AID International.

Serving as an important foundation for this collaboration, RAD-AID has designed and deployed its Radiology-Readiness AssessmentTM tool since 2008, to assess, plan and deliver radiology in poor and medically underserved regions. Over the last seven years, these RAD-AID Radiology-Readiness Assessments confirmed the near-complete absence of health information technology in low- and middle-income countries. To begin addressing this significant health care disparity, RAD-AID and Merge developed RMI4. As a resource for carrying out this initiative, RAD-AID recently enhanced the Radiology-Readiness tool to include PACS-Readiness, a data analytics tool for specifically planning international deployment of PACS in facilities having little or no prior experience with imaging platforms.

“Merge takes corporate social responsibility very seriously and is excited to partner with RAD-AID to bring radiology and health information technologies to medically underserved and resource-limited countries across the globe,” said Justin Dearborn, chief executive officer, Merge Healthcare.

The collaboration envisions the creation of a constructive, educational and supportive roadmap for medical imaging facilities and health institutions in underserved regions of the world to adopt radiology imaging informatics systems.

Now THIS is what I'm talking about. Here's a chance to deploy the software I appreciate most in areas where it will do a tremendous amount of good. And maybe I could share some of my meager radiology expertise as well. (Ironically, when I first contacted RAD-AID, I was asked if I knew how to implement the dcm4chee open-source system, which I don't, but perhaps I won't have to learn it after all...)

RAD-AID itself is an interesting operation.

RAD-AID began in 2008 to answer this need for more radiology and imaging technology in the resource-limited regions and communities of the world. The organization began as a few people at Johns Hopkins, and has grown to include more than 3,500 contributors from 200 countries, 45,000 web visitors per year, 33 chapter organizations, and on-site programs in more than 14 countries.

RAD-AID’s mission is to increase and improve radiology resources in the developing and impoverished countries of the world. Radiology is a part of nearly every segment of health care, including pediatrics, obstetrics, medicine and surgery, making the absence of radiology a critical piece of global health disparity.
The organization sends teams to dozens of countries, and truly has a positive impact upon health care.  I've been in touch in particular with the team working in Ghana, and there was even an immediate opportunity to go there which I can't at the moment.

But the need is great, and we all can help.

Go to, and consider volunteering. Even if you can't volunteer at the moment, please consider a donation, either to the Ghana project HERE, or to RAD-AID in general (popup link on their homepage). 

This is a worthy cause, one which should be close to the hearts of those in the imaging business.

See you in Ghana! (Or maybe Nepal, or maybe...)

Thursday, January 07, 2016

The Demonstration

Image courtesy of
Hi, everyone. I see we have some folks here from Administration, and from IT, and even five or six radiologists. That's great. I was sent here by your EMR vendor to give you a look at the new RIS add-on, DoctorThingy. It's a nice piece of software that can be used in either RIS-driven or PACS-driven mode. We could probably run it both ways, but we don't recommend doing that. Why? Well, you might have some trouble synchronizing worklists, and some exams might just get read twice. We don't want that to happen, do we? So let's see how this looks.

Your overhead projector will only work in landscape mode, but we recommend using portrait mode. No, we can't turn the projector sideways, it's bolted to the ceiling, isn't it? Maybe you could all tip your heads to the left? No, no, I'm just kidding. But keep in mind that you would normally see this wonderful informational window stacked on your portrait monitor with another window below it. Of course, you could get one of those nice Barco 12 MegaPixel monitors and have room for lots of windows! Or you might need a fifth or a sixth monitor for our window, and your old PACS text window and your PowerScribe window. Oh, you don't have that yet? Oops.

Our early implementations of the DoctorThingy were PACS-driven.  That's probably because no one had invented RIS-driven workflow back then. But now most of our sites go RIS-driven. That means we replace your PACS worklist with our page that includes your worklists. And it will show you how many reports you have to sign, and let you do that without opening another app, and we know you hate opening other apps! When you select a patient, it shows everything you have in the EMR about him. Oh, yes, you can have as many worklists active as you wish. No, that won't bog down your page. Your PACS can't handle that? Well, that's a good reason to go RIS-driven, isn't it? Ha ha. Anyway, our RIS when teamed with DoctorThingy replaces your worklist completely. You can make any kind of worklist you want, using any criteria you can think of. What's that? You want just to search for a individual patient? Easy peasy! Here is the search window. You can search by name, date of birth, ID, and AARP number. Really? You want to search by modality? Or you want to go back and review the MRI's you've read in the last week? Hmmmmm. The DoctorThingy search window won't do that. Never has. But don't worry. If you minimize DoctorThingy and open CollosusSearch, you can find just about maybe all the patients with a certain astrological sign who had defagrams in months that contain the letter "R". Isn't that worth opening up another app to see? Oh. Forget what I said before about opening another program.

What's that? You need voice clips on the ER exams? Well, DoctorThingy had voice-clips. You know, saving them as .WAV files and all. But we dropped that. No, we have no plans to put it back. Well, OK, I'll ask. You have voice-clips in your PACS viewer? That might work. If you can get to your PACS viewer text page. Oh, silly me, it will be hidden by the DoctorThingy window. But if you have a proper portrait monitor, you could still arrange things so you could see it after all. I think.

Oh, you want to know about workflow with your PACS? Oh, yes, we've integrated at another site to the same PACS. Yes, ONE other site. You'll be the second. But we really appreciate your help with beta-testing the system! Yes, the existing installation is in Nome, Alaska. Nome. N-O-M-E. Shall we go for a site visit? You all go on ahead, I'll meet you there in July. Since I haven't been there, I really don't know just exactly how this will work with your PACS. But it's really really powerful. Great software.

I know you guys want some kind of demo program you can play with. Sorry, but this nice demo you are seeing on the screen is straight from our HQ inside the NORAD mountain. It's only for the demonstrators like me. No, you can't have access to it. But your site already has the code. What? It isn't online yet? Well, once it is, you can probably play with it, if IT can set up a test environment for you. That shouldn't take too long, right? No more than a month or so. Because I'm told this project won't go live until April Fools Day, and that's almost three months from now! That's certainly enough time for you to iron out any and all difficulties presented by this wonderful software. IT people, do you know how it works? Are you all ready to get it going? Oh, well, you'll figure it out.

So don't worry! Just because you are being forced to use this untested integration of new software without adequate prep time which will completely upend the way you do your job shouldn't bother you! It will all work out. It always does. Just look at how well your PACS runs! On second thought...

If there are no further questions...

Friday, December 18, 2015


Hey, Dad!

What, Frasier?

There isn't a lot of time, Dad, and there's a lot to say. The vet will be here pretty soon, you know.


Yeah, Dad. I'm almost 17 years old, damn old for a Jack Russell Terrier, and I'm not doing so hot. I know you see it when you look at me.

Yeah, Fras. I know. I had hoped you didn't understand.

I put on that dumb face so you won't worry about me. But it's OK, Dad. Really. I'm ready. I can barely breathe, I can't eat, I can't stand up anymore. I'm not having a very good day, and I'm tired. Really, really tired. It's time. We all know it.

I'm sorry, Frasier. We don't want to let go of you. You aren't hurting, are you?

Nah. Just uncomfortable. But this whole  dying thing is darn undignified, you know? Why you humans keep yourselves going when you've reached this state is beyond me. If you really loved your loved ones like you love me, you would let them go in peace. Personally, I'm looking forward to it.


Cut it out, Dad. No tears, please. OK, maybe a few if you must. I know you and Mom and the kids (and even that little devil dog Sophie) love me. It's been a damn good life. I don't have any regrets and you shouldn't either. Really. Loved our walks, loved sleeping in the bed with you, licking your pillow (even when you yelled at me for it). I really liked the frozen yogurt on my birthday, and the occasional McDonald's cheeseburger and fries. It's all good. It really was.

You are a very good boy Frasier...

Yeah, I tried my best. At least you never played that stupid human game of "Who's a Good Boy?" I can rest knowing that I was.

Will we see you again?

Ha. That's the Big Question, isn't it? Wish I could tell you. Jewish law is kinda vague on that. Supposedly, there are 5 kinds of souls. Animals have the most basic version, the life-force. That goes back to G-d. Humans have all 5, and they say go to a different part of Heaven.

I hate to disagree with you and the Rabbis, Frasier, but I'm pretty convinced you have a human soul, too.

Hope you're right, Dad. I've always thought so, but I'm just a dog. If so, we will meet again. But even if not, I'll be back with G-d which is a fair trade-off, don't you think?

We love you Fras... Godspeed.

Love you too, Dad. Don't forget me, but don't grieve too much. I'll be fine. I promise. And you will too.

Sunday, December 06, 2015

Exhibits At An Exhibition: PACS, HYPOTHETICALLY-Speaking

Having little time at this year's RSNA, I was able to only briefly stop in to see friends at the Visage and lifeIMAGE booths. Both products show nice incremental improvements. Visage offers deconstructed PACS, with better collation of prior studies in this incarnation. It is a viable alternative to a full-fledged PACS, IF your IT folks can handle the concept. Big IF for some. Again, there is no worklist option included; "That would make us a PACS company!" So what's wrong with that?

lifeIMAGE continues to progress, now with even better connectivity. See this nice summary from Imaging Technology News for details. Many PACS vendors offer some form of image sharing in competition with lI, but the latter does it better. I've said it before and I'll say it again:  NOT using an image-sharing system is MALPRACTICE. Period. If you never believe anything else I write, believe that.

I have stated elsewhere that if I were to need a new PACS, my list would be short, based on experience, discussion, research, gestalt, instinct, hubris, and maybe a little luck: Merge, McKesson, Intelerad, and Sectra. Unfortunately, I only had time to visit the first two.

In addition to the Code Name: Avicenna project, Merge offers the latest version of PACS, Merge 7.1, to be released in the Spring of 2016. This latest descendant of the venerable AMICAS PACS (Version 3.7 is still in use at Mass General!) includes a number of tidbits gleaned from Emageon and DR, the systems Merge has assimilated over the years. The major improvement concerns the worklist, which can be used in composite mode, with up to 10 separate worklists operating on-screen at once. And unlike a certain system we know and love, this has no IMPAXT upon the speed of the client. Rules for the next study to be read can be specified so the most appropriate (and urgent) study is the next one to be read. (The next iteration, still a Work In Progress, will further assign studies based on RVU, subspecialty, etc, and should truly be Universal across the enterprise.)

My Merge-based IT people will be pleased to know that user-management is now templated, allowing quicker assignments of permissions and so forth. And the slippery menu-driven preferences is now on a single pop-up window. There is user-level XML integration which could, for example, be used to keep windows open or closed after completing dictation.

There is a new Macro Manager that will combine multiple repetitive actions. There is advanced breast-tomosynthesis with slab-viewing and position markers, as well as PET/CT fusion.

From DR comes embedded dictation with Speech Recognition (which I won't use!), and further improvements on an already excellent hanging protocol functionality. I'm excited to say that there will no longer be the same degree of dependence on series labels (which I cannot get the techs to standardize for love, money, or prolonged tantrums); one can specify, for example, what T2 means on an MRI from Scanner Vendors X, Y, and Z, and then key a hanging protocol to show all the T2 images. You get the idea.

I proposed the HYPOTHETICAL scenario of a failing Big-Iron PACS and asked what Merge could do in such a HYPOTHETICAL situation. HYPOTHETICALLY speaking, Merge could either provide an overlay to the database of the HYPOTHETICALLY failing PACS, assuming that component retained its integrity. Alternatively, Merge could move in as the primary PACS in such a HYPOTHETICAL situation, using DICOM Q/R to retrieve priors in the near term while migrating the entire database in the background. Fairly standard, although the ability to front for a failing system might not be as facile with the other vendors. Should the users of the HYPOTHETICALLY impaired PACS have a Merge PACS somewhere, that existing system could perhaps be used as a secondary server. Also, it would be easier to create a unified worklist for all the PACS in an enterprise if they happened to be from Merge. Food for thought.

McKesson is one of those rare PACS for which we hear minimal if any complaints, even fewer than for Merge and the others. No doubt there are some cranky rads out there who could find something wrong with it, but they are a minority indeed. McKesson PACS is now known as McKesson Radiology, a regression from the old Horizon moniker. The company has a much greater presence in my home state than I knew; they might actually have the majority of PACS here, or at least a significant pleurality.

McKesson is also proud of its hanging protocols, although the emphasis in the demonstration seemed to be on the fact that once they are set up, one wouldn't need to change them. But drag-and-drop and scripting is available for those who want to tweak things. As with Merge, they are not based on series descriptors. If your mouse wheel can tilt to either side, this motion can shift sequential hanging protocols.

There is a nice embedded advanced imaging module that does "~80%" of what one gets with an external TeraRecon, most everything but vessel fly-through. It even has lesion tracking. Tomosynthesis and PET/CT viewers are fully integrated.

Add-on modules include "Imaging Fellow" which can open RIS/EMR data, and is supposed to be able to open "any other exam from any accessible database." This would allow for data mining if you were so inclined.

PeerVue was purchased by McKesson years ago and is now called Conserus. (I would have gone a different direction...sounds too much like Cons 'R Us.) This critical-result software sends texts and emails and other reminders about things that need to be seen NOW.

The "Intelligent Worklist" allows prioritization by rules as we saw with Merge PACS (although the AMICAS/Merge worklist continues to have by far the best visual clues.) This module will monitor foreign PACS, allowing a sort of unified worklist, but still launches the foreign PACS client. I think it is capable of opening the study in your McKesson PACS if you have one, but I wasn't completely clear on that one.

A collaborative tool allows instant pinging of a colleague, referrer, etc, to get them to view a study. Right now, this spawns a second viewer program, not the main PACS viewer itself. This is to be incorporated into the main viewer eventually.

For those who work from or view from home, the main client can be used, although a VPN is required. It was unknown as to whether SSL would suffice.

When asked the HYPOTHETICAL question about the HYPOTHETICAL scenario in which a HYPOTHETICAL PACS needed replacing, the McKesson folks offered up similar solutions. The Intelligent Worklist could probably access the HYPOTHETICALLY failing PACS, as long as one had McKesson for the actual reads. Of course, they would be willing to migrate the old database in such a HYPOTHETICAL situation, and McKesson has in-house capability to do so.

With the observations now documented, I shall now stray into opinion territory. Emphasis on opinion.  Or really just me babbling on.

I have no clue at this point in time if I might be involved in any HYPOTHETICAL PACS replacements. I suppose I would suggest sending RFP's to the four companies mentioned above if that HYPOTHETICAL ever occurred. My good friend Mike Cannavo, the One and Only PACSman, has some very wise and mildly cynical ideas about RFP's. Adding in my own sarcasm, basically the IT folks don't know the questions to ask on an RFP but think they do. I have just one very easy question:  "Does the damn thing WORK?" Vendors will of course respond in the affirmative, but this really requires a far more complex answer with quite a few nuances and shades of gray. Perhaps the better question would be: "Does the damn thing work the way I want/need it to work?" I would love to hear the response to that one.

Mike noted an uptick in the number of vendors offering PACS and PACS-related wares at this RSNA:
So what was new? There are more PACS vendors for sure. I would venture to say that at least 70% of the vendors at RSNA 2015 had something PACS or PACS-related. It's just a matter of time before former PACSman award winner Ernie's Welding and Fabricating becomes Ernie's Pipes and PACS.

Even though we have had some market consolidation with high-profile mergers and acquisitions, for every one vendor that gets gobbled up, it seems like four new vendors appear. How many of the newbies will be here next year is anyone's guess, but if history repeats itself and 10% remain, it's a lot.
The problem is, even though some might have an innovative feature here and there, these tiny vendors probably won't be around in a few years, and many that are maintain their viability because their products are cheap (in price, but probably quality as well) and they appeal to small operations being run by those who don't understand what it is they are buying.

Ironically, the Powers That Be at one of our places blackballed AMICAS years ago because a consulting company (someone you hire and pay $50,000 to tell you what you already think you know) told them it was "too small" and would likely be acquired. Well, they were half-right. IBM now owns Merge, which owns AMICAS, but instead of quashing it, ala GE, the acquisition has strengthened the company and the product. GE assimilated DynamicImaging, among others, cannibalizing its PACS components into the Universal Disappointment. DI no longer exists in any form. Merge, however, is still alive, being billed as "an IBM company". AMICAS PACS lives on, and continues to grow. My friends from Emageon and DR Systems might roll their eyes a bit, but at least the best of their PACS components live on within Merge PACS, and credit is given to the predecessors as is due. I'm good with that.

McKesson Radiology is in many ways at the other end of the spectrum, being one of the last Big-Iron companies. Their product list contains hundreds of entries, and PACS is far from the largest offering. Still, there is a lot to be said for having a HUGE presence in the health-care marketplace, and to have a product with relatively few complaints. (However, I probably don't even have to say that simply buying from a huGE company doesn't guarantee a quality product.) Supposedly the rule at McK is that a call to the support center MUST be answered within 3 rings. I can't vouch for what happens after that. Many have said McKesson's architecture is a generation behind, and that there are too many different clients for different purposes, but I didn't discuss that with them at this point.

I have had very nice chats with Sectra and Intelerad folks over the years. In fact, Sectra invited me to come to their headquarters in Sweden, but I could only go in July, and Sweden apparently closes for vacation that month. My contact at Sectra has since left for a different company, as folks in this business are wont to do. I do keep in touch with some good friends at Intelerad as well. It is of note that both companies demurred somewhat as to what could be accomplished when given bits and pieces of the HYPOTHETICAL failing-PACS situation.

I'm in my eleventh year of blogging about PACS, and the more things change, the more they stay the same. What worked before still works and works better, and what didn't work still doesn't work, and may even be worse. (And the attitude of IT doesn't seem to be much different at all.) Some companies listen better than others, and some even listen to the right people, the end-users of their wares, and not just the people with the checkbook.

Remember Dalai's First Law of PACS: PACS IS the radiology department. It has to work. And not just HYPOTHETICALLY.

Saturday, December 05, 2015

Exhibits At An Exhibition: Siemens Press Conference

"Pictures at an Exhibition" Courtesy TzviErez

I'm back from a rather brief trip to Chicago and RSNA. I had two days to see stuff and get some edumacation, as we say down here in the South, and I tried to make the most of it.

Educationally, I used my limited time to concentrate on PET and thyroid/parathyroid imaging. I come out reassured that we are doing things correctly. I'm still a little confused as to the best application of SPECT/CT to parathyroid imaging, so I'll probably be doing some experimentation when we finally get the darn thing sometime early next year. One presentation claimed better accuracy with good old pin-hole/planar imaging than with SPECT/CT. We'll see.

I began my 48-hour RSNA marathon early Monday at the Siemens Press Conference. Somehow, Siemens still thinks I'm some sort of journalist, which speaks more toward my friendship with people who decide such things than their better judgement. Not to worry, though, the room was filled with real reporters from real publications, who will properly convey the things correspondents are supposed to write. But you might want to question their judgement: some of them said they were readers of this blog, or at least familiar with me, and if I were them I probably wouldn't admit it. One VERY wise lady from a VERY respected publication did note the iconoclastic tone I generally manifest, proving that she really does read this. Thanks, Ms. C.P.!! I'm going to tattle, though. Some of the reporters were on their laptops doing things other than paying attention to the presentations, and one reporter who used to work for Siemens asked some very long and barely comprehensible questions at the end. Which were answered quite throughly.

Having been a regular attendee at the Siemens event, I was surprised this year to see new faces. In years past, Dr. Hermann Requardt, (PhD in Physics!) CEO of Siemens Healthcare, presided over the meeting, with Dr. Gregory Sorensen, (Neuroradiologist) CEO of Siemens Healthcare North America, in the supporting role. They are no longer with us, at least no longer visible, having been replaced respectively by Dr. Bernd Montag, also a physicist, and David Pacitti, recently of Abbott Labs. Requardt is now on the board of Bruker, Inc., and is the new Chairman of the Board of SuperSonic Imagine; Sorenson was removed just in October.  HMMMMMM.... Perhaps their vision didn't match the current trends, but I can't say I heard anything much different than last year in that regard. Back in February, Siemens announced the change of CEO's. Joe Kaeser, President and CEO of Siemens AG, said: “Mr. Requardt and the managers and employees of Healthcare can be quite proud of their highly successful work together over the past years. I have the greatest respect for Mr. Requardt’s decision to make way for a generation change. We are now setting up Healthcare as a separately managed business within Siemens in order to pave the way for an equally successful future in a highly dynamic market and innovation- driven environment. This is now the task of Bernd Montag, Michael Reitermann and Michael Sen. They will have the full support of the Managing Board and their direct partner, Board member Siegfried Russwurm, who worked in the company’s former Medical Engineering and Medical Solutions units for ten years.”

I could report chapter and verse of what was said, but I'll leave that to the real reporters. What I will convey is my impression as the only physician in the room. (At last year's event, I was one of two along with Dr. Sorensen.)

Technologically, there was a smattering of this new or upgraded scanner or that, the standard stuff. Dr. Montag announced 510K approval of Siemens CT scanners for lung screening programs, and the new "teamplay" software for data transparency and availability (acknowledging the ubiquity of tablets in the healthcare environment). The new HELX touch-control ultrasound scanners should reduce operator variance thorough streamlined user interface. It's supposed to be easy for inter operative use by surgeons. Thanks, Siemens. We also note the advanced robotic and even 3D capability of the new MultiTom Rax X-ray room. Good incremental improvements, all. No mention of PACS, advanced visualization, etc.

The main message I got from the hour-long session is that Siemens understands the changes in healthcare, both here and pending, and wants to help physicians navigate them successfully, "Enabling Healthcare Providers Worldwide" in their words. The flip-side is that Siemens is invested in these changes, assumes they will come, and is resigned to the fact that they ARE coming. The transformation process to the new reality has three components:

  1. Consolidation of Providers 
  2. Industrialization--Dr. Montag: "Medicine is not an art anymore. It must be managed like a company in a controlled fashion." How sad.
  3. Managing Health--i.e., the transition from fee-for-service to value models
The process supposedly is inexorable, like the Law of Gravity. 

Diagnostics, particularly imaging are pillars of healthcare, and have been almost from the beginning. In fact, Roentgen himself was an early Siemens customer, and the company archives contain a letter of complaint from the man himself, noting the rather high equipment costs. Some things never change. Indeed, Siemens has been in on quite a few innovations in medical imaging, PET, PET/CT, PET/MRI, dual-source CT, etc.

Dr. Montag tells us that "90% of medical decisions are based on technologies in the Siemens portfolio." This, I think, is a little misleading. We could say that 95% of the world is lit by technology in the GE portfolio, the remaining 5% still using fire, but that really doesn't get us anywhere. I might have phrased it differently, but we get it.

Further examples were given of how Siemens can and will holistically improve health care, radiation therapy guidance, laboratory productivity, and triaging patients. Siemens will help us with standardization, consulting, and a world-wide network geared to mastering the digital transformation, leading to better outcomes at lower costs. 

In the end, 10% of the costs of healthcare relate to diagnosis, and our value thus depends on early diagnosis which could reduce the price of the remaining 90%. That's a better definition of value than I've heard to this point.

Still, I'm personally not as convinced as the good folks at Siemens that this value thing is permanent. Much will depend on the upcoming elections among other things. But I do understand the need to conform to the environment in which they wish to sell their wares. No doubt if fee-for-service comes back, Siemens will exercise its flexibility once again, and pivot back to whatever worked in the old days. Like selling scanners to doctors' offices. Just like GE. Still, if your going to scan, you might as well have the best scanner.