ITL Strikes Back

I received this response from the imaging center owner:

I've shared your thoughts with the ITL group that we met with on May 4,2005. The enclosed attachment is their response to your concerns. Based on their response as well as the points I've listed below, I feel that I must go forward with the purchase of this product.
* I've signed a contract
* (Imaging Center) has the opportunity to save a significant amount of money vs. other PACS systems.
* The product is on a single platform which has benefits that none of the others have.
* Several of the Radiologists in (your) group that I've asked about time saved, said 20% to 40%. If you weigh that against 4 or 5 calls a day until they get used to it, your group comes out way ahead.

Now, the response from the president of ITL:

Dear (Imaging Center Owner):
It was great to see you Wednesday, and we appreciated the time and courtesies extended to us by the entire (Imaging Center) team in discussing implementation of Image Technology Laboratories WarpSpeed seamless RIS/PACS. We are eager to see (Imaging Center) realize improved business efficiencies and quality through the deployment of the WarpSpeed system.
We appreciated the time, albeit brief, that Dr. Dalai afforded us, and respect his radiology expertise. While we are disappointed and disagree with his conclusions, it underscores the traditional distinction between image management products and information system solutions. Given his experience with, and knowledge of, particular image management/storage systems this is not surprising. While we don’t question the sincerity of his intentions, it does not provide license for him to make incorrect pronouncements as fact when commenting on RS/PACS in general, and ITL in particular.
Many of Dr. Dalai’s opinions may have certain relevance in his environment. We do not mean to trivialize them, nor do we wish to engage in a technology debate of image management products and our seamless RIS/PACS solution. However, please allow me to comment on some of the incorrect conclusions expressed relative to ITL:
Within the simple context of an image management system, one might understand some of his assertions. For example, while some image management products omit the “... computer between each modality and the main server”, RIS requirements generally dictate use of a computer at or near each modality. In a seamless RIS/PACS environment, a computer strategically placed at this important “pressure point” improves quality by automatically ensuring data consistency and integrity. Historically, non-seamless RIS/PACS data inconsistencies are handled by a manual downstream QA “exception” resolution step. Billing quality is enhanced by allowing the person closest to the procedure, namely the technologist, to provide the CPT codes as the study is pushed into the workflow from this computer. The technologist can also specify study priority, hold / preliminary push status.
Dr. Dalai’s comment that “...I am assuming that the radiologists with whom they partnered had little PACS experience “when he raised the issue of CT slice thickness when looking at comparison scans is incorrect as well. One of ITL’s founders was the radiologist assigned to bring PACS to Albany Medical Center. Moreover, within an imaging center or community hospital, the majority of the comparison scans are intentionally performed using the same protocol, including slice thickness. Slight differences in patient position on the table between scans, as well as the natural variations associated with the human respiratory cycle, were important considerations to our team when that area of function was designed. It is a rather trivial matter to automatically adjust the linked comparison scrolling based upon the DICOM Frame of Reference and Image Plane Module information. While this is not an issue in most installations, we are incorporating that change as part of our commitment to (Imaging Center).
“...data distribution structure is reminiscent of Agfa and Siemens designs from five to eight years ago” Our internal enterprise-class architecture uses many technologies that didn’t even exist five to eight years ago, such as transactional asynchronous message queuing, high-performance distributed file systems and distributed objects to implement a unique hybrid push-pull data model that is impossible to convey and understand properly in a short 10-minute drawing session. We are confident that no other industry player has implemented such an architecture. It is precisely this workflow architecture that gives us our strength in delivering value to the entire medical imaging business.
“The majority of systems today are web-based, relying on the architecture of the Internet itself, rather than reinventing the wheel” The Internet is an implementation of a homogeny of RFC (Request for Comment) “standards”. We utilize as many of these RFCs as is necessary and appropriate and our system can and does run within a LAN environment as well as across the Internet via VPN.
We constantly reevaluate “web-based” technologies (whatever one chooses that phrase to mean), especially those associated with Linux and Windows, such as the .Net infrastructure. It is not our intention to enter into a debate with Dr. Dalai over the virtues of thick-client vs. thin-client or two-tier vs. three-tier architectures, since it is a very complex set of issues, especially with respect to security, viruses/spyware and performance. The medical imaging community is just now waking up to the inherent security issues and starting to produce white papers and articles necessary to more widely appreciate these problems. Dr. Dalai stated “Most systems today use the web approach for remote access, which has proven to be safe if implemented properly.” This isn’t about proper implementation techniques, rather it really is an issue of security exposures in the underlying web-enablement technologies. See http://www.microsoft.com/security/default.mspx. We will be happy to discuss our web-portal capabilities with you privately under an NDA.
“From a hardware standpoint, I would be very concerned about their proprietary assembly of the core of the system” There is a distinction between configuring the “off the shelf” server systems we procure and integrate with our software versus Dr. Dalai’s allegation that we assemble the system around Intel server motherboards. Dr. Dalai mis-understood what we were trying to convey. We do procure our servers from a major rack-mounted “off the shelf” supplier. Our choice of servers happens to use Intel SMP motherboards, reflecting our positive experience with Intel, along with other standard components that we specify. There are no custom ITL components in any of the computers we supply. ITL is a software developer and systems integrator, and we deliver turnkey medical imaging business solutions.
“...their product is for all intent and purpose in beta” The ITL WarpSpeed seamless RIS/PACS system is employed and has been in production since 2001. The study volumes at each of these locations equal, or in some cases significantly exceed, the current volume at (Imaging Center). The reliability track record of these systems and our software has been excellent. Our comments regarding the Company’s dedication to always looking for feedback and improvements were misinterpreted as a sign of weakness and immaturity of the system. However, our years of experience while at IBM has instilled in our engineering team the value of seeking feedback as a means of ensuring a constantly improving product that provides real value. Any feedback from Dr. Dalai in such a context would be appreciated, obviously subject to his time constraints, but is not required.
Dr. Dalai’s group has evidently struggled through some unfortunate history with specific image management vendors. I share his irritation with systems that require additional personnel and resources to manage daily operation. These challenges are increased significantly when stand-alone image management systems attempt to incorporate RIS and workflow enhancements as add-ons. Our seamless RIS/PACS WarpSpeed system and commitment to (Imaging Center) will ensure that you realize an improvement in the efficiency of your business without experiencing the same frustrations.
Finally, SEC regulations on selective disclosure preclude discussions on the Company’s financial position beyond our public filings. ITL became a publicly traded company in 2000 and the management of ITL remains optimistic about its future.
The ITL team is excited about starting the installation as soon as possible and establishing a long-term productive relationship with (Imaging Center).

Sincerely, President & CEO

Well. I guess I've been told, huh? I am rather disturbed by the whole thing, especially the total trust the owner of the imaging center places in this little company because they are willing to give it to him cheap. This comes after he promised he would not go through with the purchase if I honestly felt it was not a good idea. I guess money talks louder than most other factors. The CEO's response assumes either that I would never see his letter, or that my opinion has little bearing on the ultimate purchase. Seems to me it's probably not the best idea to refer to criticism as having a "license to make incorrect pronouncements". You know, the whole tone suggests a company at the edge. There are probably better ways to tell someone he is, in your opinion, filled with feces (even though I'm not at the moment). Perhaps that is the way business is done in the state of New York.
I'm not going to go through each point and re-refute it. I stand by what was said in the initial letter, and I am NOT convinced that any item was settled by the ITL response. I am most amused by the stonewalling behind SEC regulations as an excuse for not discussing the financial status of ITL.
ITL brought their entire engineering team down here. They took 20 minutes to get their demo running. Even then, they didn't bring a touch screen, which they describe as the key to navigating their client. Buying this product on this basis is like buying a car from a brochure without ever driving it, and that's being kind. Add to that equation that the car in the picture of the brochure has no steering wheel, but they promise your car will have one, and of course it will work perfectly.
This software, from my point of view, is just not there yet. It's cute; they made it look rather like the graphics from Star Trek, complete with appropriate sounds, and this is certainly endearing to me. But cute doesn't get the work done.
I am far from a PACS guru. What I know I have learned through a lot of research on the web, reading what I can about the various products out there, and various approaches. I missed SCAR last year, but I'll try to make it this year and learn some more from the real gurus. That being said, I do have some pertinent knowledge of PACS, and I know my partners. I conclude that this purchase is a very, very bad idea.