Another Look At Impax 6.0

I don't think anything I have ever authored has stirred up as much interest (trouble?) as the post about Impax 6.0. My blog received hundreds of hits from Agfa sites around the world, including Belgium, Ontario (my friends at the old Mitra operation in Waterloo), Massachusetts, and even right here in South Carolina. Wow. If only I got paid per view.

Meeting with the Agfa folks at RSNA was somewhat surreal. Everyone on the Agfa staff could not have been nicer and more helpful. My questions were answered promptly, and several folks spent a great deal of time with me, which I truly appreciate. However, there was obvious tension in the air. I don't really think they are afraid of lil' ol' me, but I know they would have been happier if I hadn't posted my little ditty on the web. I felt rather as though (please forgive me, gentle reader) I had, um, passed flatus in front of everyone. We could all smell it, but no one wanted to actually mention it. There were one or two rather cryptic references to "stuff posted on the internet" to which I demurely replied, "no one really looks at the internet, do they?" So, before I go farther, I will ask a favor of all of you. If you look down a bit, you will see a comment button. That is your connection to me. If you have something to say about what I post here, by all means let me know. If I find I have written something in error, or there is more information germaine to the problem at hand, a retraction or addendum will be posted ASAP. I am not doing this for money or even fame. I get great enjoyment out of sharing my thoughts and observations, and I hope I've helped clarify things here and there. It never ceases to amaze me that people really do read this stuff.

Another preamble...I need to clarify as well my position on Agfa. Given the limitations placed on our PACS selection by IT (we had to choose between Agfa, Fuji, and GE to replace our Impax 3.5), I was convinced that Agfa was the lesser of the evils, and the 6.0 demo gave me hope that they were on the right track for the future. Bob Pryor's "we dropped the ball" speech really "got me right there", as they say, although some of our upper level administrators have since laughed at my naivety, suggesting that this is a common tactic. Oh well, it sounded good at the time. We will have lived with Impax 4.5/5.2 for 15 months before we are to get 6.0. The older product is rather uninspired compared to the up-and-comers today, and has glitches that have not been fixed, and apparently will not be fixed with 6.0 coming online. These glitches include little annoyances like the cursor disappearing from the screen when you type a comment (I accidently discovered that you bring it back by pressing the "TAB" key), impossible-to-deploy hanging protocols, cryptic approaches to worklist wizards, intermittent prefetching of priors, waits of 5-55 minutes for manual retreival of priors, and a host of other things. Add to that promises of rapid database migration and merger of a whole lot of data from our two Agfa hospitals that now need to be on one system which so far appear significantly delayed at best (all the more poignant since my group now has the contract at the other place as well) and you can see why I continue to be wary.

All that being said, what follows serves mainly to add additional information. In my opinion, I actually had the majority of it right the first time, and that without any direct data from Agfa. Here is more of the story, this time with their help.

You may find it amusing that Agfa has finally posted information about Impax 6.0 on their site, which was not there when I wrote the original article. Within you will find actual screen-shots, although they are rather small and do not reproduce well (I tried, obviously.)

OK. First off, let's talk fundamentals. Impax 6.0 is built on the .NET platform, and is written in Common Runtime Language. For better or worse, this is the main approach Microsoft is pushing, and since we are all running Windows, that does represent an advantage. As with all things Microsoft, there will be a torrent of updates. Agfa tells me that CRL 1.1 is currently shipping with .NET, but 2.0 is in the works. Therefore, "....we intend to stay current with Microsoft updates. We'll need to, since many Windows users have computers set to autodownload updates from Microsoft." What happens, I wonder, if CRL x.x gets downloaded before Impax is ready? I guess that isn't supposed to happen. The .NET/CRL approach does indeed get rid of Java, but don't think there won't be some similar problems with CRL.

Early users had reported stablility problems; one site told me their Impax 6.0 (which was used in appended fashion on top of 4.5) was up "at least 80% of the time". This is what scared me the most. At RSNA, Agfa assured me that the problem was solved with "a Microsoft patch". To be fair, Impax 6.0 was deployed at most of the computers in the Agfa booth, and I didn't see any obvious crashes. Our demo went off without a crash or a lock-up.

There are three beta sites currently running in the US, with 20+ sites in Canada and Europe. The deployment strategy (and of course it was planned this way all along) is that new sites get 6.0 starting early 2006, with us groady old legacy sites set for upgrade June 2006 or so.

At least three servers will be required: one to for the SQL database, one for HL7 traffic, and one managing curation of the data and the .NET structures. I have seen examples of a five server configuration with an additional .NET server. The system is supposed to handle approximately 100 concurrent users per server (I assume per .NET server). Yes, it is web-deployable, and you can set it to work with anything from one through five monitors.

Once you sign on to the system, the main screen is the worklist and messaging center. I had forgotten that it has a dark grey-green theme, which is a little easier on the eyes that total black and white. There is a "Communication" tool that gives login messages, tip of the day (e.g., don't buy GE), case of the week, etc. This is controlled by the role of the user, and much of what you can access also is based on your role, i.e., physician, tech, CIO. You can edit how each role works, allowing easier adjustments than if you had to change the functions of each individual.

To the left on the main screen are found the worklists, which are customizable by the user. You can set it up just about any way you like and have it change by the day, or maybe even the hour. I can establish Dr. Dalai's Special worklist, for example, that pipes all MRI studies to me on Thursdays from 10:00AM to 10:14:32AM, sends me all Nuclear Medicine, and retains every exam on patients with insurance, leaving the uninsured to be read by my colleague down the hall. OK, I'm joking about that last one, but you get the idea. There are "pseudo-Boolean" operators available to allow something like, "Study CONTAINS CT, or Patient Name IS NOT Joe GEUser. You can drag an individual study from one worklist to another, say to set up a peer consultation or something like that. You can drag the columns around and they "stick" where you left them. In an article to come, I'll share my views about this sort of hyper-customization. It does give the user unprecedented power to create really detailed worklists, but to be honest, I probably won't do much more with it than simply select "Everything New Today".

A button labeled "Relevance" (should this be "Relevants"?) determines if prior studises are listed. There is also a "Refresh" button. Although I assumed the worklist would refresh instantly via Instant Messenger-type mechanisms, we were told that one might set the system to poll for new studies every 5 minutes or so, and you might want to "refresh" to catch a study in between. Hmmmmm. OK.

When you actually get to the point of double-clicking a study, the viewer launches, and the main display shifts to show study highlight, the order, the study information, report and key-images if these exist, and a list of prior exams. The study highlight box is supposed to be everything you need at one glance to get rolling, like reason for study, ordering jerk, I mean honored clinician, the tech that performed the study, etc. This can be individualized to the role or even the individual level with dragging and dropping various elements. Same with the Order pane. "Study" shows modality information. All panes can be resized ad nauseum, much like a web-page with movable frames.

The viewer itself has a new look as compared to older Agfa products. There are 9 BIG buttons on top, 5 of which have adjacent drop down arrows (actually inverted triangles) in buttons almost as big. These are supposed to cover most functions. This toolbar can be set to autohide, much like the Windows Task-Bar. There is still deep access to a myriad of functions with a heirarchical right-click menu. Multiple patient windows can be opened and you keep track of them with tabs on the bottom of the screen. The system keeps track of the last 20 patients, so if you get that lightning bolt a hour later that a particular bone probably shouldn't be in three pieces after all, you can go back and review said study. There is one-click access to Voxar 3D, and images generated within can be saved as additional sequences of the study. There is right-click access to export by CD-ROM, e-mail, and disk-save, the latter in whatever format you choose (jpeg, tiff, crayon, etc.) There is nearly infinite customization possible, somewhat like 4.5/5.2 today, and hopefully it is a little easier to set up. I did not ask about hanging protocols, but they couldn't be worse than what we have now, which is totally unusable.

My earlier post noted that spine-labelling, CT linking, cross-referencing on orthogonal planes, remote administrative access, etc., were going to be available only on a later version. These were present on our demo (or were said to be in the case of remote admin, and I do not doubt that this is so). My information may have related to a much earlier beta version, perhaps, or they did a whole lot of work on the thing before RSNA. Spine labelling is still pretty primitive however, and I was told that they were getting "beat up" over this by everyone who looks at it. Expect improvements eventually. There is no longer a "simple" MPR tool; if you want MPR, you use Voxar.

When I first saw the Impax 6.0 demo, way back in 2003, I had not had any time on the older 4.5/5.2 systems. In the end, the 6.0 viewer, while certainly improved, does show deep down its heritage. Case in point: the clone window. With the majority of new systems, you can drag a sequence to any frame/pane/viewport, and do so as many times as you want. Personally, I like to view my CT's with multiple windows. I view a chest CT, for example, with the same sequence displayed in triplicate, using lung, mediastinal and bone windows. The fourth port in a 2x2 display gets the scout or coronal reconstruction with cross-reference lines. Here is what that looks like (NOTE...this is a screenshot from Amicas LightBeam, NOT IMPAX!!!):

Agfa doesn't work this way. You can do something similar with their "clone window" concept, that does link the windows together (which it should since it is the very same data), but doesn't let you link them to a prior. This is a serious lack in my book, and this is exactly the way the older Impax platforms function. I am left with the nagging sensation that Viewer 6.0 is much closer to Viewer 4.1/4.5/5.2 than I would have guessed.

Our demo was choreographed by Bob, Agfa's Senior Marketing Manager, and he did a very good job, I might add. He made one statement that I keep replaying in my mind: "We worked with 12 doctors on this, and they agreed it was perfect!" I can't get any two of my partners to agree that the sky is blue, let alone anything of more substance. I will make a little side-wager that those 12 docs had used mainly Agfa PACS for a long time. We all tend to become a little inbred, and happier with the familiar. That would explain the "perfect" designation of a product that does things in somewhat similar manner to the old way. This is a path to stasis. There are a lot of new ways of doing things that are work very well, and it is important to seek opinions of those who use the "other guys'" stuff as well as your own loyal customers. Now don't feel like I'm picking on you, guys, I've told this to Amicas and GE and everybody else who will listen.

Impax 6.0 is without question a significant improvement over its predecessors. Will it really become my favorite PACS? Likely not, but I will give it a fair shot, I promise. We have yet to see whether or not it will get in my way.......