Sunday, October 16, 2005

Portable Patients? LogMeIn to Napster PACS

From Penner Patient Care (

Of the thousand daily frustrations I experience as a radiologist, perhaps the most painful is that of the portable patient. You see, patients migrate from hospital to hospital, from clinic to clinic, from office to office. They may be in search of a second opinion, a specialist, the answer they want to hear, convenience, drugs, or some combination of the above. As often as not, they acquire a mountain of imaging studies along the way. When asked why they had a particular study at a particular site, the answer is invariably, "My doctor told me to have it there." Add to that the dependence on our ER's for emergent (or subemergent, or impatient care, as I like to call it), and the ER's love of imaging studies. Put it together and what have you got? No, Cinderella, not Bippity Boppity Boo (my daughter made us watch that tape about a thousand times, and it stuck), but rather a collection of the patient's imaging studies spread across a city or even a state.

Americans place a tremendous amount of trust in their physicians. I think it is well-deserved, for the most part. But I must editorialize for a moment. You are all aware of the huge number of imaging devices being placed in clinicians' offices. With declining revenues, the docs had to turn somewhere to keep their incomes steady, and imaging is nothing short of a cash cow. Now, every last one of these installations is placed solely for the benefit of the patients, or so I'm told. It is just so much more convenient for them to have their scan right there in the doctor's office, rather than trudge down the block to the cold, impersonal hospital where parking is at a premium and the waiting room smells funny. It should not be shocking to learn that utilization of imaging resources doubles, triples, or even quadruples if it is in the physician's office. This is simple human nature. Mrs. Jones has a pain. To scan her or not to scan her. Hmmmmm. To generate technical revenue or not to generate revenue. Well, OK, maybe the thought process isn't so blatant as that, and most likely every single scan on an individual basis is justified. Still, the statistics bear out that the coin in this case lands on "heads" significantly more often than "tails". Here is a quote from our literature:

As shown in this article, the empiric literature reveals that self-referral constitutes approximately 60-90% of nonhospital radiography and sonography and smaller percentages of imaging in other modalities and settings. Nonradiologists performing their own imaging are at least 1.7-7.7 times as likely to order imaging as non—self-referring physicians in the same specialty who see patients with the same problems. When self-referral consists of referral to an outside facility in which the referring physician has a financial interest, imaging is increased by as much as 54%, depending on the modality. Nonradiologists' interpretation of images is usually less accurate than that of radiologists; the practical significance of this difference in some instances is debated. Other important deficiencies, such as in image quality or patient safety, are up to 10 times as common among nonradiologists as among radiologists, although a very few specialties, particularly cardiology and orthopedics, have records approximating those of radiologists. The limited evidence available generally indicates that increased financial incentives, such as those in self-referral, lead to more imaging and that self-referral involves overutilization.

B. E. Kouri, R. G. Parsons, and H. R. Alpert. Physician Self-Referral for Diagnostic Imaging: Review of the Empiric Literature. Am. J. Roentgenol., October 1, 2002; 179(4): 843 - 850.

There is great debate amongst the radiological community about this sort of thing. We are really upset when clinicians install scanners in their offices and read the output themselves. Now, what about the situation of clinician-owned scanners feeding scans to radiology groups that contract to read them, or even participate in the scanner equity? Well, whatever your opinion about all of this, two factors are evident: First, the insurance companies, our sometime friends, are hemorrhaging money over this issue, and will likely be the ones to put a stop to anything smacking of self-referral. Second, it is here for the time being, so, add to the list of patient exams those performed in their physicians' offices.

Back to things technical. Mrs. Jones, our patient with abominable, I mean abdominal pain, has undergone the following imaging studies within the last week (and whilst this patient is fictional, the list is shorter than some in the real world):

  1. Abdominal and Pelvic CT, SestaMIBI myocardial perfusion scan, and Gastric Emptying Study at County General
  2. Barium Enema at Baptist Memorial
  3. Gallbladder Ultrasound done in the ER at East Methodist
  4. HIDA scan at University Hospital
  5. Repeat CT at her internist's office machine
  6. Corpora Cavernosagram inadvertently ordered by intern at University Hospital

Obviously, she didn't get #6. Still, this is quite a bit of imaging, not to mention radiation. I'll avoid the obvious controversy as to why Mrs. Jones had the repeat CT. Let's assume her pain got worse and her internist wanted to monitor her progress. To accomplish this, it is critical to have the old scan available to compare to the new. I deal with this scenario several times a day. The ideal situation would, of course, have the patient get all her studies at one location, which somehow never happens. Sometimes the patient brings old studies on a CD-ROM or even on (yucch) film. Others have studies on varying other PACS systems in town. At last count, we use the following systems which we may have to access for comparison studies:

  1. Agfa Impax 4.5 at our two largest hospitals
  2. Amicas LightBeam at our two next largest hospitals
  3. GE Centricity 2.0 at an Oncology clinic we cover
  4. ScImage PicomOnline for remote reading of studies from a 64-channel CT at a Cardiology clinic
  5. GE Centricity Web 2.0 for comparisons at the Oncology clinic from the one hospital in town we don't cover
  6. MedView 5.0 from StorComm for remote viewing of musculoskeletal MRI from an Orthopedic clinic.
  7. Amicas LightBeam for importing imaging from various physician-owned scanners (MRI, CT, etc.) scattered around the state (work in progress...still need a guru!)

The Oncology clinic seems to be the nexus of this mess at the moment, and our viewing rooms there each have 7 monitors and three computers. Looks rather like the bridge of the Enterprise, but somehow my phasers won't blast the clinicians no matter how hard I squeeze the trigger. Comparing CTs slice by slice between the study on the monitors in front of me and those behind me is a real pain, and this is certainly a set-up for disaster. It would be a terrific advantage to be able to pull up the comparison within the PACS I am currently using to read today's study.

You see the problem. So, what to do? I propose a rather bold solution: a city-wide, a state-wide, or even a national PACS system. Before you fall off your chair laughing, keep in mind that even Cuba has a national PACS, IMAGIS. On a smaller scale, Austin Radiology had wired up their 9 hospitals and imaging centers together with one unified Fuji Synapse system as of a couple of years ago. (Their web-page mentions 14 sites today.) They specified that studies had to arrive at point B from point A within 3 seconds, and at that point they were paying quite dearly for the communication network to accomplish this. But the important thing to remember is that they did indeed network the town together.

I proposed this radical idea of a city-wide PACS to the powers-that-be, and was told, "You can't expect us to work with that other hospital that's suing us..." referring to the acrimony generated by a competing hospital's challenge of a certificate of need. Petty politics scuttled a potential savings of several million dollars, and compromised patient care. This sort of stuff has to be overcome somehow. All I can do is to point out the economy of scale, that a big PACS might be cheaper than two smaller PACS, and more importantly, that mobile patients need to have their imaging studies equally transportable.

I've been dealing on a small scale with the problem of networking widespread scanners and disparate PACS systems. I am not well versed in DICOM, and I could probably express myself better in this venue if I studied this more. (Someday, I would like to have even a tenth of the respect DICOM guru David Clunie enjoys in this field.) My simplistic view of connectivity is that you have to establish some sort of TCP/IP connection, usually via VPN, and you must know the AE titles, ports, and IP addresses of the origin and destination systems. I find myself trying to remember IP addresses from a dozen sites, and if I'm off by one digit, we accidentally send Mrs. Jones' scan to the ChiComms or someone equally distasteful. There has to be a better way.

I've been looking for ideas for another AuntMinnie article, and my friend Mark (I know at least three Mark's in the PACS business, by the way, but this Mark knows who he is...) suggested the intriguing idea of "Napster PACS": Let the network figure out who is where and what is what, like the old Napster peer-to-peer network. This is the better way. But, we have more security issues than Napster ever did due to patient confidentiality and HIPAA. But here's the solution to that: an automatically-tunneling network on the order of In their white paper, the approach is compared to a more standard VPN. Since LogMeIn folks wrote it, they win, but look over their arguments and you will agree. Basically, with proper ID and password authorization, you can tunnel into another computer. I've been using their system to maintain all the computers under my domain (about 20 or so), and it works like a charm for remote control, file transfer,maintenance, and the like.

Now, I assume this approch would require at least minor, and possibly major revisions to the way we do things, possibly some surgery to DICOM itself. But in my simplistic world, wouldn't it be nice to "LogMeIn" at the remote site, scanner, etc., and have the receiving PACS system instantly recognize you as a friendly source of data?

The final piece of the puzzle requires matching patients. Is today's Mrs. Jones at the Oncology clinic the same Mrs. Jones that was scanned at University Hospital last month? There are a number of ways to figure this out, but sooner or later we are going to have to have some sort of universal identifier for all of us. The Social Security number is probably the best bet for this, although we have to deal with the situation of multiple people using the same number, something that happens a lot, I'm told, among immigrants whose legal status in this country is questionable. Perhaps we could append the patient's initials and/or date of birth onto the SSN ('Social as it's called here in the South) to individualize it further.

I think this idea has the potential to markedly simplify the way we connect, and to solve the problem of the portable patient. I await the bashing of the experts.

The Nuclear Family

Personalized license plates are relatively cheap here in South Carolina (which is where I live if you didn't already know), and I've taken advantage over the years. I guess the next series will include "PACS" and "DALAI".

Saturday, October 08, 2005

Yes, I finally followed the lead of Mr. HisTalk and purchased my very own domain name, I guess that puts me on the map, huh? However, it's rather the same situation as we saw many years ago when ESSO became EXXON: New name, same old gas. The blog remains hosted with at the same old place, but I just had to join the dot com revolution. Better late than never. But the best part is that my good friend and colleague (whom we shall refer to as Dr. X, although Dr. Z might be more appropriate) will no longer have to run a Google search to find me. I did it for you, pal!

Wednesday, October 05, 2005

Garbage In, Garbage Out

(Image by Tim Jensen as seen on

The "C" in PACS stands for "Communications", and that doesn't just mean bandying the "Pictures" in the "Archive System" back and forth. For the radiologist, the picture is worth a thousand words, and on a Medicare patient, at least ten cents.

I realize this discussion will border on RIS/PACS integration, and that is not really where I want to go with it. I'm going to concentrate on two narrow areas, getting documents into the system so I can see them associated with the images, and getting my preliminary report out to the clinician that ordered the study.

Document scanning has been around a while. I was first introduced to the concept in 1990 when I went to visit a little company in Birmingham that had the idea to use a scanner to digitize paper and store the images. I don't know what became of that particular company, but the concept sure caught on nicely. Today, in the PACS world, a company called PacsGear sells PacsSCAN software that lets you scan in a document and transfer it to the patient's study as an additional sequence of the exam. This seems to be the most popular method of accomplishing this task. There are some other software packages, and even Merge has a module to do this, eFilm Scan, which does about the same thing. It would be nice to have this functionality built in to a reading station, or at least a QA station, but the only system I know of that does this is the MedView client from StorComm, and I think I've made my feelings about that thing pretty clear elsewhere. PacsGear also has a similar program to "print" into a DICOM study, which might allow placement of a graph or a JPEG image of some sort. Until we reach the Nirvana of a completely paperless hospital (excluding the bathrooms, I would think), paper history sheets and the like will still be around, and we need this sort of solution to at the very least stem the flow of paper to my desk. Hey, it's a start!

The most brilliant radiologist in the world (obviously not me) is worthless if his or her interpretations don't get where they are needed in a timely manner. There are many solutions to this little problem, some of which are actually practical:
  1. Call the result to the ordering clinician. They love it when I do this, but you just can't call each and every case and still have time to read the day's stack/pile/worklist.
  2. Yell it out to your secretary/aide/resource person so they can call it in for you.
  3. Dictate it and press some sort of priority key which, in theory, is connected to a buzzer or electroshock equipment somewhere in the vicinity of your transcriptionists to alert them to drop everything and transcribe your study first. They are then to fax it or read it over to the phone to the illustrious ordering physician, or at least to one of his/her minions.
  4. Dictate into a voice-recognition system, edit the report, autofax it to said illustrious clinician.
  5. Type a brief preliminary report into the appropriate field in the PACS system; the clinician knows to look here as soon as the exam is toggled as "read".

Of all these wonderful options, I like the one where I yell at my helper, but good helpers are hard to find these days, especially if you yell at them constantly. From various threads on the VR topic, I am firmly convinced that it is not ready for prime time, and has the potential for administrative abuse in replacing transcriptionists with radiologists who are forced to do all the editing themselves. Sorry, I have enough going on during the day that I don't need yet another job-title. I suppose the absolute ideal would be a transcription pool so vast, fast, and accurate that the minute I press "end", the report is en route to its destination. All that takes is a tremendous amount of money, right? No problem. Oh well, it looks like Option 5 seems to be the best compromise, at least for stat call reports to the ER and to others similarly equipped with PACS viewers.

This should be a simple task, but alas, it isn't as easy as it looks. The big question is where do you put this "comment window", and how do you signal the docs that there is something to be read? Rather than give you the blow-by-blow (or the yawn-by-yawn) of which company does what, let me create the image in your mind of the perfect woman, oops, I mean perfect comment system...had you going there, yes? Personally, I'm a one-stop shopper. Give me the Mall of America with a zillion stores under one roof rather than Michigan Avenue where I have to walk outside in Chicago weather, which ain't pretty around RSNA time. I want a complete, combined demographic and comment window, with a field for me to type in my own, well, comments. There should be a flag on the worklist to show if there are comments from the technologists and/or the radiologist. If your worklist doesn't take up the entire screen, it would be nice for this window to live below the worklist, and be populated with the proper information for the active study. Otherwise, it could be a floating window that appears when you click the study for display. Simple enough, yes? OK, someone go program this and let me know when its done. I'm going to go yell at my helpers.


I think I need to flesh this out just a little more. We are having a bit of a discussion with Amicas about whether or not this Super Duper Whiz Bang Master Comment, Demographic, and Preliminary Report window should pop up all by itself or not. My PACS admin thinks it should, but frankly, I really am not all that concerned. I like to have the option to do it myself. The auto-pop-up thing acts too much like a pop-up ad for my taste, plus it usually ends up covering something I want to see anyway. I would just as soon click a button to get it. BUT, I would like to see a flag on the worklist to show if there is a technologist or a radiologist comment to be viewed.

Agfa has a potentially useful addition to its comment field: precanned preliminaries. This saves you from typing the same thing 5,000 times a day. It's a good idea, but their implementation is typically harder to use than it has to be. (Are you listening, Waterloo?) You click in the comment window which spawns a second comment window which in turn has three panes (as in window panes). The top pane has the precanned report selection, the middle is a free-form area to write your own, and the bottom shows the conglomerate of your selections. The odd thing is, you can type directly into the bottom, final pane, so why the middle one? I must be missing something. When finished, you must click Save, which places your beautiful prose back into its proper field in the information window. Ducky. Why can't we just type straight into that area, huh? Doesn't allow for precans you say? Well, how about making the precans available by via right-clicking in the field? I like it, although if you have too many precans you might end up with a famous case of Dalai's Right-Click-O-Rrhea. It's worth the risk in my opinion. All systems need to autostamp with ID, time, and date, and that has to be permanent. No fair going back and changing all of your partner's preliminaries to "normal" or "31 week gestation". OK, guys and gals...get programming!