Tuesday, January 24, 2006

New PACS Workstation Design

I know I've been disappointing my readers with my lack of blog activity. My group has taken on a new hospital, and the hours are rather long, giving me less time to indulge my fantasies of being a writer. I was on call at the new place this past Saturday, and I did not leave my seat from 8AM until 2PM. Therefore, I propose the above modification for PACS stations at that hospital. It shouldn't be too expensive, as long as we don't contract with the Air Force for the seat components...

How to make a RIS-less RIS

There aren't too many pictures that come up when you search for "RIS", so how about a flourless chocolate cake instead? RIS-less, flourless, what's the difference?

This post may disturb my friend Mark, who recently left Amicas for Empiric Systems, the creators of a very nice web-based Radiology Information System, or RIS. I am going to tell you how I'm going to forgo purchasing his product for my independent PACS operation, and that means he won't be selling me one for a while. It's a great system, but I need to trim my costs where possible.

Speaking of Marks...some of you may know I tried to hire back a PACS guru named Mark M., who was driven out of town for various reasons by a certain IT empire. Fortunately for him, but unfortunately for me, he likes his new spot, and he couldn't be lured back to my place. But Fate always has something interesting up her sleeve. Our PA came to me one day and said, "I know this really great PACS guy, who might be interesting in your weird, I mean progressive ideas. He is thinking about moving, so why don't we get in touch with him?" What's his name? Mark S! Must be karma again. He came to look around, liked what he saw, and we now have our PACS guru. He is already hard at work creating our independent system, and I'll report back as we progress.

Anyway, back to RIS's or the lack thereof. To achieve the RIS-less RIS, you must first define what you need out of such a contraption. At the bare minimum, we need to attach demographics and reports to a study. Yes, a RIS can provide much more than that, but keep in mind, the clients for our little operation are mainly clinicians with scanners in their offices (DON'T even say it...), with relatively small volumes and internal billing and scheduling. Therefore, we can stick to the very basics, at least for now.

I have mentioned PACSGEAR in earlier posts, and I had the chance to meet some of their staff and play with their products at RSNA. They offer two products that solve my "RISsy"-fit, and later I'll tell you about a third that is really nice.

This illustrates the concept: You have a sheet of demographics, history, or whatever that you want the rad to have available with the scan. With the PACSGEAR PacsSCAN program, you just scan the piece of paper with a regular old TWAIN document scanner (they recommend a heavy-duty version rather than the $25 Best-Buy bargain), bring up

the patient in question via the little dialogue window ("Lookup" will fetch the pertinent info from your PACS or RIS if you have one), and off you go. Just press SCAN and the document becomes yet another DICOM sequence in the designated exam. Couldn't be easier.

Print2PACS does something similar, but instead of scanning a physical document, you quite literally print a DICOM image into your examination. With this little program, our transcriptionists can print the report straight into the system, where it can be viewed along with the rest of the examination. Print2PACS makes it possible to store other things like DEXA or cath reports, or even JPEG images if you have a need to do so. Now, this isn't a perfect solution. What you get on the viewing end is a picture of a report, and it can't be edited or minipulated. (I suppose you could play with its window and level, and magnify it if you wanted, but you can't change any of the words.) Still, it gets the report in front of the clinician, which is the goal.

The third product in the PACSGEAR suite is one that doesn't really contribute to the RIS idea, but it is great for our purposes none the less. PacsSCAN Film adds a film digitizer to the picture, if you will, and will scan yucchy old film into your shiny new PACS system. But it goes one step beyond just digitizing...it will divide out sheets of multiple images into understandable sequences that fit right in on the PACS workstation. No more big picture full of smaller images that you have to pan around to view. This is a great thing for those of us reading from sites who are still filming.

I have to add that there are free programs out there that do much of what we're talking about here, basically converting .TIFF or conventional print files to DICOM. I've played with some of them, and while they do actually work rather well (especially for being free), they are not as smooth and elegant as the PACSGEAR products. Therefore, PACSGEAR gets the Dalai Seal of Usability. I'm looking forward to being one of their customers.

Sunday, January 15, 2006

A Quote from "The Ascent of Man"

Let me take a moment to introduce you to a life-changing passage. Some of you may recall the PBS series, "The Ascent of Man", a series of essays brought to life by the philosopher Dr. Jacob Bronowski. We in the health-care field aspire to the designation of "scientist", and to the acquisition of knowledge. We must keep in mind, however, that knowledge has to be tempered by humanity. The passage which I have quoted below, is, in my opinion, one of the most poignant and important things I have ever encountered:

THERE ARE TWO PARTS to the human dilemma. One is the belief that the end justifies the means. That push-button philosophy, that deliberate deafness to suffering, has become the monster in the war machine. The other is the betrayal of the human spirit: the assertion of dogma that closes the mind, and turns a nation, a civilisation, into a regiment of ghosts — obedient ghosts, or tortured ghosts.

It is said that science will dehumanise people and turn them into numbers. That is false, tragically false. Look for yourself. This is the concentration camp and crematorium at Auschwitz. This is where people were turned into numbers. Into this pond were flushed the ashes of some four million people. And that was not done by gas. It was done by arrogance. It was done by dogma. It was done by ignorance. When people believe that they have absolute knowledge, with no test in reality, this is how they behave. This is what men do when they aspire to the knowledge of gods.

Science is a very human form of knowledge. We are always at the brink of the known, we always feel forward for what is to be hoped. Every judgment in science stands on the edge of error, and is personal. Science is a tribute to what we can know although we are fallible. In the end the words were said by Oliver Cromwell: 'I beseech you, in the bowels of Christ, think it possible you may be mistaken.'

I owe it as a scientist to my friend Leo Szilard, I owe it as a human being to the many members of my family who died at Auschwitz, to stand here by the pond as a survivor and a witness. We have to cure ourselves of the itch for absolute knowledge and power. We have to close the distance between the push-button order and the human act. We have to touch people.

Jacob Bronowski
The Ascent of Man
BBC, 1973

Monday, January 09, 2006

...Coming to a Hospital Near You

With apologies to George Lucas, and anyone else who ever had anything to do with Star Wars, including those who watched the movie, not to mention PACS and IT personel around the world...

In a Radiology Department in a Hospital far, far away….


Radiologist NEMA Organic, sends a desperate message for help…..before being taken prisoner by the evil IT Empire aboard its Death SAN…..
Young PACS administrator Luke DICOMmer hears her plea, and together with PACS guru OhbigWAN Pirogue, mounts a frantic search across the enterprise.

They enlist independent service guys LAN SCSI and his sidekick TapeBackup, whom they find at the LossyCompression Canteen. Along with their faithful laptops, QR and ICUP, they take off in the Millenium RadNet to save their helpless heroine.

Watch as they battle DarthRAIDer and the CIO of the IT Empire aboard the Death SAN. Witness the climactic laser pointer battle of good against evil. See studies broken and patients merged. Watch as the fate of the enterprise hangs in the balance!

Coming to your hospital.

May this farce outwit you.

Wednesday, January 04, 2006

Seven Thousand Hits!

Wow. Congratulations to the 7000th visitor, from Source Medical in Birmingham, Alabama.

It seems like just yesterday we were at 6000. Actually, it was about three weeks ago. Time flies when you're having fun. The first anniversary of Dalai's PACS Blog is coming up pretty soon. I'll have to come up with something appropriate.....

Monday, January 02, 2006

Another AuntMinnie Thread

Periodically, the issue of why Amicas (and Stentor, oops, I mean Philips, iSite) don't burn DICOM CD-ROMS comes up on AuntMinnie.com. The fact is that neither PACS system does this, at least for now. I do believe Amicas will be adding this functionality shortly. In the meantime, there are a few options:
  1. Buy an eFilm License from Merge (if you didn't get one as a QC station originally), at a cost of $950 per year or $3100 for an unlimited time license.
  2. Use the FREE product from K-PACS that does more or less the same thing, and includes a viewer.
  3. It is actually possible to open a study from within Amicas LightBeam and then save it and manually burn it, but this has too many chances for error.

The thread got rather contentious, which seems to happen a lot on AuntMinnie. Even David Clunie weighed in on this; apparently he receives a very large number of non-DICOM disks from Amicas sites and it makes his life miserable. Dr. RW cited a case of something missed because someone had to compare a non-DICOM study on one machine to the DICOM study on their PACS workstation. (This is exactly why I think the Napster PACS idea has come of age.) Mr. Clunie actually advocated avoiding Amicas and others that don't burn DICOM CD-ROMs.

Given the other methods that exist to get the DICOM CD-ROM, I think it is a little drastic to tell people to avoid a PACS system on that criterion alone. Remember, never buy a PACS based on one particular bell or whistle (even a very important one), or you'll end up with a ScImage or ITL type product. Avoiding a system on the same basis will exclude some good companies. Still, I DO think Amicas and Philips need to get their DICOM-burning software finished yesterday.

For those CD's already out there, I wonder if there is a translation program that will convert an examination from Amicas or iSite (or for that matter Siemens proprietary ECAT PET) to regular ol' DICOM format? I know a few people that would gladly pay a reasonable amount for something like that. I have found a few pieces of software over the years that will do the conversion to some degree, although the process is rather painful and not worth it in the end. Once someone creates this, they may feel free to pay me a 10% royalty for the idea.

News Flash!!!

Andreas Knopke just posted this on the AM thread:

Hi Dalai,

We already contacted Stentor in order to get some information on their proprietory image format but without any luck. They answered with something like "DICOM will be supported soon". Amicas' JPEG2000 + XML template format will be supported soon by our DICOMReader ( free download at http://www.dicomreader.com) because it is quite easy to "dicomize" it.

Regards, Andreas

Thanks, Andreas! Great minds think alike, huh? Don't worry about my royalty, just make sure everyone knows about this!

An AuntMinnie Thread about Siemens Syngo PACS

Sometimes, discussion threads on AuntMinnie.com become a little contentious. Take in point this thread about Siemens Syngo PACS. I won't copy it here, but suffice it to say that a question about this product morphed into a rather long discussion with an entrepreneur by the name of Stephen Levkoff, PhD.

Dr. Levkoff started out in the financial world, and amassed a great deal of expertise in computers and databases. His fame was tarnished somewhat by a famous failure, Decision 2000, which he created for Reuters. The Observer notes:

But Reuters' attempts to compete with Bloomberg led to financial disaster and a series of lawsuits. In 1989 the company hired a former Smith Barney executive, Stephen Levkoff, to devise a bonds analysis database to rival Bloomberg. But the product, released as Decision 2000, was regarded as a technological disaster and cost $10m after Levkoff sued.
Another lawsuit, from brokerage house Cantor Fitzgerald, followed over a failed joint venture through which Cantors would provide Reuters with a live feed of US Treasury securities prices.
Even worse was to follow with Reuters' next project, codenamed 'Armstrong', an ambitious attempt to correct what it had failed to achieve with Decision 2000 - fusing real-time market data with legacy information. Armstrong proved to be another huge disaster and cost the company some $20m.

In the interest of fair and balanced reporting, Dr. Levkoff responded thusly when I posted this snippet:

In response, I saw the Observer many years ago. It was an attempt to hammer Reuters for its incompetence in financial markets other than foreign exchange. Reuters failed in two major deals with two industry experts: Cantor Fitzgerald (government bonds) and me (multicurrency analytic systems). In my case, they wanted to integrate D2000 functionality into ALL Reuter terminals –but with no royalty payments. The business landscape is littered with numerous other IP vendor lawsuits against Reuters for various material breaches of contracts, bad, faith and lack of fair dealing. Cantor Fitz and I had the wherewithal, strong legal position and balls to fight back. We won – more than you will make in a lifetime as a radiologist in private practice.
I didn't respond to the Observer nor will I now. I consider the Observer article libelous – incorrect and uninformed. D2000 was extremely successful. Clients in 30 countries were serviced by 6 redundant data centers via a failsafe global network. It significantly undercut the "Reuters Terminal (RT)" - a proprietary PC platform that delivered nothing but real time data that was only a small part of D2000.
Decision 2000, a highly viable multi-lingual Bloomberg competitor with operations in 30 countries, subsumed the RT functionality and offered more advanced real-time analytics than Bloomberg has today - in an industrial strength platform. D 2000 became a $250 million disaster for Reuters AFTER I sold it to them - they mistakenly did not understand the financial markets or the expertise necessary to compete. They hired 1000+ (semi-competent) people to attempt to do what I had done with 150. They bombed badly and attempted to blame me long after I left the company. If you can read, you should review the federal case that we brought against and books written by insiders at Reuters. D2000 comes out very well.

Dr. Levkoff's goal is to "develop and acquires very high end multi-modality imaging centers." What differentiates him from a hundred other similar operations is that he wishes to apply his years of expertise to the world of health-care informatics, PACS, RIS, and so forth. His analysis

"...found that Siemens Syngo Suite offers the only fully integrated, industrial strength RIS/PACS solution in the market. The platform - Fujistu Siemens servers, Sun Solaris (UNIX), Oracle (db), EMC (storage) - is the only one in the industry capable of supporting multiple, fully redundant data centers with real-time database replication and synchronization. At the June 2005 SCAR meeting in Orlando, most vendors not only completely failed our platform requirements but scoffed at our requirements for a completely fail-safe, multi-data center integrated health care information environment. However, post-Katrina, the need should be obvious to all health care executives."

Interesting analysis, but when I posted this, Dr. Levkoff decompensated:

If bullet-proof, uncrashable hardware was the end-all to end-all, we would all still be using UNIX on Sun boxes. Somehow, Katrina or no, that has not been first and foremost in everyone's mind. Wintel boxes are considerably less expensive, and with off-site storage, you should be covered. The best Unix box hooked up to the best SAN becomes inoperative when immersed in water, last time I checked.
The Siemens Syngo/eSoft approach is very esoteric (read: strange) although it does work well once you get used to it. They have unified the appearance of their modality controls and workstations, and from a very brief peek at RSNA, their PACS uses the very same interface. That is a good thing to some extent, but how many rads are going back into the control room and running the CT scanner? I personally don't think this interface is the easiest or the most straight forward for PACS use. It has certainly been a long time in coming. I would be curious to hear from any rad who is using this product.

His response:

Hello Dalai Lama - You sound like a weak Siemens competitor. Your Wintel comments are extraordinarily naive - typical of the industry. Microsoft does not offer an industrial strength operating system for zero-downtime environments - particularly across data centers. Further, you obviously don't understand the concept of running multiple, fully redundant data centers with real time database replication....On the user interface issue, you may find it "strange" because you are accustomed to doing things a certain way. Loosen up - it’s very intuitive and flexible. Additionally, commonality of user interface across applications and modality is essential for training, cross-training, quality control, and leveraging personnel for operating efficiency. As a CEO, I would not make a purchase decision that did not offer all of the characteristics of the Siemens Syngo Suite, given its availability. Also, I wouldn’t hire a radiologist who couldn’t scan.

Just a little bit over the top. I won't keep quoting the thread, but suffice it to say that things went straight downhill. He became more and more angry and condescending with every post. I finally gave up and invoked the "Dalai Shroud", declaring Dr. Levkoff deceased with respect to my future interaction with him.

Daniel Braga, another AuntMinnie poster, has the last word so far on the thread, asking the most pertinent questions of all:

How many radiologists did you meet with to discuss their impressions of the viewer? How many hospitals did you visit using the product that you would be buying?
Dr. Levkoff is obviously a very brilliant man, and has done a great deal research in PACS and healthcare informatics. Unfortunately, his wisdom has manifested itself into tunnel vision, and he has sandbaged himself into a particular corner. Even more sadly, he cannot tolerate the disagreement over his choice of, well, corners, and he has lashed out to the point of destroying his credibility, at least to me. He had much to contribute, but in trying to change the entire industry in one fell swoop, he lost his chance to do so meaningfully. RIP.

Predictions for 2020 by Digital Doctor

Digital Doctor has posted several incredibly eloquent messages on AuntMinnie.com. Here are his predictions for 2020, which I suspect will turn out to be right on target:

The Future of Medical Imaging - 2020’
By: Digital Doctor
Sat 31 Dec 2005

My Predictions for 2020!

Government Regulations
In the United States, we will face a healthcare CRISIS on or before 2017 due to a lack of funding for Medicare and Medicaid. As Medicare and Medicaid are the "insurers" for approximately 30% of all medical care in the United States, you can perhaps only imagine the potential for havoc. The United States CARE Act will be passed prior to 2012, which will mandate federal registration of radiologic technologists. PACS Systems Analyst (a radiographer with minimal certification in PACS), PACS Administrator and PACS Manager will become recognized growth opportunities for radiographers. Registration will be required as part of the CARE Act. Many clinicians will truly question the necessity of radiologists (but not for the first time) and a political struggle will ensue for the future of medical imaging. Ultimately, radiologists will win for several reasons despite the overwhelming anti-radiologist movement. Radiologists will put more weight behind the radiographer role as well so that the two professions will be inseparable to better support their own role.

Expansion of Services
Medical Imaging will, of course, become an even more integral component of healthcare as (in the United States) utilization will continue the trend of expansion of 7% every year. Medical Imaging will assume as much as 25% of total hospital revenue on average.

Expansion of Roles
The Radiology Practitioner (introduced in 2003) will become an essential role in the United States due to expanded utilization of services and a reduction in reimbursement. Physician Assistants have been assigned to Radiology Departments since least 1995, which I would argue fulfills a similar role, as both the Radiology Practitioner and Physician Assistant are "physician extenders." The Radiology Practitioner will require a Masters Degree and two years residency (in addition to four years practice and registration in a Medical Imaging specialty).

The "One Touch" scan will revolutionize technologist workflow. Technologists will be able to focus attention on patient care and post-processing. OLED monitors (displays) will be the predominant technology of the day; however, OLED will soon be replaced by 3D Holographic displays which will offer the first "true" 3-Dimensional views of the human form in medical imaging.
"Personalized Medicine" (the most overused medical "buzz" phrase of the current decade) will finally be a reality at about the same time as healthcare in the United States nears collapse. Driving "Personalized Medicine" will be the introduction of several new "multi-modality" scanners. An “Omni Scanner” will be introduced that is able to perform diagnostic radiographs, Computed Tomography, as well as Magnetic Resonance and Nuclear Medicine scans.

TRIP (Transforming the Radiology Interpretation Process) by SCAR will become an extended initiative. By 2020 radiologists will interact visually, verbally and tactilely with PACS (renamed Medical Imaging Informatics in 2008). The radiologist will don gloves that will act as a virtual keyboard, a mouse and a multimedia controller (think the "Shuttle Pro" by Contour Design) "all-in-one." PACS systems will offer, "Visual memory cues" (not CAD) that will act as mnemonic prompts for radiologists and clinicians to remember specific patients and abnormalities. PACS will track and respond the eye movements so that visual fixations will result in image zoom and pan or will activaate functions upon which the user has a visual fixation.

AN ENTIRELY NEW MODALITY WILL BE INTRODUCED which will assume much of the workload of Computed Radiography and Digital Radiography. The new modality will not utilize ionizing radiation as a means for imaging. The new modality that will (possibly) continue to be known as Digital Radiography will undergo the most dramatic changes, as "unlimited" radiographers will utilize equipment that is more similar to Computed Tomography than Computed or Digital Radiography. Radiography Equipment will become much more portable so that the "Radiography Suite" (not the portable machines of today) will be portable. Computed and Digital Radiography will often acquire tomographic images from which 3D images will be automatically constructed by the modality. Computed Tomography will "top off" at 2048 "slices" which will become the new "unbreakable barrier" for years to come. Computed Tomography will automatically generate any required MPR, MIPS and even 3D volumetric series.
Nuclear Medicine and Magnetic Resonance (and likely Computed Tomography to some degree) will be the true driving force of the "Personalized Medicine" trend. Nuclear Medicine, in particular, will lose the moniker "Unclear Medicine" as images will begin to resemble the image quality captured in the 256 "slice" Computed Tomography images of 2008.
Computer Aided Detection will become so ubiquitous that CAD will be a standard feature on every modality. Every modality will utilize CAD for nearly every conceivable procedure that will increase in-office utilization of Cardiologists and nearly every medical specialty group.
Structured Reporting will become a reality and will drive major changes to the workflow of radiologists. In fact, Structured Reporting will be hailed as the "saving grace" of Radiologists. The innovations related to Structured Reporting and CAD will so alter the job function of radiologists that the profession of radiologist will either disappear (not likely) or become more interventional (especially as radiation therapy and nuclear medicine take on many new roles) or radiologists will offer "value added interpretation" (very likely).

Educational Trends
In response to the CARE Act and technological innovations the minimum educational requirement for radiologic technologists will be an Associates Degree (two years post primary school). More offerings of advanced degrees will be available for technologists seeking to specialize. Magnetic Resonance will have been recognized as a "primary modality" by the ARRT before 2012.

Even more COOL stuff on the horizon in 2020
BEYOND SIMPLE IMAGE DATA...Radiologists will utilize tactile and auditory senses by donning a suit that will provide additional sensory data to perform diagnosis - this data will be derived from image data (or data collected during the scan). Surgeons and Interventionalists will be able to utilize this data to perform remote surgeries. WAVELET COMPRESSION utilized by nearly every PACS and modality will be replaced very soon with "Fractal Compression" which will finally compensate for the overwhelming data sets generated.

Seen at the Westin Savannah

Forgive me, but I saw this vehicle and its, um, accessories, in the parking lot of the Westin Savannah, and I just had to share. If anyone is offended, I'll remove this post, but hey, it isn't my truck!

And while I'm at it, is this a case of X-Ray Vision?