Saturday, December 29, 2007

The Latest In USB Acoutrements

I hesitate to post this, but I got a good laugh out of it, and you will, too. These adorable little pups plug into any USB port (I think they work equally well with USB 1.0 and 2.0, although perhaps they perform faster with the latter.) Just in case you don't quite yet have the visual of exactly what it is they do, here is a movie clip of the little critters in action. I know I want one. This might be just the advertising gimick for some large companies out there to demonstrate their "loving" attitude toward their customers.

Friday, December 28, 2007

I received an invitation to join a new social network from its founder, Steven Chan, MD, MS, a private practice radiologist in New York State. The idea was to create a FaceBook- or MySpace-like site to ". . . allow our natural connections with each other with the aid of the internet to foster new collaborations, idea exchange, new ventures, and job opportunities for us radiologists. We restrict membership only to invited industry leaders, radiologists, and rads recruiters (the non annoying ones)." I've personally never met a non-annoying recruiter, but I guess they do exist.

I went to Steve's site, liked what I saw, and signed up. The front page fills in more details of the site's goals:

Welcome to radRounds!

radRounds is a tool for radiologists. It was created by radiologists to help with clinical work and enriching one's career. Some examples of uses might include:

  • Finding another radiologist who can help with an MR imaging sequence, job search, or tough case

  • Talking privately to an inside-connection about that practice you plan to join

  • Establishing a new collaboration to start a multi-center clinical trial

  • Leaving radiology and looking for an investment banking job

  • Searching for the dream job or hiring the dream candidate / future partner

  • Keeping in touch with alumni from your residency program and old friends from the RSNA

  • Discussing the latest topics and turf battles of radiology

  • Finding out the next time someone gives a lecture/CME on your area of interest

  • Starting your own (private or public) group or blog

And, above all, sharing one's interests, expertise, and connections with others. radRounds will most rapidly improve with the help of the people who use it. Spread the word too and invite a fellow radiologist. By the way, suggestions and comments are all strongly encouraged.

OK, I'm spreading the word. radRounds is a site worthy of our participation. I think it will be complementary to several existing radiology sites such as, and of course Check it out!

Tuesday, December 25, 2007

Amicas + Siemens = ???

In response to my RSNA report about Amicas and Siemens, Anonymous asks this question:
Thanks for expressing your analysis on Amicas. I couldn't help but notice Amicas and Siemens in the same sentence. Do you think this would be a good acquisition for Siemens with the recent GE / Dynamic Imaging aquisition?

Interesting thought. The speculation on who will buy whom runs rampant, especially around RSNA time. I'll give you some rudimentary (read: uneducated) analysis about the topic, and follow that with what I hope actually does happen.

With that large company having just acquired the smaller company as mentioned by Anonymous, there aren't too many operations left that need a new PACS, let alone have the resources to afford one. Those that come to mind immediately are Siemens and Cerner. Philips bought Stentor a few years back, Fuji has their own, and Kodak has spun theirs off as CareStream (still sounds more like something the urologists should be dealing with than a PACS.)

Cerner had at one time a solution written by Cedara, now owned by Merge. I looked at it briefly in 2003 and wasn't terribly impressed. Neither were many others, as there were very few ever installed. Today, Cerner's ProVision™ PACS offering (which I didn't bother to look at whilst at RSNA) has these features according to their web site:

The Cerner ProVision™ Workstation is a comprehensive solution for diagnostic softcopy reading of digital images. In order to provide you with increased flexibility, the workstation supports multi-monitor configurations, "set up and save" viewing protocols, global user preferences, and comprehensive MPR features eliminating the need for specialty workstations.

In addition, the Cerner ProVision Workstation allows you to:

  • Increase productivity and physician satisfaction with decreased report turnaround
  • Generate continued returns from legacy investments and compliance to DICOM standards
  • Provide increased patient safety with synchronization of patient, procedure and image information when configured with Cerner’s RadNet including voice recognition and access to the EMR
Uh, well, nothing really distinguishing there, I'm afraid. Some of our hospitals use Cerner's Millenium RadNet, and since this is a kinder, gentler blog, let me simply say that I really, really like using Empiric's I'm not sure how Cerner feels about its latest PACS, nor if it is thinking it needs a replacement. But, it pays to keep one's eyes open on such things.

Siemens has had a somewhat irregular history in the PACS field. SIENET Magic PACS came and went, and I don't think anyone would consider it particularly beloved. There was much hype in recent years about SIENET® Cosmos, which was a combined RIS/PACS product using Siemens syngo® common user interface, and e.soft which Siemens in 2000 defined thusly:

"e.soft is the first medical imaging computer that will adapt itself to the way the system's users work--and then do the work for them. . ."

So, syngo is an environment of a sort, that runs under Windows. e.soft is the programming language, although some of the definitions seem to be a little fluid.

Today, Cosmos has evolved into the syngo® Suite. The environment works something like this when integrated with the Siemens Sorian RIS:

It's an interesting concept that attempts to place a common interface on everything from the order entry to the scanner to the PACS. This is a good idea in theory, but most rads don't run the scanner, and most clerks don't read the images. I use the syngo/e.soft system on my Leonardo, I mean syngo workstation on which I read my PET/CT's. It is usable, but more than a little esoteric, and quite frankly, I would find it difficult to use as a PACS. That's my opinion, and I'm sticking to it. Sales of Cosmos/syngo PACS have not been great. I suspect I'm not the only one who can't quite get used to the idea. There are those who think that the Siemens back end is bullet-proof (see this thread), and I won't dispute that per se, but I'm not sure a PACS needs to be bullet-proof in this day and age. Anyway, the bottom line to me is that Siemens really should consider a new PACS. Let the common interface idea go.

Now comes the editorial part of my answer. PACS is one tough business. Many of the small fry are either bought out or go under every year. Anonymous of course cites one of the largest PACS acquisitions, probably followed closely by Philips' buying Stentor to create iSite. As near as I can tell, iSite is doing well under Philips' stewardship. (And Sectra, the "jilted" product, is doing OK itself.) If Cerner or Siemens wanted to buy a company, who is left? I would leave out the much smaller players, such as eRad, and so forth, and make a rather short list of Amicas, Emageon, and Agfa. Yes, Agfa PACS is apparently for sale, as I noted earlier, although it has yet to be sold. I have no idea how many suitors have approached Agfa, but I suspect the number is quite small, as it is probably a very expensive purchase indeed. Emageon has had its troubles, but its stock price has stabilized this month, albeit at a rather low level. The last time I looked at the product, it seemed good, and I'm looking forward to seeing it again in Seattle at SIIM.

And Amicas? Well, that's a different story. Amicas has a lot of cash in the bank, a new product in the works, and a veteran manager, Dr. Steve Kahane, at its helm. If I were giving Siemens (or Cerner) advice, I would say buy it, buy it NOW. Siemens, in my humble opinion, needs a new interface, and Amicas has a really good one. BUT, if I were giving Amicas advice, I would say, "Stay independent!" Being your own company allows a degree of lattitude that prompts development of innovative products. I know the folks at Amicas, and they know what they're doing. Would they survive under a large company? Most likely, as long as they were given a very long leash, but a leash is still a leash, isn't it? This is one of those "if it ain't broke, don't fix it" situations.

I realize that Amicas' stock hasn't done spectacularly well, either, and it just goes to show that the market doesn't understand the PACS business too well. For what it's worth, Amicas is buying back some stock:

"AMICAS chose to repurchase under Rule 10b5-1 because a 10b5-1 plan allows us to focus on the business rather than worry about timing and trading of our stock. This plan also allows us the flexibility to repurchase shares when the company may otherwise be precluded from doing so under insider trading laws," said Stephen Kahane MD, CEO and chairman of AMICAS.

Do the Big Companies do that? I suppose so. But I'm not interested in buying the stock (sorry, Steve), but I am interested in a PACS that works. Would Amicas PACS work as well (and be as affordable) if it were Siemens Vision Series PACS? I can't answer that. But I selfishly hope the status quo continues. It's working for me.

Laziness, Or Something Else?

AuntMinnie user rogens50 asks if radiologists are "cutting our own throats" with laziness?" I've reproduced part of his post below"

This is a big pet peeve of mine. I have a group in which I think there are very good radiologists. However, I am constantly annoyed at reading reports which are basically just descriptive words and seem to make no effort to get down to the nature of the patient's problem or try to make a diagnosis. This problem is not only unique to my group, buy almost every group in which I review studies. Since we are busier and busier these days, many people in the group treat the reading list like the old "Space Invaders" game in which the only purpose it to shoot down as many enemy spaceships (in this case, patients on the PACS reading list) as quickly as possible. I guess I may be too "anal" about this since I was trained in a residency program where my favorite mentors constantly implored me that "nothing makes you smarter than the old films". In the old days, it was a pain to look at many of old studies and reports which were stuffed in the jacket, but now in the PACS era, all of this information is one or two mouse clicks away. I feel it is the radiologist role to give as accurate assessment as possible as to what is going on with the patient as opposed to generate some generic descriptive report. It seems that there is no academic curiosity or underlying desire to provide any real depth of information to the referring physician and thus help the patient. I can give numerous examples.

Rogens then does cite several situations illustrating his point, such as obvious instances when only the most recent chest radiograph (if that) was reviewed in comparison to the current study. He recommends:
In general, I feel you should try to approach the case is it were you or a family member. Certainly, you may not be quite as diligent as if they were your images, but this is at least a mindset you should have. If you read some of these reports and you and your family member had unnecessary procedures or imaging studies as a result of it, you would feel the radiologist is not doing his job.
And what might the consequences be if we continue?
By generating these kinds of reports, we are taking ourselves away from truly helping the patient. At some point clinicians and administrators may say, "If this is the kind of information I am getting, I might as well get cheaper dayhawks or maybe in the future, send them to India" Therefore, are we cutting our own throats by providing trivial readings?
But even rogens50 realizes that this may not be so easy...
I will admit when I am on call and drowning in studies, I reluctantly cut some, but certainly not all corners, but still try to provide as much information as possible. I try to address situations where the radiologists are overloaded with studies (call) at group meetings and try to correct this problem. Sometimes on call, I feel like I am the Lucille Ball character from the clip where she is trying to keep up on the candy production line. . .

I thought everyone would appreciate the video clip above in light of the analogy.

I'm going to assume rogens is fairly fresh from training. That is not meant in a derogatory manner, but just as a point of speculation. As an aside, my group has hired a number of new kids in the past year or so, and their training and work ethic has been phenomenal. I'll bet rogens is at least up to their (very high) level. Now, I'm assuming he is new because his main thesis demonstrates some naivetee. No, not the part about adding diagnostic value to the reports, and reviewing as many pertinent old studies as possible. There, rogens is spot on. This is a necessary part of our interpretations, and must not be neglected.

No, rogens goes astray with the assumption that the problem is laziness. Really, I don't think even he believes this to be the cause, but perhaps it is the first answer that comes to mind. While sloth may be the answer for some of us some of the time, and for a few of us a lot of the time, it is not the real underlying problem. Rather, the sheer volume we face each day is the biggest obstacle to providing the level of service we think optimal. Based on the "Lucy" remark, rogens understands this, too, but he only mentions "drowning in studies" on call. For most of us, that's just the beginning.

Veteran poster MISTRAD puts it best:

Our workload as rads has so dramatically increased over the last decade, I think we are getting close to our maximum capacity to read studies. Sure, you could read more hours, but frankly for me after a 9 hour shift reading 150 or so studies, I am burned out. I agree with all of your points, but I don't know if the solution, other than hiring more people, is easy.

But, hiring more radiologists means diluting the revenue, and that is the last thing most groups will consider. No, more and more of us are trying to replace shrinking reimbursement with even more volume. At some point, that too will fail, as we will indeed max out on how many studies we can read. Not only do we run the risk of issuing a "typical radiologist mumbo-jumbo, non-commital, uncompared" report, but the faster we push through that heavier volume, the more findings we will miss. At some point, the patients' welfare has got to take precedence over our scramble for one last dollar.

So, rogens50, you have a very valid point. We do need to do better in the areas you outline. But I can guarantee you that in the majority of cases, the problem is emphatically not that we are lazy, nor are we playing games to get the work done and get out. We are tired, we are overworked. I won't be so crass as to claim that we are underpaid, however, and that may be the problem. We may well be so concerned about avoiding being underpaid, that we create worse problems.

Lucy, I feel your pain.

Monday, December 24, 2007

Why Medical Care Is So Expensive

Image credit:

I ran across this patient problem list the other day. This is completely real, but anonymized to protect the innocent:
    1. Probable occlusive coronary artery disease but fairly asymptomatic. Patient will return for a Persantine Cardiolite.

    2. Systolic murmurs consistent with mitral insufficiency and aortic sclerosis. She will return for an echocardiogram.

    3. Labile hypertension. We need to rule out renal artery stenosis. Patient will have a CT angiogram of her renal arteries.

    4. Historically occluded left carotid. I do not believe it with a lesion in the right. Patient will have a CT angiogram of her carotids.

    5. Chronic right-sided leg pain. She could have occlusive vascular disease in her lower extremities. We will do the CT angiogram of that as well.

    6. Ongoing tobacco abuse. I advised her not to smoke. She is not going to quit. She made that very clear to me.

    7. History of lung cancer. Treated with radiation therapy. No evidence of metastatic disease.

    8. Dizziness. Probably due to vascular disease. I do not think it is due to any significant arrhythmias. We will place a holter on her to be on the safe side, however.

At least she doesn't have kidney stones or the heartbreak of psoriasis. I'm thinking this little workup on this 80+ year-old patient is going to cost about $15,000+ or whatever Medicare will pay. Let's hope her kidneys hold up with all that iodinated contrast she's about to get.

Now you know how doctors think. Test every twinge, and if the test shows something, order more tests. I wonder why some still carry stethescopes.

JibJab's 2007 Year In Review..What More Can I Say?

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Saturday, December 15, 2007

Voice Recognition and Value

Dr. Giles Boland has written an editorial about the value radiologists can provide with speech recognition (Dr. Boland prefers the more popular though less accurate term Voice Recognition). Dr. Boland is on the radiology staff of Mass General, and he is a member of RCG HealthCare Consulting, which provides "Complete IT & Management Consulting for Radiology Departments and Imaging Practices". From the RCG website, we find that Dr. Boland is:
Vice Chairman of Radiology, Massachusetts General Hospital, Dr. Boland’s areas of specialty include PACS, Teleradiology, Voice Recognition, RIS, and the enterprise digital solution to PACS and RIS integration. He has conducted aproximately 40 pesentations in over 15 countries on these topics. As a practicing radiologist, his nterests lie in Abdominal Imaging and Interventional Radiology. Dr. Boland is an Advisor to the World Health Organization, Geneva Switzerland and a reviewer for multiple scientific journals including New England Journal of Medicine, Radiographics, American Journal of Roentgenology and Journal of Intensive Care Medicine.
Those are impressive credentials. Dr. Boland's case for VRT is as follows:

Voice recognition technology cuts a swath across the process through which conventional preliminary findings metamorphose into a final report. Once a report is dictated into VRT, it is in fact a final, signed report (unless originally dictated by a radiology resident or fellow). By virtue of its electronic nature, such a report becomes available immediately across an institutional network, simultaneously to multiple caregivers. Consequently, final report turnaround times are typically drastically reduced. When VRT was introduced at the Department of Radiology at Massachusetts General Hospital in 1997, the final report turnaround time for staff dictated reports was reduced from 3 days to several hours almost immediately [11]. This efficiency was realized despite the fact that earlier VRT models were harder to use and had less efficient speech recognition software.

The implication is that the technology has improved a great deal; the closing paragraph in the editorial reads:

However, despite the real advantages to radiology customers of VRT, some radiologists would still rather promote an inferior transcription model, preferring instead to use traditional dictation methods, which delay their ability to generate final reports. Although radiologists' customers are looking for succinct, standardized, and timely final reports, some radiologists continue to use a system that their customers find less valuable. Rather than using existing state-of-the-art technology, radiologists should take an active role in convincing their peers to adopt VRT. If necessary, they should also lobby their organizations to provide the capital required to finance the transition, which generally yields a very favorable return on investment within the first year [11]. Radiologists can then rightly claim that they have been instrumental in adding significant value to their product, a major benefit to patient care and all stakeholders.
Note the derrogatory language. Those that have not embraced VRT/SR are using an inferior model. This raises some concerns. Whilst Dr. Boland has the background to know what he is talking about, the superior attitude is not particularly endearing. We have had the VR/SR debate on AuntMinnie ad nauseum, and the majority opinion amonst radiologists (NOT administrators, IT types, etc) is that it is not ready for primetime. Maybe Dr. Boland has access to more advanced software that actually works as advertised, which would make his analysis spot on. Unfortunately, the machinery that makes it out to the boonies doesn't seem to work well enough to justify the accolades. I think it is noteworthy that the JACR article contains no mention of Dr. Boland's association with RCG Consulting or the fact that RCG Consulting considers voice technology one of its areas of expertise. Perhaps it is simply understood that anyone on the Mass General Radiology staff is a part of RGC. I'm sure there is no conflict of interest here. Of course not.

I'm not so much of a Luddite that I don't appreciate what Dr. Boland is saying here. I just don't think the machinery is quite there yet. So, I'll stick with my inferior model for now, thank you.

Friday, December 14, 2007

'Twas A Month Before Christmas......A Hypothetical Bedtime Story

'Twas a month before Christmas, at RSNA,
All the vendors were tired; they'd been there all day.
The scanners were placed on the carpets with care,
In hopes that big customers soon would be there;

The techs were nestled all snug in their beds,
While big party hangovers messed with their heads;
The PACSMan with camera and me taking notes
Were on the Grand Concourse after ransoming coats,
When out on the floor there arose such a clatter,
I sprang over there to see what was the matter.
And to the exhibits I flew like a bee,
Tore right through the guards with my RFID,

The green glow of lights on white carpeted floor,
Gave a nice, eerie lustre to scanners galore,
But, what do my watering eyes then behold,
But a bright-green stretch limo with bumpers of gold
With a little old driver, who was packing some heat,
I knew in a moment this wasn't my treat.
More rapid than eagles his helpers they came,
And he whistled, and shouted, and called them by name;

"Now, Vito! now, Carlo! now, Marco and Vinnie!
On, Gino! on Louie! on, Fingers and Johnny!
To the top of the food court! the top of the wall!
Now dash away! dash away! dash away all!
Boys, grab Dr. Dalai and do it with haste,
We'll teach him to mess with us! No time to waste!"
So deep in the exhibit they took me, Dr. Dalai,
And all shook their heads at the depth of my folly.
I knew I was done for; there wasn't much question.
The pain in my chest wasn't just indigestion.

The booth then exploded with a thunderous roar,
As angry ex-customers took to the floor,
They wore plastic badges edged all in blue;
And most RFID's were torn up in two,
They came into the booth just like a great flood;
You could tell in their eyes, they were looking for blood.
Their droll little arms were all waving P.O.'s
Which they shredded all over the carpeted rows.
The stump of a pen they held tight in their fists,
One particular vendor was scratched off their lists;

The guys in the limo began looking pale,
They shook, and they quaked, and I knew they would bail.
My readers all came to my rescue that day
And I laughed when I realized I'd not soon decay,
They all winked as one, and we knew we'd prevail
Because nothing hurts like the loss of a sale;

The limo and driver and all of his minions,
Skulked out of the booth muttering "Gosh Darn opinions",
Removing his finger from inside of his nose,
And waving said finger, up the vent shaft they rose;
All over the North Hall and also the South
The news of our story came from every mouth.

Said the green-suited man as he entered the fog:
The Heck with you, Dalai, and Heck with your blog.

Wednesday, December 12, 2007

The Squawkie and the Cymbal
...A Hypothetical Post About A Hypothetical Machine

In the vacuum of my once-productive mind, there occasionally forms some strange ideas. I wondered what might happen if one tried to combine Ultrasound and CT scanners to form an US/CT device. This idea could have some interesting consequences, and following is a fictional account of how this might play out in the marketplace... Note that the machines are not real, no one has one, and no one will ever get one.

Trying to stay at the leading edge of technology is difficult at best, and expensive to say the least. The hospitals down the road, across town, or on the other side of the country are always trying to one-up each other, buying the latest and greatest, usually to be leap-frogged by the next great development.

Here at my above-average hospital in a large town in the North, we have caught the bug to buy one of the new hybrid ultrasound/computed tomography scanners, the US/CT. This is really incredible technology, which will allow us, for example, to definitively diagnose renal lesions and declare them cystic or solid on the spot. The CT image helps orient the ultrasound and can provide depth and echogenicity adjustments.

As with most advanced products of this nature, there are several choices. Black and Decker produces a rather small and relatively compact unit called the Squawkie (UltraSOUND, noise, squawk, get it?). This is a very elegant machine, with a tiny x-ray tube mounted to the hand-held ultrasound transducer. An x-ray detector belt is placed around the patient, and both the CT and the U/S images are formed as the sonographer (wearing lead gloves) performs the exam.

Bosch, on the other hand, has their own version, called the Cymbal (Cymbals make noise like UltraSound, yes?), which, typical for European engineering, takes a battle-ship like approach, mating an automated U/S transducer on an articulated arm to a full-size CT scanner. There is a continuous flow of ultrasound gel through a port near the transducer face.

These two machines obviously represent rather diverse approaches to the problem. Which to choose? My inclination is to go with the Bosch, as I like their fuel injectors, and so I would assume their US/CT device is just as well made. But the Black and Decker folks have been very persuasive. They sent a number of articles outlining the dangers of too much CT radiation, which is kind of funny since they sell a lot of regular old CT's. But they very correctly point out that the minimalist CT approach found in the little Squawkie has less CT radiation than the full-CT of the Bosch. And there's the problem. The Squawkie's limited CT doesn't produce a great image, and no one expects it to do so given its limited radiation. Supposedly it's CT is good enough to enhance the U/S image, and some say it will work better for this purpose. BUT, to the guy looking at the study, a very important factor is the ability to match the U/S to the CT, and for that, a diagnostic quality CT is needed. Black and Decker points out that the patient has probably already had one on another machine, which may or may not be true. If they have, B&D suggests simply using the computer to match the U/S to the CT, but that doesn't always work well. Heck, even the example they have in their literature shows a pretty bad misregistration of part of the U/S relative to the CT. I don't trust that approach. But we all agree, I guess, that a diagnostic CT is needed somewhere along the line. And everyone who has a Squawkie, including the academic center in the hills north of us, says that it's CT images are, ummmmm, not diagnostic.

Bosch's approach with the Cymbal assumes that the diagnostic CT is such an important part of the study that it should be included with the U/S. So, with a little planning, the patient could have the U/S and the diagnostic CT all in one sitting, and eliminate the small but extra CT dose that he would have to have with the Squawkie. To me, that is the more logical way to do it. But that's just my opinion......

Decisions, decisions......

Sunday, December 09, 2007

Dalai's Latest Phone

One of my older posts bashed Palm mercilessly, and you will still find this on my blog as Palm is probably used to this and isn't interesting in nagging me about it. I haven't had a Palm product since my old Tre0 600, and I haven't regretted the jump to Windows Mobile for a second.

I've been a little down lately, as you all know well, but nothing combats the blahs like buying a new toy. Since my old Blackjack was just over a year old, AT&T felt the need to tempt me with its new successor, the Blackjack II, and I succumbed. I'm really glad I did.

The Blackjack II, officially the Samsung SGH-i617, outdoes the older SGH-i607 in a few critical areas. First, the screen is marginally larger (about a millimeter or two in each dimension), but it is a bit brighter and sharper. The difference is quite noticeable. The Blackjack II has a great deal more on-board memory, 155MB as compared to only 55MB for the older version. That makes a huge difference in how one allocates memory space. My 2GB microSD card was easily transferred to the BJII, which is now capable of handling 4GB cards. No doubt I'll get one of those eventually. A larger standard battery means longer talk-time, and a faster processor means, well, faster processing and a bit peppier response overall.

One unfortunate change was made in the universal connector, which is how one charges the phone, connects to a computer, or plugs in headphones. It is unfortunate because I had spend a small fortune in extra chargers and headphone adapters (it works very well with Bose sound-cancelling headphones), and now I have to replace all of that. I take some consolation in the fact that the new connector (which is the same as found on Samsung's Helio phones, for some strange reason) is a little stubbier and sturdier, and has its top or front more clearly marked. I really wish Samsung had gone with a more universal mini-USB connector, which would have made my life easier. The stupid little plastic plug over the port is now chrome-plated, but still will likely break off before the rest of the phone wears out. The casing is now shiny black with chrome trim. It looks better than before, but attracts fingerprints like a magnet.

The BJII has Windows Mobile 6, with a few incremental improvements over WM5, most notably the addition of Office Mobile with limited versions of Word, Excel, and PowerPoint. There is now a GPS receiver using the SRiF Star III assisted GPS chipset. AT&T packages a trial of the TeleNav Software, which can cost $100/year to use. Fortunately, with this little tweak, you can get the GPS to work with Google Maps, which is free. Speaking of tweaks, changing the function of the right soft key in the home screen requires the use of a program such as Right-Tweaker, something that could be done with onboard software before. But, you can more easily assign shortcuts to letter keys than before. Keep in mind, this is still a Smartphone, not a Pocket PC, and it has no touch-screen. Coming from the older Blackjack, and an Audiovox PPC 6600 before that, and a Treo 600 before that, I find I really don't miss the touch screen at all.

The strangest conversion is that of the scrolling function. Previously, there was a Blackberry-like scroll-wheel on the right side of the unit. This has been removed. Instead, the D-pad controller on the front now rotates and can be used rather like the click-wheel on an iPod. I didn't believe at first that the wheel actually physically spins, but my son proved it to me by rotating it carefully with one finger whilst holding another finger steady on the wheel. It takes some getting used to, but in the end, I think it works as well as the side-mounted version. There seems to be no way to adjust the scrolling speed, however.

The bottom line: the BJ-II is a worthy successor to the BJ. There aren't any huge changes, but the improvement was adequate for me to justify the upgrade. But then, that usually isn't too difficult. Next stop, the iPhone II, due out next year...

Wednesday, December 05, 2007

The Wizard of OS

If you're here, you no doubt know about my little problem with the Big Company and so forth. I never, ever dreamed that this average radiologist from the South could cause such an uproar with a lil' ol' blog. I'm still surprised anyone even reads the darn thing at all! But, you do, and I have received a great deal of support via e-mail, AuntMinnie thread, and even the odd phone call.

We didn't have to "go here" as the kids say. So many other companies, among them Afga, AMICAS, Sectra, Emageon, Intelerad, etc. have used my comments to make their products at least a little bit better. I guess someone in this other company in question didn't think I had the potential to do that for them. Oh, well....

To those who have supported and continue to read my stuff, know that neither I or my rather amateurish but still lovable blog plan on going away anytime soon. To those who don't like my postings or have a problem with them, I only ask that you e-mail me or call me if you have questions or want to talk about it. You can also post a comment to the offending paragraph.

The way this whole scenario unfolded hurt me and my family deeply, and could have been diffused with a little dialogue. I've changed my blog postings before, and won't hesitate to do it again if I am wrong or if my comments hurt someone personally. That said, if your product sucks or I take a stance you don't like, please deal with me directly. I'm a man and I can take it. Just don't do an end around me where I have to explain my actions to others or worry about my livelihood or those of my partners being threated as happened here. As my friend the PACSMan pointed out, that is a Chicken Little way of dealing with it (although I think he changed the word little to a more "excretionary" term instead). I'm hoping that the legacy of this tempest in a teapot will be the establishment of better dialogue between all of us whose job it is to care for our patients in the best manner possible.

The PACSMan also sent me this (complete with pictures) which brought a smile to my face for the first time in several days, and has given me permission to share it with you all. I hope you enjoy it as much as I did....

Mike said, "Oy gevalt, what have you done my friend !!! Do you realize how much this whole story resembles the Wizard of Oz? It’s uncanny. Use this to explain what has happened to your blog site readers. They will fill in the blanks themselves…"


Average radiologist Dalai Lama lives an average life in an average town in the South with a hyperactive Jack Russell terrier named Blogger, along with Aunt Minnie and three colorful farm hands, Hunk, Zeke, and Hickory. One day their stern neighbor, Miss Imagination, is bitten by Dalai’s dog, Blogger. Dalai senses that Miss Imagination will try to do something dreadful, but his aunt and uncle, as well as the farmhands, are too busy with their work to listen. Dalai yearns for a better place in the song Over the Ether(net). Miss Imagination shows up and takes Blogger away to be destroyed, by order of the sheriff, over the impassioned protests of Aunt Minnie and Uncle Henry. Blogger escapes and returns to Dalai, who is momentarily elated but soon realizes Miss Imagination will return, and extract even greater revenge. He decides to take Blogger and disappear.

The Wicked Witch of the West

As they flee, Dalai and Blogger encounter Professor Marvel, a lovable but fake fortune teller who, out of concern for Dalai, tricks him into believing Aunt Minnie is ill so Dalai will not run away from home. Dalai rushes back to the farm but is knocked unconscious, inside the house, by a sudden South Carolina twister that has already forced his family into the storm cellar behind the house.

A confused Dalai awakens to discover the house has been caught up in the twister. Through the bedroom window, he sees a parade of people fly by. Then he sees Miss Imagination, also caught in the tornado, and pedaling her bicycle in midair, transformed into a witch. Moments later the twister drops the house, Dalai and Blogger over the rainbow and into OS. Glinda, the Good Witch of the North arrives and informs Dalai they are in Munchkinland. She tells Dalai he has killed the Wicked Witch of the East by “dropping a house" on her.

Encouraged by Glinda, the timid Munchkins (played by representatives of the smaller PACS companies) come out of hiding and celebrate the demise of the witch singing "Ding, Dong, The Witch Is Dead" among other cheerful songs until her identical twin sister, the Wicked Witch of the West, appears to claim the powerful ruby keyboard. Glinda magically transports the keyboard into Dalai's hands and reminds the witch her power is ineffectual in Munchkinland. The witch vows revenge on Dalai and leaves the same way she arrived, in a blaze of fire and smoke. Glinda tells Dalai, who is anxious to return home, that the only way to get back to South Carolina is to ask the mysterious Wizard of OS in the Emerald City for help. Glinda advises Dalai to never lose the keyboard and to "follow the yellow brick road" to reach the Emerald City.

On his way Dalai befriends a Scarecrow with no PACS, a Tin Woodman with malfunctioning speech recognition, and a Cowardly Lion with no PET/CT. The three decide to accompany Dalai to the Wizard in hopes of obtaining their desires. Along the way they are plagued by a forest of angry IT personnel and several failed attempts by the witch to stop them. While they arrive at the Emerald City, they are interrupted by the Wicked Witch, who flies across the sky, writing, "Surrender Dalai". The group talks to the Wizard of OS, who says that he will consider granting their wishes if they can bring him the broom of the Wicked Witch. The group then departs for the witch's castle.

Dalai comforts the Cowardly Lion

On their way to the witch's castle, they are attacked by flying monkeys, who carry Dalai and Blogger away and deliver him to the witch, who demands the ruby keyboard. When Dalai refuses, the witch tries to remove it but is prevented by a shower of sparks. She realizes the keyboard cannot be hers as long as Dalai is alive and plots on how to destroy him without damaging the keyboard's spell. As the Witch is considering on how to kill Dalai, Blogger takes the opportunity to take escape from the Witch’s grasp with Dalai crying, "Run, Blogger, run!” Outraged, the Witch screams at the Monkey, "Catch him, you fool!" but Blogger manages to escape, much to Dalai’s relief. The Witch, furious, snarls to Dalai, "Which is more than what you will, my little pretty!!!" and runs over to a large hourglass filled with red-blood sand and turns it over, gleefully telling Dalai he will die when the hourglass empties. She puts the hourglass down and runs out of the chamber, locking Dalai inside. Sobbing, Dalai calls for Aunt Minnie, saying he is frightened. Aunt Minnie appears, and Dalai tries to tell her that he is trying to get home. The witch appears, mocking and laughing at Dalai. Meanwhile, Blogger manages to find the lion, the scarecrow, and the Tin Man and lead them to the castle where Dalai is awaiting his demise. Once inside they are barely able to free Dalai and attempt an escape. The witch and her Winkie soldiers corner the group on a parapet, where the witch sets the Scarecrow on fire. To douse the flames, Dalai throws water on them, and accidentally splashes water on the horrified witch, causing her to melt. To the group's surprise, the soldiers are delighted. Their captain gives Dalai the broomstick to thank him for their liberation from the witch. Upon their return, the wizard tells Dalai and his companions, "Go away and come back tomorrow!!" Thanks to Blogger, though, they discover the wizard is not really a wizard at all, just a man behind a curtain. They are outraged at the deception, but the wizard solves their wishes through common sense and a little double talk rather than magic.

The wizard explains that he too was born in South Carolina and his presence in OS was the result of an escaped hot air balloon. He promises to take Dalai home in the same balloon after leaving the Scarecrow, Tin Woodman and Lion in charge of Emerald City. Just before take off, Blogger jumps out of the balloon's basket after a cat. Dalai jumps out to catch Blogger and the wizard, unable to control the balloon, leaves without him. He is sadly resigned to spend the rest of his life in OS until Glinda appears and tells him he can use the ruby keyboard to return home with Blogger. Glinda explains she did not tell Dalai at first because she needed to learn "if you can't find your heart's desire in your own backyard, then you never really lost it to begin with." Dalai and Blogger say goodbye to their friends, and Dalai follows Glinda's instructions to "hit Ctrl-Alt-Delete and repeat the words, 'There's no place like home'." He awakens in his bedroom in South Carolina surrounded by family and friends and tells them of his journey. Everyone laughs and tells him it was all a bad dream. A happy Dalai, still convinced the journey was real, hugs Blogger and says, "There's no place like home."

When Dalai wakes up from his trip to OS, the issue with Blogger and Miss Imagination appears unresolved and are left to the audience to interpret.


Dalai's Unpleasantness

The AuntMinnie thread concerning my "kinder and gentler" blog has me really amazed. With one minor exception, the posts have been very supportive. My friend Mike Cannavo, the One and Only PACSMan has worked the story into a wonderful allegory, which I will post in the next day or two. In the meantime, I'll duplicate my last word on the subject in the AM thread:

Well.... This is all a bit stunning.

The facts of this situation are essentially as the PACSMan has related them. After seeking legal counsel, and being told that fighting a large company was impossible, I removed any and all posts that the particular large company or clinic might find offensive. I did exactly what I was asked to do. When asked by regular readers of my blog why I had done so, I answered honestly. For my own protection, I must point out that the comments above are a spontaneous outpouring, and were not commissioned or requested by me. Frankly, they will probably get me deeper into trouble. But there's not much I can do about that.

This thread indicates a number of things to me. First, I have more friends and supporters among my readers than I might have guessed. My blog continues to get upwards of 200 hits per day, even in its "kinder and gentler" form. Second, there is a great desire for user-based information on the topics I write about. There is little if any other such coverage. Was I a little hard on a certain company? Yes, but that was borne of my frustration with their interface as well as their sales techniques. I meant no personal offense, and in fact, my posts were always directed to the company in general. I do wish that this particular company had done what Agfa has been doing for quite a while now, send their designers and engineers to sit beside me and my partners and see exactly how we work, and how their product could facilitate our workflow. That would have been a win-win situation. Third, there seems to be a tremendous amount of animosity in the radiology community toward this particular vendor. They know it, and what you see on this thread is just the tip of the iceberg. Perhaps this has never been said aloud before, and it's not something that becomes apparent in a focus group or a survey. That needs to be understood and dealt with, and not with a sledge-hammer.

It's time we all step back, vendors and buyers, salespeople, engineers, designers, techs, and even radiologists, and remember why we are all here: The goal is to provide absolutely the finest possible care for our PATIENTS. There has to be a new paradigm of involving everyone in every aspect of this process. To squabble and suppress does nothing good for those who need our services.

I trained as an engineer, and sometimes those principles can be applied to life. In electrical engineering, there is something called negative feedback. When one amplifies a signal, a small percentage of the output must be used to reduce the input. Othewise, the amplifier will continue to elevate its output until it melts. Similarly, in real life, a tincture of negative feedback keeps us grounded (not in the electrical sense this time), and helps us function properly. To quote from the late philosopher Jacob Bronowski, exerpted from his series, The Ascent of Man:

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."

All of us engineers should appreciate that.

Good night, everyone.

Sunday, December 02, 2007

Stupid Things People Do For Money

Here is a light, entertaining post about a foolish fellow in my own state of South Carolina who tried to use a fake $1,000,000 bill "to open an account in an Aiken, S.C, bank. Alexander D. Smith, 31, was charged with disorderly conduct and two counts of forgery..." Photo is from the Aiken County Sheriff's office via

I never cease to be amazed at the level of stupidity and deception folks exhibit in their attempts to extract the maximum amount of money out of a particular situation.

Saturday, December 01, 2007

The MILF Sale

In the "spirit" of kinder, gentler, non-confrontational, and non-controversial postings, here is some light entertainment from Spirit Airlines, offering their "M.I.L.F" Sale:

The MILF Sale

Many Islands, Low Fares - From $9* Each Way
Now is the perfect time to book that trip to paradise. Spirit is offering great, low fares to many exotic destinations at incredibly low fares - from only $9* each way! But hurry, the Many Islands Low Fares Sale ends Monday night, December 3, 2007 at 11:59 PM ET! Please see the full list of destinations below. All fares are each way, based on a roundtrip purchase and
taxes, fees & restrictions apply.

Time to go back to the islands, Mon. I wonder if they have heard of the "other" definition of M.I.L.F.?

I do hope I haven't offended Spirit, or lost them any sales with this amusing, light-hearted posting....

It seems that Spirit must have heard about that other meaning.... It seems rather ironic that they chose the "Mom" theme....

The Mom and Apple Pie Sale

With Fares From $9* Each Way
What's more good and wholesome than mom and apple pie? The only thing we could think of was a great sale with low fares to your favorite destinations - from only $9* each way. Now is the perfect time to book that trip to paradise. But hurry, mom, the apple pie and this great sale will be gone by Monday night, December 10, 2007 at 11:59 PM ET! Please see the full list of destinations below. All fares are each way, based on a roundtrip purchase and
taxes, fees & restrictions apply.
Now, that's Spirit!

Friday, November 30, 2007

Welcome To A Kinder, Gentler Blog

You will notice that all controversial posts have been removed. I hope you enjoy the remaining light entertainment.

Note to my biggest fan: you win.

Amicas Lands MedQuest, Agfa Gets Premier

Normally I don't report stuff like this, but I thought this particular blurb was noteworthy.

MedQuest operates 92 imaging centers around the South and West, and they went looking for a PACS to improve productivity for their rads and clinicians. MedQuest is owned, by the way, by Novant which owns a significant chunk of healthcare facilities.

MedQuest operates totally in the outpatient space. I'm sure they were hurt by DRA-2005, but obviously, news of the demise of such operations is a bit premature. As was predicted by many folks, DRA simply forced such companies to operate more efficiently, and they chose Amicas to help with that task.

I wonder if MedQuest is considering running all 92 sites from one server? It can be done, you know....

Agfa got a big one too, but it is a little more in the realm of a potential big deal. This article from HealthTech Wire notes the "three year, multisource" contract to provide Enterprise Image Management Solutions (EIMS) to the "alliance's more than 1,500 member hospitals and 49,000 other healthcare sites." The relationship goes back to 1995, the Dark Ages of PACS.

If I understand correctly how Premier works, this is not a guaranteed sale of 50,500 installs (I don't think all the vendors put together could handle that), but rather simply a pricing deal, offering significant discounts to the member hospitals. Feel free to comment if I'm wrong about that. Still, it's nice to be on someone's good list for a change, right?

Tuesday, November 27, 2007

Report from RSNA V: Amicas
(and a little Siemens, too..)

I'm actually going to start with the brief Siemens report. I had a chance to look at the new Symbia T16 SPECT/CT. Its footprint is MUCH smaller than that of the Philips Precedence, its bore is larger, and it does a lot of things by itself, such as QC. Set it to go at 3AM on Sunday, and the QC report will be available when you need it. Set up for a gallium scan (does anyone do those anymore?) and the proper collimators will automatically load from the tray under the gantry, and the heads will position themselves appropriately.

Software-wise, Symbia uses the Leonardo, I mean eSoft, no, Syngo, well, today it's the Molecular Imaging Workstation, MIW, for processing. I gave the Siemens folks grief about the lack of mouse wheel support, and they say it is coming. Eventually. I also groused about some problems I've been having with the PET/CT software, and they suggested I use the more generic 3D Fusion program instead of the older nuclear med version, and I will give that a try. All of this applies to SPECT/CT as well. I inquired about a thin-client, so I could properly look at PET/CT or SPECT/CT when I get a panic call from one of my colleagues. (It's good to be loved, and to have job security to boot!) So far, there really aren't any good (or cheap) options. One involves creating a virtual machine-type access to the Leonardo (I'm sticking to that term, sorry) and another involves loading the viewing software thick-client style onto the remote computer. A thin-client is in the works, but not available for the foreseeable future. So, I guess I'll have to rely on Agfa to do this, or perhaps we'll get TeraRecon, or Voxar thin-clients which will accomplish the same thing, as well as giving us a cardiac CT solution.

Coming to the Amicas booth is a little like going home; most of the faces are familiar, although the products continue to evolve and grow into great things. Version 5.0 has been released, and I've played with it on my test-server, although we can't put it on the production server until our Amicas hospital does the same. The 5.0 upgrade involved changes in server software, moving up to Microsoft Windows Server 2003, but this paved the way for the move to 5.5, and ultimately 6.0.

The big news in 5.5, due out early 2008, is a huge improvement in worklist functionality, and in particular, the way status is handled. Right now, an exam can have "status" in one dimension. It is unread, STAT, reported, whatever, but it can have only one such designation. The Amicas folks tell me that some discussion in the last Advisory Committee meeting led them to the fact that status doesn't have to be uni-dimensional, but it would make more sense to mold it to our workflow. Something can be STAT, and need extra images, and be from the ER. Thus, we can assign as many dimensions as we might need to cover the various intertwining workflows we follow daily. This is fully configurable by the site, and thus can be tailored to one's particular needs.

There are several new worklist-related tools for working with the ED, including an ED button on the worklist to go directly to the ER's preliminary report (if you can get your ER docs to cooperate, which we can't) and then there is an included mechanism to flag a disagreement. This then goes into its own worklist block, so the ER doc can be alerted, and maybe embarrassed too.

But the new worklist approach goes way beyond taking care of the ER docs. It works exquisitely well with RadStream, which I mentioned in an earlier post. Let me elaborate, based on a discussion with Dr. Mark Halsted, the radiologist from Cincinnati Children's Hospital who developed the program. (For more details, have a look at this article from Imaging Economics.) When the tech verifies a study, he or she has to fill out a brief checklist that helps assign an "acuity score" which is calculated by the program. The worklist then automatically sorts the studies based on this acuity score. The best part is that the more urgent studies percolate to the top of the list, and if I'm reading from a long worklist, the next most urgent study will come up after I close the last. And, if I'm using the Worklist Accelerator, which caches stuff in the background, I am able to read seamlessly, not missing a beat while progressing to the next-most-critical exam.

Now, it's after I'm done reading that the real impressive stuff occurs. If I need to convey a critical result, I simply click the "go to next study" button, instead of the "mark dictated and go to next study" button. A window pops up allowing me to declare this a study in need of rapid reporting. The study then drops into a worklist display block on MY computer showing that it is in progress of being called to the ordering doc (or however one wants it to read), and once taken care of, it will appear in a block noting that the critical results have been communicated. Of course, there is the complete audit trail for JCAHO's perusal, or (Heaven Forbid) that of lawyers. This is not an idle point: I have heard of cases of rads being sued for supposedly not telling the referring docs that there was finding on a patient's study. A preliminary entered into PACS might be helpful here, and no doubt that was done in these cases. But keep in mind that even calling the doc, telling him the findings, and documenting this in his report might not be enough; the doc could simply call him a liar. You see, even with a phone-call, supposedly the epitome of service, there would be no independant audit trail.

Some people prefer automation, some prefer the human touch. While Vocada Veriphy uses the former, RadStream uses the latter. The Vocada rep was almost snide in his support of automation over humans, but RadStream's use of a human in the communication equation makes rather good sense. Yes, one can automate the rules to contact Dr. Big Referrer, and Vocada will follow them. But, there is a limit to what a computer can do, and how much your referrers will appreciate the computer texting them or emailing them, or whatever. Frankly, this could contribute to the impression that radiologists are lazy, and would rather push a button and have the computer do the dirty work, instead of picking up the phone and calling them. With a human Communication Specialist (RadStream's fancy word for operator), there is the possibility of human interaction, and some on-the-fly decision making such as the referrer himself or herself needs to hear this report, not just his nurse, and the like. Yes, Vocada's automation might have some fallback rules for what to do if no one responds to the message, but it might not be enough.

While there is no set rule at this point, I believe that JCAHO prefers critical communications to be from person to person, not machine to machine. It certainly tells the clinicians that we are making every effort to get them the report as fast as possible, and as intelligently as possible. And it keeps everyone honest.

Amicas has a complementary product called VisionReach that takes care of the less critical results. Basically, the clinician can be emailed or faxed or whatever he/she chooses with the results, and the contact method can be chosen by the clinicians themselves. The emailed report can include JPEG's of key images, and there is also a link to the viewer itself. There is even a tab to allow the clinician to order a followup exam. Nothing like making it easy for them to send stuff to your site!

Carried over from Version 5.0 are a couple of additional features. The embedded Voxar 3D program has more functionality, with color presets and the ability to capture images back to the PACS system. There is also a way to easily cycle through prior studies by hitting the "-" key. Amicas only allows one prior to be visible at a time, and currently the only way to cycle is to bring up the prior list and select the one you want. This new little function will speed things along significantly.

Reading digital mammography is now FDA-approved with 5.0, but Amicas presently does not have dedicated mammo tools. Rather, one can use the regular viewer (and 5MP monitors, of course), or purchase the iRead program from Cedara. With Merge about to go under, I'm not sure how good an idea that really is at the moment.

I did get an extensive tour of Version 6.0 (I almost slipped and called it Impax 6, which would have been totally unforgivable.) I won't reveal the specifics as yet; you'll just have to wait and see. But do trust me on this: Version 6 will be one of the finest PACS GUI's ever offered, combining the easy usability of its ancestors with one heck of a lot of power. Believe it.

My advice to Amicas is quite simple...don't release this until it is ready for prime-time (unlike another Version 6 I know of), but get it ready soon. And don't sell it to GE.

The true test of a product, I think, is whether you would buy it again, having lived with it for a while. I've lived with Amicas since 2004, and I would buy it again in a heartbeat. It works, and it keeps getting better. No, I am most emphatically not on the Amicas payroll, but I am very enamoured with their products. Because they let me work the way I want to work, not the way they want me to work. It's that simple.

Monday, November 26, 2007

Report from RSNA IV: Intelerad

Here it is, my Canadian friends....I promised an update tonight, and I always fulfill my promises. Well, almost always....

My friend Rick from Intelerad was gracious enough to show me some of the improvements to be found in the latest and greatest version of Intelepacs. There has been no huge change, but a nice system is even nicer today.

Presently, my group uses the InteleViewer stand-alone program at our site that has no PACS. My boys are very pleased with it. It helps that one of them trained at ProScan, and learned speed-reading from Dr. Pomeranz himself. Dr. P. is an Intelerad user, and even was featured doing live readings from the Intelerad booth. I wonder if any fellows back in Cinci overread his live readings...

The Intelepacs worklist is a little spartan, being mainly a table of values, but there is color coding for status, and the colors can be changed at the user level. Great way to confuse your partners if they are foolish enough not to sign out of their account! Each column can be moved about, and one can sort by the column value or search for something specific within. To actually read a block of studies, simply click and drag over the ones you want, and they are sequestered to you. One can apply various worklist filters, although there is no natural division that I could see, such as a divider between one day and the next as Amicas does it. Still, this is a very usable setup.

The Intelerad folks have done something impossible; they have topped the Amicas spine labelling program. Well, it isn't a huge triumph, but they have developed a way for the computer to automatically realize if you are advancing cranially or caudally (up or down for those in Rio Linda) after starting at a particular level (which you still have to specify.) It works well.

Tab thumbnails have been added for displaying prior studies, a nice touch. There is again Voxar or TeraRecon integration. Presentation states can be saved, although one customer voiced concern about referring docs seeing how he left the window/level settings. Well, just because you're paranoid doesn't mean they aren't out to get you, I suppose, but I'm really not too worried about that.

At first, I thought the hanging protocol setup was as user unfriendly as Sectra's, but then Rick realized that I wasn't familiar with the "Capture" function. This simply captures (duh) the on-screen layout, and then you can tweak it with a complex system that is pretty much like Sectra's. But it works, and in the end, it's pretty much like Amicas' which I'm very fond of.

There is a method for ER reports to go back and forth, and an audit trail thereof. Voice clips are now included in the interface.

Bottom line, this good program has become even better, which would help to explain it's #1 KLAS rating. Not that I believe KLAS ratings, but.....

Report from RSNA III: Agfa Impax 6.4

I spent an hour or so with my old friends from Agfa, and they didn't seem to have any weapons in sight, either. My paranoia may be overstated, or at least misplaced.

We had the chance to look over some of the new stuff going into Impax 6.4, which we should receive at the end of January, 2008. There are some nice interval tweaks and fixes, which will improve the Impax experience. First and foremost is a marked improvement in the CT/MR multiplanar navigation. This will include auto-linking, and active targeting. This eliminates a significant complaint we had with 6.2, where triangulation was trying at best. Window/level and zoom parameters can also be linked. Version 6.4 will support Vista, but only if you don't have any Barco monitors. Likely a driver issue at this point. Comments, Barco? The simple search function is tweaked, and is now a bit more customizable, and usable overall. A glitch in deployment of Voxar 3D has been fixed, and I will no longer accidentally activate Voxar 39 times during the course of my reading. There is also a nice new toy, Smart seek web access. This appears as a tab or tabs in the study information are of the information screen. Basically, it is a smart browser, connecting one to various search engines such as Google or MyPACS. It is set to search on the body part or history, or what-have-you of the case up on the viewer. Could be a time saver in practice.

Agfa is working on an EMR display, called the Impax Clinical Module (we were assured that the button labeled ICM could be renamed), which requires a server box called the Enterprise Clinical Dashboard. No, I don't know how much that might cost.

A rather important new option is the incorporation of Vocada's Veriphy critical result reporting program. What Vocada (now owned by Nuance/Dictaphone) lacks in spelling ability, they make up in usefulness of their product. Veriphy is an automated system that will follow pre-set rules to notify our illustrious referring clinicians of a critical result. One can set the system to send a text with a phone number to call to get a voice clip, for example, or even send an email. This step is documented, as is the clinician's response, so the JCAHO requirement for an audit trail is fulfilled. Since this is about the only way to graft such a system (including voice clips) onto Impax, I was impressed. There are similarities to Amicas' RadStream, which the Vocada salesman poo-pooed, but in some ways RadStream works better, as it reprioritizes cases based on pre-test criteria. But you can't get RadStream for any other PACS at the moment, so it is somewhat of a moot point. Anyway, while Veriphy is a separate program, Impax will automatically log you into it upon startup.

We were also shown Works In Progress, many of which looked quite promising. Dr. K, one of our finest MSK rads (all of our rads are fine, by the way) was quite intrigued with ORTHOGON, a wizard based orthopedic measurement program. Basically, one selects the measurement to be taken, say a Cobb angle, and the program shows via a big red dot where to put the cursor next. It's easy enough for a caveman Nuclear Radiologist to use. "Follow the bouncing red dot" was the watchword.

Agfa is developing its own PET/CT and Virtual Colonography programs, and both look very promising. The PET/CT will perform autoalignment, and should work with any two datasets, no matter their modality. There is a very nice method of growing a volume of interest about a lesion, which seemed to work quite well for SUV's, as well as volume measurements. There is a report generator module as well. I have two complaints about their implementation, though. First, the blending control involves clicking over the word "Blending" at the bottom of the viewport, then dragging to control. Give us a button or a slider, please. Secondly, they are using hot-spots, areas on the viewport that will control various functions. Again, I prefer buttons. I need to see where I'm going.

The Virtual Colon piece is nicely done too, incorporating features that I have seen in some high-end products like Viatronix. In particular, there is an indication of what parts of the colon you have seen, and what you haven't, which could be critical.

AND......coming in 6.5......spine labelling! We saw a brief video of how it will work, and it will be OK, rather similar to Amicas' version, but not quite there. I asked why it has taken several years to reach this point, and was told that it took a great deal of programming to detect interspaces and such. Which is funny, because most other spine labelling programs just interpolate. Don't overthink things, guys.

So, there are many improvements coming for us Impax users. We're still toggling, though....

Sunday, November 25, 2007

Report from RSNA II...Sectra

The good people at Sectra asked me and Mike Cannavo, the One and Only PACSMan, to review their latest and greatest, IDS7, and we were honored to do so. I won't repeat the alternative name that their head of US operations, John Goble, gave to one of their non-PACS products, but it proved to us that Mr. Goble has a sense of humour, in addition to running a fine operation. You might recall that when Philips dumped Sectra for Stentor (I don't believe in political correctness, and I call 'em as I see 'em), Mr. Goble posted a letter to Aunt Minnie (which I lifted for the blog) in which he promised continued support for all of the Philips/Sectra customers who feared they might be thrown out into the cold. I gather that Mr. Goble has followed through on his promise with flying colors. In addition, he took the high road, never once trashing Philips for their decision. (I almost said abandonment, but that's a bit severe, and Sectra has prospered. Sometimes, a divorce is good for the kids.)

Anyway, IDS7DX, the radiologist version of the new software, looks uncannily like IDS5, which is the version I saw at SCAR (back then it was SCAR) in 2003. Charlotte, the apps person conducting the demo, told us that this was deliberate. Sectra wanted to preserve the look and feel of the product that was familiar to its users, but wished to update the code to .NET, and freshen and "Windowize" the GUI. This they have done, and apparently they have won an award for excellent .NET implementation. I have said disparaging things about Agfa doing similar things, carrying look-and-feel forward in version after version. I'm complementing Sectra on their efforts because they haven't recapitulated esoteric functionality, as Agfa did. Some things work, some don't, and you have to keep very close tabs on your users to find out which are which.

Anyway, as a .NET program, the new Sectra client may be downloaded via a single click, from anywhere. The same client works for everyone. No separate web-appliances need be used. Preserved is the open API construction that allows Sectra to use a large number of third-party modules, such as Voxar 3D and the like. JPEG 2000 compression is utilized as well, and for the Sectra authored volume rendering program, still in beta, Open GL rendering is performed. Nothing like using a $300 commercial card instead of a $2,000 proprietary version!

Worklists are definable at the system, role, and user level (which is what Impax 6.x was supposed to do, but doesn't.) Very complex worklists can be built through drop-downs. The worklist pane of the extensive (and to tell the truth somewhat busy) information screen does not seem to have state-indication (ala Amicas) but you have the entire list of worklists in the pane to the left of the active worklist, and a study can be dragged-and-dropped from one worklist to another. All panes on the information screen can be resized. There is a study-dependent document or comment field. There is also a blank window that can be filled with the html document of your choice, such as a calendar, stock ticker, or Dalai's PACS Blog.

The viewer component is quite similar to the 2003 version, although it seems able to handle large studies with ease. There is the ubiquitious (these days) extensive right-click menu which can be configured to your heart's content, and one can even change the alt-keystrokes for shortcuts. I must admit I still have some problems with this concept, as I did in my old review of IntegradWeb from the late, great DI. Perhaps it benefits those who have a dozen PACS systems and would like to force the keyboard shortcuts and whatnot to match each other, but maybe the industry should find a standard approach? Oh well, I digress.

The viewer is as usable as any, and more so than many. Hanging protocols, however, need work. There is a way to set up custom protocols, but it is rather cumbersome, requiring the use of a series of drop-down menus that contain every possible series description, and then dragging the various series representations to a mock display. Trust me, it is not user-friendly. Sectra apparently assumes that radiologists won't want to do this themselves, and they are correct on that.

Bottom line is that for Sectra, the port to .NET was successful, given that they did not otherwise massively alter a GUI that wasn't bad to begin with. The worklist display needs some updating, and the hanging-protocol setup needs to be revamped, but otherwise, I could like this. More than some other systems I know altogether too well....

Report from RSNA: Part I of ????

I made it to Chicago without much difficulty. As a matter of fact, Delta got me here 10 minutes early, and didn't even lose my bag! Not bad for the busiest travel day of the year.

I have yet to attend an educational session, but I'm headed straight to the Cardiac MR talk as soon as I finish this little entry.

One major change I've seen at RSNA is literally around my neck; the badges now have RFID tags, which lets the powers that be do some sort of monitoring of the attendees. No doubt this information will be used for proper ends, such as making sure that we actually do attend the educational stuff for which we are requesting credit. Personally, I'm worried that GE is using the tags to locate me when their snipers are in position. Nah, that would be too easy.

So far, I've had a quick look at the Philips Precedence SPECT/CT scanner. The darn thing is huge, and I'm not sure it will fit the room where it would need to go. I'll see the Siemens Symbia in detail on Wednesday, but I already know it's considerably smaller.


I stopped in at Amicas for a brief chat, and got to see the latest implementation of RadStream, the critical results software. It is very well done, and solves a lot of reporting problems we have at most hospitals. I've gone from a skeptic to a true believer on this one. My real appointment with Amicas is on Tuesday, so I'll have more to report then.

I wandered by the Dynamic Imaging booth, noting with sadness that this is the last time it will be a separate installation. I had a chance to talk with several of my friends, who now sport GE badges. I didn't see any weapons in view, so I accepted the invitation to see some of their latest and greatest stuff. Now, I'm not going to do anyone's product justice in my RSNA reports, since I'm going to try to write them on the fly as it were. But I can tell you that their version 3.7 has some great new stuff. There is a PET/CT reading module that is really well done, basically one of the best implementations of such software I have seen, and I can't wait to get my hands on it at our GE/Centricity site. There has also been improvements in the hanging protocol setup, and there are new overlay options that allow, for example, more optimal display of MR Spectroscopy. I even saw a peek of I5 in alpha form, which uses the same viewer, but tries to do what Agfa did on the information screen, i.e., provide all important info at a glance. They even have a "Coverflow" like display of image series. Frankly, this prototype was a little "busy" for me, but they are on the right track.

As for the integration of DI products with GE, this is still in flux, but DI promised me that they will give me a letter to post that will outline the approach they will take. I know what I'd like them to say, but..... Actually, the fellow in charge of integration of the two product lines was sitting at the table, listening to me wax poetic (that means babble) about the joys of Centricity, and especially Centricity Web. I get the feeling the GE brass hasn't a clue about some of the problems I deal with daily with respect (not) to their products. Now they do.

I've been here at McCormack for about four hours now, and I've met about two dozen folks that read my blog. Many of them had never met me before, and I hope they weren't too disappointed. Frankly, it always surprises me that anyone reads this thing. I'm just posting what I see, filtered through my biased keyboarding fingers. Really, if I've made someone think, or at least laugh, then I've done my job. If the PACS industry is hanging on my every word, one would be more surprised than me.

More to come from cold, cold Chicago!

Friday, November 23, 2007

What Dalai Wants for Christmas

Well, Hanukkah, actually, but I try to be eclectic at this time of year.

I have loved Swiss Army Knives from the first time I saw one as a child. They are fascinating devices, and of course, the more blades and tools, the better.

You may know that there are two competing companies making these little jewels, Wenger and Victorinox. Click HERE for a full history of the Wenger operation, and HERE for the Victorinox story.

Wenger periodically offers an Elite version for collectors and so forth, and this year, their masterpiece is like nothing you've ever seen, at least available for sale. In fact, it is noted in the Guiness Book of World Records:

Here are the specs:

  • 85 Implements110 Functions
    2.5" 60% Serrated locking blade
    Nail file, nail cleaner
    Adjustable pliers with wire crimper and cutter
    Removable screwdriver bit adapter
    2.5" Blade for Official World Scout Knife
    Spring-loaded, locking needle-nose pliers with wire cutter
    Removable screwdriver bit holder
    Phillips head screwdriver bit 0
    Phillips head screwdriver bit 1
    Phillips head screwdriver bit 2
    Flat head screwdriver bit 0.5mm x 3.5mm
    Flat head screwdriver bit 0.6mm x 4.0mm
    Flat head screwdriver bit 1.0mm x 6.5mm
    Magnetized recessed bit holder
    Double-cut wood saw with ruler (inch & cm)
    Bike chain rivet setter, removable 5mm allen wrench, screwdriver for slotted and philips head screws
    Removable tool for adjusting bike spokes, 10mm hexagonal key for nuts
    Removable 4mm curved allen wrench with philips head screwdriver
    Removable 10mm hexagonal key
    Patented locking philips head screwdriver
    Universal wrench
    2.4" Springless scissors with serrated, self-sharpening design
    1.65" Clip point utility blade
    Philips head screwdriver
    2.5" Clip point blade
    Golf club face cleaner
    2.4" Round tip blade
    Patented locking screwdriver, cap lifter, can opener
    Golf shoe spike wrench
    Golf divot repair tool
    4mm allen wrench
    2.5" blade
    Fine metal file with precision screwdriver
    Double-cut wood saw
    Cupped cigar cutter with double-honed edges
    12/20-Guage choke tube tool
    Watch caseback opening tool
    Snap shackle
    Mineral crystal magnifier with precision screwdriver
    Compass, straight edge, ruler (in./cm)
    Telescopic pointer
    Fish scaler, hook disgorger, line guide
    Shortix laboratory key
    Micro tool holder
    Micro tool adapter
    Micro scraper - straight
    Micro scraper - curved
    Laser pointer with 300 ft. range
    Metal saw, metal file
    Micro tool holder
    Philips head screwdriver 1.5mm
    Screwdriver 1.2mm
    Screwdriver .8mm
    Fine fork for watch spring bars
    Pin punch 1.2mm
    Pin punch .8mm
    Round needle file
    Removable tool holder with expandable receptacle
    Removable tool holder
    Special self-centering screwdriver for gunsights
    Flat philips head screwdriver
    Chisel-point reamer
    Mineral crystal magnifier, fork for watch spring bars, small ruler
    Extension tool
    Spring-loaded, locking flat nose-nose pliers with wire cutter
    Removable screwdriver bit holder
    Phillips head screwdriver bit 0
    Phillips head screwdriver bit 1
    Phillips head screwdriver bit 2
    Flat head screwdriver bit 0.5mm x 3.5mm
    Flat head screwdriver bit 0.6mm x 4.0mm
    Flat head screwdriver bit 1.0mm x 6.5mm
    Magnetized recessed bit holder
    Tire tread gauge
    Fiber optic tool holder
    Can opener
    Patented locking screwdriver, cap lifter, wire stripper
    Key ring
    Actual Size: 8.75. W x 3.25. L
    Weight: 2lbs 11oz
    Limited lifetime warranty
    Made in Switzerland

So, GE and Agfa...if you're in the process of selecting my Christmas gift, this is what I really, really, REALLY want. Remember, it's the Wenger Giant Swiss Army Knife™ V1.0, Model #16999. Oh, the price? Only $1,200.00. But I'm worth it, right?

Sunday, November 18, 2007

A Very Scary PET/CT Scan


Here is an axial PET/CT fusion sequence performed on a 36 year old woman with a history of melanoma. Does anyone see anything interesting?

I had known this patient was to be scanned, and she had been extensively counselled. I didn't realize, however, that she was on schedule for this particular day. Imagine my loss of intestinal control when I started scrolling through this study.

While I don't know for certain, this has to be one of the only, if not THE only, PET/CT scans depicting a twin gestation in the literature.

Saturday, November 10, 2007

A Weird PET Scan

video. video

Above, you will find the uncorrected and the corrected coronal images from a recent PET/CT scan performed on a GE Discovery ST. The patient is a young man in his 20's with newly-diagnosed lymphoma. There is some distortion in height due to the way I saved it, so ignore that. Notice, however, the intense, diffuse, homogeneous skin activity. This is not unusual for a non-attenuation corrected image, but we should not see this degree of activity in the corrected version. The study was repeated the next day with the same result. The patient had not eaten, wasn't cold, and had even been given Ativan. GE says nothing is technically wrong, and the patient must have something wrong with his skin. I asked the Siemens apps people, and they said there was obviously something wrong with the processing. Do I detect a little bias?

I'm at a loss here, folks. Anyone have any ideas???

Wednesday, November 07, 2007

Dalai's Laws In Action...

My friend and colleague Henry (that is his name, but he doesn't go by it) called me a few hours ago. "Dalai," he said, "I've got bad news and worse news for you. The Bad news is that the downtown campus of one of our hospitals just got cut off from the Internet. Some ditch-digger severed a main AT&T cable, and we're completely dead. The Worse news is that YOU are on call! See ya!" Actually, he didn't just leave at that point, but he did his best to inform all possible clinical services, and especially the ER, that PACS would be dead. Fortunately, the hospital's suburban campus is still online, and we can divert the patients over there. For the moment. So far, I have only had to be rude to the downtown Nucs tech, who didn't get the word and did a V/Q anyway. I was able to send our guy who gets done at 8PM over there on his way home, so all is not lost, and the normal V/Q will be read in a timely fashion.

This is a wonderfully unfortunate demonstration of Dalai's Laws of PACS, in particular, Laws I and IV. Law I, "PACS is the radiology department" is quite obvious when PACS is dead. All we can do is look at the CT console for those direst of emergency cases that can't be shipped out. I suppose we could film the hundreds of CT slices....nah. Because Dalai's Fourth Law says, "Once PACS, never back." We are not going back to film. Ain't gonna happen.

We can do little but wait for AT&T to fix the communication problem. We were told that could take from 2 to 8 hours. Right now, we're at 9 hours and counting. What should we have done here? This is a situation that is foreseeable, but not easily solvable. We have backups upon backups, but we don't have a backup for the most critical component of all in a web-based system: the Network! While it is the Internet that failed here, we would be just as dead if our LAN failed, so I'll group them together. In today's case, however, it was obviously the WAN that croaked. At this point in time, there aren't too many alternatives for broadband access. In my town, we have DSL, run mainly by AT&T, and cable, run mainly by Time Warner. There are various permutations with MetroE's and Frame Relays and such, but ultimately, all of these require physical lines, wires, fiber optic cables, or whatever, and those can be cut. The only other possibilities would be satellite internet, which is relatively slow and expensive, or a direct microwave connection to an ISP, which would be fast but still expensive. (No, I don't have time to pull the numbers, being on call and all, but trust me on this.)

I'm thinking WIMAX, the promised nationwide WiFi system, might solve this problem. Put an antenna on the roof, and you're connected. It would certainly have avoided an entire hospital being shut down by a ditch digger. Although I suppose a lightning strike or other such event could knock out WIMAX as well. Maybe we need to go back to dial-up?

The only good to come of today's experience is that we are able to tell the ER docs to think long and hard before they order useless studies. OK, we didn't use the word "useless" but the message got across. Maybe the mentality will sink in. Probably not.