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.