Meeting in Chicago

As usual, it has taken me far too long to get this report to you, but I only have one laptop up here in the North Woods, where I'm playing Camp Quack (pediatrician) for the week.  Naturally, Mrs. Dalai's Farmville crops will suffer if they aren't tended to constantly, and so I have to wait until the plowing and harvesting is complete before I can do something so mundane as post to my blog.  Beaucoup thanks, Facebook.  Love ya, mean it.

I did finally get to Chicago, accompanied by our intrepid salesman, and former PACS administrator, Garn.  As an aside, Garn's family has been very close to my group over the years, his dad and sister having sold us our very first Advanced Video Products/eMed/Access teleradiology system in the ancient, pre-Dalai era.  Garn earned his keep on this trip, literally running through three terminals to hold our USAir flight from Charlotte to Chicago that departed about 3 minutes after we arrived from South Carolina.  (I got stuck behind some slow-pokes on the moving walkway.)  That's what I call service.

I love Chicago, but I wouldn't want to live there.  Traffic from O'Hare downtown was murderous, even at 8 P.M.  For better or worse, my daughter loves Chicago and does want to live there, and will shortly begin a four-year stint at Northwestern Medical School.  (You don't want to know what that will cost, but we're talking yet another delay in my retirement.)  I had the chance to scope out her apartment building, and I was glad to see that security wouldn't let me in.  You have to find some peace wherever you can when you send a small (4'10") child to live in the big city.  It's going to be a long four years.

Merge Headquarters is in a very nice, new building just south of the Chicago River, with a great view of Grant Park.  We were fortunate enough to catch the Taste of Chicago in progress down in the park, and had a great lunch there, instead of sandwiches in the airy conference room.

Comparing Merge Central to the old AMICAS headquarters in Boston's New Balance Building is an apples vs. oranges exercise.  The new Merge office has miles of glass, with all executive offices completely visible to the hallways.  At AMICAS, the offices were, well, offices, and the place had a more informal dot.com-era feel with more free-form workspaces.  Yes, everyone at Merge wears a dark suit, a white shirt (although I saw a few renegades with pinstriped shirts), and a requisite orange tie, or scarf for the ladies.  The Merge logo is everywhere, and I quickly gave up on my grand idea to suggest a corporate name change.

You see, this Merge is not your daddy's Merge.  When the Click/Merrick folks (Messrs. Ferro, Dearborn, et. al.) took over, they remade Merge into a completely different company than its predecesor.  No more financial shenanigans, and no more anything but a drive to turn the old framework into a billion-dollar company.  I think they have a good chance to do it, too.  But when us old folks (like me and Mike Cannavo) think of Merge, the spectres of the past and visions of eFilm on every monitor loom close to the surface.  I'll say it here: Merge might be better off renaming itself AMICAS, but there seems to be a significant investment in things orange and blue, so I'll drop that line of thought.

I had the opportunity to meet with some old friends from AMICAS, Paul Merrild, now Senior Vice President - Marketing Corporate Strategy, and Kurt Hammond, VP Sales.  Justin Dearborn, Merge CEO was present, as was Nancy Koenig, now Executive VP for Sales.  Alas, Mr. Ferro could not be there, but I was told he had recently returned from Washington and various White House meetings.  More on that shortly.

When you've questioned a big company publicly, as I've done here, it creates an uncertainty, a degree of apprehension, that can only be defused by a face-to-face meeting.  I'm sure the Merge folks (maybe even the old AMICAS guys) were expecting this version of Dr. Dalai:

Of course some will say after reading this piece that this is what Dr. Dalai had to drink in Chicago:

Which is true?  That is in the mind of the reader.  To be enigmatic, I'm reminded of the pilot episode of "Fantasy Island".  Mr. Roarke's assistant, Tattoo, was asked what he thought of his employer.  Tattoo said, "Some call him..." (Tattoo points to Heaven), "and some call him..."(Tattoo points down).  "And what do you call him, Tattoo?"  "I call him Mr. Roarke."

The truth is, as usual, somewhere in between.  We had a good, frank discussion, I came away impressed, and the Merge folks probably were slightly relieved.

On the wall of the Merge conference room are 60 framed patents from the Cedara division in Toronto.  About 45 of these are for various imaging processes or devices, and 15 are for master data management.  I believe Merge considers the Toronto office, and the 120 engineers (including 12 DICOM experts) located there, one of the most important parts of its operation.  (There are 50 more engineers out in the field.)  Cedara provides a number of OEM'ed products sold to the likes of GE and other big vendors, distributing Merge products much more widely than I had imagined.  But in the realm of RIS/PACS, I was told that Merge is now the Number Four vendor, behind GE, Philips, and McKesson.  They claim a rather large footprint of 1500 hospitals, and 2200 Imaging centers, for almost 4000 "points of presence".  I don't think this includes the ubiquitous eFilm users, either. It does represent a coming together of several cultures, Merge, AMICAS, Emageon, etc., with all that entails for the company.

I'm hoping this high figure doesn't include eFilm, as I'm not a big fan.  However, Merge loves eFilm, which it acquired in 2002:

In 2002, Merge also acquired a Canadian software developer eFilm that developed medical imaging and information workflow products and services. eFilm provided Merge with a software-only image viewer that could be downloaded over the Internet. That acquisition allowed Merge to attain its goal of becoming a global leader in diagnostic imaging software tools by achieving a record 20,000 downloads of its eFilm Workstation software in 2002. eFilm Workstation displays diagnostic images, using a standard PC and monitor, and provides exceptional navigation and viewing tools for optimal radiological interpretation. 

Someone at the table jokingly called eFilm the "Duct Tape of PACS" and then instantly regretted providing me with a pithy quote for the blog.  But most of us, especially males, appreciate the comparison and find it complementary, so here it is in print.  The analogy is apt:  a duct tape repair will hold, but it might not be pretty, and neither is the eFilm interface.  But it does work, and it brings in significant (and easy) revenue for Merge.  Apparently it is quite popular in other countries such as Brazil where there is only 5% penetration of digital imaging.

Merge has a far-reaching long term outlook, which will utilize their know-how in various fields to provide solutions to other vendors, such as Meditech and Allscripts, as well as for the various 'ologies, Cardiology, Anesthesiology (perioperative monitoring software), Pathology (storage for the rather large images of tissue slides, etc.), and Gastroenterology (in the form of storage for endoscopic images).
While Merge doesn't want to get into the HIS and similar ends of the EHR business, they wish to be complementary to those who are in that space.

The patient experience will be an important part of Merge's future, and they have a very nice patient kiosk up and running.  It can do everything from check you in to dispense a CD-ROM of your recent imaging studies.  In fact, it was this technology that Michael Ferro was trying to get the White House to understand as one aspect of the Meaningful Use of EHR technology.  Merge is also trying to get PACS wedged in there as well.

I had a brief demo as well of some of the CAD products from Cedara, including a very nice system for breast MRI and liver CT and MRI.  I gave Merge the Million Dollar Idea after seeing these programs:  rework the engine for PET/CT.  The autodetection and so forth would work perfectly in that venue.  I'll gladly accept $500K for this really great suggestion.  Small bills, please.

The ultimate plans for PACS involve Enterprise Content Management (ECM), a vendor-neutral archive developed by Emageon that came with AMICAS, as the main repository.  For the clinicians at least, a Web Access platform will overlay this, providing a zero-client viewer via AJAX (and not Flash) technology, with fast server-side rendering.  Note that this is not an appended web server (ala the bad old Web 1000) but an integrated viewer.

A related product promises to help with the portable patient problem I've been bemoaning for years.  The "Outside Study Gateway" is useful for trauma and other transferred patients with outside exams, which encompasses just about every patient in my experience.  This is to be accomplished as part of PACS, since the PACS is already in place, you know.  It should be capable of operating without a VPN, which to me, having people that can do VPN's at my beck and call, isn't a big deal.  I believe module actually requires an add-on server, which will cost extra, but if it works as advertised, I would strongly recommend that you buy it.

But what I really came to Chicago to discover was the future of AMICAS PACS, and I think the answer here is satisfactory.  The Merge people feel that Merge and AMICAS were more complementary than competitive, except in the realm of RIS/PACS.  Everyone agrees that AMICAS had a great PACS, and Merge had a good RIS.  These two programs, respectively, will be the go-forward products.  Everyone at the table wanted to be certain I deliver this message clearly, so I will quote verbatim:  "The approach to RIS/PACS will be the consolidation of the best practices of all of the applications into a single platform workflow and viewing solution."  Well, there you have it.  All Merge RIS/PACS customers, including those using AMICAS PACS, Fusion PACS, or RadStream (from Emageon) WILL BE SUPPORTED, and will have an upgrade path.  How much the upgrades will be wasn't mentioned.  What I will call AMICAS 7 will ultimately include the best of all worlds, blending the best of the legacy products, and using the ECM as the back-end.  (In discussing this with my PACS administrator today, we wondered how this will affect the way AMICAS currently stores images, with DICOM going to backup and JPEG2000 on spinning RAID.  Perhaps everything will now be DICOM, which would require a larger online storage facility.  Fortunately, storage is cheap these days.)

Feeling I had to be at least a little ornery, I questioned whether Merge would be able to graft the AMICAS front-end onto the Emageon ECM.  After all, our friends at another larGE company have yet to successfully do something similar with the new GUI they bought a few years back and their shiny new LINUX back-end.  I got a few laughs with that one.  Basically, Merge feels that the ECM is a very different animal than the LINUX thingie (technical term mine), more DICOM-friendly, and more amenable to having other interfaces plugged into it.  (I refrained from asking if I could get IMPAX 6.x to plug into it, too.)  The ECM should have better standards, and an interface has already been created for the Camtronics/AMICAS Vericis cardiac program.

At this point, in the meeting, I felt cautiously optimistic.  I was impressed by way my old AMICAS friends have transitioned into this new reality, as well as Ms. Koenig's and Mr. Dearborn's enthusiasm for where the company is and where it's going.  Merge will not only make a go of all this, but will actually succeed mightily.  But now I'm now going to share with you the best part of the show, and the person I met that completely and totally "gets it".  I'm referring to Luc, the Director of Patient Experience.  After the talking points and the white-boarding, and so forth, Luc walked me down a corridor, and opened an unmarked door.  Inside the long, narrow room, were....Video Games!  There were various driving games, a machine that played multiple legacy games, and a coin-operated version of Guitar Hero.  Luc asked me which I thought was the most popular, and flailing a bit, I pointed to the multiple game console.  80,000 games in one box is not to be sneezed at, right?  Well, Luc laughed a bit and shook his head.  No, the most popular game is the machine with the simplest, easiest-to-use interface, which would be Guitar Hero.  So what was the point of this lesson?  Simply this:  To create an interface, especially for patients, but quite applicable to physicians, one must simplify, but still have a complete understanding of how the thing had to work in the hands of the users.  It was not enough, Luc said, to bring a radiologist or two into the company and see how they like things.  Rather, it is necessary to go observe how the radiologist uses the GUI in the hospital, in his environment.  Only then will it be apparent how things should work.

Looking back, I'm not sure if Luc was thinking more about the patient-kiosk interface we were about to see than the AMICAS PACS interface that is already here.  But I still think he gets it, and by extension, I'm hoping Merge does as well.

This is a different path than I hoped to be following six months ago, but I'm more and more hopeful that it is a good one.  I know that my favorite AMICAS developers have been working to impart their knowledge about Version 6 to the Cedara folks in Toronto, and for that I will be forever grateful.  Certainly this was above and beyond the norm for a departing employee, but that's the sort of people they are.  With some luck, their colleagues in Toronto will prove to be worthy successors.

So, did I drink the Kool Aid?  Nah, I had a Diet Pepsi at the Taste of Chicago...