Dalai in RSNA "Wonderland"

For the second year in a row, AuntMinnie.com has allowed me the privilege of substituting my foolish ravings for Mike Cannavo's far more thoughtful and educational RSNA articles. Below you will find my final draft, which was altered slightly by the AuntMinnie editors to be a bit more politically correct. The officially published version can be found here. 

Dalai in RSNA Wonderland

or

Dalai in Vendorland

Chapter 1: Down The Scanner Bore

Dalai was very tired that morning; tired of sitting at his PACS station and getting slammed beyond belief. Twice, he had peeped over to his partner’s stations, but they were lost in conversation, leaving the long list of exams for Dalai.

Suddenly there appeared out of nowhere none other than The One and Only PACSMan, wearing a white T-shirt and with eyes bloodshot. “Goombah!  I’m late for my scan!” he muttered. Dalai was not generally prone to hallucination, and it later occurred to him that the white-clad PACSMan should not have actually been there in the reading room at that time. But Dalai followed PACSMan's mad dash out of the door to the reading room, down the hall, and into the MRI enclosure. The PACSMan popped into the MRI bore, and disappeared. In another moment, Dalai followed, not stopping to think just how foolish this action might be.

The journey down the bore was slow and rather odd. It was quite dark, but here and there could be seen glowing jars of radium, and chest x-rays on old-style viewboxes. Where would this end? Perhaps Dalai would exit another MRI in China, or New Zealand, or maybe in the clinicians’ .05T device across the street. What would Mrs. Dalai think? Probably that Dalai had gone to hike the Appalachian Trail, or was otherwise misbehaving.

With no warning, Dalai found himself sprawled on the floor of the Grand Concourse of McCormick Place, having narrowly missed a delegation of sonographers from Japan standing by the Starbucks counter. He spotted the white-shirted PACSMan bouncing down the Concourse, headed for the Technical Exhibits.

Dalai tried to follow but was stopped by the guards. “Badge, Please” they croaked. All Dalai had was his radiation monitor badge, but clearly this wasn’t what was needed. Behind him appeared a pedestal with a large red button labelled “Scan Me!” Dalai pressed it, and a warm glow enveloped him, and his tiny radiation monitor had grown into a proper RSNA blue-edged ID . “Only vendors ‘till 10, Doc!” cried the guards. Another pedestal and “Scan Me” button appeared. Dalai pressed this as well. He felt a tingle up his leg, and his badge turned Exhibitor brown. “You may pass!” said the guards, nodding toward the entrance.

CHAPTER 2: The Rat Race

Dalai wandered into the thick of the Exhibit Hall, and soon encountered a cluster of rather odd-looking black-suited men, milling about the various technical displays in more or less circular fashion.

“Whatever are you doing?” asked Dalai timidly.

“Why my good man, we are running the Imaging Sales Rat Race!” said the first of the gentlemen. “It serves no purpose, we end up where we began, but we look busy and everyone gets a prize. Did you bring one for all of us?”

“Um..well, I only have my iPhone,” mumbled Dalai.

“Hand it over. We’ll use it to place orders for all of our modalities, and everyone wins!”

The dark-suited man grabbed for Dalai’s phone. “Patience! First, we must....” Dalai cried.

“Yes, Dalai! Patients First! The patients deserve the best of the scanners, which you cheap doctors seem loath to provide!”

“I didn’t mean it that way! It’s Administration’s fault! They HATE spending money and salesmen too! And they want to comply with the Laws, known and unknown! But of course for me, Patients come First! Don’t be so easily offended!”

And with that, the odd men got up and resumed their circular trek.

Chapter 3: The PACSMan Gets a Little Bill

The white-clad PACSMan reappeared, rounding a corner behind a huge display of bone-containing plastic phantoms. He looked straight at Dalai, and howled: “My Bill! My Bill! this is outrageous! $5,725 to look in my head? I’ll have someone bumped off, I will! Get going buddy, right now! Leave the scan, bring the cannolli!"

“He thinks I’m his personal radiologist,” Dalai thought to himself. “Patients First”, yes, but really...

Another pedestal arose with another button labeled “Scan Me!” Dalai pushed it, and this time felt a migrating itch travel from head to toe. His badge turned green, the RSNA color of important people who are not physicians.

As he was unable, and, by virtue of the new badge unqualified, to fix the PACSMan’s Bill, Dalai was able to escape to the next booth.

Chapter 4: Advice from Aunt Minnie

Dalai’s flight took him to a booth containing several plush leather motorized massage chairs. In the last was seated a little old lady, smoking a Cuban cigar.

“Who are YOU?” she cackled.

“I’m not quite sure anymore,” said Dalai rather hesitantly. “I was once a radiologist, but I seem to have become a number of other things. I started out trying to care for Patients First, but now I seem to have to please everyone! I have to fix Bills and such. I’m not sure I even remember what FEGNOMASHIC stands for.”

“Repeat it for me, Sonny!”

“OK, if you insist...Fibrous Dispepsia, Elusive Granuloma, Generic.....”

“Wrong! Wrong from beginning to end!” She puffed the cigar for a moment. “So if you don’t know who you are, why do you think you are a radiologist? Why can’t you go with whatever you are now? Like they say, if it looks like your Aunt Minnie, sounds like your Aunt Minnie, it’s your Aunt Minnie. That’s me, Dalai!” And she cackled some more.

“By the way, Sonny, if you push that button behind you, you’ll turn into something else entirely, since you don’t know who you are anyway. Neither looking or sounding like a duck, eh? Push it and get outta here!”

Dalai looked and there was yet another pedestal and red button, although it lacked the “scan me” label. He pushed it, experienced a transient rash across his torso, and his badge turned red for a non-member physician.

Chapter 5: Cheshire CAT-Scanner

The next booth over was the home of the Cheshire CAT-Scanner. Dalai walked up to the massive device, which had a huge display panel on top.

“What shall I do, dear Scanner?”

“It depends on what you wish to accomplish,” scrolled across the display.

“I don’t care much at this point. I just want to scan gently, and put my Patients First.”

“Then it doesn’t matter much where you go on the exhibit floor...they all do the same thing. Except for this!”

And with that, the Scanner faded from view, with only the flashing alphanumeric display still visible.

“You’ve come to an area of unreality, of madness. The real world doesn’t work this way, Dalai, and now you’re mad too. You must be, or you wouldn’t have come here.”

“And you know I’m mad how?”

The scanner faded back into solidity. “Look at me. I can scan the entire volume of a patient in 0.066 seconds, and rather than irradiate the patient, I draw radioactivity FROM the body. They patient leaves my gantry with less dose than when he arrived. Yes? Since you believe every bit of the hype you see around you when you come to the exhibit floor, you are therefore mad. Now do you wish to play footsie with the King and Queen today?”

“I don’t think I would,” demurred Dalai.

“Too bad,” said the Cheshire CAT-Scanner silently...you’re booked for One in the Afternoon at the Palace. But you need to have a bit of a chat with the Vendors first.” And with that, the scanner vanished from the booth. A new pedestal appeared in its place, with the familiar “Scan Me” button. Dalai shrugged, and pressed it.

Chapter 6: The Mad Vendor’s Cappuccino Party

With a sudden, brief attack of GERD, and the conversion of his badge back to blue, the color of full members of RSNA, Dalai walked down to a very large booth, finding a lovely Danish Modern dining room table and chairs placed directly in front of a huge brass espresso machine. Several dark-suited types were scattered about the table, with one wearing a meatball-splotched tie.

“Have some cappuccino, Dalai,” said one of the diners.

“But we’re out of cappuccino!” said another.

“Hey Dalai,” said the man with the tie, “How do you qualify for Meaningful Use?”

“I believe I can guess that,” responded Dalai.

“Do you mean that you think you can find out the answer to it?” said another dark-suit.

“Exactly so,” said Dalai. “It’s simple, really, isn’t it? But wait...what’s Meaningful Use anyway?”

“You mean you don’t know?” cried the Mad Vendor. “Darn. Neither do we. But that won’t stop us from trying to sell it to you!” And the dark-suited men began to bicker amongst themselves, telling stories of customers that got away.

Dalai got up and left the table, ultimately exiting the madness of McCormick altogether, and wandered south.

Chapter 7: Nothing's Cricket in Hyde Park

After walking quite a distance, Dalai found himself in a quaint, tree-lined neighborhood, with one house that stood out, clearly a palace. The King and Queen themselves were inside, sitting on matching thrones. They were incredibly angry, calling out, “Off with your revenue! Decapitate your capitation!” Sprawled before the thrones were a dozen other radiologists, just as confused as Dalai by the whole proceeding.

“Patients First!” bellowed the King. “You tried to steal the revenue! Call the witnesses!”

The Mad Vendor approached the dais. “I tried to get them to participate in Meaningful Use! But they wouldn’t buy my wares. I’m a poor man, your Majesty, and a very poor salesman.”

“And a very poor speaker. But you tried to put Patients First. Stand down.”

“But your Majesty, I’m already on the floor as it is!”

“Then SIT down!”

The assembled courtiers snickered in delight.

“Call Dalai to the stand!”

Dalai approached with hesitation, but then stood straight though with head bowed.

“What do YOU know of this business?” asked the King, and the Queen nodded, sure of what was to come.

“Why, nothing, your Majesty. I’ve always tried to put Patients First, but to no avail. With the coming cuts and payment shifts, we radiologists can’t serve them as we once did. And no one knows how radiologists might participate in Meaningful Use!”

“Matters not,” said the King. “If they cannot transmit Patient Data to Us, they are not worthy. Haven’t they signed the Meaningful Use Attestation?”

“No, your Majesty.”

“Aha! All of you must have meant some mischief, or else you’d have signed your names like honest men! Off with their revenue! Decapitate their capitation!”

Chapter 8: Back Home

Dalai sat up with a start, and looked around at his reading room, to which he had returned from his rather bad daydream. His colleagues were still locked in conversation, and the list had grown to gargantuan proportions. He picked up the microphone, put it down again, got up, and walked out of the hospital. The other rads eventually discovered his absence, after receiving several frantic calls from the Emergency Department inquiring after reports. They realized what had happened, although Dalai’s trip to Vendorland and Hyde Park could never be known to them. Still, they longed for the simple life when Patients really did come First.

The End

The Siemens RSNA Press Conference ...and some thoughts on IT

For the third year running, Siemens has somehow acquired the idea that I'm a true journalist, a member of the press, and invited me to their annual RSNA Press Conference. In return, I'll report to you what was said.

Presiding over the conference was Dr. Hermann Requardt, (PhD in Physics!) CEO of Siemens Healthcare, with Dr. Gregory Sorensen, (Neuroradiologist) CEO of Siemens Healthcare North America, in the supporting role. 

Dr. Requardt blended optimism with realism, noting that the healthcare market continues to expand, although we must continue to temper this with cost containment and determine ways to achieve the balance. The US was (and probably will continue to be) the lead market in this business, the target market most receptive to innovation. However, the European market is flattening, and the Far East is ramping up healthcare spending. But, "if you can't pay your physicians, you can't buy new MRI's," says Dr. Requardt, and that's certainly true. Even so, Siemens orders were stable from 2011 to 2012, with revenue and profit increasing slightly.

Probably stung by the barbs thrown at healthcare spending, especially directed at imaging, Siemens acknowledges a dramatic need for efficiency, and doesn't want to be seen as part of the problem, but rather the solution, "which is innovation," according to Dr. R. One somewhat surprising part of the solution: less expensive, entry-level, "good enough" scanners manufactured in China by Siemens are being sold world-wide, and actually moving quite well here in the good old US of A. (Dr. Sorensen later said that HALF of these "good enough" scanners are sold to the US, and conversely, their high-end machines sell well…in China.)

Siemens grasps that the mountain of data thrown at radiologists is nothing short of disruptive, terming it a "Data Tsunami". The solution is to be found within IT, which becomes the enabler for productivity.

Siemens is making the best of the Accountable Care movement, viewing it as a US-driven movement from "what's wrong with the patient" to "what's going to help the patient," assuming that outcome-optimized medicine will be based on knowledge.

Dr. Sorensen then gave a brief overview of Siemens' past, present, and future. It turns out that Siemens is the largest and oldest company in the world, dabbling in everything from power plants to power Doppler ultrasound, yielding a background of durability and long-term outlook. He revealed this year's Breakthrough Innovations:

• The First Wireless Ultrasound probe, allowing for cordless scanning, say in the operating room. You can see Dr. Sorensen holding the probe above. 
• Their new full-field mammography offering will have the lowest available dose, 30% lower than the competition. 
• New Angio suite. 
• Interpretation software for AmyVid, Lilly's new amyloid PET agent. Apparently, the interpreting physician will be blinded as to patient history for this scan. (Not that we get one anyway)
• Siemens will soon offer the "highest performance" 3T MR, the Prisma. 

For the future, Dr. Sorensen notes that 20-40% of US healthcare is wasted, often because we pursue diagnostic dead-ends. "The value of knowing is paramount, and the worst treatment is the treatment you didn't need."

Siemens optimistically (can you say wishful thinking?) believes ObamaCare will sharpen the US market, though they think we will still stay in the lead. To this end, they must improve upon their value-based product, with the hope that demand for high-end products will continue.

The team lastly traced the cyclic nature of health care spending with respect to the growth and contraction of any particular national economy: “From Underinvestment to Cost Cutting.” We’re clearly beyond the fat years, and into the last stage. And it seems that there is usually a time-lag between recovery of an economy, and recovery of the health care industry. I’m not holding my breath on that one.

I want to revisit the point about IT being the solution, the enabler of healthcare. (I'm assuming they don't know some of MY IT people, although I realize that isn't what Dr. Requardt meant.)

The sentiment was also reflected by Paul Chang, M.D., in his Eugene P. Pendergrass New Horizons Lecture, "Meaningful IT Innovation to Support the Radiology Value Proposition."  (Note that the information on lectures to follow is from the RSNA Daily Bulletin.) PACS, according to Dr. Chang, is a "commodity-level service". To really show the value we rads provide, we need IT. First, IT provides advanced workflow to help quality in radiology, and help all the clinicians get their needed information as well. Rads used to collaborate with clinicians daily, looking over the old-style films. PACS has done away with that to a considerable extent. We need to follow the examples of the new social media, says Dr. Chang, like Facebook and Twitter, which leverage the technology of the Web to share content and collaborate virtually. We need to improve how we mine data from our reports and the EHR in general, an area where we are woefully behind. And, we need to demonstrate our value directly to the patients, using IT to connect to them as well as to the clinicians. "We have to become irreplaceable and add measurable, demonstrable, and differentiable value to our clinical colleagues in this aligned environment," said Chang. "We have to be perceived as irreplaceable in this aligned model and have to provide evidence ... and demonstrate to that aligned enterprise that we truly add value," Chang said. "In other words, we need to be a differentiable value innovator."

Next, let's consider the contributions of Dr. Keith Dreyer, who gave another New Horizons Lecture, "The Future of Imaging Informatics: Meaningful Use and Beyond". The development of PACS and so forth was driven, said Dr. Dreyer, by the imaging necessities under the soon-to-be historical fee-for-service payment system that incentivizes volume while being neutral on value, with a focus on maximizing productivity and volume and reducing the cost of doing business. Since the US Government wants to lower costs, we are now steered toward bundled payments and accountable care organizations that "shift risk from the payers to the providers...and even to us..."  Meaningful Use arose from the need to monitor this transition. "Radiologists need to adapt, not only for incentives, but because this is where the future of healthcare is headed. Previously, technology was driven toward improving productivity while reducing costs, but in the new model, the push is to improve the quality of care, access and safety, with the assumption that those improvements will reduce costs."

"At the expense of some productivity, we're going see a dramatic increase in quality that will be measurable by metrics that we'll be required to measure but also an increase in relevance," said Dreyer.

"They really haven't been optimized for performance metrics such as quality, safety, access, and outcomes," he said.

If radiologists were incentivized by outcomes, they would likely want, for example, to open up a chat session with referring clinicians who have questions on a difficult case they recently read to guide them through it. If the motive was patients first, they might wish to have a system that extended that chat functionality to patients, Dreyer said.

Meaningful Use ". . . provides a fertile ground for innovation in radiology access, communication, and utilization..."

We should add the opening statements of Dr. George Bisset III, RSNA president, as quoted on AuntMnnie.com:

"What I mean is owning our patients' problems," he said. "I mean being more fully invested in them, thinking of them as 'our' patients as much as anybody's -- owning their fears and their frustrations; owning their need for clear, understandable information; and owning their health behaviors and capacity to make good health-related decisions. I believe it's time to redefine what we mean by patient care, viewing it not so much as a product we deliver but as a virtue we live and breathe as we go about our daily duties."

Bisset sees the current healthcare chaos as a "golden opportunity." The changing environment of value-driven healthcare is an opportunity to address radiologists' invisibility. He advised paying attention to small details -- even relatively routine exams such as mammograms or chest radiographs may be alarming for some patients. Spend a little time in the waiting room and ask patients what can be done to improve the experience, he added.

To create a patient-centered practice it boils down to four principles, according to Bisset:

1. Dignity and respect: Healthcare practitioners should listen and honor patient and family perspective and choices.
2. Information sharing: Healthcare practitioners should communicate and share accurate, complete, timely, and unbiased information with patients and families in ways that are affirming and useful.
3. Participation: Patients and families should be encouraged and supported in participating in care and decision-making at whatever level they choose.
4. Collaboration: Patients and families should be included as partners on an institution-wide basis. Healthcare leaders should collaborate with patients and families in policy and program development, implementation, and evaluation. They should also collaborate in healthcare facility design, their professional education, and in the delivery of care.

Well, then. From the luminaries of radiology, you have a relatively bright vision for the future, thanks to IT, and an attitude (marketing?) shift that portrays us as more caring than the clinicians themselves. I hope they're right, of course. But here's where I go off the rails. Since I'm NOT a radiology superstar, or even a dwarf star, I can have a contrary opinion, and no one will notice. And so, contrary I shall be.

I won't quite say that we are seeing the death-throes of radiology, because I think we will always have something to add. WE have become the master diagnosticians, and are often called upon to solve problems before the patient even gets off the gantry. We DO provide value, we DO deliver quality. Of this I am certain. Could we do better? Yes, of course. Of the the viewpoints presented, I'm frankly most in line with Siemens, who wishes to provide IT solutions which will truly help us improve what we do. And to make money in the process. This is what capitalists do, and those who do so the best are those who are flexible and provide what is needed at the proper time. Siemens IT products are quite advanced, and worthy competitors in the world market. (Yes, we chose TeraRecon over syngo.via, but the latter has HUGE potential which I think will be realized in the next few years.)

I have nothing but the highest respect, even awe, for Drs. Dreyer, Bissett, and Chang, and again, I hope their optimistic vision is correct. However, I'm feeling much less certain. Basically, they are saying that first, we need to use IT to comply with the new laws and new paradigms, "quality" metrics and otherwise, brought to us by ObamaCare, and secondly, that we need to do a better job of selling ourselves, and we should use IT tools to make this happen. Frankly, these are not, or should not be, fundamental changes. We should already be communicating to our clinicians, we should already be using advanced visualization and other accoutrements to improve our reads. But...there are HUGE pitfalls awaiting us, and thinking that IT will save us is perhaps naive. I'm very wary, for example, of the ACO concept, where we will be placed in the dichotomous positions of gate-keeper to prevent excess scans, and whipping boy when we DO advise against a scan some clinician (or patient for that matter) thinks he needs. Having a direct Facebook-style connection to our patients sounds good and right, until a patient latches on to us and is incapable of understanding what we are trying to tell them, and becomes belligerent  (Been there, done that, by the way.) Dr. Bissett's comments are well-taken, but for the most part are things we should be doing already, with the possible exception in my little mind of the ultra-high level of communication to the patients, especially of troubling results.

How do we measure our contribution to the patient's outcome, relative to the treatment they receive? Could we provide more quality? No doubt. Many scans could be read better, and we would like to make fewer errors.  But all I'm seeing here are ways to seek out and punish those responsible for "bad outcomes". Incentive to improve? Maybe. But certainly no mechanism is provided. Well, I'll take that back. With the pressure to produce removed, we can perhaps just read one or two studies per day, and we damn well better get those right. Oh. That won't fly either, will it?

As an iconoclast, I'm seeing these measures as being reactive to the new governmental restrictions, and not proactive. We are trying desperately to prove our value, when it's continuously proven every minute of every hour of every day. Radiology isn't going away, but reimbursements are going to plummet, and all of the electronic arm-waving and attempts to add even more value to what we do isn't going to change that. At best, those who play this game better than others will be more likely to be enslaved purchased by their hospitals, soon to be the only game in town, to the exclusion of predatory entrepreneurial groups who can micromanage and tailor their minions to produce whatever metric is desired at that moment.

Innovation is life in this business, as with many others. I'm certainly not rejecting the concept, and I do embrace IT (the technology, not the personell) as our path forward. However, I fear that none of this will change how we are perceived by the government and by our colleagues. At 3AM, the ER docs know quite well how valuable we are, but we will always be the folks with the expensive toys that (in the delusions of many) overspent the healthcare dollar and backed the entire field into the corner in which we now find ourselves. All the computers and all the IT men can't put our reputations together again. Sorry.

Attention NovaRad: PLEASE STOP SPAMMING MY BLOG!!

YET ANOTHER Blog Spam message from someone at NovaRad in the last hour:

Megan Billard has left a new comment on your post "Practice SafeCT": 
Thank you so much for this great information. As I was looking on the internet for more information on PACS systems I found your site and I don't think there's anything better I could have found. Thank you so much for being clear and concise in the information you share. This really is a great blog. 

And of course, the PACS system link goes to....NovaRad!

If you have to resort to this bottom-feeder tactics like spamming blogs that few people read, your product must REALLY be lacking.

This doesn't even reach the level of an RSNA Naughty Bit.

Practice SafeCT

Axial scan, 0.6 mm slice thickness, acquired with a LightSpeed VCTTM by GE Healthcare and displayed in a Soft Tissue window of W=60; C=40. SafeCT processed image on right.

Image courtesy medicvision.com 

This entry, by the way, does NOT qualify as a Naughty Bit. In fact, it's about something rather impressive.

Last year, we were quite involved in selecting an advanced visualization system. We were at one time under the impression that one of the products under consideration was going to deliver a added bonus: Dose Reduction! But sadly, this turned out not to be the case. Please read this Old Post for details. As you know, we went with TeraRecon, although it has yet to be installed. Good things come to those who wait.

In the meantime, we have been fortunate enough to afford to replace several of our CT's with the latest and greatest from Philips, which have quite advanced dose reduction built into their hardware or software. But what of the old scanners we can't yet replace? If a patient is so unlucky as to be scanned when the low slice slicers are the only thing available, do they deserve a higher dose of radiation? Now, I think I need to mention that one scan on the higher dose machines might theoretically carry a greater risk of something, but really, the excess dose is probably not all that dangerous. Still, we treat radiation with respect, and try to reduce the cumulative dose by limiting the dose of each individual event. Alas, we cannot go back and retrofit the old but serviceable scanners with the new dose reduction technology.

Or can we?

I don't know off hand if Atlantis Worldwide contacted us, or if our physicist found them. Atlantis deals mainly in used equipment, an honorable and difficult task. But they are the US representatives of an Israeli company called MedicVision, the creators of the product in question. I've had the joy of a WebX demo, and today, the chance to speak to some of the scientists behind a new approach, SafeCT. To be brutally honest, when I first heard of it, I thought it was nothing but bullsh*t. After much more exposure, I think I was full of bullsh*t, and SafeCT might well be the answer for many in our position.

So what is it? What it is NOT is a simple filter. What it is NOT is a hardware solution. It IS a software solution, utilizing a "novel" non-linear three-dimensional post-processing iterative image reconstruction algorithm that increases SNR and allows CT radiation dose reduction. From the MedicVision website:

Medic Vision’s SafeCT is based on proprietary patented iterative volumetric algorithms technology for Signal-to-Noise Ratio (SNR) enhancement of CT studies acquired over a wide range of exposure parameters on conventional CT scanners. SafeCT is compatible with all major CT platforms and PACS systems. It can serve multiple CT scanners simultaneously via their DICOM network. SafeCT has been in clinical operation at leading medical centers and private radiology practices in the Unites States, serving thousands of patients. SafeCT is FDA-cleared for distribution in the USA.
Excellent Image Quality

• Reduced image noise
• Improved visualization of anatomical detail
• Preserves the look and feel of images the site is accustomed to. 

High End-User Value

• Add-on product compatible with any CT scanner
• Eliminates the need for costly scanner upgrades or replacement 
• A single SafeCT simultaneously serves multiple CT scanners from different vendors and models, providing a solution for the entire department.
• Rapid processing—no impact on image reconstruction time at the CT console
• Unchanged clinical workflow—seamless to both technologist and radiologist
• Scalable product capable of accommodating future scanner additions.  

The website has links to dozens of papers which validate the stuff. However, I looked at a bunch of pictures which were truly worth a thousand words. If everything is as it seems, the technique enhances noisy images and reveals pathology, EVEN ON IMAGES SCANNED WITH REDUCED PARAMETERS. In other words, pump in less radiation for the scan, and use SafeCT to rescue the image, and maybe even get a better image than you would have otherwise. (They compare favorably to GE's ASIR for example.) MedicVision suggests that we could routinely cut the doses by 50%, and with more experience and experimentation, possibly to an even greater degree.

I was worried that dropping the dose and impairing the image would lose data and detail. As near I can tell, SafeCT does just the opposite. The processed images seem quite diagnostic, with lesions clearly detailed that were essentially invisible or at least not well-demonstrated prior to their digital massage. In fact, the algorithm works in part, I was told, by edge-detection, incorporated within iterative reconstruction, thus detecting lesions in a way. I suggested to the inventors that they parlay this into a CAD display, lighting up the detected anomalies in red, for example. I'll take a 5% royalty on that one.

SafeCT works by placing a processing box between the modality and the PACS, rather like any other advanced imaging processor. It's a little pricey, but in the right setting, it may be well worth the cost.

This is a product worthy of your attention.  Have a look!

Siemens Hat Einen Sehr Großen Kopf

Welcome to RSNA 2012! I shall be serving as your intrepid reporter from the floor, acquainting you with whatever takes my fancy, and that could well stray into the strange and perverse. We'll call this section Dalai's RSNA Naughty Bits.

Many of the BIG Players (but not the LarGEst) have their booths in the old Lakeside building, with Siemens dominating in floorspace and sheer volume of offerings. As an ad for Amyvid, the new Alzheimer's imaging agent, Siemens presents a very large head of an older gentleman, complete with animatronic features, and a screen embedded in the back. The clip doesn't show the animatronic activity quite so well, but the old guy is eerily life-like.

When Siemens gets a Big Head, they do it right.

Stay tuned for more from the frigid wastelands of Chicago!

Agfa IMPAX RSNA Preview

I think I see some Dalai-esque influence here...

Full coverage from the RSNA floor to follow!

Golden Dalai!

So THIS Is Why I Missed That Lesion...

From Health Imaging:

GE Healthcare has issued a notice to users of its Centricity PACS alerting them that images could be lost when transferring between two or more Centricity PACS systems.

The potential safety issue is related to the Centricity to Centricity (C2C) exam transfer module and affects Centricity PACS versions 3.X, 4.X and higher.

“When another process in the destination server attempts to access the same object or table, the transfer process of a particular image may be terminated,” read GE’s advisory. “Once terminated, the transfer service skips the image being sent, and continues to send the next image in the exam. The loss of an image could result in a mis-diagnosis.”

GE recommended the sending user verify the number of images to be sent with the recipient as users may not notice when an image is skipped during transfer.

The company also said it will provide a patch to 3.2.X and 4.0 systems to address the issue.

Actually, this sounds like a rather isolated problem, but if you have the indicated software, get it patched ASAP!!

OK, Maybe Merge IS For Sale?

You'll remember the flurry of posts a few months ago about Merge maybe being for sale, prompted by apparent inquiries of potential suitors. We were assured at the time that this was simply all financial due diligence and no sale was pending.

Perhaps that wasn't quite the case. Reuters reports, via Chicago Business, that five possible buyers are quite interested in this non-sale:

Merge Healthcare Inc., a Chicago-based provider of medical-imaging software that is exploring a sale, has attracted interest from at least five private-equity firms, Reuters reports, citing people familiar with the matter.

Chicago-based companies Thoma Bravo LLC and GTCR LLC are among the buyout firms that have met with the company's management and are considering submitting offers this month, the sources told Reuters.

The other companies are Francisco Partners of San Francisco, and Welsh Carson Anderson & Stowe and Avista Capital Partners, both of New York, according to Reuters.

Merge's chairman, Michael Ferro, is also the company's largest shareholder, controlling a more than 31 percent stake through various ventures, including Merrick RIS Inc.

In September, Merge said the company had appointed New York-based investment bank Allen & Co. LLC to evaluate strategic alternatives, including a possible sale.

But Merrick RIS will also earn a fee if the company is sold.

If the sale price is more than $1 billion, Merrick RIS will receive a 2 percent “success fee,” according to filings with the Securities and Exchange Commission. If the sale price is less than $1 billion, the success fee drops to 1 percent.

In February, Merge increased Merrick's fee if the deal exceeds $1 billion, the SEC filings show. Previously, Merrick would have earned a flat 1 percent, regardless of the size of the deal.

Mr. Ferro is also chairman and CEO of Chicago-based investment firm Merrick Ventures LLC, which is affiliated with Merrick RIS. In December, Mr. Ferro led a group of investors to buy Sun-Times Media Holdings LLC, which includes the flagship Chicago Sun-Times.

Last week, Merge reported a third-quarter net loss per diluted share of 4 cents, four times the loss it posted in the third quarter of 2011. Net sales totaled $60.4 million for the three months ended Sept. 30, up 0.5 percent, from $60.1 million during the same period in 2011.

Merge Healthcare, Thoma Bravo, GTCR and Avista declined to comment, while representatives of Welsh Carson Anderson & Stowe and Francisco Partners did not immediately respond to a request for comment.

Merge's stock price closed at $3.07 today, down 54.6 percent, from a year-high on Feb. 28 of $6.76 a share.

$20 Million for Merrick if the price tops $1 Billion, eh? Not a bad payout.

It would be poetic justice of a sort if Thoma Bravo ends up with Merge. Bravo had signed an agreement with AMICAS in 2009 (see Here and Here), only to have the offer dislodged by Merge. The AMICAS stock went for $6/share, at that time, although I'm not financially savvy enough to figure out what percentage of Merge that now involves, so I'm not sure if Thoma would end up with a bargain or not.

I can say that Merge has been a far better master of AMICAS than I anticipated, and I'm actually worried about how things might fare under a new owner.

IF Merge is sold, though, I have two requests to the new powers-that-be:

1. Keep as much of the team intact as possible, and hire back any of the folks from the prior incarnation of AMICAS that will deign to join up.
2. PLEASE change the name of the PACS back to AMICAS. That would make me really, really happy. With all due respect to Merge, "Merge PACS" just doesn't sound right...

(Hat-tip to Spidey...)

DICOM Style!

Tonight of all nights, I need a little project to take my mind off of current events, and I'm going to enlist your help to create it.

I'm not going to tell you exactly what I'm up to, although students of popular culture will figure it out quickly. With lots of luck and hard work, I'll have it done by RSNA; that might be a bit ambitious, so don't be disappointed if it's not complete by then.

Oh, yes...how do you participate? It's easy. Use your cell-phone as a video camera, or use a REAL video camera (or a real camera in video-mode) and film, I mean video yourself saying the following:

"Oppan DICOM Style!"

If you would, say the words crisply and with vigor, look happy, or intense, or whatever.

I'm not sure how many responses I will get on this, but I'll use as many as possible. If you don't want to do this yourself, find someone else in your enterprise or company who is willing to take one for the team, I mean participate in this fun exercise. CEO's (anyone know Jeff Immelt?), PACS luminaries (David Clunie, Mike Cannavo, Bernie Huang), and other Big Names in the business are particularly encouraged to join in.

Please send your clips to:  doctordalai(at)gmail.com.

Thanks for your indulgence.

Disney Buys Lucasfilm, Lucas Lowers Tax Burden

Cartoon by Robert Arail

May the Force be with you...and a few million shares of Disney stock wouldn't hurt either...

And by the way (from NewsWatch)...

That Lucas struck a deal in 2012 may be no accident, either, advisers say. Long-term capital gains tax from the sale of assets held more than one year are taxed at a rate of 15% for investors in the 25% income-tax bracket or above (Lucas’s level), and zero for investors in the 10% or 15% bracket. Those rates are set to jump to 20% and 10%, respectively in January. “He probably wanted to take advantage of the lower rate on long-term capital gain while it’s certain,” says Bill Smith, managing director at CBIZ MHM, a national accounting and professional services provider.

I wonder what the tax rates are on Tatooine?