Frasier

Hey, Dad!


What, Frasier?


There isn't a lot of time, Dad, and there's a lot to say. The vet will be here pretty soon, you know.


Vet?


Yeah, Dad. I'm almost 17 years old, damn old for a Jack Russell Terrier, and I'm not doing so hot. I know you see it when you look at me.


Yeah, Fras. I know. I had hoped you didn't understand.


I put on that dumb face so you won't worry about me. But it's OK, Dad. Really. I'm ready. I can barely breathe, I can't eat, I can't stand up anymore. I'm not having a very good day, and I'm tired. Really, really tired. It's time. We all know it.


I'm sorry, Frasier. We don't want to let go of you. You aren't hurting, are you?


Nah. Just uncomfortable. But this whole  dying thing is darn undignified, you know? Why you humans keep yourselves going when you've reached this state is beyond me. If you really loved your loved ones like you love me, you would let them go in peace. Personally, I'm looking forward to it.


Frasier...


Cut it out, Dad. No tears, please. OK, maybe a few if you must. I know you and Mom and the kids (and even that little devil dog Sophie) love me. It's been a damn good life. I don't have any regrets and you shouldn't either. Really. Loved our walks, loved sleeping in the bed with you, licking your pillow (even when you yelled at me for it). I really liked the frozen yogurt on my birthday, and the occasional McDonald's cheeseburger and fries. It's all good. It really was.


You are a very good boy Frasier...


Yeah, I tried my best. At least you never played that stupid human game of "Who's a Good Boy?" I can rest knowing that I was.


Will we see you again?


Ha. That's the Big Question, isn't it? Wish I could tell you. Jewish law is kinda vague on that. Supposedly, there are 5 kinds of souls. Animals have the most basic version, the life-force. That goes back to G-d. Humans have all 5, and they say go to a different part of Heaven.


I hate to disagree with you and the Rabbis, Frasier, but I'm pretty convinced you have a human soul, too.


Hope you're right, Dad. I've always thought so, but I'm just a dog. If so, we will meet again. But even if not, I'll be back with G-d which is a fair trade-off, don't you think?


We love you Fras... Godspeed.


Love you too, Dad. Don't forget me, but don't grieve too much. I'll be fine. I promise. And you will too.

Exhibits At An Exhibition: PACS, HYPOTHETICALLY-Speaking

Having little time at this year's RSNA, I was able to only briefly stop in to see friends at the Visage and lifeIMAGE booths. Both products show nice incremental improvements. Visage offers deconstructed PACS, with better collation of prior studies in this incarnation. It is a viable alternative to a full-fledged PACS, IF your IT folks can handle the concept. Big IF for some. Again, there is no worklist option included; "That would make us a PACS company!" So what's wrong with that?

lifeIMAGE continues to progress, now with even better connectivity. See this nice summary from Imaging Technology News for details. Many PACS vendors offer some form of image sharing in competition with lI, but the latter does it better. I've said it before and I'll say it again:  NOT using an image-sharing system is MALPRACTICE. Period. If you never believe anything else I write, believe that.

I have stated elsewhere that if I were to need a new PACS, my list would be short, based on experience, discussion, research, gestalt, instinct, hubris, and maybe a little luck: Merge, McKesson, Intelerad, and Sectra. Unfortunately, I only had time to visit the first two.

In addition to the Code Name: Avicenna project, Merge offers the latest version of PACS, Merge 7.1, to be released in the Spring of 2016. This latest descendant of the venerable AMICAS PACS (Version 3.7 is still in use at Mass General!) includes a number of tidbits gleaned from Emageon and DR, the systems Merge has assimilated over the years. The major improvement concerns the worklist, which can be used in composite mode, with up to 10 separate worklists operating on-screen at once. And unlike a certain system we know and love, this has no IMPAXT upon the speed of the client. Rules for the next study to be read can be specified so the most appropriate (and urgent) study is the next one to be read. (The next iteration, still a Work In Progress, will further assign studies based on RVU, subspecialty, etc, and should truly be Universal across the enterprise.)

My Merge-based IT people will be pleased to know that user-management is now templated, allowing quicker assignments of permissions and so forth. And the slippery menu-driven preferences is now on a single pop-up window. There is user-level XML integration which could, for example, be used to keep windows open or closed after completing dictation.

There is a new Macro Manager that will combine multiple repetitive actions. There is advanced breast-tomosynthesis with slab-viewing and position markers, as well as PET/CT fusion.

From DR comes embedded dictation with Speech Recognition (which I won't use!), and further improvements on an already excellent hanging protocol functionality. I'm excited to say that there will no longer be the same degree of dependence on series labels (which I cannot get the techs to standardize for love, money, or prolonged tantrums); one can specify, for example, what T2 means on an MRI from Scanner Vendors X, Y, and Z, and then key a hanging protocol to show all the T2 images. You get the idea.

I proposed the HYPOTHETICAL scenario of a failing Big-Iron PACS and asked what Merge could do in such a HYPOTHETICAL situation. HYPOTHETICALLY speaking, Merge could either provide an overlay to the database of the HYPOTHETICALLY failing PACS, assuming that component retained its integrity. Alternatively, Merge could move in as the primary PACS in such a HYPOTHETICAL situation, using DICOM Q/R to retrieve priors in the near term while migrating the entire database in the background. Fairly standard, although the ability to front for a failing system might not be as facile with the other vendors. Should the users of the HYPOTHETICALLY impaired PACS have a Merge PACS somewhere, that existing system could perhaps be used as a secondary server. Also, it would be easier to create a unified worklist for all the PACS in an enterprise if they happened to be from Merge. Food for thought.

McKesson is one of those rare PACS for which we hear minimal if any complaints, even fewer than for Merge and the others. No doubt there are some cranky rads out there who could find something wrong with it, but they are a minority indeed. McKesson PACS is now known as McKesson Radiology, a regression from the old Horizon moniker. The company has a much greater presence in my home state than I knew; they might actually have the majority of PACS here, or at least a significant pleurality.

McKesson is also proud of its hanging protocols, although the emphasis in the demonstration seemed to be on the fact that once they are set up, one wouldn't need to change them. But drag-and-drop and scripting is available for those who want to tweak things. As with Merge, they are not based on series descriptors. If your mouse wheel can tilt to either side, this motion can shift sequential hanging protocols.

There is a nice embedded advanced imaging module that does "~80%" of what one gets with an external TeraRecon, most everything but vessel fly-through. It even has lesion tracking. Tomosynthesis and PET/CT viewers are fully integrated.

Add-on modules include "Imaging Fellow" which can open RIS/EMR data, and is supposed to be able to open "any other exam from any accessible database." This would allow for data mining if you were so inclined.

PeerVue was purchased by McKesson years ago and is now called Conserus. (I would have gone a different direction...sounds too much like Cons 'R Us.) This critical-result software sends texts and emails and other reminders about things that need to be seen NOW.

The "Intelligent Worklist" allows prioritization by rules as we saw with Merge PACS (although the AMICAS/Merge worklist continues to have by far the best visual clues.) This module will monitor foreign PACS, allowing a sort of unified worklist, but still launches the foreign PACS client. I think it is capable of opening the study in your McKesson PACS if you have one, but I wasn't completely clear on that one.

A collaborative tool allows instant pinging of a colleague, referrer, etc, to get them to view a study. Right now, this spawns a second viewer program, not the main PACS viewer itself. This is to be incorporated into the main viewer eventually.

For those who work from or view from home, the main client can be used, although a VPN is required. It was unknown as to whether SSL would suffice.

When asked the HYPOTHETICAL question about the HYPOTHETICAL scenario in which a HYPOTHETICAL PACS needed replacing, the McKesson folks offered up similar solutions. The Intelligent Worklist could probably access the HYPOTHETICALLY failing PACS, as long as one had McKesson for the actual reads. Of course, they would be willing to migrate the old database in such a HYPOTHETICAL situation, and McKesson has in-house capability to do so.

With the observations now documented, I shall now stray into opinion territory. Emphasis on opinion.  Or really just me babbling on.

I have no clue at this point in time if I might be involved in any HYPOTHETICAL PACS replacements. I suppose I would suggest sending RFP's to the four companies mentioned above if that HYPOTHETICAL ever occurred. My good friend Mike Cannavo, the One and Only PACSman, has some very wise and mildly cynical ideas about RFP's. Adding in my own sarcasm, basically the IT folks don't know the questions to ask on an RFP but think they do. I have just one very easy question:  "Does the damn thing WORK?" Vendors will of course respond in the affirmative, but this really requires a far more complex answer with quite a few nuances and shades of gray. Perhaps the better question would be: "Does the damn thing work the way I want/need it to work?" I would love to hear the response to that one.

Mike noted an uptick in the number of vendors offering PACS and PACS-related wares at this RSNA:

So what was new? There are more PACS vendors for sure. I would venture to say that at least 70% of the vendors at RSNA 2015 had something PACS or PACS-related. It's just a matter of time before former PACSman award winner Ernie's Welding and Fabricating becomes Ernie's Pipes and PACS.

Even though we have had some market consolidation with high-profile mergers and acquisitions, for every one vendor that gets gobbled up, it seems like four new vendors appear. How many of the newbies will be here next year is anyone's guess, but if history repeats itself and 10% remain, it's a lot.

The problem is, even though some might have an innovative feature here and there, these tiny vendors probably won't be around in a few years, and many that are maintain their viability because their products are cheap (in price, but probably quality as well) and they appeal to small operations being run by those who don't understand what it is they are buying.

Ironically, the Powers That Be at one of our places blackballed AMICAS years ago because a consulting company (someone you hire and pay $50,000 to tell you what you already think you know) told them it was "too small" and would likely be acquired. Well, they were half-right. IBM now owns Merge, which owns AMICAS, but instead of quashing it, ala GE, the acquisition has strengthened the company and the product. GE assimilated DynamicImaging, among others, cannibalizing its PACS components into the Universal Disappointment. DI no longer exists in any form. Merge, however, is still alive, being billed as "an IBM company". AMICAS PACS lives on, and continues to grow. My friends from Emageon and DR Systems might roll their eyes a bit, but at least the best of their PACS components live on within Merge PACS, and credit is given to the predecessors as is due. I'm good with that.

McKesson Radiology is in many ways at the other end of the spectrum, being one of the last Big-Iron companies. Their product list contains hundreds of entries, and PACS is far from the largest offering. Still, there is a lot to be said for having a HUGE presence in the health-care marketplace, and to have a product with relatively few complaints. (However, I probably don't even have to say that simply buying from a huGE company doesn't guarantee a quality product.) Supposedly the rule at McK is that a call to the support center MUST be answered within 3 rings. I can't vouch for what happens after that. Many have said McKesson's architecture is a generation behind, and that there are too many different clients for different purposes, but I didn't discuss that with them at this point.

I have had very nice chats with Sectra and Intelerad folks over the years. In fact, Sectra invited me to come to their headquarters in Sweden, but I could only go in July, and Sweden apparently closes for vacation that month. My contact at Sectra has since left for a different company, as folks in this business are wont to do. I do keep in touch with some good friends at Intelerad as well. It is of note that both companies demurred somewhat as to what could be accomplished when given bits and pieces of the HYPOTHETICAL failing-PACS situation.

I'm in my eleventh year of blogging about PACS, and the more things change, the more they stay the same. What worked before still works and works better, and what didn't work still doesn't work, and may even be worse. (And the attitude of IT doesn't seem to be much different at all.) Some companies listen better than others, and some even listen to the right people, the end-users of their wares, and not just the people with the checkbook.

Remember Dalai's First Law of PACS: PACS IS the radiology department. It has to work. And not just HYPOTHETICALLY.

Exhibits At An Exhibition: Siemens Press Conference

"Pictures at an Exhibition" Courtesy TzviErez

I'm back from a rather brief trip to Chicago and RSNA. I had two days to see stuff and get some edumacation, as we say down here in the South, and I tried to make the most of it.

Educationally, I used my limited time to concentrate on PET and thyroid/parathyroid imaging. I come out reassured that we are doing things correctly. I'm still a little confused as to the best application of SPECT/CT to parathyroid imaging, so I'll probably be doing some experimentation when we finally get the darn thing sometime early next year. One presentation claimed better accuracy with good old pin-hole/planar imaging than with SPECT/CT. We'll see.

I began my 48-hour RSNA marathon early Monday at the Siemens Press Conference. Somehow, Siemens still thinks I'm some sort of journalist, which speaks more toward my friendship with people who decide such things than their better judgement. Not to worry, though, the room was filled with real reporters from real publications, who will properly convey the things correspondents are supposed to write. But you might want to question their judgement: some of them said they were readers of this blog, or at least familiar with me, and if I were them I probably wouldn't admit it. One VERY wise lady from a VERY respected publication did note the iconoclastic tone I generally manifest, proving that she really does read this. Thanks, Ms. C.P.!! I'm going to tattle, though. Some of the reporters were on their laptops doing things other than paying attention to the presentations, and one reporter who used to work for Siemens asked some very long and barely comprehensible questions at the end. Which were answered quite throughly.

Having been a regular attendee at the Siemens event, I was surprised this year to see new faces. In years past, Dr. Hermann Requardt, (PhD in Physics!) CEO of Siemens Healthcare, presided over the meeting, with Dr. Gregory Sorensen, (Neuroradiologist) CEO of Siemens Healthcare North America, in the supporting role. They are no longer with us, at least no longer visible, having been replaced respectively by Dr. Bernd Montag, also a physicist, and David Pacitti, recently of Abbott Labs. Requardt is now on the board of Bruker, Inc., and is the new Chairman of the Board of SuperSonic Imagine; Sorenson was removed just in October.  HMMMMMM.... Perhaps their vision didn't match the current trends, but I can't say I heard anything much different than last year in that regard. Back in February, Siemens announced the change of CEO's. Joe Kaeser, President and CEO of Siemens AG, said: “Mr. Requardt and the managers and employees of Healthcare can be quite proud of their highly successful work together over the past years. I have the greatest respect for Mr. Requardt’s decision to make way for a generation change. We are now setting up Healthcare as a separately managed business within Siemens in order to pave the way for an equally successful future in a highly dynamic market and innovation- driven environment. This is now the task of Bernd Montag, Michael Reitermann and Michael Sen. They will have the full support of the Managing Board and their direct partner, Board member Siegfried Russwurm, who worked in the company’s former Medical Engineering and Medical Solutions units for ten years.”

I could report chapter and verse of what was said, but I'll leave that to the real reporters. What I will convey is my impression as the only physician in the room. (At last year's event, I was one of two along with Dr. Sorensen.)

Technologically, there was a smattering of this new or upgraded scanner or that, the standard stuff. Dr. Montag announced 510K approval of Siemens CT scanners for lung screening programs, and the new "teamplay" software for data transparency and availability (acknowledging the ubiquity of tablets in the healthcare environment). The new HELX touch-control ultrasound scanners should reduce operator variance thorough streamlined user interface. It's supposed to be easy for inter operative use by surgeons. Thanks, Siemens. We also note the advanced robotic and even 3D capability of the new MultiTom Rax X-ray room. Good incremental improvements, all. No mention of PACS, advanced visualization, etc.

The main message I got from the hour-long session is that Siemens understands the changes in healthcare, both here and pending, and wants to help physicians navigate them successfully, "Enabling Healthcare Providers Worldwide" in their words. The flip-side is that Siemens is invested in these changes, assumes they will come, and is resigned to the fact that they ARE coming. The transformation process to the new reality has three components:

1. Consolidation of Providers 
2. Industrialization--Dr. Montag: "Medicine is not an art anymore. It must be managed like a company in a controlled fashion." How sad.
3. Managing Health--i.e., the transition from fee-for-service to value models

The process supposedly is inexorable, like the Law of Gravity. 

Diagnostics, particularly imaging are pillars of healthcare, and have been almost from the beginning. In fact, Roentgen himself was an early Siemens customer, and the company archives contain a letter of complaint from the man himself, noting the rather high equipment costs. Some things never change. Indeed, Siemens has been in on quite a few innovations in medical imaging, PET, PET/CT, PET/MRI, dual-source CT, etc.

Dr. Montag tells us that "90% of medical decisions are based on technologies in the Siemens portfolio." This, I think, is a little misleading. We could say that 95% of the world is lit by technology in the GE portfolio, the remaining 5% still using fire, but that really doesn't get us anywhere. I might have phrased it differently, but we get it.

Further examples were given of how Siemens can and will holistically improve health care, radiation therapy guidance, laboratory productivity, and triaging patients. Siemens will help us with standardization, consulting, and a world-wide network geared to mastering the digital transformation, leading to better outcomes at lower costs. 

In the end, 10% of the costs of healthcare relate to diagnosis, and our value thus depends on early diagnosis which could reduce the price of the remaining 90%. That's a better definition of value than I've heard to this point.

Still, I'm personally not as convinced as the good folks at Siemens that this value thing is permanent. Much will depend on the upcoming elections among other things. But I do understand the need to conform to the environment in which they wish to sell their wares. No doubt if fee-for-service comes back, Siemens will exercise its flexibility once again, and pivot back to whatever worked in the old days. Like selling scanners to doctors' offices. Just like GE. Still, if your going to scan, you might as well have the best scanner. 

Code Name: AvicennaThe Future In Progress

One of my Radiology professors back in residency, a very wise man, had a saying: "The more dogmatic you get, the more likely you will be wrong."

In the medical business, there is a tie for the three most important little words: "I was wrong," competes nicely with "I don't know." (If you were wondering, the four scariest words in the radiological lexicon are: "You read a scan...")

The Future has a way of sneaking up on us, and occasionally biting us on the behind. In my youth, I thought for example, that age 50 was a long way off. Now I'm well into that decade of life, and the 60's are looming. As Steve Miller put it, "Time keeps on slippin', slippin', slipping', into the Future..."

All this leads us to the fact that I was dead wrong about something futuristic, something I thought we wouldn't see until many years from now. Something I saw this week at RSNA at the Merge booth. I was quite adamant that it would not be possible for a computer to read scans and such for at least 5-10 years. What I saw proves me wrong, or at least indicates that being dogmatic led me down the wrong path yet again. I was blindsided by a Work In Progress titled "Code Name: Avicenna", a peek into the future at some very disruptive technology (I use that term with all due respect and awe) brought about by the new consortium between Merge, now a wholly-owned subsidiary of IBM, and IBM Watson Health.

Let us speak a moment about Avicenna, whom I'm assuming is the inspiration behind the Code Name: Avicenna project. Since you are reading my blog, you are of course quite intelligent and well-educated, and thus you have probably heard of Avicenna. I, however, had not, so I turned to the Wiki:

Avicenna (c. 980 – June 1037) was a Persian polymath who is regarded as one of the most significant thinkers and writers of the Islamic Golden Age. Of the 450 works he is known to have written, around 240 have survived, including 150 on philosophy and 40 on medicine.

His most famous works are The Book of Healing – a philosophical and scientific encyclopedia, and The Canon of Medicine – a medical encyclopedia, which became a standard medical text at many medieval universities and remained in use as late as 1650.

Besides philosophy and medicine, Avicenna's corpus includes writings on astronomy, alchemy, geography and geology, psychology, Islamic theology, logic, mathematics, physics and poetry.

Image courtesy StatusMind.com

Pretty amazing guy. Now personally, I would have gone with "Code Name: Maimonides",  after Moses Maimonides, an equally famous physician of the middle ages, or at least with his acronymed nickname Rambam (for "Rabbeinu Moshe Ben Maimon"). But then this isn't my project, is it?

The choice of the code name for this Watson-based process clearly tells us where we are going; Watson is learning medicine, and doing so at a very young age, as did Avicenna who became a physician in his teens.

IBM Watson, image courtesy IBM.com

Everyone has heard of IBM's Watson. Watson thinks, or at least simulates it nicely:

We produce over 25 quintillion bytes of data everyday and 80% of it is unstructured. Therefore, it’s invisible to current technology. IBM Watson is a cognitive system that can understand that data, learn from it and reason through it. That’s how industries as diverse as healthcare, retail, banking and travel are using Watson to reshape their industries. Watson is designed to take data in all its forms—including unstructured—and understand it, reason through it and learn from it. In a sense, Watson can think. When Watson thinks with you, you can outthink.

I cannot proceed without mentioning the old joke about the movie 2001: A Space Odyssey. The rogue self-aware computer, "HAL 9000" was supposedly a joke on IBM, the acronym being one letter off, yes? Arthur C. Clarke (or was it Stanley Kubrick?) denied this, claiming that HAL stood for Heuristic ALgorithm, and in fact IBM did help considerably with the movie details.

And this brings us to IBM's acquisition of Merge, which I blogged about when it was announced. It has since been finalized:

IBM itself whet our appetite for what was and is to come on the Watson Health website:

IBM today announced that Watson will gain the ability to “see” by bringing together Watson’s advanced image analytics and cognitive capabilities with data and images obtained from Merge Healthcare Incorporated’s medical imaging management platform. IBM plans to acquire Merge, a leading provider of medical image handling and processing, interoperability and clinical systems designed to advance healthcare quality and efficiency, in an effort to unlock the value of medical images to help physicians make better patient care decisions.

Merge’s technology platforms are used at more than 7,500 U.S. healthcare sites, as well as most of the world’s leading clinical research institutes and pharmaceutical firms to manage a growing body of medical images. The vision is that these organizations could use the Watson Health Cloud to surface new insights from a consolidated, patient-centric view of current and historical images, electronic health records, data from wearable devices and other related medical data, in a HIPAA-enabled environment.

I can't quite shake the thought of HAL, I mean Watson, watching us, but in a good way:

While it is just a Work In Progress, Code Name: Avicenna presents the first steps in realizing the unified goals of teaching Watson to see radiologic images (among others) and putting that, ummm, knowledge to good use for our patients. And you can see it in action today. Here is Merge's description of the demonstration, i.e., Code Name: Avicenna...

Merge PACS™ workstation viewer and IBM Watson Health – a vision for how to help radiologists with clinical decision making

Radiologists and cardiologists today have to view large amounts of imaging data relatively quickly leading to eye fatigue. Further, they may have limited access to clinical information relying mostly on their visual interpretation of imaging studies for their diagnostic decisions.  In this demo, we present a futuristic workstation for radiologists where their normal viewing of imaging studies is augmented with clinical and imaging summaries to help their clinical decision-making. This technology could assist by running in the background to collect relevant clinical, textual and imaging patient data from electronic health records systems. It could then analyze multimodal content to detect anomalies and summarize the patient record, collecting relevant information pertinent to a chief complaint. The results of anomaly detection would then be fed into a reasoning engine which uses evidence from both patient-independent clinical knowledge and large-scale patient-driven similar patient statistics to arrive at potential differential diagnosis to help radiologists’ clinical decision making. Compact clinical summaries, along with the findings from imaging studies, would be available both for simultaneous viewing and export as a DICOM SR report.

The demo will show our vision of this futuristic technology using the Merge PACS™ workstation. The radiologist will open an exam from the Universal Worklist (UWL).  When the exam is opened, both the PACS viewer and the IBM Watson Health work in progress will be launched in separate monitors to show respective content. The ultimate output from the tool in the form of a pre-populated radiology report will then be presented to the radiologist to review and consider in making his or her decisions.

DISCLAIMER: The capability demonstrated here is for DEMONSTRATION PURPOSES ONLY. The capability is in the research and development phase and is not available for any use, commercial or non-commercial. Any statements and claims related to the capability are aspirational only. The case study in this demonstration is a hypothetical case study using fictitious medical information and do not represent an actual medical case. The results contained in this demonstration were obtained in a controlled environment and represent a vision of possible future technology. The demo will show our vision of this futuristic technology using the Merge PACS™ workstation.

The punch-line to Code Name: Avicenna is quite simple. IT WORKS (something typical of Merge products, but sadly not for others in the same industry). A case was presented to Watson consisting of history, physical findings, lab values, and a CT. Well, it was a CT-pulmonary arteriogram, so Watson had a little clue there. The demonstration progressed to show Watson's integration of the data into a cloud-display of likely diagnoses. He, OK, it, proceeded to analyze the CT, showing outlines of his its regions of interest. And Watson found the majority of the emboli on the very positive sample scan. Watson's ROI's matched those of the training radiologist quite well. And it then displayed dozens of priors from its memory with similar findings. The most likely differential became "pulmonary embolism", which was of course correct.

As an aside, many have wondered just how Watson acquires the images upon which he it trained. I had asked this question of the Merge execs early on, but they weren't ready to answer until now. Basically, the scans are collected with secondary use rights, to which the institutions providing them must agree. The images and reports and other data are anonymized, so there is no privacy problem. To date, several Big Name operations have signed on to this effort, including many you might have heard of. (I'm not supposed to name names as yet, but I, for one, was quite impressed with the players so far.) I'll be glad to sign mine over, too. There simply is no downside to doing so. There are 30 BILLION images in Merge's iConnect cloud service already. That should keep Watson busy for a millisecond or two, once they are allowed to be, shall we say, assimilated?

Now you might say that Computer Aided Diagnosis is already here. You would be missing the point. CAD doesn't learn. Watson, being a cognitive computer, learns. It learns the way I learned to read CT's. Hopefully it will read them better than I do. Think of it this way... I went to college to learn the chemistry and physics (and for me, engineering and computer science) needed to understand higher concepts. I went on to medical school to learn how the body is put together with all that chemistry and physiology and stuff. I learned where the pulmonary arteries were, and what happens if a clot gets lodged in one. In radiology residency, I learned how it looks on a scan if that happens. (Well, to be fair, the scanners weren't fast enough for CTPA grams back then, and so we learned the concept with conventional arteriography, but you get the idea.)

One physician was overheard saying something like, "Bah. My first-year residents could get that one." Yes...A COMPUTER can match the achievement of a human that has gone through college and medical school. Let this sink in.  Code Word: Avicenna shows us THAT A COMPUTER IN THE EARLIEST STAGES OF LEARNING HOW TO READ COMPLEX IMAGING STUDIES CAN MATCH A FIRST-YEAR RADIOLOGY RESIDENT.

This, people, is the epitome of disruptive technology. This is a sea-change in how radiology will manifest in the future. The implications here are staggering. To me, this is MUCH more important and noteworthy than an extra Tesla on a magnet (although a Tesla in my garage would be most appreciated) or an extra hundred slices on a CT. Code Name: Avicenna represents the most important development in our field in a very, very long time. This is a fundamental change in the way we do things. It assists the radiologist, allowing him/her to perform at the highest possible level, but does not replace us. Not for the foreseeable future, anyway.

I was right on that one, at least.

I have seen the future, and its Code Name is Avicenna. Seriously. Trust me, I'm a doctor! But if you don't believe me, just ask Watson.

Reading Rooms

Back before most people could even spell PACS, we read from film, and nothing but film, and our offices reflect that legacy. This is the plan of one of our hospital reading room suites from 1990, still in use today:

The plan consists of eight similarly-sized offices, with X-ray view boxes on one wall, built-in shelves and a big wooden desk. The room hanging off the edge is the restroom, if you couldn't tell. Today, four of these offices have hospital PACS workstations, with one of these also having a PACS station for our PACS, and another having a Nuclear Medicine workstation. Another only houses our PACS computer. Two of the remaining offices have no workstation, and the third is used by one of our administrative assistants.

The computers are scattered in a haphazard manner. Some sit on the old wooden desks, some sit on (sort of) ergonomic tables. Some sit on the old built-in mini-desks.

Aesthetically, the offices are, well, not very aesthetic. We have dark carpet, beige walls, and white ceiling tiles. And whatever chairs happened to find their way in there, from an old leather and wood extravaganza bought for me 25 years ago, to several Herman Miller Aeron Office Chairs. There are bright fluorescent lights on the ceiling, and maybe a lamp here and there for more subdued illumination.

There is a lot of room for improvement, which will eventually happen. To be prepared if the department wins the lottery, I've been looking into the office suite I would like to have should cost be no object. (Well, if cost were no object we would all be on vacation in the Caribbean, but you know what I mean.)

Eliot Siegel, M.D., Chief of Imaging at the Veterans Affairs (VA) Maryland Healthcare System in Baltimore, has done extensive research into the ergonomics and design of radiology reading spaces:

Through trial and error, Dr. Siegel and colleagues discovered that redesigning the entire reading room is vastly more effective than simply adding computerized workstations to the previous film-based environment. Initially a single, unpartitioned space, the Baltimore VA reading room now features areas where radiologists can work independently and others where they can collaborate when necessary.

“In a digital environment where we are interacting with computer workstations, it is really critical to rethink the entire design of the room in terms of lighting, sound, temperature and other elements,” Dr. Siegel said. “Some factors that were less important in a film-based environment become extraordinarily important in this new digital environment.”

One of those factors is lighting. Back in the days of film, the light-boxes were the most important occupant of the room. Turn out the lights, turn on the box, flick the film onto the clip (I became far more adept at making the film lodge in the holder by flicking it with my ring finger from a foot away than I ever was at actually interpreting the images...)

(L)ighting is a key to improving the overall radiology work environment in a digital workspace. Because overhead fluorescent lighting cannot be adjusted for brightness and often flickers and causes glare, Dr. Siegel switched to indirect, incandescent lighting which helped reduce physician eye strain. In addition, using a blue light behind the workstations decreases radiologists’ stress level while increasing visual acuity, the team discovered.

“It is a very calming and relaxing environment,” Dr. Siegel said. “In fact, it is so relaxing we’ve had clinicians and visitors say that they would love to take a quick nap in the low-stress environment.”

And Dr. Siegel reminds us to keep ambient noise in mind:

If a facility can make only one change, Dr. Siegel recommends implementing a sound-masking system. At the Baltimore VA, the system emits a constant sound at a frequency close to human speech, which helps minimize noise distractions from the lobby and MR imaging scanner, both which are immediately adjacent to the reading room. Although the ideal reading room includes sound-proofed walls to eliminate ambient noise, the sound-masking system is a more affordable option.

“We found that just using the sound-masking system, which costs about $500 for an approximately 500-square-foot room, can significantly decrease distractions associated with noise in and outside the room,” Dr. Siegel said. “In our experience it has been effective, and it can even increase the accuracy of the speech-recognition systems being used now.”

And we mustn't forget that radiologists breathe:

Because controlling temperature and ventilation is also critical and can impact productivity, the facility’s new reading rooms have a subset of workstations equipped with individual controls for each user, Dr. Siegel said.

“Many of us work in environments where the air doesn’t move much and gets stale,” Dr. Siegel said. “Nobody would drive a car where they didn’t have air blowing or couldn’t control the temperature, but how many radiologists will sit in a room for 8 or 10 hours without being able to easily adjust the temperature or ventilation?”

These factors influence radiologist comfort, and help to minimize workplace injuries and complaints. Hey, if my thumb hurts, I can't trigger the microphone and so I'll have to go home on disability. Let's do what we can to prevent this.

Extensive work on workstation environments had been performed at Cornell, and Dr. Siegel applies the lessons in a humorous manner in this video:

Using Dr. Siegel's VA reading room sketch

and the concept of an "Imaging Interpretation Theatre" as seen in THIS paper from Hugine, et. al.,

as a starting point, I used my HGTV planning software (really!) to revamp our current space:

I'm childish enough to be thrilled with the ability to "walk through" this imaginary space I've created!

I've toned down the "theatre" to a small conference area, and I've made the reading areas a little too office-like in this first attempt, but much can change when (and if) we actually get into design mode. Personally, I like the idea of a "pod" as seen in Hugine's article,

but I don't see that happening in our neck of the woods.

Going through the Cornell checklist tell me this will be a tedious project, but well worth the effort.

By the way, we do NOT plan to have a glass door on the bathroom. There's nothing to see in there but plumbing...

Addendum: 

The Visage booth at RSNA 2015 had a very nice implementation of the Image Theater concept:

Paris...

I have no eloquent words of comfort beyond those many have already spoken. We have lost yet more innocent lives in the name of unspeakable evil. Paris faced the terror over the weekend that Israel faces every hour.  It MUST end. 

This is a war. Literally, the war between good and evil. There is only one possible outcome, but it will be painfully achieved. Prepare for some painful times ahead.

If I Had A Hammer...The SMT Epilogue

PACSGenius has wiped all his posts about SMT and changed his name on AuntMinnie.com to Burt Stone, I guess an allusion to Burt Wonderstone, and his disappearing act. Mr. Ellery himself, the head of Singular Medical Technologies, put a bit of an explanation on the now-defunct thread, but that paragraph, and even Mr. Ellery, have disappeared.

The most poignant punch line of all comes from someone within the radiology practice that spawned this spawn:

They don't know what the Hell they are doing and talking about.

Basically the work station is 4 seperate computers attached to one set of monitors which you can toggle between systems. The worklists are each on a separate computer but you can't pick from it. You have to log on to each PACS separately.

The Powerscribe works with all because its essentially the same hospital system and they share license agreements.

It's far from grounbreaking and after reading their posts and knowing them I have to laugh because they are really wet behind the ears and have very little healthcare experience...

Too funny.

Sadly, the good people of Sunshine Singular won't think any of this is funny. But this is the risk one takes to bring a product to market. Have you ever watched Shark Tank? Those who make the cut to stand before the billionaires already have some degree of success. Even so, I've seen some poor schmucks torn limb from limb by the Sharks. They respect confidence and knowledge, but being superbly accomplished businesspeople, they can see right through bullshit and hubris, and won't tolerate it for a second. SMT wouldn't have survived 30 seconds. Well, I take that back. The Sharks are probably not familiar with this small niche-market, and could possibly have been convinced to invest in this limited, brute-force "solution". They, like many docs and administrative-types who don't have the slightest grasp of informatics, might believe the distortions and out-and-out mistruths that were told about this product.

SMT may well blame me when their little company crashes and burns, but they really shouldn't bother. They didn't do their due diligence before investing a lot of money their "solution". They found that GE wouldn't talk nicely to Agfa and some fly-by-night charged them millions to connect and didn't deliver, so they created this brute-force solution. Maybe it works in their environment, sort of, and maybe not all that well according to someone who actually uses it.  But it is an amateurish, even childish mistake to assume in an uninformed vacuum that such a "solution" is going to make zillions of dollars, and to invest your own and other people's money chasing that dream. I've seen this happen up close and personal, when a friend came up with software that he was certain he would sell to every medical practice in the nation. Didn't happen. Won't ever happen. He and his sponsors are out about $50K. I did try to warn them...

I don't know if self-delusion is uniquely American or not, but I seem to see a lot of it on shows like "Shark Tank" and "America's Got Talent," not to mention IT departments here and there.  You see people who are absolutely, positively, adamently convinced that they have found THE NEXT BIG NEW REVOLUTIONARY TECHNOLOGY or have the greatest act the judges have ever seen, and so on. When their puny accomplishments are rejected by those who know better, these poor folks are so fundamentally shocked and surprised, their facial expressions are absolutely painful to behold. Maybe this is the result of the liberal philosophy giving everyone a trophy for showing up and breathing, but it is pitiful to say the least.

But don't worry. When I get around to creating Dalai PACS, it will be the best thing since sliced bread. Investment opportunities will be limited, so act now!!

The Law Of The Instrument

We've all heard some variant of the meme about hammers and nails. It can be attributed to two gentlemen coincidentally named Abraham, Abraham Kaplan, a philosopher, and Abraham Maslow, a psychologist. From the Wiki:

The concept known as the law of the instrument, Maslow's hammer, Gavel or a golden hammer is an over-reliance on a familiar tool; as Abraham Maslow said in 1966, "I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail."

The first recorded statement of the concept was Abraham Kaplan's, in 1964: "I call it the law of the instrument, and it may be formulated as follows: Give a small boy a hammer, and he will find that everything he encounters needs pounding."

Maslow's hammer, popularly phrased as "if all you have is a hammer, everything looks like a nail" and variants thereof, is from Abraham Maslow's The Psychology of Science, published in 1966.

Those of us who peruse AuntMinnie.com have seen this concept acted out by a fellow we'll call PACSGenius. Mr. Genius says he works for a radiology group in Florida who has solved all of their problems with a system from Singular Medical Technologies (SMT). Mr. Genius is so enthused about SMT, he has proposed it as a substitute for VNA's, and a solution to my own troubled hospital PACS installation.

If only it worked that way.

First, let's review some of PACSGenius' claims as posted on the Aunt Minnie PACS Forum. Here is the opening spammy advertising volley:

We currently use them at 12 central Florida hospital locations and our rads are also using them from home. The only issues we had were broadband from the Rads homes but once we had them on 80mb/s things smoothed out. Leadership swears by them. The turn around times were significantly lower with these. 1 month to setup too, barely any issues with hospital IT.
{snip}
I am a PACS admin, have been for 12 years. Prior to that I worked for GE healthcare. We have a rad group with 40 rads and 12 facilities none of which had 1 single PACS database that were merged in any way. Our first solution was a Cloud Based PACS over lay. that was 3 mill for all facilities and it was a total disaster. They are now bankrupt. We found these guys SMT, they build workstations that are configured to work with multiple clients. This let my RADS access all the sites they needed. I didn't know this was an issue until I ran right into it. No disrespect, just wanted to share my experience. AGFA, GE, MCKESON, MERGE. Not one was able to do what these guys did. GE didn't want to talk to AGFA, AGFA hates MckEsson. It was a bloody nightmare to get images to even transfer. Much less to actually work together. If you know of 2 major PACS systems that work hand in had I'd love to hear about them. That's all.

{snip}

Average cost of an HL7 $25,000 plus support usually about $1400.00 a month.
We tried that. In fact we leased Fuji PACS and a Powerscribe 360 server. Cost for that was $27,000.00 per month. That required 2 HL7 interfaces and it only worked with 2 GE and AGFA which I will add was a nightmare to get them to work with us. Worse part was when we were done instead of decreasing turn around times our turn around times increased.

See the not so beautiful fact about HL7 is that instead of speeding thing up it slowed things down. It's basic network topology. The more hops and the more servers your images have to hit the slower things get.  Our standard study availability after the HL7 and Fuji Pacs for a plain film to show up on our diagnostic screens was selected went from 2 to 6 seconds to 27 seconds. Multiply that times 1000 plain film a day and you get the picture.

So while HL7's give you the ability to access they kill your turn around times. For most locations we deal with the broadband is weak and limited. Adding on all of this back and forth was horrendous.
So HL7 was a huge FAIL.

Then we tried an overlay (Compressus) at 4 Million that was not a real solution. It took 2 years and never got off the ground. Because, drum roll..... HL7's would not work properly causing the patient ID's for several of our sites were different the interface was too complex and created duplicates of patients and studies were missed and some took forever to appear in the right work-lists.

So here are the numbers:
HL7 interfaces, up front about 78k, plus support.
Fuji Pacs was close to 890k for 2 years.
Compressus 4 Million.
Average time it took a plain film to show up with this awesome HL7 tech: 23 to 25 seconds.

Cost to implement Singular at all our locations 459k, plus support about 32k a year. Savings: Dropped 3 Rads off our schedule to the tune of 1,489,000 in salaries.

Turn around times using these guys for 1 plain film to show up: 5 seconds. CT's are just as fast as being at the hospitals.

Our practice is currently on the 99th percentile with MGMA and we are turning plain films and imaging cases within 17 minutes.

So if you like spending money, and making things slow down then these guys are not for you. I recommend a hefty HL7 or 2.

These units let the RAD sit in front of 1 set of screens rather than rolling up an down a hallway full of 7 to 14k diagnostic screens. I know for a fact that saved us a ton of money just in hardware alone. We used to have 10 reading stations in one room now we have 2. It may not be groundbreaking because it's not a phone app that talks back but it just WORKS.

In response to our malfunctioning PACS, Mr. Genius suggests:

This may help: singularmedicaltechnologies.com developed a system that we use every day at 12 facilities. It's helped us read for sites we never had access to on an active work-list and we are able to read for which ever PACS the facility has. No lag, instant real time radiology without a third party overlay system.

Yeah, that's going to get me back up and running.

And finally, Mr. Genius declares the VNA another nail to be hammered:

Check this system out. We don't need VNA. We access multiple sites directly from one station instantly. No lag, comparison availability, active master list no matter which PACS you use. We love it! It's helped us out tremendously. singularmedicaltechnologies.com

I can only go by my experience within the confines of the Radiology group. When the hospitals we work with decided to look at VNA to manage their imaging we were concerned about our situation. Although we were excited because one of the things told to us were that the VNA would solve all of our imaging problems. We would finally have a fully operational work-list. That is the things my RADS wanted the most. So we were all sitting there at meetings for over 2 years cheering on the VNA wagon. Well the wagon came and left. 2 million dollars in and everybody in the hospital was sharing images expect the Radiology group!. You can imagine what happened then.
We were told and I quote: The distinguishing characteristic of a VNA is that it can handle many different types of images and associated data without being locked into the products of a single vendor. We were so happy we couldn't stand it. The reality was that the system worked great for the ED's but all the PACS vendors said no. So back to the beginning for us. I was just saying VNA's at some point may fix this but it doesn't seem to work for RADS. That's all. I may have misunderstood your post. I read VNA's and was immediately ready to grab my pitchfork!!!

Quick question, what do you guys use to merge your different versions of PACS? I have looked everywhere but all I find are Overlays for the cost of the space shuttle program.

Apples and oranges. I'm sad to say that in my humble and non-litigatable OPINION, PACSGenius has completely and totally misrepresented the capabilities of Singular Medical. And to boot, he has disclosed the salaries of the radiologists for whom he works, which he should not know in the first place, and for us this public airing of private, inside information would have been a termination-level offense. His employer may be more forgiving.

Mr. Genius has probably done considerable damage to Singular with his wildly off-the-mark posts, but to be fair, let's look at just what SMT really does offer. Here's what it isn't: it is NOT a VNA. It is NOT a unified viewer that merges disparate PACS onto ONE worklist. It is NOT an overlay nor a cloud solution.

So what IS this revolutionary new technology? This:

Basically, it is a way to select which of multiple PACS you wish to activate on a single workstation. How this is done is not revealed, but it is reasonable to assume Singular uses some sort of virtualization and server-side rendering with a thin/zero footprint client, perhaps similar to Calgary Scientific's approach. Interesting, although not at all revolutionary. HERE is Singular's rather long-winded (non) explanation of how it all works.

The sad fact is, Singular is an expensive way to solve the multi-site problem, without actually solving it. It does allow monitoring of multiple worklists on the same 5th screen, and the toggling between PACS is smoother than might be accomplished with a multiport KVM. (The latter can be found supporting DisplayPort technology which might or might not properly drive your 3MP monitors.) Given the mini-rack to the left in the photo of the station, maybe all Singular has done is smooth out a software-driven KVM.

In many if not most cases, PACS clients can live in relative harmony on a single workstation, as long as it is robust enough. We generally run IMPAX, multiple AMICAS/Merge clients, and GE UV on a single station with minimal hiccoughs. To be fair, we don't have the added problem of PowerScribe, but if that's the only remaining problem Singular solves, well, it's a bit of overkill.

Does this $500,000 hammer work for the rather narrow nail it is really intended to hit? Yes, I suppose it does. I'm not ever going to be a customer, and I'm not going to grace Singular with my presence at RSNA. But in the end, it solves a problem that doesn't need solving.

PACSGenius went on and on about how he couldn't for love or (lots of) money bring the umpteen disparate PACS together in one reading list. In the middle of the diatribe, AuntMinnie regular DICOM_Dan (who claims not to be a reader of my blog but we all know better ;-{)} ) tells us:

That's the beauty of standards, DICOM/HL7, and of the systems that should be able to interface with each other. We do reading for multiple sites and all images come into 1 system. There are bidirectional HL7 interfaces to handle other information and send back reports, and ONE single viewer for multiple institutions. Building a workstation that sounds like it's basically just able to provide the different apps doesn't seem like much of an feat (or even new tech). 

And that is how it SHOULD be done. I don't know precisely how Dan's approach is configured, but it has the potential at least for unifying patient records, i.e., finding a prior from a different institution than the current study, presenting one unified worklist, and so on and so forth, all things Singular cannot do.

I'm constantly whining about vendors who don't make products that fit radiologists' needs because it is IT and the C-suite occupants who make purchasing decisions. The flip side is that most rads are not well-trained in informatics, and might well be taken in by "REVOLUTIONARY NEW TECHNOLOGY" such as this. I've seen it happen, and it isn't pretty.

Caveat Emptor. Spend the $500K elsewhere and do it right.

PACSGenius did leave a parting shot on the AM thread:

You are correct about one thing you are one of those Rads who is "non-well trained in informatics". What is it? Fear that you may actually be wrong? I'm done. No need say more.

At least he's right about that last broken sentence. He finally found a nail.

ADDENDUM

It seems there is a little more incestuous relationship between SMT and what appears to be the only radiology group using the product:

Sunshine Radiology (from Website):
529E Central Ave
Winter Haven
(863) 299 1155

Singular Medical Technology (from DNS lookup):
529E Central Ave
Winter Haven
(863) 299 1155

(BTW DNS lookup: https://who.godaddy.com/whois.aspx?domain=singularmedicaltechnologies.com&prog_id=GoDaddy )
indicates Registrant email: *******@sunshineradiology.com

Gordon Ellery III (from LinkedIn):
Currently:
Interim CEO & COO, Singular Medical Technologies
and
Director of Operations, Sunshine Radiology

Hat tip to PACS FERRET and DICOM_Dan.

Creeping Improvement

This is a real product, by the way, available on Amazon. If PACS cures could come in a squeeze-bottle, they might look like this:

But sadly, the only sectors that get squeezed when the PACS malfunctions are the radiologists, the techs, and, most importantly, the patients.

IMPAX 6.6.1.x was installed last weekend, along with a plethora of hardware and network renovations. New cores, various new servers, some of which sport SSD's instead of spinning disks. The new dual 1Gb lines have yet to be installed.

I can report significant improvement overall, but I'm afraid we aren't quite there yet.

The good news first. We are seeing overall faster loading and transition between the last study and the next. Most of the time. We are seeing tremendous improvement in searches, which used to take up to 60 seconds, now clocking in at no more than a second or two. Images scroll faster, mostly, and are no longer slowed by having demographics/annotations activated. 6.6.x has a newer study list which will filter in the relevant priors. There is an MPR module (which is nothing new but we didn't have it before). There is now a button to save a layout as a hanging protocol.

But the picture is far from rosy as yet. As reported by the users:

1. When pulling in a group of studies to dictate, about 50% of the time the patient data did not load correctly onto the left screen. It got progressively worse as I worked over night.
2. Shortly after I began at 2:00 a.m. the system slowed, not to the point of before but it was clearly slower than earlier in the day. It remained this way until about 7:30 this morning. the system would periodically not accept mouse inputs for about a 5-10 second intervals as the system cycled from one study to the next, regardless of modality. The system did that "thumbnail updating" during those intervals.
3. Approximately 10 times overnight the system would bring in the comparison study as a micro thumbnail image in the left upper corner of the screen. 
4. We had a study pull in the wrong patient demographics/study on the left screen for a study he was dictating on the right. It pulled in the data from a study done a year earlier.
5. Also, intermittently the proper prior did not load correctly. Example, I loaded right hip film  to read and a left foot loaded as comparison, then on third screen was a prior hip film.
6. And finally, studies that were suppose to go into failed verification were showing up on the list to dictate and listed as new even though there was no RIS ID for the study. 

This is being addressed, and hopefully these things will be resolved. In fact, some fixes are well underway as they relate to a look-up table of body part and modality priority for the relevant prior pulls. But the business of incorrect matching of patient demographics and images is really, really serious, and in fact represents an FDA-reportable event. Need I say more?

6.6.1 still suffers from the legacy of how IMPAX does things. Tools are toggled on and off as we've seen for many, many years. I have NEVER heard ANY IMPAX user praise this approach, unique in the industry, but Agfa persists in being "special". Similarly, we still must endure the backward approach to claiming studies. EVERY other system out there give ME control of a study once I open it; IMPAX lets someone else open and snatch it away from me. I was told years ago that this was to accommodate academic sites where the professors must grab things away from residents. Guess what? WE don't HAVE residents. We are NOT an academic site, and we really don't like this machine behavior, which incidentally can lead to studies not being read because someone accidentally closes something someone else has clicked as "Dictation Started". Bad move. There is still no way to display the same series in multiple active viewports so as to show it in different window settings. The only way to do this is with a "clone" window, separate from the main display.

IMPAX 6.5.x and earlier versions supposedly had hanging protocols, but the implementation was so very bad that it couldn't be used. 6.6.1 has a new and improved version. It works, but it is severely hobbled. Unlike every other drag-and-drop hanging protocol implementation (Merge, GE UV, etc.), we are limited to displaying within the preset modality parameters. If you've set CT to display in a 2x2 format, that's the only way your protocols will work. You may NOT have the same dataset in multiple viewports. And so on. I'm quite unimpressed. It does work a bit better with MR than CT in my hands, but I read a lot more CT than MR. 

IMPAX 7, a.k.a. IMPAX Agility, will solve at least some these problems. Once it is approved as an upgrade for 6.x, that is, which has yet to happen. 

Believe it or not, I don't expect perfection. What I do expect, and even demand, is communication and  interaction. I have whined for over 10 years on this blog about the disconnect between the vendors, IT, and the physician end-users of PACS. (Same thing applies to EMR's, but that's another post.) 

Our experience is a classic example of how things go wrong when we rads are taken out of the loop. We had no good lines of communication to IT, who assumed a lot of things were OK when they weren't, and who didn't think to ask us to champion absolutely critical upgrades and expenditures. This allowed system-wide deterioration which nearly shut down a hospital. 

We had no good feedback loop back to the vendors. Since we are NOT their customers, they take their cues from IT and C-suiters who generally have no concept of radiology workflow. The hanging-protocol thing is a great example. Clearly, Agfa had no clue as to how I wanted it to work, and frankly I can't imagine anyone finds it useful. Contrast this with AMICAS PACS which had a very simple, working solution back in 2003.  Listen to your customers and they will tell you what they need. Except I'm not the direct customer, am I? 

For the past 10 years, I've tried to be the feedback loop, along with a very few others. Clearly, I haven't succeeded. We finally made progress when my colleagues who took back the night got sick and tired of the decaying situation. I tip my hat to them for this tremendous accomplishment.

Hopefully, our PACS experiences will inspire others to rise out of their complacency. Things CAN be better. You simply have to reach this point, as did someone who suffered from a different "Network" outage:

Am I communicating this properly? 

EMR's Suck Epically!And I'm Not The Only One Who Says So...

When something in the health-care field reaches the attention of Conservative columnists, it must be either really wonderful, or very, very bad. This time, it's the latter.

I'm a big fan of Michelle Malkin, a very articulate Conservative writer, who appears periodically on Fox News broadcasts, and the pages of Townhall.com. In her latest column, she notes quite clearly that "Doctors Agree: Obama's Electronic Medical Records Mandate Sucks". This doctor concurs.

For the past several years, medical professionals have warned that the federal electronic medical records mandate—buried in the trillion-dollar Obama stimulus of 2009—would do more harm than good. Their diagnosis, unfortunately, is on the nose.

The Quack-in-Chief peddled his tech-centric elixir as a cost-saving miracle. “This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests,” he crowed at the time. In theory, of course, modernizing record-collection is a good idea, which many private health care providers had already adopted before the Healer of All Things took office.

But in the clumsy, power-grabbing hands of Washington bureaucrats, Obama’s one-size-fits-all EMR regulations have morphed into what one expert called “healthcare information technology’s version of cash-for-clunkers.”

Indeed. "I'm from the Government and I'm here to help you!" are some of the deadliest words in the English language. Few if any of the promises have proven to be accurate.

In 2014, RAND researchers interviewed doctors who spotlighted “important negative effects” of the EMR mandate on “their professional lives and, in some troubling ways, on patient care. They described poor EHR usability that did not match clinical workflows, time-consuming data entry, interference with face-to-face patient care, and overwhelming numbers of electronic messages and alerts.”

{snip}

In Massachusetts last month, physicians decried the failure to achieve true “interoperability” between EMR systems despite a $30 billion federal investment through the Obama stimulus. Dr. Dennis Dimitri, president of the Massachusetts Medical Society, noted at a rancor-filled town hall that the mandate has “added significant time to the daily life of most physicians in their practices,” WBUR reported. “It has not necessarily lived up to expectations in terms of its ability to provide cues to physicians to make sure that necessary treatments are not being missed. It has certainly not been able to swiftly disseminate information from one clinical setting to another.”

The most ironic thing is that what was pledged was truly desirable and eminently achievable. Sadly, what has happened in the private world of medical software is magnified ten-fold when the government jumps in. I have bemoaned the sorry state of PACS software in particular for over 10 years on these very pages. The poor excuses for life-and-death patient-care software can be attributed at least in part to the fact that the end-users generally don't buy the software, and so it is written for those who do. Make the government that customer, or at least the entity that writes the RFP, and you have a recipe for disaster.

The EPIC failures of the most ubiquitous EMR tells us a lot about what really happened:

(The problems are) in no small part due to the cronyism embedded in the federal stimulus “incentives” – a massive chunk of which the White House doled out to behemoth EMR company Epic Systems, headed by Obama crony Judith Faulkner. As I’ve noted repeatedly in this column the past three years, Epic continues to be plagued by both industry and provider complaints about its creaky, closed-end system and exorbitant fee structure to enable the very kind of interoperability the Obama EMR mandate was supposed to ensure.

Now, even left-wing Mother Jones magazine reports this week that “instead of ushering in a new age of secure and easily accessible medical files, Epic has helped create a fragmented system that leaves doctors unable to trade information across practices or hospitals. That hurts patients who can’t be assured that their records—drug allergies, test results, X-rays—will be available to the doctors who need to see them. This is especially important for patients with lengthy and complicated health histories.”

Worst of all, physicians have been bribed to accept the concept of "Meaningful Use" which is simply the ability of their shiny new EMR's to transmit "anonymized data" (nudge, nudge, wink, wink) to Washington, and they are fined if they don't put the spyware in place. The American Medical Association, whose membership now comprises less than 10% of U.S. physicians, sold us out for figurative bowl of pottage, but now, too late, realizes its huge mistake:

The American Medical Association, which foolishly backed Obamacare, is now balking at top-down government intrusion into their profession. Better late than never. The group launched a campaign called “Break the Red Tape” this summer to pressure D.C. to pause the new medical-record rules as an estimated 250,000 physicians face fines totaling $200 million a year for failing to comply with “meaningful use” EMR requirements.

Malkin closes with a modest suggestion:

The Obama White House has responded by doubling down on its destructive EMR rules that punish both patients and providers. Congress must intervene. Rep. Steve King (R-Iowa) introduced a bill Thursday to repeal the draconian penalties “so that providers can get back to the business they are uniquely trained to do—utilizing their skills and knowledge to heal the sick and support the continued vitality of the healthy.”

Prescription: Butt out, Washington. Primum non nocere. 

Primum non nocere, by the way, is Latin for First, Do No Harm. Indeed, this is the one of the Prime Directives of medicine. Those who provide fractured software should take note. Pandering to IT and CIO's with programs that ignore the needs of the physicians who use them is tantamount to "doing harm" to patients. Abusing one's relationship to politicians in high places to sell exorbitantly-priced, crappy, dangerous spyware is even worse.

From the original Hippocratic Oath:

With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage.

Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so.

Rather Epic advice, don't you think?

"EHR State Of Mind"

ZDoggMD WHO????  From Dr. ZDogg's website:

ZDoggMD is a physician, off-white rapper, and the founder of Turntable Health. He’s not a businessman. He’s a business, man. OK we stole that line from Jay-Z but you get the idea. A hospitalist at Stanford for almost 10 years, Dr. Z currently resides in Las Vegas—a city he finds simply adorable.

Dr. Dogg, actually, Dr. Zubin Damania, in his copious spare time, creates poignant, biting rap videos that cut right to the heart of what's wrong with medicine today. His latest offering, "EHR State Of Mind," targets, you guessed it, EHR's, and by proxy, electronic medicine in general.

Without further ado:

Watch the whole thing. Then watch it again.

Yes, it's funny, but it's sad, and it is spot on. Here's the bottom line: Most medical software programs, EHR's, PACS, etc., are VERY poorly written. They are hard to use, they get in the way of patient care, they don't communicate well if at all to other systems, they were designed to appeal to CIO's and IT types, and ignore most anything to do with how physicians and such actually use them. Or try to use them.

I'm just waiting for the first class action suit against one or more of the companies who have shoveled these steaming piles of poor coding and even worse interfaces upon us. All it will take is the deaths of a few patients that can be directly attributable to these embarrassing excuses for software. Mark my word, it will happen. Of course, these multi-billion dollar companies will pay off the plaintiffs and keep doing what they are doing. That worked for Ford and the Pinto cases; Ford committed corporate murder rather than pay $100/Pinto to fix a fatal flaw. So it will be here. And most tragic of all, CIO's and IT folk will continue to buy from the vendors who promise the best prices, the least work for the support people, the biggest installed base, and just generally anything and everything EXCEPT being usable for the end-users. That would be us.

There are very few rogues out there such as myself and ZDogg who are alerting the public to the fact that the electronic emperor has no clothes. Clearly, we are not getting anywhere, and that is because we physicians have completely lost control of this situation. And I doubt we'll ever get it back.

IBM Goes Mac!

From FoxNews.com:

IBM, at one time a Windows PC heavyweight, is now deploying Macs internally and is seeing a precipitous drop in helpdesk calls.

How precipitous? Only 5 percent of Mac users call the helpdesk, compared to 40 percent of PC users, according to Fletcher Previn, VP of Workplace-as-a-Service at IBM, who spoke about the program at a conference held recently in Minneapolis.

Based on the positive results, IBM is now rolling out Macs to its employees at a rate of 1,900 devices per week. The tally so far for the four-month-old program is 130,000 Macs and iOS devices into the hands of IBM employees, according to a post from JAMF Software’s user conference, where Previn was speaking.

And IBM is managing all of those devices with a tiny staff of 24 people, which comes to one helpdesk person for every 5,400 devices. . .

One of the ironies is that IBM was a PC pioneer in the early 1980s and subsequently became one of the largest Windows PC suppliers in the world. IBM eventually sold its PC business to Lenovo and over the last decade has become a software and services company.

This on the heels of IBM's purchase of Merge Healthcare to feed images to Watson. Talk about a string of really good decisions! If it weren't for antitrust laws, the next logical step would be for Apple to devour IBM and then gobble up Microsoft just for grins. Take that, Bill Gates!

@AgfaMinions

Cute! I'm sure we've done the proper licensing with @Disney. Right?

Meeting and Networking

Cartoon courtesy of the NewYorker.com

Early July:

Radiologists complain about deteriorating PACS speed and function. Loudly. Note that access via Web from outside the enterprise over <50 MB line works far better than connecting within the enterprise.

Mid July:

Just completed the assessment of where the reading stations are physically connected to the network. Confirmed that not only are they connected to newer switches, but every connection between the core switch and the actual devices are clean. All connections are running 1000 Mbps and Full Duplex, there are no errors on any of the ports between the core switch and the reading stations. Checked the WAN connections and those links are clean as well.

Physical network connectivity has now ruled out as a source of slowness.

Early August:

The overall global performance issues have been resolved through updating servers, workstations, and tweaking settings according to best practice configurations.

Early September:

Radiologist insists on plugging workstation directly into server at datacenter. Voila! Perfect performance!

Mid September:

1. Network: Switched Virtual Interfaces migration to new core infrastructure (removes extra hop/loop in datacenter - to be completed by end of September). We do not know if there will be any perceived impact or benefit, but it is within the realm of possibility. 
2. Network: Installation of additional 1 GB connection between campuses and data center (escalated with vendor requesting to have completed by mid-October)
3. Cisco engaged to perform network assessment (to begin after above network changes are in place) which will be analyzed and Radiologist feedback obtained to determine next steps for long-term measures if image retrieval performance is not resolved through the accomplishments by the end of November.

Late September:

Switched Virtual Interfaces migration to new core infrastructure removes extra hop/loop in datacenter.  Likely that the change will not be seen by the end user.  WAN Upgrade with installation of additional 1 GB connection between campuses and data center waiting on date, anticipating mid-October.   Improved bandwidth will improve network performance.

Mid October:

“We don’t need Quality of Service (QoS) for PACS as PACS only uses 30% of the existing 1GB bandwidth, and that hasn't been a problem.  The additional 1GB upgrade had been planned since last year.”

Draw your own conclusions.

Making Mars Great Again!

PACS Wars

Universal Improvements

I have referenced some of our trials and tribulations with the new GE Universal Viewer, which is technically version 5.x of Centricity.

We've found that some of our problems were of our own making, with the help of some unusual programming on GE's part. The disappearing measurements, for example, didn't really disappear. Rather, my hanging protocol created a clone of the main window, and if things are measured there, they won't show up, although they do live on as the Saved Presentation. Lesson learned. Various other "glitches" were due to our lack of understanding of something esoteric. Well, if they all worked the same, no one would buy the expensive PACS, now would they?

However, one problem has not yet been fixed, that of skipped images. We thought at first this was also due to the clone window handling, but apparently it is a coding error. Which is to be fixed. IN THE RELEASE AFTER NEXT!!  Um.....GE....a glitch that hides patients' image data is a VERY SERIOUS PROBLEM! This is the sort of thing that calls for emergency hot-fixes and mea culpas to the FDA. I do have to admit that the problem is not as bad as what we saw with Centricity 2.x, wherein scrolling would simply jump over images; UV 5.x tells us when it's skipping images by flashing "0% Loaded" in the missing frame. This is a definite improvement, but...you can do better!

Anyway, a team from GE came by the other day to show us how things will improve.

The two apps people who came to visit were well-known to me, one having demoed Centricity to us about 12 years ago, and the other having shown me the Universal Viewer for the first time at RSNA 2012. They brought a laptop-based workstation and server, and a cargo-load of monitors. Given the fact that we just redid all the workstations, couldn't we have simply, temporarily downloaded UV 6.x on our station, saving a LOT of time and effort? Oh well, I guess that's why I'm not in sales.

The team showed us a few things we already had that we didn't know about. For example, two CT series can be synchronized by "Image Registration" as well as position or slice number. The modifier was there all along under the Sync menu, but I never thought to look there. Perhaps theres also a "Sync by Phase of the Moon when Study Acquired" or "Sync by State of Consciousness" in there, too. I'm sure there are other little Easter Eggs hidden in the somewhat scattered GUI I haven't found as yet.

UV 6.x apparently plays nicer with Windows than 5.x. We had complained about the Navigator pane disappearing behind the Patient Folder; resizing the latter will solve this temporarily, but the windows all revert back to where they were upon opening the next study. Ah, Windows. Some problems scrolling through old reports after clicking somewhere else supposedly will be improved in the next release as well.

One of the main deficiencies in UV to date has been the lack of the promised ability to read PET/CT without adding the Advantage Workstation Server. We were shown the AW functionality, which is FINALLY tightly integrated into UV about 12 years after it was supposed to happen. It does appear to work as I would expect it to, with all windows, planes, 3D renderings, cartoons, and other stuff linked. Adjust one, the others all follow, whether on UV or AW. Very nice. This gives us the full PET/CT reading capability, matching that of the old AW upon which we now depend. Works for me. There's also a nice OncoQuant module which we may or may not get that will allow serial lesion measurements. That is, after all, what we do in oncologic imaging. Having a table of what was there before could certainly help us to be certain we measure all the lesions seen last time. Each. And. Every. Single. One.

I took a few moments to rant about the control layout of UV, which is not terribly logical, and can get worse depending on what buttons are pressed, and what the state of the viewer might be. For example, when using measurements (obviously the bane of our existence), the buttons for linear measurement, ROI, etc., are placed to the right of the "Study Dictated" button, which is otherwise nicely placed at the end of the line. Yes, said GE, you are not the first to complain about that. Well, gee, GE, how about trying these things out with real users before deploying them? Little problems could be caught before they become big problems. That would be nice, and few companies do it. My services are available for a very reasonable fee!

Having heard of our difficulties with another PACS, the reps approached me after the demo and wondered if this might be the time to present their wares to the troubled site. Since the problems there might not be the fault of the PACS itself, I urged patience. A LOT of patience. Like wait until I've fully retired patience... Some of my former partners have told me quite clearly that they would really rather not have to use UV anywhere else. To them, I urge patience as well; UV represents tremendous progress over its predecessors, and you never know how much better it might get...