Sunday, November 15, 2015

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:







video


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.

Wednesday, November 04, 2015

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!!

Sunday, November 01, 2015

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.