PACS Tidbits

New stuff in PACS seems to be overwhelmed somewhat by the Trump-like stampede of EHR data. Still, I've got a couple of items which might interest my loyal readers, all four of you.

Let us start with GE. Our Universal Disappointment Viewer should be updated to the next version sometime in the next few weeks. For those who haven't heard, our current UV has a number of problems, not the least of which involves not displaying one or more slices from a CT series when scrolling through. Fortunately, we do see a blacked-out pane with the phrase "0% loaded..." to let us know that we might be missing something. That is a major step up from our earliest go-round with Centricity 2.x years ago, which would skip images and not be kind enough to tell us it had done so.

As it stands, the "0%" thing happens on nine out of ten CT's, forcing us to close and reopen the exam, sometimes three or four or five times.

So...let's run some numbers. It adds 30 seconds to the exam each time we have to go through the close-and-reopen cycles. The busy site has maybe 40 CT patients per day (I'm underestimating), and for simplicity's (not Centricity's) sake, let us say they operate 5 days per week, and 50 weeks per year. That would be 10,000 patient-exams per year. So that's 9,000 exams that need to be reopened, wasting 4,500 minutes or 75 hours wasted for this year of Universal joy. At $200/hour (EXTREMELY reasonable rate), that would be $15,000 blown because of this poor coding.

I am hereby submitting a bill for this amount, $15,000.00, to General Electric for our professional services and time lost. I would urge all other departments experiencing this sad software error to do the same.

GE, please contact me for the address to send the check. I'll let everyone know when it arrives. Or if it doesn't.

While we are waiting on the check that's certainly in the mail by now, let us turn our attention to Agfa. You haven't heard much from me about our situation there, and you won't for a while. But in my search for an image-sharing solution (I still favor lifeIMAGE for this purpose) I stumbled across the fact that Agfa has an offering in that realm. Which has been deployed exactly never. I've learned not to beta (or alpha) test when patients are involved, thank you. Also, I'm hearing that Agfa plans to standardize and unify all of its installations onto one uniform platform. I'll assume this platform will be Agility, but I have no confirmation of that as yet. Good luck.

Onward and upward. Apparently Fuji has released Version 5.0 of Synapse PACS, and in an article on ImagingBiz.com, (which was sponsored by Fuji and written by Fuji USA V.P.'s), it was the "hit" of RSNA 2015. I must have missed that somehow, perhaps because I rarely wander over to the Fuji booth. But the Veeps do make the new version sound quite intriguing.

Our latest Synapse PACS has beefed-up archival and worklist/workflow-engine capabilities—from unique sharing features to EHR interoperability tools to workflow-optimizing options that take integration beyond the enterprise, into the cloud and, from there, wherever collaboration is happening—or should be happening.

In a nutshell, the need today is for a diagnostic-level PACS workstation that extends through the PACS to any desktop that a PACS might touch. That’s why the Fujifilm team came up with the Synapse 5 PACS viewer. It’s designed to help users keep up with the changes that have already taken place and, more importantly, to help them stay out ahead of what comes next.

Nice to hear this from the company that has the reputation of taking years to update things.

When I first saw Synapse in action in the early 2000's, I was told that the local group had insisted on three-second transmission times for any study. Of course, it turns out that the group itself figured out how to accomplish this without help from Fuji. But speed is indeed an important factor today:

Going into the Synapse 5 PACS design phase, our team knew the only way to achieve sub-second image access while also virtually caching large datasets and enabling reads from wherever, whenever—including with 3D—was to approach server-rendering technology in a whole new way. That’s why we came up with not just a new viewer but a next-generation viewing application, one combining architecture changes as well as technology advancements.

With the new Synapse 5 technology, there’s no client at the desktop, and the image rendering occurs on the server. This allows the technology to be far less dependent on the viewer side, and it allows users to simply log in and choose their interface as well as their screen—Explorer or Firefox or Chrome, desktop or smartphone or tablet—or work with any combination of preferences.

Yup. Server-side rendering and a zero footprint client. Nothing novel, but Fuji is the first of the big-iron companies to implement this on this scale. I think it's a good idea if done right.

One of our favorite aspects of Synapse 5 PACS is its brilliant simplicity. Like most cutting-edge websites and more than a few apps, it uses HTML5 and was largely inspired by what you’ve seen in the world of e-commerce. It’s got a user-friendly, intuitive GUI, with high performance, limitless scale and strong security.

Can you say "Hyperbole?" I knew you could.

Here’s another reason we were so busy answering questions at RSNA 2015: As “disruptive” a technology as Synapse 5 is, it’s barely a disruption at all for existing customers. It’s not a forklift of a database or a migration or a platform change. It’s just an upgrade to our current Synapse 4 platform. Current Synapse users will be able to light up an entirely new viewer that will work off of the existing database they already have.

An upgrade? Definitely. I'll bet money it is a HARDWARE upgrade, requiring a new server (or more likely many servers) added to the back end. I could be wrong.

We haven’t forgotten to take what we’ve heard from radiologists and apply it. That means, among many other things, that our new viewer makes it easy to look at a screen for eight hours a day. We’ve thought through ergonomic implications, right down to details like minimizing wrist strain, and we’ve geared everything toward greater efficiency and productivity.

Oh, still my beating heart! Someone cares about us poor rads? That would be nice...

But now a thinly-veiled slap at our competitors...

There’s been a lot of talk lately about “deconstructing PACS” in order to free it from silo-ed systems. Customers want fast image viewing, diagnostic integrity, flexible worklist, integrated 3D, platform independence and information lifecycle management. Legacy PACS does not perform all of these functions well, which is why Synapse 5 is so different.

Synapse 5 PACS inherently does what PACS deconstructors would do if they could: It helps transform healthcare organizations as they enhance collaboration and optimize workflows across the enterprise.

I'm not seeing anything that says Visage and TeraRecon can't do all that, too. In fact, Fuji's non-deconstructed PACS sure sounds a lot like Visage's deconstructed PACS. But I'm sure there are differences.



Remind me to stop by Fuji's booth next RSNA. If I'm still in the business, that is.

Lingering Frustration And Bad Design

Mrs. Dalai loves HGTV, and so I end up watching it quite a bit. I think I've even become somewhat of a house connoisseur after all this time.

So let's look at a house, pictured above. Wouldn't you love to live in this house? It's a great house! 4 bedrooms, 3 bathrooms, gourmet kitchen with granite countertops, stainless steel appliances, the whole nine yards! The house contains every gadget you could possibly want.

But there's a problem. The house was designed by someone who lives in a cave and doesn't drive a car. It is part of, well, a rental community, owned by an absentee landlord who will never set foot in the neighborhood, living in a corner office suite in some skyscraper somewhere. Can you see what's wrong? Hopefully, you did before you moved in. Because once you're in, it's too late.

My metaphor might be a bit stretched, but I think it is clear nonetheless. It is all too easy to design something wrong when you don't know anything about those who will use your product, and when the end-users aren't even the targets of your sales pitch.

So it is with PACS and EMR's, and so I've been saying here and elsewhere for a very long time. But it seems that with the greater penetration (government-mandated or not) of EMR's has come a deeper understanding and acknowledgement of just how flawed they are from the user's standpoint, the only one that counts.

This graphic from Gomerblog nicely outlines the problem:

And I will shout about the problem as loudly as I can:

THE PEOPLE THAT CREATE THESE PRODUCTS AND THE PEOPLE THAT BUY THESE PRODUCTS ARE NOT THE PEOPLE THAT USE THEM!!!

Moreover, there seems to be very little interest in correcting this.

But wait, the world is beginning to feel our pain, and attention is coming from a very unlikely source: the government! Read this article, "Frustrations linger around electronic health records and user-centered design" in Healthcare IT News, and be encouraged. At least some in relatively high places seems to get it:

In a provocative prime-time speech, meanwhile, Acting CMS Administrator Andy Slavitt threw down the gauntlet: "I'm certainly not bashful about what we need to do better, and I'm not going to be bashful here, even in the face of some very good reasons for optimism, about ways we need to take our game up across the board.”

The health IT industry has done very well in the years since the HITECH Act, said Slavitt. "But we're still at the stage where technology often hurts rather than helps physicians providing better care."

Wow. Someone from the government is here to help us!  He actually said out loud what I've been saying for years. These poorly-written, outlandishly expensive software extravaganzas can HURT patients. Yowza!

Mr. Slavitt, my new governmental hero, continues my, I mean his, rant:

To bolster his case, he rattled off a series of actual quotes from frustrated clinicians. One complained that in his EHR, "to order aspirin takes eight clicks; to order full-strength aspirin takes 16."


Slavitt said CMS is newly committed to taking a "user-centered approach to designing policy." He asked vendors to do the same, with a similar spirit of empathy: "Step back and look at what you don't think is working, and make it better."

This, from CMS? Someone pinch me...

Perhaps the additional attention comes from the fact that more and more physicians have become disgusted with the status quo:

That dissatisfaction is getting worse, not better. A study published this summer by the American Medical Association and the American College of Physicians found that physicians are more frustrated with EHRs than they were five years ago.

Forty-two percent of respondents said their EHR system’s ability to improve efficiency was "difficult or very difficult." Some 72 percent said the same about its ability to decrease workload.

We saw similar feedback in Healthcare IT News' first-ever EHR Satisfaction Survey this past fall. In addition to numerical scores, we also asked for anecdotal feedback from more than 400 people who took the poll. Opinions such as "not very intuitive," "cumbersome" and "too many clicks" cropped up over and over again.

So what's the problem? As usual, that can be stated with two little letters:  I and T. The article continues:

In his landmark book, The Design of Everyday Things, Don Norman, director of The Design Lab at University of California San Diego wrote:

"The reasons for the deficiencies in human-machine interaction are numerous. Some come from the limitations of today's technology. Some come from self-imposed restrictions by the designers, often to hold down cost. But most of the problems come from a complete lack of understanding of the design principles necessary for effective human-machine interaction. Why this deficiency? Because much of the design is done by engineers who are experts in technology but limited in their understanding of people."

Of course, in healthcare IT there are other challenges. EHR vendors would probably love to have all their products look as sleek and intuitive as the latest iOS release. But they also have to ensure they check all the boxes to comply with certification criteria from the Office of the National Coordinator – all 560 detailed pages of the 2015 Edition.

"I know some people inside big EMR companies who want to do excellent design, but in an organization that's owned by IT, it's difficult for even a design advocate to have their voice heard and affect the process," Amy Cueva, co-founder of the design-centric Health Experience Refactored conference, told Healthcare IT News in 2013.

I have been saying this in reference to PACS for much of my career, and it applies equally to the superset of EHR's. Let me emphasize these very important statements:

Why this deficiency? Because much of the design is done by engineers who are experts in technology but limited in their understanding of people.

(B)ut in an organization that's owned by IT, it's difficult for even a design advocate to have their voice heard and affect the process...

There is some light at the end of the tunnel, but...

That's changing, thankfully, as more and more efforts are being made industry-wide to make EHRs easier to use and perhaps a bit better-looking. One of those ONC certification criteria, after all, is that vendors employ a user-centered design process when developing their tools, and report the results of usability testing.

A study published this past November in the Journal of the American Medical Informatics Association took a look at UCD processes at 11 unnamed vendors, seeking to understand the challenges and opportunities for better design practices.

"Our analysis demonstrates a diverse range of vendors’ UCD practices that fall into 3 categories: well-developed UCD, basic UCD, and misconceptions of UCD," wrote researchers from MedStar Health's National Center for Human Factors in Healthcare, noting that the latter category might refer, say, to the mistaken belief that responding to end-users' requests and complaints qualifies as user-centered design..."

But we aren't there yet...

Dishearteningly, the researchers found some respondents still didn't see the business case for investing in UCD processes. It even found that some smaller EHR vendors didn't even have any usability experts on their staff.

And this is the bottom line. As with PACS, in most places, IT controls every facet of the EHR. Software wonks create these jumbled messes while insulated from the actual users. IT folks buy the stuff while equally removed from the wants and needs of those who have to use it. It needs to be reiterated...physicians use EHR's (and PACS) to take care of patients. What a concept. Healthcare IT is used for HEALTHCARE! This isn't some app for your iPhone that won't hurt anyone if it fails or if it isn't usable. This is life and death, people. That's not an exaggeration. It has to work and work well. And today, it doesn't. It gets between physician and patient, impairing instead of facilitating that sacred relationship.

We just aren't there, yet. But maybe someday...

Cinders, EHRs, and Other Disappointments

I admit to being addicted to new technology. I love gadgets of all shapes, sizes, and sadly, prices. If there's some technological toy out there I'm missing, let me know and I'll run right out and buy it.

The crowd-funded sites, Kickstarter and Indiegogo, are the perfect trap for suckers people like me. Here, we find a plethora of inventions that one just has to have, requiring only a small investment for a piece of the future. Dangerous places, these.

Sometimes, the invention is so outlandish that it doesn't get funding, but some creations are so tempting and apparently within the realm of possibility that the rubes like me line up to part with their hard-earned cash. I've fortunately only gone down the tubes once, that on a pre-Apple Watch smartwatch wherein the inventor collected funds but never actually made a working copy of his invention. Fortunately, I didn't lose much on that one.

A more frustrating situation arises when the invention sort-of works but doesn't really. Such was my experience with Cinder, a screen protector for the iPhone 6 series.

The enticing property of the Cinder that made me dump a perfectly good Rhino-Shield was the curve...curved edges, that is, as you can sort of make out in the picture above. And why do we need this? Just ask Cupert, the makers of Cinder:

We created CINDER - the picture-perfect, seemingly invisible, ultra-thin glass screen protector with a form-fitting, edge-to-edge wrapped screen design, providing the ultimate user experience.

Unlike dull and ordinary flat screen protectors, CINDER beautifully combines flawless form with practical functionality in a precision-fitted, curved glass screen protector with specially-developed nanotech adhesive to ensure easy installation and reusability.

{snip}

Engineered to be the most elite, user-sensitive screen safeguarding accessory, CINDER protects your iPhone 6 or iPhone 6s at the highest possible level without compromising design or functionality. Real curved glass edges seamlessly wrap around the iPhone 6 and 6s Series screen - no gaps or hard edges to chip. Just impeccably beautiful, iPhone-flattering protection that’s practically invisible.

Nice idea, but for the majority of users, per Amazon.com reviews, the Cinder just didn't work. It was not washable as claimed, it was very fragile, often breaking when installed, and it was not made from Corning Gorilla Glass as had first been claimed. For me, the problem was that it did not snugly fit around the glass of the screen, and thus, it was dislodged by the iPhone's protective case, and you MUST use a case to cocoon your iPhone should it fall to the floor. When I informed Cupert that every single case I tried knocked their stupid Cinder off the screen, they simply said, "Try another case." No refund, no nothing. So instead of the damnable Cinder, my iPhone now sports a Thule case with built-in screen protector, and I'm pleased with it. But I now have about $100 of unusable protectors and cases sitting in my drawer, thanks to my infatuation with a concept that just wasn't properly produced.

There are probably a million other similar product design missteps like the Cinder. Even Big Companies like Fiat-Chrysler can go down the tubes on a foolish idea. Take something as mundane as a gear-shift lever:

Image courtesy FoxNews.com

You would think it hard to bung that up, but you would be wrong. From FoxNews:

Electronic gear shifters on some newer Fiat Chrysler SUVs and cars are so confusing that drivers have exited the vehicles with the engines running and while they are still in gear, causing crashes and serious injuries, U.S. safety investigators have determined...

Agency tests found that operating the center console shift lever "is not intuitive and provides poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection," investigators wrote in the documents. They upgraded the probe to an engineering analysis, which is a step closer to a recall. NHTSA will continue to gather information and seek a recall if necessary, a spokesman said...

In the vehicles, drivers pull the shift lever forward or backward to select gears and the shifter doesn't move along a track like in most cars. A light shows which gear is selected, but to get from Drive to Park, drivers must push the lever forward three times. The gearshift does not have notches that match up with the gear you want to shift into, and it moves back to a centered position after the driver picks a gear.

And so it is with EHR's. These gargantuan and hideously expensive systems have great potential to improve health care, but unless they are well-made, and programmed for success, they can do just the opposite. And they do.

I hope you are already a fan of ZDoggMD, a physician-rapper (much funnier than a physician-blogger). ZDogg has encapsulated the frustrations with today's EHR's in this painfully hilarious video:

You will find the lyrics and background information on ZDogg's website.

His bottom line is this:

Simply put, the Tower of Babel of existing EHRs may not ever talk to one another, but they do share one thing: they come between us and our patients. Staring at a screen to click boxes and satisfy quality measures while figuring out the seventeenth digit for an ICD-10 code—this nonsense robs us of precious time and attention that should be spent on and with patients. I would never advocate going back to paper. Ever. But we need to demand technology that binds us closer to those we care for, technology that lets doctors be doctors. And nurses, and RTs, and case managers, and dietitians, and scrub techs—[insert crucial care team member here].

Which is what I've been saying for YEARS about PACS. The damn things work just enough to justify their existence, barely. They are clearly designed by people who do NOT understand our workflow, and they get between us and our patients, or their images, anyway. This is not how it should be. So why are EHR's so hard to use? Easy. Poor design, poor testing, and no real incentive to change.

As with PACS, EHR's are sold not to the end-users, but to the IT department and the CTO/CIO, who probably have absolutely no idea how it should work. Their criteria will be some combination of the following:

1. Which product is cheapest?
2. Which product is most expensive? (If it costs more it must be better!)
3. Which is the Big Name Company that everyone thinks you have to have?
4. Which company will do the maintenance and let IT off the hook?

Notice that having the thing actually work in the hands of those who use it is not on the list. 

A comment on ZDogg's page from someone who claims to work for THE Big Name in the EHR business is quite revealing:

People wonder, "why aren't EHRs designed with providers in mind?" I've worked at Epic and can tell you why not:

1. Physicians were on staff, but hard to reach. They were technophiles and barely practicing as others mentioned.
2. It really is a billing platform with some patient stuff tacked on. Everything useful you see is probably a workaround and one level away from not working at all.
3. Quality Assurance (manual testers) are supposed to be a surrogate for users, as there is no beta testing. They are intentionally hired without CS background and maintained as laymen with a very lite, monkey-see-monkey-do training. However if they are not lickety-split quick to master the software, they are fired. Quality Assurance ends up being more like Self-Reassurance.
4. There is absolutely no testing of interoperability. There is however plenty of testing for the several convoluted ways of sharing data between Epic servers.

And in fact, interoperability is another HUGE bugaboo with EHR's. As ZDogg rapped, er, said in the video, "Bought the new software, and though we use it here, I can’t use it over there, different systems everywhere!" In fact, Epic has been charged with overtly blocking data from other systems. Rather ominously, the original piece from ihealthbeat.org has been taken down, or at least yields a 404 error. But what happens in Vegas stays on the internet, and so the cached version is still accessible:

Thursday, November 5, 2015

Connecticut reportedly has launched an investigation into several hospital networks and Epic Systems over their information sharing practices after a state law (S 811) took effect last month, prohibiting the use of electronic health records to block the flow of health data, Politico reports.

Background on Law

The law, which was passed in June and took effect Oct. 1, makes information blocking an unfair trade practice and subjects violators to penalties. According to Politico, the law based its definition of information blocking on the one used in the Office of the National Coordinator for Health IT's April information blocking report.

In addition, the law aims to slow the rate of health care network consolidation.

State Investigating Complaints

According to Politico, the Connecticut Attorney General's Office is reportedly investigating complaints under the law, including those against Epic and health systems in the state (Allen, Politico, 10/30).

The investigation stems from independent medical groups' allegations that hospital networks are using EHRs to dictate patient referrals and bring patients back to their networks (Walsh, CMIO, 11/3).

Critics allege that Epic -- which holds more than 50% of the state's hospital EHR market -- is unfairly collaborating with certain health networks against smaller physician practices.

For example, state Sen. Len Fasano (R), who co-sponsored the new law, said he heard anecdotes about physicians struggling to access patient information recorded at large hospitals, in particular Yale-New Haven Health System.

He said, "It was impossible for them to gain access to a patient's full medical record unless they were associated with the hospital," adding, "Independent doctors cannot properly care for their patients if they are denied access to full medical histories."

Meanwhile, state Senate President Martin Looney (D) said Epic was being used "as both a coercive tool to shut out nonparticipating practices and, in some cases, force them to be sold to larger health care networks."

Epic's Response

Epic spokesperson Eric Helsher said the vendor is not responsible for creating the conditions that led to such complaints, noting that the health care landscape is changing.

He said, "Physicians are aligning with health systems to reduce costs and improve patient outcomes," adding, "Epic enables this alignment by providing deep integration around a single patient record, a robust patient portal to increase patient engagement, and population health management and analytics tools that drive coordinated care" (Politico, 10/30).

So...Epic admits no responsibility although it created a proprietary system in a space that should be trying to integrate. Heck, even the majority of dysfunctional PACS can talk to each other, at least to some degree. Epic's stance is tantamount to Apple saying that from now on, an iPhone can only call other iPhones, but why would you want to communicate with a filthy, stinkin' Android anyway? Not cool, and at least in Connecticut, not legal.

And this unbelievable combination of hubris, arrogance, and indifference to the real needs of the patients, let alone those of us striving to take care of them, sets a rather nasty tone for the future.

I have said repeatedly on this blog and elsewhere for the past eleven years that PACS is a critical, life-saving creation. Dalai's First Law, in fact, states that PACS IS the Radiology Department. And as it is used today, the EHR the patient's entire record, and his connection to healthcare. Nothing happens in an electrified hospital that doesn't pass through the EHR. If it works, great. If it fails, people die. You might recall the little Ebola episode in Dallas from 18 months ago, and the Epic Fail that contributed to the near-disaster. (I say "near" because "only" one person died that time.) What I said then is still true:

Do you sense a familiar refrain? (Lawyers please note...THIS IS ALL MY VERY OWN HUMBLE OPINION, as is every other word that I have ever written or ever will write, unless quoted from someone else, and worth every cent my dear readers paid for it.) Once again, here in the Health Care Field of Dreams, we have badly written, badly designed software, created with minimal input from those who have to use it, selected and then implemented by IT types who also don't have to use it and don't understand enough about those who do to get it done right. This has to stop. Right. Bloody. Now. Hit CNTL-ALT-Delete and start over.

With Epic and the government having their hands deep inside each others' panties, we may well be stuck with these unusable systems for the foreseeable future. (And as an aside, if you deconstruct the Meaningful Use rewards and penalties, doctors are being bribed to buy EHR's that have the certified and confirmed ability to transmit data to Washington, D.C., so again, we won't expect the government to do anything about anything.) But, the demise of Mr. Duncan, and no doubt dozens if not hundreds more that he inadvertently infected between his two ER visits may level the playing field.

It is clear that Epic's epic Dallas fail (which might not really be totally attributable to Epic per se, but rather to the way the product was set up in the field, not passing that one lil' bitty critical entry to where it should go), contributed to Mr. Duncan's being released when he should have been locked up in the local version of Wildfire. It is possible, just barely possible, that this tragic episode will awaken the public to the dangers inherent in the IT-controlled medical software industry and its acronymbysmal spawn, EHR's, CPOE's, and the occasional unruly PACS. Get enough people upset about this, and they will call their congressmen, and more importantly their lawyers. (I would submit that more gets done by class-action suit in this country than by Congress.)

I realize that replacing these huge legacy systems which were outdated before they were even conceived would cost somewhere in the trillions of dollars, and so I'm not holding my breath that this will ever happen. But maybe a few million and billion dollar suits and fines would get the attention of the Epics, the Cerners, McKessons, and all the others who create these nightmares. Or maybe, just maybe, the execs will read this, and the other rebellious propaganda we are starting to see online, and realize that they are causing damage rather than progress, and be inspired to turn it all around. I'm a staunch believer in the electronic record, PACS, computers, iPhones, Apple Watches, and anything else technical. This is the future, without question. But it has to be done right, and so far that hasn't happened.

And don't underestimate the power of the individuals. Go to ZDogg's site, letdoctorsbedoctors.com, and express your opinion about EHR's. It's a start.

This sorry state of medical software cannot go on. The time has come to fix it. Now.