Dalai's PACS Blog

DoctorDalai.com Second-Most Read Blog!

2012-01-28T07:31:00.001-05:00

I have it on good authority that this blog is the second-most read publication of its kind at some large PACS companies.

I find this very disappointing. Don't you guys have anything better to do?

Seriously, thanks for reading. Your patronage is much appreciated.

(BTW, HISTALK is deservedly number one.)

PeerVue Purchased!!!

2012-01-26T19:46:00.001-05:00

Don't know by whom as yet. More to come.

Sono-Roast

2012-01-21T23:06:00.000-05:00

Do you own or operate a GE Logiq P6? I don't, although it looks like a very nice machine. But do be careful with yours. It seems there has been a bit of a problem...

From the FDA:

Class 2 Recall
GE LOGIQ P6 Ultrasound System

Date Posted January 21, 2012
Recall Number Z-0834-2012
Product GE LOGIQ P6 Ultrasound System. The device is intended for use by a qualified physician for the evaluation of soft tissue and blood flow in the clinical applications of: Fetal; Abdominal; Pediatric; Small Organ (breast, testes, thyroid); Neonatal Cephalic; Adult Cephalic; Cardiac (adult and pediatric); Peripheral Vascular; Musculo-skeletal Conventional and Superficial; Urology (including prostate); Transesophageal (TE); Transrectal (TR); Transvaginal (TV); and intraoperative (abdominal, thoracic, vascular and neurological).

Recalling Firm/
Manufacturer GE Healthcare, LLC
3000 N Grandview Blvd
Waukesha, Wisconsin 53188-1615
Reason for
Recall GE Healthcare has recently become aware of a safety issue associated with the Probe of your LOGIC P6 system that may impact patient safety. GE Logic P6 probe head has a possibility to cause burn injuries to patients or operators.
Action GE Healthcare sent an "URGENT MEDICAL DEVICE CORRECTION" letter dated December 23, 2011 to all affected customers. The letter identifies the product, problem, and actions to be taken by the customers. The letter instructs customers to discontinue use of the affected product. Contact the GE Support Center at 1-800-321-7937 or your local GE Healthcare service representative for questions regarding this issue.
Quantity in Commerce 2270
Distribution Worldwide Distribution-USA (nationwide) including the states of AL, AZ, AR, CA, CO, CT, DE, FL, GA, IL, IN, IA, KY, LA, ME, MA, MI, MN, MS, MO, MT, NE, NV, NH, NY, NC, ND, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, and WI. and countries of VENEZUELA, UNITED KINGDOM TURKEY, TUNISIA, THAILAND, TAIWAN, SWITZERLAND, SWEDEN, SPAIN, SOUTH AFRICA, SLOVENIA, SLOVAKIA, SINGAPORE, SAUDI ARAIA, RUSSIAN FEDERATION, ROMANIA, REPUBLIC OF KOREA, QATAR, PROTUGAL, POLAND, PHILIPPINES, PERU, OMAN, NORWAY, MEXICO, MALAYSIA, LITHUANIA, LEBANON, KOSOVO, KENYA, KAZAKHSTAN, JAPAN, JAMAICA, ITALY, ONDONESIA, INDIA, HUNGRY, HONG KONG, GUATEMALA, GERMANY, FRANCE, FINLAND, EGYPT, DENMARK, CZECH REPUBLIC, CROATIA, COLOMBIA, CHINA, CHILE, CANADA, BULGARIA, BRAZIL, BELGIUM, BAHRAIN, AUSTRIA, and ALGERIA.

Recalling Firm/ Manufacturer	GE Healthcare, LLC 3000 N Grandview Blvd Waukesha, Wisconsin 53188-1615
Reason for Recall	GE Healthcare has recently become aware of a safety issue associated with the Probe of your LOGIC P6 system that may impact patient safety. *GE Logic P6 probe head has a possibility to cause burn injuries to patients or operators.*
Action	GE Healthcare sent an "URGENT MEDICAL DEVICE CORRECTION" letter dated December 23, 2011 to all affected customers. The letter identifies the product, problem, and actions to be taken by the customers. The letter instructs customers to discontinue use of the affected product. Contact the GE Support Center at 1-800-321-7937 or your local GE Healthcare service representative for questions regarding this issue.
Quantity in Commerce	2270
Distribution	Worldwide Distribution-USA (nationwide) including the states of AL, AZ, AR, CA, CO, CT, DE, FL, GA, IL, IN, IA, KY, LA, ME, MA, MI, MN, MS, MO, MT, NE, NV, NH, NY, NC, ND, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, and WI. and countries of VENEZUELA, UNITED KINGDOM TURKEY, TUNISIA, THAILAND, TAIWAN, SWITZERLAND, SWEDEN, SPAIN, SOUTH AFRICA, SLOVENIA, SLOVAKIA, SINGAPORE, SAUDI ARAIA, RUSSIAN FEDERATION, ROMANIA, REPUBLIC OF KOREA, QATAR, PROTUGAL, POLAND, PHILIPPINES, PERU, OMAN, NORWAY, MEXICO, MALAYSIA, LITHUANIA, LEBANON, KOSOVO, KENYA, KAZAKHSTAN, JAPAN, JAMAICA, ITALY, ONDONESIA, INDIA, HUNGRY, HONG KONG, GUATEMALA, GERMANY, FRANCE, FINLAND, EGYPT, DENMARK, CZECH REPUBLIC, CROATIA, COLOMBIA, CHINA, CHILE, CANADA, BULGARIA, BRAZIL, BELGIUM, BAHRAIN, AUSTRIA, and ALGERIA.

Whoops. So let me get this straight. The probe which might be used to scan breasts, testes, and other important parts might burn them? Ouch! I'm keeping my small parts away from this particular device for the foreseeable future. Check your serial number against the table published on the FDA page.

I suppose users could double-charge for thermography as well as sonongraphy...

Hat-tip to Dasmah of the Kuwait PACS Club.

Dalai Meets The Next President

2012-01-15T17:53:00.001-05:00

Mitt and Ann Romney
Charleston, SC 1/14/2012

Sometimes it's good to be in the right place at the right time, especially when you live in the state that boasts the First in the South Presidential Primary.

Mrs. Dalai, Dalai, Jr., and I were in Charleston for the wedding of a friend's niece, and had the day to wander around. It was a bit chilly, but we took a leisurely stroll through the revamped Market (slaves were never sold there, by the way) and had some rather good seafood for lunch.

As we approached the Charleston Place Hotel, we noticed the Romney-Bus parked outside, with a small crowd gathering, and we proceeded over to check it out. Yes, Governor Romney himself was to appear momentarily, and, indeed, after waiting only briefly, he and his wife walked around the corner. The Governor shook the hands of the twenty or so of us standing on the sidewalk. He got to Junior first, and then to me. He looked me in the eye, and shook my hand quite firmly. I nodded my head gently, greeting him as "Governor." Romney paused a bit, as if to give me a chance to say something else, perhaps something more intelligent. Now here's where you will all think I've lost it, and you may well be right. In that pause, in that hesitation, I sensed...humility. I can't totally tell you why, but I did. In my old age, I've learned to rely on my instincts, and they don't lead me wrong too often. Well, usually they don't.

Here is a very wealthy and powerful man, quite likely to be the Republican nominee, and then, God-willing, to be the President of the United States, displacing the accident of fate we have now. Do I think Mr. Romney is perfect? Heavens, no. He has a lot of baggage, just like every other candidate, and most of the rest of us, for that matter. But the man has presence, he has charisma, he has charm, and he does have the air of confidence. But my instinct, my gut-feeling, my sixth-sense, tells me that these characteristics are tempered by humanity, humility if you will. I didn't have the chance to meet any of the other fellows on the trail, so I can't put them through the same test. I'm not sure they would pass.

I can't expect any of you out there to feel what I felt, or to trust my intuition. Frankly, it's pretty much a moot point, as Mr. Romney is expected to win his third victory here in South Carolina, and with that set the tone for the rest of the primary season. Beyond that, I can only hope he learned his lessons about Romney-Care, and will do a little better spinning the Bain story. On various other issues, he says mostly the right things.

They say one casts a vote either for the candidate one likes, or against the fellow one doesn't. Come November, perhaps we'll be able to do both.

Decisions, Decisions...

2012-01-11T16:41:00.002-05:00

Dear Vendors:

Yes, we've narrowed it down. No, I'm not going to tell you how just yet.

And while its always nice to see you folks, coming by to chat isn't going to have any effect on anything.

Sincerely,

Dalai

Speech Recognition Doesn't Even Work In Editor Mode!!

2012-01-10T09:16:00.001-05:00

Image Courtesy TMONews.com

It seems I was part of an experiment and didn't completely realize it.

One of our in-house transcriptionists as been using speech-recognition in what I call "editor mode". In other words, my dictation is run through an SR engine (I don't know which one) to provide the first draft of the report. She then edits it while listening to the dictation, and places the final report on the RIS for my review. This should give us the best of both worlds, the speed of SR and the accuracy of a human.

Except it doesn't work.

The particular transcriptionist is really superb at what she does, and before this little experiment, her reports rarely had any mistakes at all. But throw in SR, and all bets are off. Almost every report produced in this manner had at least two or three mistakes. And these were NOT typos, making them much harder to spot. For example, I dictated something about activity in a stump of an amputee. The SR translated "stump" as "stomach" and this made it by the editor and would have made it by me if I hadn't remembered the case itself. I can cite dozens and dozens of other, similar glitches.

I asked that SR be turned off for this week as an experiment, and wouldn't you know it? Absolutely NO mistakes on our reports. None. Zero. Nada.

Once again, I'll yell it from the hills and the valleys: Speech Recognition is NOT READY FOR PRIMETIME! Period. Maybe in five years.

Even Siri agrees with me on this, although she knows I'll turn her off if she doesn't.

How Much Is An EMR?

2012-01-06T09:55:00.001-05:00

MediNote EMR, courtesy Carson Doctors Group

I have to take a moment away from the compilation of the Advanced Visualization results to whine about something else: EMR's.

One of our hospitals is plunging headlong into the EMR quagmire, and I am on the EMR/EHR/EFR Committee (specifically the CPOE Committee) as a representative from radiology and things technical. You would think it a daunting task to upgrade a full hospital system to electronic status, and you would be correct. Fortunately, the IT types and physicians involved are very capable, and really interested in doing a good job, and I have been quite impressed with their efforts to date.

HOWEVER, we have a tremendous stumbling-block, and it relates to the software already in place. While not going into chapter and version (and not naming names, as I think I might have signed something that said I would keep my big mouth shut), years ago, a really bad decision was made to go forward with the version of HIS/RIS (what we used to call EMR/EHR/EFR) that was little more than a port of an old Data General green-screen terminal. In other words, we are stuck with 10-year-old technology emulating 20-year-old technology. It sucks. Period. And we now are charged with making a square CPOE peg, among others, fit in a rather ancient round hole.

You would think that in the process of upgrading, we might simply forklift out the old green-screens and buy something new. Apparently, this won't work. It seems that our small hospital system was told that it would cost $30 MILLION to replace the whole shebang. $30 MILLION. Yes, that would be MILLION with an M. Now, I'm not sure just who set that price, but it was accepted as gospel, and a heck of a lot of work is now predicated on the premise that we must update but not upgrade. Bah Humbug!

I need to poll the audience. Does it REALLY cost $30 MILLION to replace an EMR for a relatively small hospital system? We're talking 300 beds or so, not the Mayo or Man's Best Hospital. Really? Seriously? $30 MILLION!!???

If this is truly the case, somebody out there (I'm thinking Merge Healthcare has the wherewithal to do so) needs to reinvent this genre. I cannot believe that EMR/EHR/EFR's have to be this expensive, not to mention requiring a two to three year implementation period. It just doesn't make sense to me, and I insist there has to be a better way to do this. Right now, I think the software companies are frankly just fleecing their customers in their frenzy to comply with all the Meaningless Use crap from Washington. Please do feel free to prove me wrong.

$30 MILLION? I'm not buying it. Literally or figuratively.

The Advanced Visualization Caucus

2012-01-04T21:48:00.000-05:00

"Glass View" on IntelliSpace, Courtesy of Philips.

(Note...this is NOT an endorsement of any particular product!!!)

The First (and probably Last) Annual Advanced Visualization Shoot-Out (a.k.a. Dalai's Advanced Visualization Caucus, Mini-RSNA) went off with only a few hitches, which I'll outline in a moment.

The vendors all arrived early this morning, and set up their wares in our hospital auditorium. The digs weren't all that fancy, but the cavernous room was nice and warm on an unusually cold day down here in the Deep South. Everyone found a corner with adequate electrical outlets, and within an hour, we had a Technical Exhibit Hall that rivaled some I've seen at relatively large meetings. OK, it wasn't quite RSNA, but this ain't Chicago, and thank God for that!

Pat, the PACS Goddess!

Before I go any further, I must express profuse thanks to Pat, our PACS Goddess. She juggled three dozen variables, kept vendors, docs, and administrators on time and on schedule, and just generally made this thing happen. I'll admit that I came up with the general idea and some of the specifics (mostly stolen from the Stanford PET/CT shoot-out), but Pat deserves the lion's (sorry, Tiger's!) share of the credit for her hard work that brought us all together. And I am extremely grateful to the vendors themselves who came down for this little shindig at no small expense. As proof of their attendance, here are non-Photoshopped images of each vendor team. Note to Corporate: they all actually did show up here to South Carolina, so please pay their expenses. Trust me, NO ONE would visit this particular spot if they didn't have a good reason! Here they are, in no particular order:

Team Siemens

Team Vital

Team Tera

Team Philips

Team GE

A-Team

Team Techs

The last photo, of course, depicts two of our superb CT techs, who will actually have to use whatever we purchase. And I pity the fool who doesn't take their opinions into account. Needless to say, I will!

And that is really the bottom line. This is a decision that affects the way our techs and rads will operate, and so we have to pick the solution that is right for our particular shop. We are quite fortunate in that regard: each of the five contenders would do the job for us, and do it well. The key is to drill down to the one that will work best...for all of us.

Gathering five major companies in a room together is a monumental feat. One vendor suggested that their willingness to do so was related in some way to...me! It seems that the majority of the attendees are devotees of my blog (one poor fellow even used the word "star-struck" which indicates that he needs to get out more) and thus wanted the chance to participate in this event. I'm honored and humbled, and glad that my reputation (good, bad, or otherwise) contributed to the chance to make a good decision for my hospital.

I suppose you want to know which product won the competition, yes? Sorry...for that, you will have to wait. Pat the PACS Goddess and I will have to compile the questionnaires (and quiz those who didn't bother to fill one out) to see which system will take its place in our place. All of these systems actually work well; each does some things better than others, and better than the rest.

Each of our participants watched the various programs put through their paces. We had intended to see only our own data run through the processing protocols, but not all of our cases exported properly to disk, which is our own fault and not that of the vendors. Frankly, I wish we had had a week or two more to set this up, but the auditorium was available TODAY, and not again for months, so it was now or never. We were able to view a mixture of our own cases and those from the vendors' stashes, and I think it all turned out well in the end.

I'm not going to go into minute detail about every facet of every system. The post would grow to epic proportions, and you would be bored silly by the end of it. Here are some rather vague tidbits:

The program I initially thought would be best...wasn't.
The program I initially thought would be worst...wasn't.
The level of automation is quite high with all five.
The more raw horsepower, the more complex the interface.
Several pieces of software are not yet approved (remember, RSNA=Real Software Not Available).
There are several ways to display transparent/translucent bones.
No one would give me one of the ubiquitous iPad's.
There are vendor-specific iPhone/iPad apps that the vendors don't know about.
Everyone was anxious to know who won and when the P.O. would be cut, although some were more anxious than others.

So, without further ado, my personal favorite was:...........,,,mjkhgyuftdseaweqTWAYESURIDTOF

Note from Mrs. Dalai: Hi, everyone. I found Dr. Dalai fast asleep with his head on the keyboard. You must have worn him out today! I'm sure he'll come back and tell you who won, eventually. In the meantime, I'm putting him to bed without his dinner.

Help Dr. Dalai Quiz Advanced Visualization Vendors!

2011-12-27T10:23:00.003-05:00

I'm hoping my loyal and wise readers can give me a hand. As you know, we are set to have a "shoot out" between several Advanced Visualization vendors next Wednesday. The list as it stands includes GE, Philips, TeraRecon, Siemens, and Vital Images, narrowed mostly by our initial look at CT scanners.

This is a big decision with lots of money involved, and we want to do it right. Therefore, I'm turning to my friends out there for advice. Here are the basic questions we are asking the vendors. PLEASE let me know if we've left something out...

Please provide a brief overview of your system. A drawing would be great.
What is your licensing scheme for both thin and thick clients?
Are there two tiers of functionality? Please elaborate on which functions are included for each level. In particular, do you offer on thick and/or thin client:
Coronary/cardiac evaluation
Stent planning
Brain perfusion
PET/CT with automatic registration and propagation of lesion ROI’s from prior to new study
SPECT/CT processing
Fusion of any two modalities
Creation of report-quality AVI’s
Transparent/translucent bone rendering
Vessel seeding/growing
Is any special hardware required for the thick client?
How many servers are required for full functionality? Is there a user or a slice limit per server? Please outline or provide a table to illustrate.
Does the thin client require any additional software to be installed, i.e. Java, .NET, etc. If so, what version?
Will the thin client work on a MacOSX, iOS, Android? Does either thin or thick client function well in a Citrix environment, the latter utilized on desktop machine or mobile device with iOS or Android?
How does the user login to either product? Does the system have its own user database or can it authenticate to Active Directory?
Has your product been fully integrated with IMPAX 6.5? Please describe the usual workflow we would experience when accessing a study on your system via IMPAX.
How will we handle routing of separate datasets to your system as opposed to PACS? (We will likely want to send full thin-slice images to your server but not to PACS itself.)

Have I forgotten anything? Oh, yes...Happy New Year, everyone!!!!

ADDENDUM

Here are the questions in final form as sent to the various vendors:

Advanced Visualization Demonstration Questions
General
Please provide a brief overview of your system. A drawing would be great. Handouts are appreciated.
How many servers are required for full functionality? Is there a user or a slice limit per server?
Please outline or provide a table to illustrate.
What is your licensing scheme for both thick and thin Clients?
Are there 2 Tiers of functionality, as in Thin and Thick Client? Please elaborate on the functionality available for each Tier.
Will both clients function well in a Citrix environment?
What is the client to server ratio for each type of Client?
Does the thick client require any special hardware?
How does the user login to either product?
Does the system have its own user database or can it authenticate to Active Directory?
What type of auditing functionality does it have?
Has your product been fully integrated with AGFA’s IMPAX 6.5? Please describe the usual workflow we would experience when accessing a study on your system via IMPAX. (Any images created on your system would be stored on IMPAX.)
How will we handle routing of separate datasets to your system as opposed to IMPAX? We will likely want to send full thin-slice images to your server but not to IMPAX.
Thin Client
How do you access the thin client?
Is it URL based?
Is it dependant on a specific browser or require any additional software to be installed, i.e. Java, .NET, etc? If so what version?
Will the thin client work on a MacOSX, iOS, or Android?
How many concurrent users can it support?
In situations with low bandwidth (outside the Hospitals) how does the thin client perform?
What happens if the connection between server and client times out?

Hopefully we haven't missed much.

My primary goal is to see how these various systems will perform in a pseudo-production environment. I do realize that some of the demonstrations will be hobbled by the restraints WE have placed on the vendors. We are asking them to use data from OUR scanners (which include both GE and Siemens), and we have NOT given the cases to them in advance. Some vendors noted that their automation depends on "learning" the scanners from their DICOM headers, and I almost caved on this issue, but ultimately decided to keep the playing field completely level, for better or worse.

Staging this sort of comparison is quite interesting, and the emotions and actions inspired can be amusing as well. One vendor wanted to place servers in our data center as a long-term demo. Another, as above, wanted the data in advance to train its automation on our particulars. Several requested connections to IMPAX for the demo. We said "no" to all of these, although I'm still wondering if we needlessly limited some of the vendors in our efforts to be "fair" to all. We'll see.

Doing my research at RSNA was fun as well. I had the chance to meet several of the CEO's of the companies involved, some after more or less showing up at their carpeted ranches unannounced. (I did not get to GE's mega-booth, which took some maneuvering to avoid, but I'm sure Jeff Immelt had better things to do than talk to me anyway.) All but one vendor seemed quite interested in making sure I saw what I needed to see; the outlier found an apps person who was clearly brilliant, knew the product inside and out, and barely spoke a word of English. Next time, I'll be courteous enough to make an appointment.

In the end, we probably won't go wrong with any of these fine products. I'm just hoping to find the marriage made in I.T. Heaven, although those are probably contradictory terms...

Duh...Importing Outside Studies Into PACS Avoids Repeats

2011-12-26T11:00:00.003-05:00

See the recent Aunt Minnie article with a similar title. Basically, someone did some research and found that if a patient has an outside study on CD, AND it imports successfully, they are less likely to undergo additional imaging.

(Graph courtesy Sodickson, et. al., August 2011 Radiology, 260,408-413.)

Gee whiz, folks, is anyone surprised? We don't have to repeat studies performed an hour ago as long as we can actually see them? Knock me over with a feather.

This is such an obvious observation that I'm really surprised at Radiology for publishing it, although I guess one has to prove everything in this day and age. The AuntMinnie article cites a talk at RSNA by Michael Lu yielding similar observations about hepatocellular cancer patients.

My thought is, of course, to avoid even the CD, and have direct transmission of the prior exam into the system where the patient now resides. lifeIMAGE, for example, does this very well. In my humble opinion, there is no longer any need for the fragile and fickle CD-ROM's. The only impediment to switching away is politics, which will be overcome sooner or later. Why not get on the bandwagon now? This is such a no-brainer, it isn't even funny.

Hat tip to The Once and Former PACSMan.

Chicago Sun-Times To Be Sold...To Consortium Including Merge/Merrick's Ferro

2011-12-21T10:46:00.001-05:00

Yesterday's Chicago Sun-Times reports that the venerable paper is to be sold to a consortium of investors including Michael Ferro, of Merge Healthcare and Merrick Ventures fame:

The sale of Chicago's No. 2 newspaper is imminent, sources close to the situation said.

Sun-Times Media is expected to announce Wednesday that it has struck a deal to be bought by a group of local investors led by Michael Ferro, chief executive of Chicago-based Merrick Ventures, a technology holding company. The group also includes John Canning, chairman of Chicago-based private equity firm Madison Dearborn Partners.

The new group plans to name Timothy Knight, the former publisher and CEO of Newsday, which was once controlled by Chicago-based Tribune Co., as CEO of its holding company, sources said.

Existing Sun-Times investors who will remain stakeholders include Chicago Blackhawks owner Rocky Wirtz as well as Mesirow CEO Richard Price.

Talk about branching out! There are some nay-sayers out there, however, who obviously aren't aware of Mr. Ferro's financial accumen:

Many industry observers have scratched their heads over why the new group is plunging into the newspaper business at such a perilous time for the industry and the economy. The Sun-Times emerged from bankruptcy with little debt, and the paper has dramatically reduced costs under Halbreich by, among other things, slashing its workforce and outsourcing its printing operations to Tribune's Freedom Center.

But as is the case for almost every newspaper company, the Sun-Times' revenue has been under pressure for years as advertisers, like readers, gravitate toward the Internet. Tyree's group (In 2009, an investor group led by Mesirow's previous CEO, Jim Tyree, rescued the Sun-Times from bankruptcy for about $25 million. Tyree died earlier this year. The Tyree group paid $5 million in cash for the company and agreed to take on $20 million in liabilities) tried to reverse the trend by emphasizing a digital strategy aimed at making the most of relatively strong Web traffic. But it is too early to tell whether a recent initiative to boost revenue by charging for some online content will pay off.

One longtime industry executive speculated that the risk the new investors are taking may be mitigated by the acquisition price. That has yet to be disclosed but will likely reflect the fact that the Sun-Times remains a work in progress in an industry under siege, the executive said.

Rescuing the Sun-Times might be harder than rescuing Merge, given the fact that print newspapers are going the way of the buggy-whip and corded telephones. Merge was purchased for pennies (?dimes?) on the dollar, and rapidly turned toward success. Look for some unusual paradigm changes that will turn the Times around in a way none of us would expect. Like maybe an iPhone/iPad app that checks your pulse as you read the e-newspaper and adjusts content accordingly. Who knows?

I'd like to be the first to apply for special PACS correspondant for the Sun-Times. There might be better writers on staff, but none who can write from the heart like yours truly..

Mar-Mar, Misses, and Madness

2011-12-18T18:51:00.000-05:00

Not long before RSNA, we lost Marion, my mother-in-law, affectionately known as "Mar-Mar". Her health had been deteriorating for a while, and then she fell, compressed a couple of vertebrae, and spiraled down quite rapidly. Fortunately, she had left instructions to avoid all heroic measures, and she died peacefully with Mrs. Dalai and I and her long-term care nurse by her side. I hope to go in the same manner, although not for quite a while.

In the course of working up her fractures, it was discovered that she had a mass, which turned out to be malignant. I asked her physician to review her images with us prior to biopsy, and there was indeed a truly ugly lesion. The hospital used a PACS that shows thumbnails, and we could easily see a very tiny image from a study performed last year. And that thumbnail quite clearly showed the very same lesion, although somewhat smaller. Mar-Mar's cancer had been missed, and allowed to progress for at least 10 months.

In her particular case, this was a blessing. Rather than prolong her dying with futile and probably painful therapy, the miss prolonged her living. She had 10 months of having lunch with the ladies, playing cards, and generally doing what she wanted to do. We have no regrets, and no anger toward those who made the error.

That last one is the most important item for today's discussion. Anger plays a huge part in the deterioration of our society, in general, and in the medical malpractice game in particular. Let me diverge a moment to tell you about something that happened to me a few days ago. Bear with me and the relationship will become clear.

I was at the neighborhood strip mall, having mailed a package at the Post Office branch. I started to pull out of the parking place with my lumbering, gas-guzzling SUV, when to my shock, I saw a beat-up little red sedan cruise right behind me. I slammed on my brakes, fortunately in time, and avoided the otherwise inevitable accident. I suppose it would have been my fault had I hit, but I had looked both ways, and I've got to assume the driver sped up as I started out of my parking spot. But that isn't the important detail. The driver, a girl in her 20's wearing a black chef's tunic, stopped about 20 feet from me, got out of her car, and started shaking her fist and yelling, while a young bearded male in the passenger seat sat and watched the show. I waved gently, as if to say, "yeah, I know, but we're all OK." She kept it up, so I drove off the other way. She followed me for a mile or so, then got tired of it and went on her way.

What does this have to do with misses and malpractice? I've got enough friends who happen to be litigators to know that two things drive a malpractice suit: anger and greed/envy, and they go hand-in-hand. (And as an aside, the majority of cases appear to reach the attention of a lawyer because ANOTHER DOCTOR told the patient that something wasn't done as well as HE would have done it.) As with the young lady driving the beat-up car, an accident or even an incident that approaches such is enough to promote rage in some of us, perhaps even most of us. It doesn't matter that the act was unintentional. I did not set out yesterday to trash some kid's little red jalopy. I think it's also reasonable to say that no physician decides some morning to cause harm to his patient. A missed finding, like a parking-lot collision, is an accident. It is not meant to happen, and everyone would prefer that it doesn't. This is where greed and envy can augment the madness of rage. The young lady above, at some level, realized that my truck was likely worth 8-10 times what her beater might bring, and no doubt this got her all the more riled. Why should that doofus have a nice car? Who gave him the right to almost plow into me? He must think he owns the road, having an expensive car like that. I'll show him!

In the case of a miss or other adventure in medical errors, I think the same thing applies, although certainly with a little more justification. There is clearly a relationship between doctor and patient. If something goes wrong, the patient feels betrayed And the patient gets angry. Given the perception of docs as wealthy, the next step in the mental equation may become: he hurt me (or could have hurt me) and he's going to pay! He can afford it!

While a financial award could put a car back together again, it may not be able to fix what was broken by the medical error. Somewhere along the way, our society has decided that money can compensate for the damage, and maybe that is true. However, juries of our "peers" are wont to award huge sums as punitive measure to "punish" the "bad" doctor. And let us not forget the fact that the litigator might receive 30-50% of the proceeds.

This is wrong. The whole scenario is horrible, and accomplishes nothing but padding the pockets of the litigating AND the defending lawyers. It leads to millions and billions of dollars spent for "cover your ass" procedures and tests. And it's all predicated on the anger over an accident and the thought that there might be a gold-mine to be had having won the malpractice lottery. This must stop.

I want this to be Mar-Mar's legacy: we must forgive those who make honest mistakes. We need to remove anger, greed and envy (and lawyers) from the equation, and somehow set up some entity, some body or board, that would determine actual damages and arrange for those to be made as whole as possible, but without multi-million dollar punitive, redistributive, awards . I know this is next to impossible, as there is way too much money to be made by trying "rich" doctors in front of a jury of their "peers" who would love nothing more than to sock it to them. But it is the right thing, and all but those who profit from the malpractice industry, not just the lawyers, but the plaintiff whores who sell their testimony, know that I'm spot on. Mar-Mar would approve.

How The Kvetch Stole Chanukah

2011-12-10T16:50:00.001-05:00

Dalai's Note: I was trying to think of a Christmas theme to pervert for next year's RSNA article. Dalai, Jr. suggested something about the Grinch (or GErinch) stealing RSNA, and in my creative fervor, the phrase, "all the Joos down in Joo-ville" came to mind. I Googled this, and found that someone had beaten me to the punch (line). I present the absolutely hilarious piece by David Goldstein below. (If the terminology is confusing, ask one of your Joo-ish friends. If you don't have any Joo-ish friends, don't bother reading!)

Every Joo
Down in Joo-ville
Liked Chanukah as such…

But the Kvetch,
Who lived just north of Joo-ville,
… not so much.

The Kvetch hated Chanukah, the whole Chanukah season.
Now don't ask me why. What? Should I know the reason?
It could be he wasn’t a mensch, that is all.
Or his petzel, perhaps, was two sizes too small.
Such meshug’as comes from one thing or another,
But like most Joo-ish boys, we should just blame his mother!

But,
The reason, whatever,
His mom or his putz,
The Kvetch hated Chanukah. Oy, what a yutz!
For he knew every Joo down in Joo-ville tonight
Was busy preparing menorahs to light.

“And they’re giving out gelt!” he sighed as he said
“I need waxy chocolate like holes in my head!”
Then he nervously whined as his fingers tapped horas,
“I MUST stop the Joos from igniting menorahs!”

For,
The Kvetch knew that soon…

… All the Joo girls and boys
Would say the baruch’ha, then unwrap their toys!
And then! Oh, the oys! Oh, the Oys! Oys! Oys! Oys!
If it’s not what they wanted, the OYS! OYS! OYS! OYS!

Then the Joos, young and old, would sit down for a nosh.
And they’d nosh! And they’d nosh!
And they’d NOSH! NOSH! NOSH! NOSH!
They would nosh on Joo-latkes, and Gefilte-Joo-Fish,
Which was surely the Kvetch’s least favorite dish!

And THEN
They’d do something
Which made the Kvetch plotz!
Every Joo down in Joo-ville, Bar Mitzvahed or not,
Would sit down together, their proud ponim’s grinning.
Then dreidels in hand, all the Joos would start spinning!

They’d spin! And they’d spin!
AND they’d SPIN! SPIN! SPIN! SPIN!
And the more the Kvetch thought of this Joo-Dreidel-Spin,
The more the Kvetch thought, “I can’t let this begin!
“Oy, for fifty-three years I’ve put up with it now!
“Chanukah, Schmanukah! Stop it!
… But HOW?”

Then he got an idea!
And the moment he had,
He said
“I’m no Einstein, but this… not half bad!”

“I know just what to do!” Then he donned an old sheet,
And dug up some sandals to wear on his feet.
“I’m the Prophet Elijiah! They’ve set me a plate!”
(For the Kvetch couldn’t keep Joo-ish holidays straight.)
“The Joos ‘ll oblige ol’ Elijiah, no doubt!
“I will simply walk in. Then I’ll clean the place out!”

“All I need is a camel...”
He looked far and near,
But this wasn’t the desert, and camels are dear.
Did that stop the old Kvetch...?
That pischer? No, never:
“If I can’t find a camel,” the Kvetch said, “...whatever.”
So he called his dog, Max. Then he took an old sack
And he tied a hump onto the front of his back.

THEN
He climbed on this
dog-dromedaryish mammal.
You never have seen
Such a schmuck on a camel.

Then the Kvetch cried “Oy vey!”
As old Max started down
Toward the homes, while the Joos
Where still schmoozing in town.

All their driveways were empty. Just SUV tracks.
All the Joos were out last-minute-shopping at Saks,
As he rode to a not-so-small house on old Max.
“It’s a good thing I brought” the old Prophet Kvetch thought,
“All these bags with to stuff all the stuff the Joos bought.”

Then he looked at the chimney. It seemed quite a stretch
That a fat goy like Santa could fit, thought the Kvetch,
“Still, the goyim believe stranger things, that’s for sure.”
Then the Kvetch shrugged his shoulders, and walked through the door
Where the little Joo dreidels were all strewn about.
“These dreidels,” he grinned, “are the first to go out!”

And he schvitzed, as he shlepped, with an odor unpleasant,
Around the whole house, as he took every present!
Barbie dolls! Mountain bikes! Brios! And blocks!
Pokemon! GameBoys! And all of that shlock!
And he stuffed them in bags. Then his arms spread akimbo,
He shlepped all the bags, one by one, out the wimbo!

Then he shlepped to the kitchen. He took every dish.
He took the Joo-latkes. The Gefilte-Joo-Fish.
He cleaned out the Sub-Zero so nimbly and neat,
Careful to separate dairy from meat.
Then he shlepped the Joo-nosh right out the front door-a.
“And NOW!” kvelled the Kvetch, “I will shlep the menorah!”

And he grabbed the menorah, and started to shlep on,
When he heard a whine, like a cat being stepped on.
He spun ‘round with shpilkes, and coming his way,
It was Ruth Levy-Joo, who was two, if a day.

The Kvetch had been caught by this small shaina maidel,
Who’d been watching TV on her big RCA’dle.
“The Prophet Elijiah?” she quizzed the old fool,
“You visit on Pesach, they taught us in shul.”

And although the old Kvetch was surprised and confused,
It’s not hard to lie to a girl in her twos.
“Bubbeleh… sweatheart…” he started his tale,
“Your dad paid full price, when this all was on sale!
“And like any good merchant, I just want to please ya.
“I’ll ring it up right, then I’ll refund your VISA.”

Then he patted her tush. Put a Barney tape in.
And she spaced-out as fast as the spindle could spin.
And as Ruth Levy-Joo watched her mauve dinosaura,
HE went to the door and shlepped out the menorah!

Then the match for the shamas
Was last to be filched!
Then he shlepped himself out to continue his pillage.
On the walls he left nothing at all. Bubkes. Zilch.
And the one speck of food
That he left in the house
Was a matzoh ball even too dense for a mouse.

Then
He did the same schtick
In the other Joos' houses.

Leaving knaidlach
Too dense
For the other Joos' mouses!

It was quarter to dusk…
All the Joos, still at Saks,
All the Joos, still a-shmooze
When he packed up old Max,
Packed him up with their presents! The gelt and the dreidels!
The chotchkes and latkes! The knish and the knaidels!

He hauled it all up to his condo in haste!
(A Grinch might have dumped it, but why go to waste?)
“Shtup you!” to the Joos, the Kvetch loudly cheered,
“They’re finding out Chanukah’s cancelled this year!
“They’re just coming home! I know just what they’ll say!
“They’ll ask their homeowners insurance to pay,
“Then the Joos down in Joo-ville will all cry OY VEY!”

“All those Oys,” kvelled the Kvetch,
“Now THIS I must hear!”
So he paused. And the Kvetch put his hand to his ear.
And he did hear a sound rising up from the shtetl.
It started to grow. Then the Kvetch grew unsettled…

Why the sound wasn’t sad,
It was more like the noise
Of a UPS trucker
Delivering toys!

He stared down at Joo-ville!
And then the Kvetch shook,
As truck after truck
Replaced all that he took!

Every Joo down in Joo-ville, the Golds and the Steins,
Re-ordered their presents by going online!

Chanukah HADN’T been cancelled!
IT CAME!
…On UPS trucks… but it came just the same!

Then the Kvetch, staring down at the gifts where they sat,
Stood kvitching and kvetching: “For this, I did that?
“It came without traffic! It came without tax!
“It came without shopping at Bloomie’s or Saks!”
And he kvetched on and on, til he started to shvitz,
Then the Kvetch thought of something which might make him rich!
“Maybe stores,” thought the Kvetch, “don’t need mortar and bricks.
“Maybe toys can be bought with a few well-placed clicks!”

And what happened then…?
Well… in Joo-ville they say
That the Kvetch raised
Ten million in venture that day!
And the minute his web site was ready to go,
He raised ten billion more on his new IPO!
He sold back the toys to the homes they came from!
And he…

… he the Kvetch…!
Founded YA-JOO.COM!

©2000 by David Goldstein
All rights reserved
[An HA holiday tradition, with apologies to the late, great Dr. Seuss — but not to the greedy, litigious bastards at Dr. Seuss Enterprises, LLC. So there. Happy Christmukah.]

Water On Mars!Government To Level Planetary Playing Field??

2011-12-10T13:32:00.001-05:00

From Fox:

NASA Rover Finds Convincing Evidence of Water on Ancient Mars

A well-traveled NASA Mars rover has found some of the best evidence yet that water flowed on the Red Planet's surface long ago, researchers announced Wed., Dec. 7. The Opportunity rover, which landed on Mars nearly eight years ago, has discovered a thin, bright mineral vein along the rim of a huge crater called Endeavour. This mineral is almost certainly gypsum that was deposited by liquid water billions of years ago, researchers said.

"This is the single most powerful piece of evidence for liquid water at Mars that has been discovered by the Opportunity rover," Steve Squyres of Cornell University, Opportunity's principal investigator, told reporters here today during the 2011 winter meeting of the American Geophysical Union.

I can see the headlines now...

The Obama Administration announced plans for immediate interplanetary water redistribution yesterday. "The water-gap between rich and poor planets is unfair and unsustainable; it must be addressed immediately," according to an unnamed spokesman...

You Might Just Be An Occupier If...

2011-12-04T09:40:00.001-05:00

You just might be an "Occupier"

(from this week's Jewish Press, NY, Dec 2 issue)
By Steven Plaut (from stevenplaut.blogspot.com)

Many of us are scratching our heads, and in some cases other parts of our anatomy, trying to make sense of the "Occupy Wall Street" movement and its sundry clones around the US and now around the world.

Just what do these urchins really want? What do they think and believe?

Well, we thought we would recruit Jeff Foxworthy to try to assist us. Most of you probably are familiar with the great American comedian from the Deep South. He is best known for his comedy shticks based on the refrain, "Then you just might be a redneck." For example, if you have 24 pickup trucks and none of them work, then you just might be a redneck. That sort of thing.

Well, it occurs to us that Jeff Foxworthy could really clean up if he altered his shtick slightly to comment on those "who just might be Wall Street Occupiers."

Here we go:

1. If you dismiss anything you dislike as "neo-liberalism," then you just might be a Wall Street Occupier. Never be tricked into attempting to define that nonsense term.

2. If you refuse to recognize the fact that every idea of Marx's was debunked over 160 years ago, then you just might be a Wall Street Occupier.

3. If you wear Nike shoes, designer jeans, and carry your smart phone to the demonstrations against capitalism, then you just might be a Wall Street Occupier.

4. If you think that REAL communism could really work but it just has never been tried or tested, you just might be a Wall Street Occupier.

5. If you pretend that you have never heard that communism produces starvation and cannibalism, then you just might be a Wall Street Occupier.

6. If you pretend you think the United States controls an empire, even though you cannot think of any colonies it owns, then you just might be a Wall Street Occupier.

7. If you think other people must always be required to relinquish their material things so that you may pursue social justice and feel idealistic and righteous, then you just might be a Wall Street Occupier.

8. If you consider your own property to be sacred, while other people's property should be used for social engineering and doing good, then you just might be a Wall Street Occupier.

9. If you think it is the main purpose of universities to indoctrinate students in leftwing ideology, then you just might be a Wall Street Occupier.

10. If you think shooting terrorists constitutes "war crimes," then you just might be a Wall Street Occupier.

11. If you favor academic departments in which only enlightened leftist opinion may be expressed and where there is no room for non-leftist dissenting opinion to be heard, then you just might be a Wall Street Occupier.

12. If you believe that the only legitimate way for Israel to defend its citizens against terrorism is to capitulate to the demands of the terrorists, then you just might be a Wall Street Occupier.

13. If you believe that eating meat is murder, while partial birth abortion is not, then you just might be a Wall Street Occupier.

14. If you use the term Islamophobia often, but never use the term Islamofascism, then you just might be a Wall Street Occupier.

15. If you believe that everything wrong with the world is because of the United States, and that anything left over that is wrong with the world is the fault of the Jews, then you just might be a Wall Street Occupier.

16. If you think there is nothing useful to be learned from the fact that Cuba used to be the richest country in Latin America and today is the poorest country in Latin America, then you just might be a Wall Street Occupier.

17. If you are not aware of the fact that Cubans steal boats to sneak into the US but no low-income Americans steal boats to sneak into Cuba, then you just might be a Wall Street Occupier.

18. If you think there is nothing we can learn from comparing the histories of East Germany with West Germany before the unification, or North Korean with South Korea, then you just might be a Wall Street Occupier.

19. If you think that all arguments may be settled by telling a non-leftist that he reminds you of Rush Limbaugh or Glenn Beck, then you just might be a Wall Street Occupier.

20. If you claim that the fact that are proportionately more blacks in prison than whites proves that the courts and police are racist, but the fact that there are many more males in prison than females is because males commit more crimes, then you just might be a Wall Street Occupier.

21. If you support proposals that make real problems of the world worse, just as long as advocating them makes you feel caring and righteous, then you just might be a Wall Street Occupier..

22. If you think Israel is an apartheid regime, then you just might be a Wall Street Occupier.

23. If you prefer that poor people in the Third World starve rather than that they should embrace capitalism and live like you do, then you just might be a Wall Street Occupier.

24. If you believe that acts of violence against Jews or Americans are never terrorism but rather resistance, then you just might be a Wall Street Occupier.

25. If you think the US itself caused the 9-11 attacks on itself because of American insensitivity and racism, then you just might be a Wall Street Occupier.

26. If you believe that terrorism is caused by poverty, then you just might be a Wall Street Occupier.

27. If you believe that SUVs threaten life on earth, and - more generally - that the planet is in imminent danger of destruction unless everyone does what you want them to do, then you just might be a Wall Street Occupier.

28. If you assert passionately that Marxists care about people, while Conservatives hate all people and small animals and are not as smart as leftists, then you just might be a Wall Street Occupier.

29. If you believe that, if one country is rich and another poor, it must be because the rich one stole wealth away from the poor one, then you just might be a Wall Street Occupier.

30. If you demand social justice but have no idea how to define what it means or explain how to achieve it, then you just might be a Wall
Street Occupier.

31. If you do not think you need to get a job first before you become a leader of the working class, then you just might be a Wall Street Occupier.

I couldn't have said it better myself!

Farewell To Chicago and RSNA 2011

2011-12-02T22:48:00.001-05:00

Even though it's a bit chilly down here in the Deep South, it is still considerably warmer than Chicago, and it's good to be back home.

My major concentration this trip was on Advanced Visualization, in preparation for our Shoot Out coming in January. I looked closely at the four major vendors involved. I got to meet the CEO's of three of the companies, and had prolonged demos at the same three. One company has invited me to its headquarters, which I must decline while we are in the midst of the decision process. I'm sure I'll still be welcome even if we chose one of the "other guys"...

On other topics...I was really amazed at the number of people who recognized me and/or admitted to being regular readers of this blog. I know I disappointed several of you by not making it back to your booths, and for that I apologize profusely. Contact me earlier next year, and I'll try to do better.

Finally, you may have heard by now that my good friend Mike Cannavo, still the One and Only PACSMan, has gone corporate. He now works for one of the large PACS companies (no, not that larGE company) and has had to hang up his pen. Mike wrote the annual RSNA wrap-up column for AuntMinnie.com for many years. Now that he has retired, so to speak, I have been offered the chance to take over this prestigious piece. Rather than try to duplicate Mike's inimitable approach, I decided to go quite far afield with a piece of fiction and parody. So, without further ado, please enjoy my first (and possibly last) AuntMinnie RSNA column:

An RSNA 'Christmas Carol'

December 1, 2011 -- For years, the PACSman Awards were an annual tradition inAuntMinnie.com's coverage of the RSNA conference. With the PACSman hanging up his typewriter last year, the baton has now passed to the Dalai Lama of PACS, radiologist and blogger Dr. Sam Friedman, who shares his unique RSNA experience.

CHICAGO - The PACSman was gone, and radiology wasn't looking too good either, no doubt about it. The somber, funereal atmosphere in McCormick Place at the RSNA conference was pervasive, even palpable.

Radiologists wandered the halls, heads bowed, hoping to learn something that might make them a better hospitalist, or pathologist, or whatever the Affordable Care Act might actually support. But there were still some bright spots here and there. A new scanner, a novel technique. A shred of hope for some disruptive technology.

I entered the Technical Exhibit Hall, hoping more for some free candy to quiet my rumbling stomach than any particular revelation. I was immediately swarmed by salesmen in ill-fitting Men's Wearhouse suits.

"A happy RSNA to you, Dalai, would you be so kind as to have a look at our wares?"

"Bah, humbug!" I replied, looking for something to scrounge, or even some swag to take back to my family -- a key chain, a little flashlight, anything to justify my trip to this drab, cold place.

"But Dalai, this is the most incredible of all radiology meetings!" they said. "Surely you have found something amazing here!"
I shook my head and kept walking. There was nothing wonderful here. Why did I choose imaging anyway? Because I loved the field? Ah, the foolishness of youth.

Finding no solace, I turned on my heel and returned along the Grand Concourse to the North Building. In a small basement classroom, I found the session I was seeking, an uplifting little talk titled "Tales of Alleged Radiology Fraud and Abuse."

I settled into the chair and pulled out my iPhone, hoping to find a pleasant email from home. Instead, there were three angry emails from my PACS administrators, all expressing escalating desire to serve up my partners as Christmas dinner for the local wildlife.

As the speaker droned on about the loopholes in Stark II, I found myself becoming drowsy, and to my embarrassment, my head nodded, my chin hit my chest, and I shuddered, startled back awake once again ...

But ... something was wrong, very wrong. I looked about. The harsh lines of the plain McCormick Place classroom were gone. Rather, as I looked around, the room was plush and even gilded. The chairs were comfortable. A man with a bushy mustache at the podium was wearing a suit with narrow lapels and an even narrower tie, and he was speaking about the "revolutionary EMI Mark I." There was a heavily pixelated image on the screen that seemed to be a brain, but it was not very well defined. I blinked. On the podium, emblazoned in gold, was the inscription "the Palmer House Hotel."

Wait! The Palmer House? EMI Mark I? How was this possible? The Mark I was introduced at the RSNA annual meeting in ... 1972! Could it be?

"You bet your ass, goombah!"

I turned to the source of the booming voice next to me.

"PACSman!" I cried out in surprise. "How did you get here? How did I get here?"

It was then I noticed that while he was there beside me, he wasn't quite all there; I could see through him to the gentleman seated two chairs away. He was bound in Cat-5e cable, with broken hard drives lashed to his feet. Strangely, no heads turned in annoyance over our conversation.
"Dalai, buddy, you ate some bad shrimp last night," the PACSman continued. "I told you not to go to any parties put on by the big companies, but does anyone ever listen to me? Oh well, it's nothing but a thing anyway."

"But PACSman, I thought you were gone!" I exclaimed. "Why are we at an RSNA from 40 years ago?"

"One thing at a time, bubbie," he said. "Yes, I've departed your world for one I think will be better. Live and learn, or maybe die and learn, heh? As for the why, look up, friend. You've been brought here to RSNA Past so you can remember the joy and love you once had for medical imaging. Can't you feel the electricity in the air? This was the day when CT became king! Cross-sectional imaging, baby! It all started here!"

Indeed, I could feel the excitement creeping up on me. It was none other than Dr. Sir Godfrey Hounsfield himself speaking to the enraptured crowd at the Palmer House ballroom. What I wouldn't give to have been there -- I mean here -- I mean, whatever.

I listened for a few more moments, but again, my head started to nod, and once more I awoke with a start. I was back in the modern McCormick Place, but instead of re-emerging in the small classroom, I was seated in the cavernous Arie Crown Theater, front row and center. And the gaseous apparition of my friend the PACSman was seated next to me. Clearly, my strange journey wasn't over.

"Hey, Dalai! Pay attention," he admonished. "The president of the American Medical Association is schooling you guys about how much trouble you're in. Something about triple jeopardy and not getting paid. Sounds like a triple whammy to me."

And he was right about that. I couldn't take any more of this. I got up and walked out, magically disturbing no one, the PACSman trailing behind, broken hard drives clanking at his feet.

We wound our way over the bridge to the Grand Concourse, then wandered aimlessly to the Technical Exhibit Hall in the South Building. Before long, we encountered a booth that easily covered the area of a football field. There were hundreds of black-suited, brown-badged gents milling about, looking for anyone wearing the coveted blue-rimmed name tag. I had one on, of course, but I was now accustomed to my invisible status, and I expected to remain unaccosted. The shiny new scanners, lights blinking, spun their tubes in futile pursuit of customers.

"PACSman, what are we to see here?" I asked.

"Isn't it obvious?" he asked. "Here's the deal. No one knows where healthcare is going, so we're all going to start enjoying Thanksgiving again for the first time in 75 years. Instead of freezing our asses off, we'll do an interactive virtual conference with scheduled demos and everything. No muss, no fuss, and no 'free' meals. As a bonus, system prices will drop 30% because vendors won't have to pay for RSNA. It's sheer brilliance, I tell ya!"

I sat down on a PET/CT gantry and bowed my head. The room spun, and when I looked up again, we were seated on a bench beside Lake Michigan. It was a blustery day, with winds one only sees in Chicago in the winter. Strangely, I felt no chill, as I watched leaves blowing through the PACSman's shadowy figure.

I looked behind me and gasped. The once-stately Lakeside Center was in ruins, shattered black pillars and glass everywhere.

"PACSman! What happened here?"

"Oy, Dalai, you need to lay off the Kung Pao, OK? Welcome to RSNA 2045," he said. "Or, well, it would have been if there still was an RSNA. Which there isn't."

"But why?"

"What did you expect?" he said. "Between the UnAffordable Care Act, the doctors' 'fix' that fixed you guys good, and all of your good friends, the clinicians, you radiologists didn't stand a chance."

"But who reads imaging studies now?" I asked.

"Geez, Dalai, why do you even care? OK, OK," he said. "You've come this far. Look, imaging reached the point where it didn't pay squat, right? So no one wanted to do it anymore. Even physicians' assistants and nurse practitioners wouldn't touch it. Imaging got so cheap that people got their scans at Walmart and everybody's data were stored in the cloud or on some vulture -- I mean, vendor-neutral -- archive. Got that? So many images were crammed into all these interconnecting networks that ... badda bing, badda boom, they grew self-aware. So, the damn computers are doing the diagnosing themselves. Whaddya think of that? End of the line for radiology."

"No, PACSman!" I exclaimed. "It cannot be! This is an honorable profession, and it cannot end this way!"

I sat back down on the bench, staring at the frigid breakers on Lake Michigan, the wind whipping through my spectral presence by the ruins. I slowly drifted off to the crashing of the waves.

"Dammit, Dalai, watch what you're doing!"

I looked up quickly. The PACSman was standing next to me, very much alive and quite solid, nursing his foot, which I had apparently stepped upon in my delirium. We were in the Technical Exhibit Hall once more. Again, something was different. The booths were lit more brightly than ever before, the scanners positively glowed, and the salesmen were all grinning and patting each other on the back. The customers with blue badges were smiling too, several making excited cellphone calls, clearly happy with a deal they had just made.

"What ... what's going on?" I mumbled, totally disoriented by this, the final shift back to reality. But it was a different, better reality than the one I had left but a moment ago.

"Gawd, Dalai, you really need a cup of coffee or something," PACSman said. "They just announced record sales for this RSNA. All the big boys have sold more scanners in the past three days than they had in the past five years! It's a damn miracle!"

"Yes, PACSman, yes!" I exclaimed. "It had to happen! So many of us love radiology. What a relief! How were we rescued?"

"Probably something to do with that first Tuesday in November, goombah," he said. "Hey, I'd like to stand around and shoot the breeze, but I have to get back to my new home away from home. I'm in a good place now ... good company, good people, good product, and all that jazz."

As he walked away, he turned, smiled at me, and said, "Hey Dalai, guess who gets the Flashdance Award?"

I laughed, thankful that some things never change ...

I ambled my way to the glass portal of the Grand Concourse. The sun was shining brightly, and the traffic cops had shed their slickers in the warm afternoon.

I went outside and walked down by the Hyatt for a ways, then looked back at the sparkling edifice of McCormick Place. I couldn't help but notice the huge banner: "Welcome to RSNA, 2012."

In addition to regular posts in the AuntMinnie.com PACS Digital Community Forums, Dr. Friedman also maintains a blog at www.doctordalai.com. His observations and opinions are entirely his own.

I guess I should probably keep my day job....

Vital: Denoising Is NOT Dose Reduction

2011-11-30T20:49:00.001-05:00

After my visit to Kang and HealthFortis, which, by the way is associated with lifeIMAGE, I had the chance to wander over to Vital Images, and discuss our upcoming Shoot Out for Advanced Imaging. I must have been in the company of the right people (hear that, John?) as before I knew it, I was introduced to the CEO and to the EVP of Sales. After the pleasantries, I had the chance to really look hard at some of the things I needed to see, and had a really informative chat with our intrepid (and beleaguered, mostly by me) salesman and technical folks. I left knowing much more that I started with, but I'm going to leave the feature-list for the report of the Shoot Out itself.

One thing I do want to publish right now, though, is some information about denoising. Vital has a really nice denoising subroutine, which will take a noisy scan and smooth it out. Vital made it clear to me, however, and said that absolutely I have their permission to broadcast to the world, that this is NOT dose-reduction software. All it does is make an image that is degraded for whatever reason (NOT to include deliberately degraded) look prettier. No guarantees on whether data is lost, although almost certainly there won't be much lost at all, but users are urged to toggle back and forth between the pretty and the not-so-pretty pictures.

Where the idea of using denoising for dose-reduction came from, I'm not sure. I don't believe Vital ever promised this at all. I think in retrospect we must have found it perusing information from Clarity which DOES promise that one can lower the parameters to levels that produce ~~crappy~~ dose-reduced scans and then "rescue" them with their box, which performs digital filtering on the images:

Clarity is server-based and seamlessly integrates into your existing DICOM network. During installation of the Clarity solution, dose-optimized protocols are established on the CT scanner(s) to deliver desired image quality at reduced dose levels. Low dose images are transferred from the CT scanner to a Clarity server that resides on your DICOM network. Based on desired results that have been pre-determined by your Radiology staff, Clarity algorithms enhance image quality and automatically route the final images to their intended destinations.

I'm not buying it. In either sense of the term.

Much obliged to the good folks at Vital.

CPOE So Easy A Caveman Surgeon Could Use It!

2011-11-30T19:57:00.000-05:00

Whilst cavorting with old friends at lifeIMAGE (see the previous post), I had the chance to connect with another old friend, Kang, formerly one of the technical gurus of AMICAS, now CEO of his own little company, HealthFortis. (He's working with another AMICAS alum, Dmitry, whom I sadly didn't get to see this trip.)

Kang, having created some wonderful stuff AMICAS over the years, needed a new challenge, and he picked a big one: CPOE, aka Computerized Physician Order Entry. (Some say "Provider" instead of Physician, which clearly tells us physicians that we are no longer held in particularly high regard, but whatever.) CPOE is clearly a tough nut to crack, as one must create software that physicians (even surgeons and, yes, even orthopedic surgeons) will have to use to order stuff for their patients. Keep in mind, these are guys (and gals) who are used to scribbling something illegible on a piece of paper over the course of three seconds, and then faxing or maybe throwing it (literally) at someone with the full expectation that their intentions will be telegraphed magically. Of course, sometimes they will lower themselves to simply barking said orders at someone, in person or by phone, with the same somewhat unrealistic expectations of completion.

Now that EMR's and such have taken over, computerizing this process in the form of CPOE is felt desirable, and even necessary. But no one asked the physicians about this, and therein lies the path to big trouble.

Our largest hospital system instituted Cerner Millenium CPOE over the past few years, and the physicians to a man (and woman) seem to hate it with a passion. I'm on the CPOE committee for one of our other hospital systems, and we are struggling with the joys of trying to crowbar a entry process into the ancient legacy MediTech Magic program, you know, the one that ports a 1980's green Data General window to Windows. I'd rather be the bagel delivery-boy for the Gaza district.

Kang nicely outlines what is wrong with pretty much every CPOE product out there: it tries to make docs do things differently, and, trust me, docs do not want to do things differently. Why are we forcing them to take 5-20 minutes and 59 mouse-clicks to accomplish what they once did with a piece of paper and a pencil in 3 seconds? The intelligent approach is to first make it easy for the physician to use CPOE, and then leverage all the nice things that an electronic approach can deliver. This, of course, includes "Decision Support at the Point of Decision." Brilliant!

HealthFortis takes a very simple approach. There are just a few points of entry, but they spawn everything appropriate to taking the order, and all of the entry boxes allow for free-text, much like Google, with a list of possible entries building and then narrowing as you type. To find your patient, you might simply type Do Da, which would bring up Doctor Dalai, among other less interesting people. Select the patient and then a simple window appears, wherein you enter the diagnosis and, if you wish at that point, the exam to be done. Here's where the magic starts. Suppose you enter "AA". The program gives a few possibilities, such as "AAA", which we then select. You are then given a list of possible exams, ranked by ACR recommendation codes from 9 (good choice) to 1 (you have to be kidding!). Clicking the exam you want spawns an order in HL-7 to be delivered back to your HIS/EMR. If the condition/symptom isn't quite so specific, the program brings up more data and options to help you decide. Of course, you can still override this and forge on ahead with an arteriogram for little toe pain, but you will definately get a "1" for that choice, and you will be told just why that is inappropriate.

There is included some nice stuff like searches for recent orders of the same type (did you really want to repeat the CT for the 10th time this month?)

Right now, the system is in its infancy, having been online for only a few months, but it is growing, and I'll predict there will be rather wide-spread acceptance. The order-sets for the moment include more radiology exams than anything else, at least as I understand it. Kang did outline a heuristic learning function, which will help grow the database; as more and more entry-pairs are collected, the system will learn which are being used most frequently, and make them more easily available.

This is one of those offerings that is elegant in its simplicity and usability. I'm not sure it will be ready for full hospital use in time to derail MediTech, but it possibly could be deployed at least to physicians ordering stuff from outside the hospital. I'll take that for now.

Make it easy and they will come. Guaranteed.

Disruptive Technology

2011-11-30T13:14:00.001-05:00

I'm sitting at one of the RSNA Bistro venues, having just spent $20 on a mediocre buffet meal which did at least consist of some mildly healthy alternatives. I've got a couple of things to tell you about, some from the meeting, of course, but one gleaned from FoxNews while perusing the net over lunch.

Let's start with the fun stuff. I think I've stumbled across the next revolution in photography, and truly this is a disruptive technology. I'm referring to the new Lytro camera, which uses "light field" imaging instead of regular old, well, light. Here are the three models, the middle version having 16 GB of storage for 750 images, and the others coming in at 8GB for 350 images.

I'll refer you to Lytro's site for an explanation of what goes on in this little box.

Basically...

Capture living pictures with the press of a single button. By instantly capturing complete light field data, the Lytro gives you capabilities you've never had in a regular camera...

Since you'll capture the color, intensity, and direction of all the light, you can experience the first major light field capability - focusing after the fact. Focus and re-focus, anywhere in the picture. You can refocus your pictures at anytime, after the fact.
And focusing after the fact, means no auto-focus motor. No auto-focus motor means no shutter delay. So, capture the moment you meant to capture not the one a shutter-delayed camera captured for you.

And here is what you can create. Click anywhere on the image to refocus, double-click to zoom.

This is the start of something big, I think, although it will probably take quite a while for this to migrate into mainstream photography. Of course, it took quite a while for digital to overtake film. You saw it here on DoctorDalai.com first.

On to things Radiologic.

I attended a seminar on the lifeIMAGE LINCS, the lifeImage Network Cloud Service, narrated by CEO Hamid Tabatabaie, former CEO of AMICAS if you didn't know. LINCS is now fully operational, and it is being used at multiple centers. Hamid showed us a live view of user stats, and the system is quite impressively active. For the full explanation, check the lifeIMAGE website. In brief, the system facilitates easy, HIPAA-compliant sharing of studies between institutions, with the idea of empowering physicians themselves to "be the network". Most every permutation is considered, as long as someone in the equation has a LINCS account. The study can be sent or received with a few clicks among LINCS members, and if a "foreign" study is to be imported to LINCS, appropriate electronic paperwork is presented. A study can then be nominated to be uploaded to PACS, pending approval by whichever human you designate.

Two partnerships offering viewer options and more were announced:

lifeIMAGE is demonstrating a technology intergration with Vital Images, an advanced visualization and analysis software company, which shows Vital’s FDA-cleared universal viewer launching from LINCS. The two companies are also exploring a collaboration to provide on-demand access through LINCS to advanced visualization tools and comprehensive clinical solutions for cardiovascular, neurovascular and oncology imaging.
lifeIMAGE also has partnered with ClearCanvas, a leading provider of innovative diagnostic imaging applications, including Picture Archival and Communication Systems (PACS) and workstations. ClearCanvas offers a free version of its diagnostic workstations in an open-source format, as well as an FDA-approved clinical version, that will connect the 15,000 members of the ClearCanvas community to lifeIMAGE.

In my own humble opinion, this places lifeIMAGE on the road to creating a Cloud-based PACS, although when I suggested this to Hamid he just smiled and shook his head. Maybe someday.

lifeIMAGE literally offers us a life-saving (and disruptive) technology, and that is NOT an exaggeration. At our trauma hospital, it is more likely than not that a patient will arrive with a CD from St. Elsewhere that has not even been reported, and probably not even reviewed. And sometimes, that CD won't even load. In the best possible circumstance, we the rads spend 10 minutes loading the CD and reviewing it with the house staff. In other cases, the patient is rescanned, the new scan interpreted, and then reviewed with the residents, adding 30-40 minutes to the process (and doubling the radiation dose if anyone cares about that.) Of course, in the worst possible scenario, the patient could well be dead 20 minutes after arrival in the ED if he is the victim of severe trauma. What would we give to have the images in hand and reviewed before the patient hits the door? A few dollars goes a long way, and that's what lifeIMAGE costs when distilled down to the basics.

Not to sound histrionic, but isn't the patient's life worth that? (And no, I don't get a kickback from Hamid.) This is damn good technology, and you should, you MUST look at it.

My second disruptive technology is one you can't buy, directly, that is. Fovia sells their 3D technology not to end-users like me, but rather to PACS and Advanced Visualization companies, including Merge (where I use a limited thick-client version on my PACS), as well as GE, and Vital, among several others. The full version of their engine operates as a thin-client with server-side processing, and it works very, very well. Fovia has taken a very logical approach. "Which would you bet on as the best investment," asked Ken, Fovia's CEO, "a system that uses proprietary graphics cards, one that uses off-the-shelf gaming video cards, or one that uses the CPU of your computer and leverages Moore's Law?" Ken's answer, of course, is number three.

Fovia has bucked the system, going against the prevailing paradigm of proprietary graphics cards (viz TeraRecon) or gaming cards (nVidia, etc.) and does the graphic processing with a server's CPUs. This may seem counterintuitive at first, but stop and peek inside your computer. Even the little MacBook Airs now have a dual-core processor, and what you can buy for $1K on the street (well, don't buy it on the street, but you get the idea) outstrips anything you could have purchased for $10K 5 years ago. Add multithreading to the mix, and you can see that leveraging your investment based on the assumption that CPU's will become more powerful makes considerably more sense than assuming any other factor will accelerate to the same degree. Fovia notes a 30-50 fold increase in the speed of their product over the last 5 years, based in part on the rapid growth of CPU processing power. Fovia's system is highly scalable and flexible...the more CPU's, the faster it runs. Given Intel's recent announcement of a 50-core chip, the speed of processing might be as close to instantaneous as possible.

You will agree that Fovia's High Definition Volume Rendering (HDVR) can produce some powerful images as you will see in this gallery page iframed from Fovia (if it doesn't load, go to this LINK):

Fovia's claim to fame is the use of a frequency domain-based algorithm, for the techies among us. This involves "deep supersampling," rendering each voxel 32,768 times. Sounds pretty involved to me.

While you can't buy Fovia directly, you can buy some products which use its technology. As an aside, I discussed with the execs the possibility of Fovia creating its own GUI, its own wrapper for the incredible viewing software. The answer? "Others have suggested that..." I guess we'll have to wait and see. But for the moment, they do a darn good job in the background.

ADDENDUM:

Dr. Robert Taylor, CEO of TeraRecon, sent me this comment on the dedicated-card vs. GPU vs. CPU debate:

I read your blog this AM and noticed the barb from Fovia about proprietary cards. To set the record straight, I just wanted to point out, TeraRecon also has a full SW option and we only use the VolumePro (VP) because it happens to be dramatically better than using software and scalable. We can now render over 70,000 slices in real time (the combination of many users working at once) from a single 2U server thanks to this technology. Today, and for the foreseeable future, that's impossible with SW (Fovia, GE, Philips) or GPU (Vital, Siemens).

When the sledgehammer (VP) is not required, we also have the nutcracker (SW), and this is why we have sold hundreds of laptop-based systems that work without a graphics board in sight. We also hope and expect that one day CPU technology will be able to do what is needed, and we're fine with that. It's the application that matters in the long run.
Thanks!
Robert

RSNA 2011: Siemens Hints At The Future

2011-11-29T10:17:00.001-05:00

I mentioned something in the last post about attending the Siemens Media Breakfast, and I promised to elaborate.

As a quasi member of the press, perhaps we should say vanity press, I was once again invited to the annual media event. Being on my new eating program, I didn't take much advantage of the proffered breakfast, but I did listen intently to the talks given by Hermann Requardt, President and Chief Executive Officer of Siemens Healthcare, and Gregory Sorensen, MD, Chief Executive Officer, Siemens Healthcare North America.

There were the usual announcements and scanner refreshes/updates. The Siemens Biograph mCT gets some new software to allow better quantitation and reproducibility. We are told that this is the best selling PET/CT on the market today. Wish I had one. The Biograph mMR, the PET/MR scanner, has been installed at 10 sites with 20 pending orders. Wish I had one of those, too, but a $5M expenditure is not in my future. While it was said that the mMR has no competition, Philips apparently has one about to be approved, and GE did announce one in the works.

Two new CT scanners were announced, the Somatom Definition Edge, a single-source scanner utilizing the new Stellar Detector, with 0.3mm routine spatial resolution, and the "business class" Somatom Perspective, a 128-slice state-of-the-art machine with low dose imaging and a lower price point.

There will be two new Acuson units, the cheaper S1000 and the top of the line S3000, the latter having built in automatic fusion to other modalities.

There is a new association with Eli Lilly to distribute the latter's amyloid tracer via Siemens' PET NET network.

The syngo family is mobilized, in other words, it can be accessed remotely, via computer or iPad or whatever. Supposedly mobile apps will allow manipulation, although on the exhibit floor, there was a some hemming and hawing as to how much one can or cannot do on an iPad.

More important than the machinery are the rather candid observations offered by the Siemens execs.

Dr. Requardt opened with a statement that we all know is true: Healthcare spending at current levels is not sustainable. In developed countries, there is the desire to decrease costs, but in emerging countries there is need to increase access to health care. Siemens sees a "sweet spot" wherein the two curves meet, and they plan to position themselves to take full advantage of this. Turning the conventional paradigms around, Siemens now views therapy as the driver of imaging, and using industrial terminology, healthcare becomes a "project" business, wherein innovation is the solution and not the problem. The disconnect between diagnosis and treatment lead to increased nonconformance costs, and a shift to emphasize therapy my better satisfy patients' needs and wants.

Dr. R rather humbly (or not) noted that Siemens had "misdirected" some investments because they didn't realize the healthcare sector was "not fast enough to respond to technology". Hate to say it, but this implies the sector wasn't smart enough to grasp some of what Siemens offered. Or perhaps what Siemens gave us here and there wasn't what we needed at the time. Particle therapy was cited as a case in point. Siemens developed/created/improved the technology, but it hasn't sold well. Apparently, this was NOT one of the "non-regret" moves Siemens wants to see in the future.

I've already alluded to the statement about PACS. "We will focus on core secgments," said Dr. Requardt. "RIS/PACS today is a commodity these days, with dramatic changes in network environments. Our future investments will reflect this." Is Siemens dropping out of the RIS/PACS market? It seems that with every vendor now offering a ~~Vulture~~ Vendor Neutral Archive (VNA), Siemens no longer wants to compete (much?) in this space. Sad, given the fact that the new syngo.plaza might actually be their first workable interface.

Dr. Sorenson took over, describing the demographic "wave" of aging Baby-Boomers (hey, I'm one of them!!) 80% of healthcare costs are for older patients, and Medicare is decreasing spending. Imaging expenditures are being cut back in particular, with still some increases for primary care. Dr. Sorenson describes imaging reimbursement as a bubble: reimbursement was so high that it created its own demand. (To be fair, the equipment companies, including Siemens, need to stand up and acknowledge the role they played in dangling those reimbursements in front of clinicians as incentives to purchase their scanners.)

In what I find to be a rather ominous, but still realistic, approach, Siemens plans to address the increased scrutiny we docs are now experiencing, mainly from governmental sources. This drive masquerades as a drive toward minimizing "practice variability". IT tools will move us toward evidence-based, rational care. Reading deeply between the lines, our systems will tattle on us physicians if we stray from the government (or third-party payer norm, whatever that is. Big Brother will be watching us. Now, I don't blame Siemens for this, and being a good Capitalist, I will even applaud them for blazing a path to profit through this mess. But I'm still not happy about it at all. It's probably time to retire.

Siemens will spend 1.4 Billion Euro on R&D this year, and it certainly shows. That's actually just about the same number as their reported profit.

Finally, Siemens, the German company, now manufactures half of its CT's in China. "We make it wherever it's adequate to make it." The factories in China are 100% staffed by Chinese nationals, and the facilities are identical to their German counterparts. Far better to invest in China than to be the main investment, I would say.

I wonder what Siemens will bring us next year?

View From The Balcony..

2011-11-28T17:24:00.001-05:00

I'm back at RSNA for what must be the 13th or 15th time since my first time way back in 1990. Or was it 1989? Back then, the meeting spanned the entire Lakeside building, which was all there was of McCormick Place at the time.

Today, many of the BIG vendors have reoccupied Hall D of the Lakeside building, although I'm seeing a lot of empty space in the periphery of the North and South exhibit halls.

I'm sitting up on the Balcony Cafe in exhibit hall. It's quieter up here, the wifi is strong, and there are numerous power outlets. My iPhone 4 is gobbling up battery power, thanks to iOS 5.0.1, and I've stolen Mrs. Dalai's Macbook Air to facilitate reporting from the floor.

The atmosphere here is pretty vibrant, and there seems to be a lot of interest at the booths, although I have no idea of how much money is actually changing hands.

I've been to several educational sessions already, and I've spent some time on the floor. There isn't a LOT thats new, but there are a few interesting things here and there. I'll have a separate report on the Siemens Media Breakfast later, but their big news involves the introduction of two new CT scanners. And, there was a remark made in passing almost concerning the act that RIS/PACS is now a commodity, and as such it may not justify quite the same level of investment it once did. That's unfortunate, as syngo.plaza might actually be Siemens' first functional PACS.

I've had a look at one of the two SPECT/CT candidates, and while its bone SPECT images haven't improved much, there are some other minor improvements. I'll have a peak at the other one tomorrow or Wednesday.

A friend of mine who works at McKesson had me take a look at their latest PACS GUI. While it's busy and has maybe too much customization, I'm coming to appreciate what it can do; it's a very powerful interface, and if I needed to replace a PACS, it would be on my short-list of competitors. McK has finally decided to converge the various clients, so the view is more or less the same no matter if you access the PACS from home or office. So far, no iPad client, but there is something pretty revolutionary in the works, although apparently not yet enough of a work-in-progress per se that it can be seen by the likes of me.

Probably my greatest accomplishment today was to connect the folks of Blackford Analysis to a major PACS vendor. The rest is up to you, mates!

What has surprised me most of all is the number of folks who remember me from earlier interactions, and continue to read the blog. I continue to be humbled by the fact that anyone actually looks at this thing, but you all have my deepest gratitude for doing so.

Tonight, dinner with some old friends, and then meeting up with some other old friends. My daughter might even be able to break away for a moment and join us!

I'm tired already, and it's only Monday at RSNA...

Your Village CalledTheir Radiologists Went To RSNA

2011-11-27T20:25:00.001-05:00

I'm on my now-annual trek to Chicago for RSNA. I go every year now that my daughter is in school up there in the frigid North.

(As an aside, I think I've come up with a wonderful idea viz-a-viz the horrendous weather in places like Chicago and Buffalo. We need to swap cities with Mexico. Chicago could trade places with, say, Cancun, and New York City and Mexico city could easily flip-flop. No? Well, darn..)

I've been bombarded with advertisements from a sampling of the zillions of vendors out there in the imaging space, and you might hear about some of these when I submit The Dalai's to Aunt Minnie. More on that later.

There is one marketing communication that is just so far off the wall, I have to let you know about it even while I'm still in the air. I won't name the name, but the ad comes from one of the publishing houses specializing in things radiologic. Where they came up with this idea, I haven't a clue, but here's what you could see if you happen to be in the right place tomorrow at the right time:

RSNA Tribute Flash Mob – Monday November 28 at 9:45 AM
Haven't you all wanted to participate in a flash mob? Here is your chance! We have created an RSNA Tribute song (and dance) to be performed on Monday morning at 9:45am right before the exhibits open. If you have never heard of a flash mob, here's the story:

The music ("R-S-N-A" to the tune of "Y-M-C-A" – EVERYONE knows this song!) starts and just a couple of people start dancing and singing along…gradually more and more people join in and before you know it there are a whole bunch of folks rockin' out. So you are wondering what you have to do? Just click on the link below. We've posted the very basic dance steps (don't worry, they are quite simple) with music. You don't have to be a singer – the music has been professionally recorded and will be broadcast at full volume! We will have the expert support of some Chicago college dance students, so you won't be alone and you can just "follow the leader" as they dance! We plan to have a short rehearsal in Chicago. Our goal is to record this to relive the celebration, and laugh (a lot). We are quite sure that this will be a first for RSNA and we feel that it is the duty of all (the) family members to bring a bit of liveliness to this staid and somber meeting.

Here are the new lyrics, ~~butchered~~ sung on YouTube:

And for those far more coordinated than I, here are the dance instructions:

I'm probably going to be in an educational (OK, I'm trainable if not educable) session when this goes down, so I'll expect reports and links to videos of the actual event.

Frankly, I think I need to ~~pervert~~ rewrite YMCA myself...

Hey Doc, My Ass Hurts, Oy Vey!
I need me a CT TODAY!

Ummm...never mind...

Addendum...It actually went down!

Hat tip to Ken from Fovia.

iPads From Our Futures Past

2011-11-26T15:40:00.001-05:00

Apple loves to sue people and companies that even hint at coming close to imitating their stuff. The latest prolonged battle targets Samsung, whose Galaxy Tab is said to be a "slavish copy" of the iPad. In response to several legal defeats, Samsung is slightly modifying the Galaxy to prevent anyone from possibly confusing it with an iPad. Not that anyone would have.

If you are at all interested in the legal machinations, check out THIS article from Mashable.com.

Samsung, to their corporate credit, has come up with a novel defense that might just work in the courts. Samsung claims that the "look and feel" of an iPad has been around quite a while, as we see in this clip from Stanley Kubrick's SciFi masterpiece, "2001, A Space Odyssey":

And that's not all. Consider Star Trek's various "Padd's":

and.....

And even from the Original Series!

Yup...there's nothing new under the various suns in the Star Trek universe.

Oh, by the way, there's a tablet out there that doesn't get much mention, but I think was truly the original, forming the basis of a lot of things we deal with today:

Top that, Apple!

Another Shoot-Out, Or, A Requiem For Advanced Imaging

2011-11-23T00:39:00.001-05:00

Shoot-Out at the OK Corral

The word has gotten out to some of our potential vendors, so I might as well go public. We're having another shoot-out, and it should be quite interesting.

Our larger hospital system seems to have found some funding for an advanced imaging product of some sort, and somehow your friend Doctor Dalai has become the point-man in the decision. Initially, we were going to go with a bundled solution, as we need a few CT scanners, not to mention my beloved SPECT/CT scanner. Sadly (for the vendor in question), some of the initial prices ("good only for the next 10 days!") were way out of line, and so we are unbundling the purchase. I am thus free to pursue the best-in-breed of Advanced Imaging and SPECT/CT. Someone else gets to worry about CT.

There are only a few choices when it comes to SPECT/CT, and I've reviewed them before. But advanced imaging is another story.

To create the atmosphere for a fair and balanced decision with respect to advanced imaging software, we will arrange a "shoot out" between some of the major vendors and their products. I say "some" because we don't have enough room or time to showcase every possibility, so we are limiting the scope to a few programs that seem to have potential to accomplish what we need to do. A side-by-side comparison seems much more efficacious than the series of 20-minute demos we've been enduring. Plus, some of the vendors have been, shall we say, a teeny bit aggressive about placing their product for a prolonged demo, to the point that we were to accommodate about a half-a-dozen servers and 5 IP addresses. That might be the next step, but we need to be absolutely certain that our needs will be met before we start opening up rack-space in the data center.

The format will be similar to the Stanford PET/CT competition I wrote about a while back, with the vendors processing data we provide on a real-time basis. We will give them a script to follow, so we can see the same things done on the different machines, and then of course there will be some time for the vendors to do their own thing.

The script is still in flux, but I have a number of things that we need to see, and a few that we would like to see. In no particular order, here's what's on the list so far:

One-button processing, or as near to this ideal as possible. Of course, there must be a way to go back and manually alter anything that needs altering.
To the greatest degree possible, the system must be operable/viewable from anywhere, and any platform (PACS station, laptop, iPhone, iPad, Android phone or tablet, and whatever else comes up in the near future.)
There must be complete and total integration with IMPAX 6.5 and beyond, our illustrious PACS.
Procedures will include (but certainly not be limited to):

Brain perfusion
PET/CT viewing
Full cardiac/coronary work-up
Virtual colonography
Bone subtraction/transparent/translucent rendering
AVI creation

Suggestions for other items are welcome, although vendors need to be circumspect on this.

In addition, we have been tempted by "dose reduction" or "denoising"software, which is included in some of the advanced packages. I've discussed the concept earlier, and frankly, I still don't like the idea of dropping the quality of a scan in hopes of rescuing it later. So, to me anyway, this will not be a critical component. If it comes with, fine, if it doesn't, also fine.

The tentative schedule for the shoot-out is set for early January. Ambulances will be at the ready for the fallen.

The Match Game

2011-11-15T15:43:00.001-05:00

Once in a great while, something comes across my virtual e-mail desk that gets me excited, and when you reach my age, getting excited is rare and possibly dangerous. Nonetheless, when I saw what the folks from Blackford Analysis (http://www.blackfordanalysis.com) had to offer, I definitely got a thrill.

Blackford comes from outer space, almost literally. Their origins are in the astrophysics world, and their break-through technology is called MOPED:

Blackford Analysis’s core technology is MOPED, an algorithm developed in astrophysics to tackle analysis of immense datasets. The patented approach involves compressing the huge datasets while retaining all information needed to solve a problem – allowing speedups of many orders of magnitude over traditional techniques.

The technology comes from astronomical surveys, where instruments capture gigabytes of images per hour. This information is generally interpreted by comparison with models, essentially complex formulae driven by a set of parameters, which reproduce the observations.

Parameters might be the mass of a galaxy, or the distance it is from Earth, and there will be some combination of parameters that produces a modelled image that is very close to that actually seen through the telescope. Situations like this are called ‘parametric modelling problems’.

MOPED’s particular ability when solving such problems is that it speeds up the step that determines how well a given combination of parameters recreates the image.

After the initial compression, the time taken for each combination changes from being set by the number of pixels to being set by the number of parameters. If 10 parameters were to be determined by an image taken by a modern digital camera with 12 million pixels, the calculation would be more than one million times faster.

This means that problems that were too slow become possible, often solvable in real-time. As datasets become larger, and the cost of the hardware resources required to tackle them rocket, the case for MOPED is even more compelling: the powerful algorithm vastly reduces that hardware cost.

So what does this have to do with imaging? It seems that we can apply the algorithm to matching volumes, such as two CT scans!

Developed by Blackford Analysis, the medical imaging technology makes it possible for radiologists to anatomically link small features such as lung nodules between studies for the first time within the PACS.

While the radiology imaging software will also align CT and MR from any part of the body, instant anatomical alignment in the chest is a major breakthrough, given respiratory movement and the requirement for a deformable registration.

Blackford Analysis’ technology greatly reduces the time it takes to compare current and prior studies, a drain of radiologist’s time as volumetric datasets increase in size and complexity and become ever more commonplace.

A key advantage of the software is that it designed for integration in the existing PACS environment so radiologists can use it without having to interrupt their natural review processes by moving to another workstation.

Crucially, the alignment is achieved without any alteration of the raw slice data so radiologists don't need to worry about the authenticity of what they are reviewing.

A video is worth at least 10,000 words:

Blackford is thinking outside the box. In all of the other registration programs I've seen, an attempt is made to match the entire volume of the old study to the new. Because patients are not rigid (their bodies aren't, anyway) this doesn't work so well. Some software will attempt to distort the data-set to achieve a fit, which could conceivably distort the findings as well. Blackford takes the novel and proper approach of an instantaneous point-to-point mapping, finding the exact spot on the old study that I'm seeing in the new exam. Brilliant! That's really all we need in the end, isn't it? And it does appear to work quite well. And to have it actually integrated into the PACS viewer would be incredible.

I hope to meet with the folks from Blackwell at RSNA and see the thing live and in action.

PACS vendors: you WANT this in your product. You really do. Jump on it now.

Contact r
info@blackfordanalysis.com
B

For The OWS Crowd...

2011-10-28T17:52:00.000-04:00

It just isn't FAIR!!!!!

Hat tip to Dr. Sanity.

Dalai Gets Schooled By Merge

2011-10-28T16:56:00.002-04:00

Nanak, my PACS guru, recently asked for permission to attend a MERGE PACS training session. The description looked so good, I wanted to attend as well:

Merge Healthcare, the leading developer of information technology to create a better electronic healthcare experience, invites you to attend a specialized training session. During training, our technical experts will walk you through a deep dive of the technology’s features and functionality so you gain the critical skills necessary to maximize your investment in Merge solutions.

What: MERGE PACS KNOWLEDGE QUEST – SUPPORT 2011
Where: Daytona, Florida

Learning objectives:
Systems Overview - PACS Components
Server Maintenance
Definition of logs and what they mean
Advanced trouble shooting techniques
MWL Filtering (how it works)
Creating advance transfer rules
Managing Image volumes and watermarks
RTWL filtering
Management Tools

The two-day session was held at Merge Southern Headquarters in Daytona Beach, Florida:

As it turns out, this is also Merge's main support site, and so we got to see the "prairie-dog village" as Nanak calls it, where the support folks do their thing:

We had the opportunity to meet in person many of the folks who had been taking care of us and our system for the past few years. We also discovered the secret of their seemingly unlimited energy:

We also got the chance to have dinner with my friend Mike Cannavo, the PACS exec formerly known as the PACMan. (Mike now works for The Man at a big-name vendor.)

The course itself was frankly slightly above my level. While I do have administrative privileges, I don't dabble too much in the back-end of our system (presently Version 5.0) or the hospital's (version 6.0.4), but I did find it quite valuable to learn more about what goes on there. There are some places I'm not going to tread, and even Nanak doesn't like to dive into the DB2 database, which can be dangerous indeed, but we now know more about how to do so if need be.

One major change between our 6.0.4 and the latest 6.2 is that the name AMICAS is slowly being relegated to the trash bins of history and my failing memory. The new sign-on screen reads thus:

Perhaps I should moonlight as a PACS admin with my new education. Nah...radiology is probably easier. But I did learn a particularly valuable lesson: Nanak really knows his stuff. Throughout the whole class, he was helping me understand what was going on, and it was pretty clear he has a huge grasp of this stuff. Remember Dalai's IXth law:

A true PACS guru is worth his/her weight in gold.

In Nanak's case, that's a lot of gold. But still absolutely true.

iGrieve With Thee: Steve Jobs Dies at 56

2011-10-06T10:51:00.001-04:00

(Image credit: http://www.FoxNews.com)

Steve Jobs has passed from this world, presumably a victim of the islet-cell neuroendocrine tumor he had fought for many years. The genius (and I don't use the term lightly) behind Apple Computer was a young 56 years of age.

FoxNews has a very complete biography here. It's hard to believe that this one man had such an impact on our day-to-day lives. Some have called him the 21st Century Edison, which may be somewhat of an exaggeration, but still is fitting.

Steve (we all feel like we knew him, although few of us ever got to meet him or work with him in person) was not so much an inventor as a perfecter. He actually invented none of the products we remember him for, but he made them accessible, usable, and sometimes even fun. The personal computer had been around for years in some form or another, but Steve (and his then-partner Steve Wozniak) distilled it into the Apple II, one of the first home computers that actually did something useful. Then came the Lisa, the first stab at a home computer with a graphic interface, which was met with less than stellar response. But in 1984 came the Mac, and the rest is history.

The other iconic products from Apple were similarly perfected. The iPhone came well after various PalmOS, Symbia, and Windows smartphones, but Apple improved the experience to attract millions of users who would otherwise still be using RAZRs. (I won't get into the iOS vs. Android debate.) There were dozens of mp3 players out there before the iPod came along, but Apple now completely rules that space.

Apple had some rather spectacular failures as well. The Newton (of which I was an early adopter) never really worked as desired. Here's an article about the Newton and seven more Apple goofs. Anyone remember the Pippin? At least I never succumbed to that one.

The recent release of the iPhone 4S, Steve's last imprint on Apple, shows that Apple still may not predict the market with perfect accuracy. The remake is really much more phenomenal than it originally seemed. Better processor, better camera, more memory, better antenna system, and Siri, the latter of which in some ways brings to fruition some of the original magic conceived for the Newton projects. See this video from 1987:

...and compare to today's Siri:

It only took about 25 years to bring this futuristic technology to the future.

But Apple is taking somewhat of a hit over what is really a significant upgrade...because users were expecting a new screen and new case. A 4 inch screen and a more streamlined case would have gotten big accolades; huge new tech innovations are getting a "meh". You can rest assured that the iPhone 5 will have a new form-factor, hopefully not introduced too late to smash the competition. Personally, I'm satisfied with the iPhone 4 housing. As Steve once said, it is "like a beautiful old Leica camera".

My friends (and even Mrs. Dalai) have asked me what I think will become of Apple now that Steve is gone. I'm hoping for the best, really. Steve must have left some documentation of how he thought things should work, and his hand-picked successor, Tim Cook, seems quite qualified to carry on the traditions. There are enough brilliant people working for Apple that I can't imagine it will founder much, if at all. I have great faith in their people to carry on. You can rest assured that the motto for the foreseeable future will be: "What Would Steve Do?"

Perhaps my greatest regret about Steve's untimely passing was voiced by AuntMinnie user Elegiac:

Imagine what he might have accomplished had he focused his creative energies on developing solutions for medical informatics. It is hard to imagine how much more productive we all would be if we used a unified and properly designed PACS/VR/RIS/EMR system created by people who placed value on an integrated work environment which just works. What could have been.

Indeed. PACS vendors take note.

A hat tip to Radio17 who reminds us on the AuntMinnie thread that 3D advanced imaging is one of Steve's Pixar legacies as well. From an ACR article about Elliot Fishman, M.D.:

The Brooklyn native (and Yankees fan) arrived at Hopkins in 1980, and by the mid-1980s, began working in 3-D medical imaging. He characterizes the state of the art back then as “pretty limited.” Looking around, Fishman approached and began partnering with Pixar Image Computers (and later, with Siemens), where a cadre of elite researchers was doing seminal work on computer visualization using ultra-fast proprietary computers. Fishman’s contribution was to help Pixar adapt its massively complex technology to the medical front. Ultimately, Pixar shifted its focus away from medical computing, but its groundbreaking work opened the door for a host of scientific revolutions. In time, Pixar would enjoy tremendous commercial (and critical) success making such movies as Toy Story, Finding Nemo, and Cars.

Recalling those halcyon years of around-the-clock work, Fishman says, “The people at Pixar were the smartest people I’ve ever worked with, anywhere. I’m talking 11 over 10 — just incredibly unbelievable.” But he reserves his warmest praise for Pixar CEO (and Apple Computer founder) Steven Jobs. “He is a remarkable visionary and also one of the most charismatic people I’ve ever met.”

“One of the highlights of my career,” he continues, “was giving a named lecture at Stanford University. Steve came to my one o’clock lecture on 3-D imaging, which I’ll never forget. I figured I’d be speaking to radiologists, so even if I was wrong on some technical point, they might not know the difference. But with Steve there, I realized that if I made a mistake … ‘Oh, my God, if I say something wrong, he will definitely know.’”

Rest in peace, Steve. You will be missed.

Honey From The Cloud

2011-10-05T11:28:00.001-04:00

This is Merge week, it seems, due in no small part to the Merge Live Client Conference 2011, going on right now in Chicago. I would have been there myself, except Merge accidentally scheduled the meeting right up against Yom Kippur (which begins the evening the conference ends, Friday, September 7) making it difficult to attend. No worries, RANZCR did the same thing this year.

Today's announcement outlines something Merge is giving away for free. While I have commented on the magnanimity of some of Merge's principals before, I think it's safe to assume that Merge hopes to attract new, paying customers with this sweet offering.

And sweet it is, at least in name. Merge's Project Honeycomb promises to become "The nation's largest medical image sharing network," and given the price, it might get there. Here is the video explanation:

Kinda cute, but how will it work? The explanation for the media is here. Basically, Honeycomb is a free repository for images, according to the press release:

Merge Healthcare (NASDAQ: MRGE), a leading provider of enterprise imaging and interoperability solutions, today announced Merge Honeycomb, a revolutionary new cloud-based service that will enable users to upload, download, view, and share medical images – at no cost.

“With Merge Honeycomb, we’re harnessing the cloud in a way that encourages and enables faster collaboration among all healthcare stakeholders, resulting in a true improvement in the delivery of care and reduction of costs,” said Jeff Surges, CEO of Merge Healthcare. “With the largest network of imaging clients by far, Merge is taking this important step to connect the healthcare industry and expand interoperability.”

Announced today at the Merge Live 2011 Client Conference, attended by over 500 healthcare professionals, Merge Honeycomb will be the nation’s largest medical imaging sharing network and is open to anyone. Merge Honeycomb will officially be launched at the Radiological Society of North America (RSNA) Conference in Chicago in November, 2011. Users can pre-register now for this free service at www.merge.com/honeycomb.aspx.

Merge Honeycomb will solve a myriad of costly healthcare challenges. It will reduce the need for duplicative scans, which costs the industry an average of $35 billion a year and exposes patients to harmful and unnecessary radiation. (According to a 2010 study by the Center for Devices and Radiological Health and the U.S. Food and Drug Administration, the radiation level in one CT scan of the abdomen is approximately the same as 400 chest x-rays.)

Merge Honeycomb will also eliminate the archaic practice of using patients as transport vehicles. The need to burn X-rays, CT Scans, MRIs and other images onto CDs will be a thing of the past. When a physician needs to view images, they can log into the image sharing network via any web browser.

It also speeds the time to treatment. Referring physicians will be able to view images in realtime and make diagnoses accordingly. And because the network is permission based, images can only be viewed by those who have been granted privilege.

It is a component of iConnect, the larger (and not free) overall package:

Merge iConnect facilitates the sharing of content and results across the continuum of care. Available in vendor-agnostic modules, Merge iConnect uniquely leverages existing investments and provides added functionality when needed to deliver access to any image, anytime, anywhere. While there are many niche imaging solutions in the market, Merge iConnect is the only comprehensive suite that delivers true interoperable image exchange and management.

With Merge iConnect, healthcare images are moving at the speed of life through the power of the cloud, enabling an enterprise imaging strategy. These images are easily archived, available on demand and accessible at the point of care, which means frustrations like waiting for images and unreadable CDs are history.

The interface looks a little "Facebook-ish" to me:

But maybe that's the intent, as everyone knows how to use Facebook. (Let's hope Merge doesn't contract with Zynga to create X-RayVille or something foolish like that!)

We all know that "The Cloud" really isn't something ephemeral in the sky, but rather a server and storage farm in some bunker somewhere. Did Merge buy its own farm (hopefully not from a Zynga user) or is it buying space from Amazon Web Services or some similar provider?

ADDENDUM:

For some reason, Merge takes its time in posting its own press releases on its own site. Global News Wire has this October 6 release:
Merge Healthcare (Nasdaq:MRGE), a leading provider of enterprise imaging and interoperability solutions, announced today that it has selected Dell as a preferred provider of cloud computing services, storage and enterprise hardware products to simplify information access, management and archiving among its portfolio of image interoperability solutions.

Through its secure cloud-based Unified Clinical Archive solution, Dell manages more than 4 billion medical images and studies for healthcare organizations. Utilizing its cloud-based health information technology, Dell will host Merge Healthcare's Project Honeycomb, the nation's largest medical image sharing network. With Project Honeycomb, providers can upload, download, view and share diagnostic quality medical images – at no cost.

For providers who want on-premise image management, Merge has certified its iConnect Vendor Neutral Archive (VNA) on Dell's DX Object Storage platform, providing intelligent access, storage, protection and distribution for the fixed digital image content managed by Merge Healthcare's iConnect VNA. The data and storage management features inherent in Dell's systems combined with Merge's iConnect offering will enable healthcare providers to manage their critical medical images in a highly secure and efficient manner.

Merge will integrate its solutions within the DX platform, using Dell's capabilities to provide a highly-available, cost-effective VNA offering. By utilizing the data management features of the DX, iConnect VNA will offer advanced features such as federated storage, business continuance and nested image retention and deletion strategies.

Anyway, why again do we want this?

With Merge Honeycomb You Can:
• Eliminate the need for patient-borne CDs
• Provide VPN-free exchange of images
• Share diagnostic images securely via the Internet
• Easily view outside studies
• Eliminate waiting for images
• Eliminate image format incompatibility
• Reduce duplicate exams
• Speed time to treatment
• Increase referrals
• Reduce IT complexities associated with sharing exams

Hmmmm...sounds a lot like the mission statement for LifeImage:

lifeIMAGE enables the secure and on-demand exchange of medical imaging information from anywhere and with anyone. We provide a multi-purpose, SaaS platform to healthcare institutions, physicians, and patients to exchange information directly or integrate the information with their EHR or PHR systems. Our goal is to eliminate the need for duplicate imaging exams and avoid unnecessary radiation.

To do this, we offer applications that can be incrementally adopted to help with the transition to electronic exchange of imaging information. Our services solve image accessibility challenges inside and outside a facility’s firewall. Throughout, we are meticulous about confidentiality, privacy and HIPAA compliance.

Their solution is not free, but I have this sneaking suspicion that Merge Honeycomb, while a stand-alone module, will be far more useful and usable in the context of iConnect, and in the end won't be quite free either.

Having no hands-on experience with the new Honeycomb, I can't begin to tell you which is better, and no doubt both Merge and LifeImage will prosper with these approaches. To me, Dr. Dalai, Average Radiologist Extraordinaire, the key will be transparency. In other words, the system that gets the foreign images into MY PACS most easily wins.

Honeycomb? The folks of my generation might think of the cereal first:

The younger, more tech-savvy set might associate the term with the latest flavor of the Android OS.

I've never understood much about marketing or name-selection.

Oh, by the way, at the bottom of the press release, in the fine print, we see this disclaimer:

Merge Honeycomb as described herein is a works-in-progress. Merge Healthcare is not legally obligated to develop or continue to develop such works-in-progress that may include the features and functionality described herein.

Perhaps that's standard boilerplate language, but it seems a bit strange in a big announcement such as this. Oh well, never hurts to cover one's bases, eh?

Hat-tip to Mike Cannavo, the Once and Former PACSMan, since I don't seem to be on Merge's e-mail list these days.

UPDATE!

Fellow blogger PACSMatt (Matt Granger) attended the Merge Live! event, and adds much to our knowledge of Honeycomb:

I had a chance to demo the Honeycomb product directly and I am impressed. The feature set is right on for this initial product release. It has a social network "LinkedIn" feel to it and users are able to self register to create an account. A URL auth process follows and then you can access your free account. Although not verified, initial screenshots seem to show that "free" accounts can upload up to 10 GB of imaging data. Once logged in the user is presented with a log view screen of activity that has occurred with any images they have shared to other users. You can invite other users via e-mail to join Honeycomb or search for existing users. The search screen segments the search results between users you know (similar to 'friended') and global users accounts you haven't shown any relationship to (yet).

Uploading files is very easy as long as you have physical access to the DICOM files themselves. Once uploaded you can share the files to one or more users in your group. The sharing process has granular controls that allow you to decide how long the share is active for and whether or not the 'shared' users is allowed to download those files as DICOM objects or not. Either way the user can view the images through Honeycomb:

Images that are shared to end users are viewed using Merge's iConnect Access zero footprint viewer. Let me stress that this viewer is an amazing PACS image viewer. I have been involved with testing version 2.5 of the iConnect Access viewer for some time now and this week I was able to see the feature set in Access 3.0 which is in use in the Honeycomb product. It's truly a zero foot print viewer completely executed in JavaScript in the browser. Support summary: No Java needed, no ActiveX needed, yes IE, yes Chrome, yes Mozilla, yes iPhone & iPad, iffy on Android (for now) and no on Blackberry. It's an excellent browser and I regret I didn't get any screenshots for you. It has mote than ample toolset including cine, zoom, measurement tools, multiple viewports, full screen viewing. It's beautiful.

Did I mention that this is free? Are you considering any other image sharing services right now? Don't. This is free and it rocks. Just go to www.merge.com/honeycomb.aspx and sign up to be notified when the services launches next month. Here's a direct link to Merge's PDF document more details.

More information about the future phases of Merge Honeycomb came out today, too, as the implementation phases were shown at the "Merge Live!" event. Below is a screenshot from their presentation. Phase one and live usage will be in place by RSNA this year. Phases 2 & 3 relate to a tighter integration of Honeycomb to their iConnect Access platform.

Many thanks for the info, Matt!!!!

I received a comment as well from an anonymous reader (no one wants to admit reading my stuff, it seems):

What I'm curious about, is that lifeIMAGE already announced a similar offering to the American Society of Echocardiography (free), with plans to expand it to all? Not sure.

I'm not sure, either. I'll post what information I find on this. Sounds like LifeImage may have something up their collective sleeves...

What, Merge? No Dalai?

2011-10-04T13:11:00.000-04:00

A friend received this press release early today, and ironically, it is not yet anywhere to be found on the Merge.com website (as of 9:30 AM EDT) (UPDATE: It's finally online.)

Merge Healthcare Announces Creation of Clinical Advisory Board
Expert Panel to Provide Patient-Centric Solutions to Improve and Streamline Delivery of Care
CHICAGO, Oct. 4, 2011 (GLOBE NEWSWIRE) -- Merge Healthcare (Nasdaq:MRGE), a leading provider of enterprise imaging and interoperability solutions, announced today the development of an Advisory Board to share clinical expertise and provide consultation on new models of care and emerging trends focused on the patient-centric experience.
The Merge Advisory Board will focus on the fact that diagnostic images make up a significant and critical part of the diagnostic process, yet today, the exchange and sharing of these images is inefficient. This inefficiency fragments the healthcare process which contributes to delays in care and skyrocketing costs. The Merge Advisory Board will also address patient safety and quality of care through, among other things, focusing on the fact that patients' radiation exposures has doubled over the past 20 years and developing solutions that reduce such exposure.
Consider the realities of diagnostic imaging:
Healthcare organizations generate nearly 600 million diagnostic imaging procedures annually;
One CT scan of the abdomen exposes a patient to the same amount of radiation as approximately 400 chest x-rays; and,
$100 billion of annual healthcare costs are related to diagnostic imaging tests – but an estimated 35% ($35 billion) represents unnecessary costs for US patients and insurance providers.
The Merge Advisory Board is led by Dr. Cheryl Whitaker, Merge's Chief Medical Officer; co-chaired by Dr. Paul Chang, Professor of Radiology and Vice Chair, Radiology Informatics at the University of Chicago Medical Center; and, Dr. Keith Dreyer, Vice Chairman of Radiology Informatics at Massachusetts General Hospital.

"We are extremely fortunate to have experts from these prestigious organizations advising the Merge team," said Jeff Surges, Chief Executive Officer of Merge Healthcare. "We look forward to the clinical dialogue that will develop, and to incorporating their knowledge and expertise into the image interoperability solutions we provide to clients and the healthcare marketplace."
"Merge believes in a patient-centric healthcare experience, and empowering physicians, patients and providers to proactively manage this healthcare," said Dr. Cheryl Whitaker, Chief Medical Officer at Merge Healthcare. "I look forward to working with this distinguished group of leaders to ensure we continue to develop solutions that simplify and improve the care process."

The Merge Advisory Board consists of the following imaging and healthcare experts:

Dr. William Boonn
Chief of 3D and Advanced Imaging Lab
Hospital of the University of Pennsylvania
John A. Carrino, MD, MPH, PhD
Associate Professor of Radiology and Orthopaedic Surgery
Johns Hopkins University School of Medicine
Dr. Paul Chang
Professor of Radiology
Vice Chair, Radiology Informatics
University of Chicago Medical Center
Dr. Keith Dreyer, MD, PhD
Vice Chairman of Radiology Informatics
Massachusetts General Hospital
David Mendelson, MD
Chief of Clinical Informatics MSMC
Professor of Radiology
The Mount Sinai Medical Center
Eliot Siegel, MD
Chief of Radiology and Nuclear Medicine
Veterans Affairs Maryland Healthcare System
Timothy Zoph
Chief Information Officer and Senior Vice President of Administration
Northwestern Memorial Hospital

What? No Dalai?

To be fair, this is a list of PACS luminaries, the likes of which you will find nowhere else, and the likes of me probably doesn't belong even reading such a list.

We see some very familiar names here. Dr. Chang is quite famous in this space, in no small part for creating Stentor, developed at the University of Pittsburgh for $9 Million, which was bought by Philips for $45 Million and became iSite. He's now at the University of Chicago, and wouldn't you know it, they use iSite, according to one of my readers. I do not know offhand if Dr. Chang has had much hands-on experience with ~~AMICAS~~ Merge PACS.

Dr. Dreyer does have time on ~~AMICAS~~ Merge PACS, as Mass General uses ~~AMICAS~~ Merge PACS 6 as their web-client, something their old but functional Agfa 5.x doesn't have. His contributions to PACS are multitude as well, and he is perhaps the best choice to help Merge navigate the Meaningful Use maze. Dr. Dreyer has been a big proponent of Visage, so we may get to see how these two products play together.

Dr. Siegel is very well known in this venue. Rumor has it he will be sending Watson to the Advisory Board meetings as his proxy. The Baltimore VA has Centricity, and the University of Maryland has Agfa IMPAX.

Johns Hopkins still has Emageon PACS as near as I can tell, but the one really BIG NAME radiologist I don't see on the list, Elliot Fishman, M.D., complained (in 2007) about Emageon's inability to handle more than 100 slices before choking. Of course, that led him to use the Siemens Leonardo InSpace workstation. I don't know what PACS is in use at Hopkins today, however.

Dr. Boonn's University of Pennsylvania appears to have Siemens PACS, although I don't know if it is the new syngo.plaza or some older product. (UPDATE: I'm informed that U Penn now has Centricity.) As far as advanced imaging, the HUP website notes quite an arsenal:

Post-Processing: GE Advantage Windows, Vital Images Vitrea2, TeraRecon AquariusNet and INtuition, Siemens MMWP (Leonardo) and syngo.via, and QMass. Our 3D and Advanced Visualization Lab is staffed by four dedicated technologists who assist with workstation training for visiting fellows.

I couldn't find any reference to the PACS used at Northwestern (UPDATE: Northwestern uses Centricity), and Mount Sinai uses GE, I assume Centricity of one flavor or another, although I found mention of the use of OsiriX as well.

I certainly cannot fault Merge for choosing this very impressive panel as its Clinical Advisors. I don't think one could do much better, and this is the level of expertise I would expect to work with Messrs. Surges and Dearborn, not to mention Mr. Ferro, assuming he's working on this stuff at the moment.

I will certainly offer my services should there be some minor subcommittee formed that concerns itself with day-to-day operations of PACS software out here in the boonies. On that, I am somewhat of an expert myself. (Just ask Agfa.) I'm at your beck and call, folks. You know my number.

GE = Government Electric?

2011-10-03T21:19:00.001-04:00

I'm currently trying to drop a few pounds, in hopes of looking a bit less Buddha-esque. I'm following a program that encourages more plant-based foods, less meat and dairy, and more exercise. It's working, by the way, but don't expect me to provide Biggest Loser-style weigh-ins for your viewing pleasure.

Our ever-travelling First Lady, Michelle "Let Them Eat Arugula" Obama, has been quite involved in nutrition as well, and has helped publicize (if not develop) the new My Plate concept, replacing the old food pyramid:

Do I want the government telling me what to eat? No, but I do appreciate the research involved, and I might look at what they have IF I decide to do so. That's where it stops. The government is NOT invited into my kitchen.

But thanks to our friends at GE, and Mr. Immelt's friends in Washington, the government is about to take a little bitty baby step into your kitchen, should you purchase one of several new GE microwaves. From GE's appliance website:

1.9 cu. ft. capacity
1000 Watts (IEC-705 test procedure)
Circuwave™ 1000 cooking system
Cooking system provides more power for fast, more even cooking results
Built-in sensors monitor the moisture level in food and automatically adjust time and power to deliver perfect cooking results. One touch is all it takes.
Sensor cooking controls
Automatically adjusts time and power for delicious cooking results
Easy clean interior
Porcelain enamel interior makes it easier to clean dried-on foods. Non-porous surface also makes cleaning spills and splatters a snap.
Power Saver mode
Makes it easy to wipe up spills, splatters and dried-on foods.
X
This mode delivers a reduction in standby power while the unit is not in use. The clock continues to operate on schedule, while Power Saver is activated and during power failures.
Reduces standby power while the unit is not in use.
USDA MyPlate.gov menu
5 food groups, 19 foods and 44 pre-programmed food combinations assist in healthy meal preparation. Pre-programmed foods and recipes assist in preparation of healthy meal choices

Ummmm, wait just one minute. What was that last one? MyPlate.gov? Yes, indeed!

GE has kindly provided us with a button to access a U.S. Government-approved menu. GE is quite proud of this:

“Our goal with the MyPlate feature is to give consumers an easy way to choose and tastefully cook foods that are healthier for them, using graphics and instructions that are easy to understand,” Susan Gregory, product manager for GE microwaves, told Business Wire. “Providing quality cooked food for a wide range of items is a huge part of the MyPlate feature.” According to Business Wire, GE “worked closely with the USDA to ensure the MyPlate feature in their cooking products is in step with dietary recommendations.”

Here's how it works in practice:

OK, now I'm just weirded out. This is such a benign-looking, yet ominous development. General Electric has explicitly brought behavior "suggested" by the government, and especially the First Lady, into your home, at the push of a button. Think about this, and the implications. They are multitude.

For the moment, I'll assume that these microwave models are not Wi-Fi equipped, but you can bet subsequent models will have this feature, so as to truly access MyPlate.gov. Let me put on my tin-foil hat for a moment and ask you to keep in mind that Wi-Fi can upload as well as download. It is not a particularly great intellectual leap to consider the possibility of the oven transmitting what you are cooking, and presumably eating, back to GE, and then back to the government. Anonymously, of course, snicker, snicker. After all, GE was at the forefront of the Meaningful Use concept, which is, at its essence, nothing more than certification that your EMR is capable of transmitting data...back to the government. I wonder if other GE equipment is similarly ~~chipped~~ equipped. I don't want my CT or MR transmitting my pretty pictures anywhere, thank you. There are enough jokes in Washington.

Crazy? Paranoid? Maybe. But when two and two add up to five, I smell a rat. BiGE Brother might well be watching you, or at least your microwave. I'm going to stick with my old Sharp oven, which has been running well for 16 years, and doesn't transmit anything back to Japan as near as I can tell.

iPhone 5 Preview (WARNING! NOT FOR FAMILY VIEWING!)

2011-10-03T21:16:00.000-04:00

In honor of tomorrow's scheduled introduction of the iPhone 5 (or maybe the iPhone 4S?), Next Media Animation out of Taiwan presents this unauthorized preview. I've got a couple of partners who are anxiously awaiting the new iPhone; their resemblance to one of the main characters in this cartoon is purely coincidental.

WARNING!!! THIS VIDEO IS NOT FOR FAMILY VIEWING!

Merge RE-Focuses with Fovia . . . And Drops A Name

2011-09-30T17:12:00.000-04:00

Over two years ago, AMICAS announced collaboration with Fovia Medical, Inc. Read my post about it HERE.

On September 27, 2011, Fovia sent out this announcement:

Fovia Medical, Inc., a world leader in volume rendering technology, and Merge Healthcare, a leading provider of enterprise imaging and interoperability solutions, announced today that Merge will enhance and standardize its product offering by incorporating Fovia’s High Definition Volume Rendering® technology across its entire radiology PACS platform.

Merge, which provides image management as part of its comprehensive suite of radiology solutions, will now be able to fully capitalize on Fovia’s advanced visualization tools, therefore providing the world’s highest quality medical imaging to all of its PACS customers.

Fovia’s HDVR® server-side platform has enabled Merge to deliver high performance 3D imaging through its web-based architecture. With HDVR seamlessly integrated into Merge PACS, the company has taken advantage of Fovia’s scalable, CPU-based solution using entirely off-the-shelf hardware. By standardizing its various PACS products on an HDVR platform, Merge will be able to deliver tightly integrated, advanced visualization to its entire customer base, while simultaneously meeting their changing demands with Fovia’s flexible and highly customizable thin-client solution.

“Fovia’s powerful HDVR software provides Merge with the ability to offer unparalleled quality and performance to all of our PACS customers – both locally and over the Internet,” said Paul Merrild, Senior Vice President – Solutions Management. “Combining Fovia’s embedded software with our PACS products and services will boost radiology productivity by providing a unified workflow and consistent user experience, including the ability to view extremely large data sets interactively and in real-time.”

Ken Fineman, Chief Executive Officer of Fovia, stated, “We have built a strong relationship with Merge over the past year and are very impressed with their focus on customer satisfaction and end-to-end radiology solutions. Merge’s extensive, remote unified solution will provide a game-changing, streamlined experience for radiologists, and we are thrilled that our natively integrated HDVR will be showcased in such a robust offering.”

Which all sounds pretty similar to the 2009 announcement. (FYI, here is the 2009 press release from Fovia.) I'm assuming that the 3D engine on my current AMICAS PACS is made by Fovia, which makes me wonder about the purpose of these announcements. I do have it on good authority that the HDVR platform is executed in software on the production server, and does NOT require an additional rendering server.

You'll notice something rather sad in the current announcement; in fact, it heralds the end of an era. Nowhere is the word "AMICAS" mentioned; the system is now called Merge PACS. Oh, well. It had to happen, I guess.

With the name change come some improvements, a few of which I think are in response to my whining, I mean request for change. Merge announced some of the improvements here:

New Release: Merge PACS v6.2 From improved launching time to Instant Messenger, Merge PACS just keeps getting better! Below are some of the highlights of the new 6.2 release that will help you improve efficiency:
Halo will be operational as a native 64-bit viewer
Improved launching time for Halo
Bidirectional XML support which will improve third party integrations
PowerScribe 360 dictation integration
Instant Messenger for communication between Halo 6.3 workstations
Improved Mammography location algorithm to ensure accurate location of the breast tissue line
Embedded viewer rapid launch is intended for use with an EMR for rounding. Viewer will stay alive in the background enabling rapid restart.TSM migration tool will be used for moving studies form old jukeboxes and other storage devices to new archive subsystems, notably including ECM.

Did You Know? HALO
Q: How do I turn off the Patient Record option in HALO? A: Go to User and Groups Privileges in the Management Pages section. Select the check box location about a third of the way down on the Group Privileges section. This will turn off Patient Record for all of your radiologists. If any of the radiologists want to keep Patient Record, you will need to enable it at a User level instead of Group level.

The latter bit about turning off the Patient Record has made a huge difference for my group of cranky rads. The "Patient Record" is a sort of iSite-like extension to the Real Time Worklist (RTWL), which gives more direct access to prior exams. It was added more or less to satisfy a few users of both AMICAS and Stentor/iSite, and frankly, it bolluxed up the whole RTWL, which to me is what made AMICAS, well, AMICAS. I was quite thrilled to find the way to get rid of it, and so were my colleagues.

The release notes for v6.2 mention a number of other new and improved features, including Merge Messenger, an IM subroutine to allow communication between online users, 64-bit support, a new Exit button, and some other needed tweaks. The "voice clip" button will be moved to a more convenient location on the main tool-bar, something we had requested a while back to speed us along. If you are an AMICAS, I mean Merge PACS user, you will realize how this might help: in the current version, the voice clip button is tied to the study-level toolbar, and might be on the left OR the right screen, a bit confusing for something we use on many studies. It will now be placed (if desired, I think) on the main patient toolbar in a fixed location.

And coming in version 6.3 (or maybe later...check in at RSNA)--a PET/CT viewer! Too bad my AMICAS, I mean Merge PACS hospital doesn't have a PET/CT.

Ah, progress. I will miss the AMICAS name, however. Please feel free to send in photos (or the actual item) of anything you might have with the AMICAS amoeba logo...it might be valuable someday.

Calgary Approved

2011-09-30T16:05:00.000-04:00

Way back last year, when I wrote an article for AdvanceWeb.com about iPad apps for radiology, I featured the ResolutionMD program from Calgary Scientific, one of the first apps to use server-side processing and rendering as opposed to being an on-board thick-client.

Calgary has just received approval from the FDA for ResMD to be used as a mobile, diagnostic application, diagnostic being the key word here. From Calgary's website:

Calgary Scientific Inc. has received clearance from the UnitedStates (US) Food and Drug Administration (FDA) to market its industry-leading medical imaging application, ResolutionMD™ Mobile, as a mobile diagnostic application, in the US. With this secure, highly scalable, server-based software solution, physicians located anywhere can rapidly access, view, and interact with patient images and reports stored within any healthcare facility, and render a clinical diagnosis using their mobile devices. Prior non-diagnostic versions of this product are currently distributed and licensed under Original Equipment Manufacturer (OEM) agreements with global leaders in medical imaging and information technology. In addition to the recent FDA clearance, ResolutionMD Mobile has also been licensed by Health Canada and bears the CE Mark for distribution in Europe.

Those global leaders include GE, whose iPhone/iPad app is simply a rebadged version of ResMD.

Calgary's approach is at least in theory more secure, as patient data is never really resident on the mobile device:

. . .The mobile app offers unparalleled performance, advanced capabilities and complete security, utilizes minimal bandwidth and offers strong performance even on 3/4G wireless, and ensures that no highly sensitive or confidential patient information is ever retained on the mobile device. The patient image data cannot be lost or stolen, as in the case of traditional mobile-device rendered software, which requires that data to be sent to the mobile device. . .

And there's more:

ResolutionMD Mobile incorporates many advanced capabilities including:
Interactive 2D, MIP/MPR and 3D advanced visualization
Anywhere, anytime access to andfully interactive use of MR and CT image
Supports HIPAA Compliance –User authentication and encrypted communications further protect confidential patient information
Concurrent support for Multiple Devices and Mobile Operating Platforms – The solution enables ResolutionMD Mobile capabilities on devices such as the Apple iPhone and iPad,as well as Android devices. Future versions of the server-based software solution will support an expanded list of mobile devices and operating systems, and supplementary applications to the FDA for clinical diagnostic imaging approval on those devices other than the iPhone and iPad will occur in then near future.
Ambient Light User Assessment –Provides sample images to the user to assess the viewing suitability of current lighting conditions.
ResolutionMD Mobile is currently available on Apple iPhone and iPad devices through the Apple App Store. A demonstration version (ResolutionMD Mobile Lite) is also available on the Apple App Store, providing access to anonymized patient images. The ResolutionMD Server is available from Calgary Scientific Inc., as well as from its family of global leading OEM partners in medical imaging and information technology.

Clearly, this system is in direct competition with Mobile MIM, which was FDA-approved for mobile use back in February as I outlined here. It's hard to say which approach will win out, and most likely both apps will find their way into the clinical armamentarium. I personally give a very slight edge to thin-client, server-side processing, BUT we have to keep in mind that this approach is totally dependent on bandwidth, which the thick-client approach isn't, but how much of an impact that has on usability remeins to be seen. I'm sure we'll see others in this venue in the near future.

Another Nail in Speech Recognition's Coffin

2011-09-25T17:13:00.000-04:00

I have not been a fan of Speech Recogniton (it is NOT VOICE RECOGNITION!!!) for a number of reasons. First, it takes my eyes off of the image, where they are paid to be, and forces me to look at the developing report. Second, it turns me into an unpaid editor, doing the transcriptionist job for free. And finally, it doesn't work very well at all.

That last point is often disputed, but a recent article in the American Journal of Roentgenography reiterates the fact. And it is a fact. Basma, et. al., took the following approach:

We scrutinized 615 reports for errors: 308 reports generated with ASR (data from the hospital at which ASR had been used for 2 years) and 307 reports generated with conventional dictation transcription (data from the hospital that continued to rely on transcriptionists for report generation). A total of 33 speakers made the 615 reports; 11 speakers used both ASR and conventional dictation transcription. . .

The voice recognition software used was Speech Magic (version 6.1, service pack 2, Nuance). ASR reports were verified and signed by the author as they were generated. If the speaker was a fellow or resident, a staff member was responsible for reviewing the case before dictation of the report. Dictation was completed with a handheld speech microphone (ProPlus LFH5276, Philips Healthcare).

Conventional dictation transcription was undertaken using the E-RIS transcription system, version 1.44 (Merge Technology). Transcription was completed by transcriptionists experienced in breast imaging reporting. Once transcribed, reports were sent to the original speaker for electronic amendment and verification.

All reports dictated by attending radiologists or trainees were reviewed on the radiology information system at an electronic PACS workstation, corrected for errors, and verified, making these reports immediately available on the hospital clinical information system. The speaker assumed complete responsibility for report production, including correcting typographic errors generated by the voice recognition software or the transcriptionist.

And the result?

Among the 308 reports generated with ASR, 159 reports (52%) contained at least one error compared with 68 of the 307 reports (22%) generated with conventional dictation transcription (p < 0.01). Reports generated with ASR were also more likely than conventional reports to contain at least one major error (23% vs 4%, p< 0.01).

A total of 230 errors were found in 159 ASR reports. The most common error types were added word (46 instances, 20% of total ASR errors), word omission (43 instances, 19%), word substitution (39 instances, 17%), and punctuation error (49 instances, 21%). A total of 77 errors were found in 68 conventional dictation transcription reports. The most common error types were word substitution (15 instances, 19% of total conventional report errors), word omission (13 instances, 17%), added word (11 instances, 14%), and punctuation error (14 instances, 18%). . .

Our data showed that breast imaging reports generated with ASR are 8 times as likely as reports generated with conventional dictation transcription to contain major errors, after adjustment for native language, academic rank of the speaker, and breast imaging modality. Twenty-three percent of the reports generated with ASR reviewed in this study contained at least one error that could have affected understanding of the report or altered patient care.

They conclude:

Complex breast imaging reports generated with ASR were associated with higher error rates than reports generated with conventional dictation transcription. The native language and the academic rank of the speaker did not have a strong influence on error rate. Conversely, the imaging modality used, such as MRI, was found to be a predictor of major errors in final reports. Careful editing of reports generated with ASR is crucial to minimizing error rates in breast imaging reports.

This comes as no big surprise. You might wonder why so many ASR mistakes get through. Jay Vance, CMT, author of the AHDI Lounge Blog (Association for Healthcare Documentation Integrity, not ADHD...) comments about this on HISTALK:

“…why the radiologist didn’t catch the mistakes on the screen when using speech recognition…”

As someone intimately familiar with speech recognition editing, I can tell you the eye tends to “see” what the brain tells you SHOULD be there rather than what actually IS there. This is a well-known phenomenon among SR editors. Add to that the fact that the physicians dictating these reports using front-end SR are in a hurry to just get it over with, and it’s no surprise to see such a high error rate.

“Also keep in mind that this compared only two transcription options, with the third being back-end speech recognition…which I believe has much higher accuracy…”

You make a valid point, but the issue isn’t the comparative accuracy of front-end versus back-end SR. The comparison is between reports reviewed by a second pair of eyes versus those which are not. Whether a report is transcribed “from scratch” or edited from a SR draft, in both cases there is a skilled healthcare documentation specialist reviewing the original dictation. With front-end SR, however, it’s once-and-done, which of course is the holy grail of clinical documentation. The problem, as this study clearly shows, is that once-and-done dramatically increases the risk of medical error. Unfortunately, that risk doesn’t seem to get factored into the ROI when the front-end SR vendor is making the sales pitch.

We in the medical transcription field are doing our best to highlight the crucial risk management/clinical documentation improvement role our practitioners perform as a matter of course, a role that up to this point seems to have been taken for granted. Studies like this help prove what we’ve been saying all along: removing skilled healthcare documentation professionals from the process puts patients at risk, not to mention increasing liability for healthcare providers and jeopardizing reimbursements due to improper documentation. That’s a message we’re determined to deliver to the rest of the healthcare community as well as the public at large.

Emphasis mine. But that says it all. ASR has at least the potential to put patients at risk and increase liability. ASR does increase turn-around time, but really only for those sites that don't have adequate transcription personell. And you can see the price that one might possibly pay to save the cost of a few FTE's.

It will not be darkening my door for the foreseeable future.

Visitors From Afar

2011-09-23T16:33:00.001-04:00

As one of only a few sites running Agfa IMPAX 6.5, we were asked to host some visitors from afar, who are using an earlier version of IMPAX. They must decide if they should

Stick with what they have, which includes using another vendor's product for web-access
Move to IMPAX 6, which is why they came here, or
Jump ship to another vendor

Tough choices. I must add that their site has about a zillion Terabytes of data, and the thought of migrating is painful, and the cost steep, though still in the realm of possibility.

They group was interested in speaking to me, The Dalai Lama of PACS, in hopes that I might have some wisdom beyond the rather high level of expertise these folks brought with them. Frankly, I suspect they were disappointed. I gave a rather disjointed tour through IMPAX 6.5, and it had the bad taste to actually run properly for the visitors, just like your car won't make that annoying noise once you actually get it to the shop.

I've chronicled our trials and tribulations with IMPAX 6.x over the years, so I won't rehash them here. Suffice it to say that when it works, it works OK. When it doesn't work, well, just ask the folks in Western Australia how much fun that can be.

They say familiarity breeds contempt, but in my experience, I think familiarity more commonly breeds comfort, or at least complacency. It's hard to diss an IMPAX completely, especially when we've had mostly smooth sailing. The most recent gripe hasn't been with IMPAX per se, but with an integration to a digital voice system that got more and more wonky until it quit altogether following server upgrades. There have been numerous little things like this which get us upset. Add that to the old tool-toggling crap, and to weird things like the way someone else can dive into a study I'm already reading, and you have those special things that drive me to drink...more than I already do.

What I can say with confidence is that Agfa's upcoming Agility, IMPAX 7, if you will, will be significantly different, and almost certainly better, than its predecessor. This should probably figure in our visitors' equation somewhere. Does that answer the question?

Delousing Denoising CT

2011-09-22T21:17:00.004-04:00

I mentioned below about the possibility of a SPECT/CT purchase, which may not happen for a while, especially given the fact that no one yet makes a 64-slice version. But there does seem to be some chance to purchase a shiny new CT scanner and a bundled advanced imaging package. Our hospital needs to upgrade for a number of reasons, not the least of which is the desire to decrease radiation dose.

Most of the technology and mathematics involved in cutting dose is beyond the scope of this article (and my meager intelligence). Better detectors and newer tubes play a part, of course, and there are other ways we can improve our acquisition.

Remember, the whole point of X-ray-based imaging is to see what's inside the patient's body, and we generally do this by mapping in some fashion the density (more accurately, the attenuation coefficient) of the various tissues. In the X-ray world, which includes Computed Tomography as most use the term, we do this by passing a beam of X-rays through the victim, I mean patient, and do something to detect it at the other end. Wilhelm Roentgen, our HERO, discovered that placing a piece of film on the other side of the body part would act as a detector, showing us how much radiation got through which parts, yielding a nice map of Mrs. Roentgen's hand.

Not very sharp, I'm afraid, and the amount of radiation Roentgen's old Crookes Tube produced would scare the pants of any self-respecting health physicist today. Various improvements have come about in the last 110 years, or so, including far more sophisticated tubes, better film, the addition of a phosphorescent screen, Bucky grids, and of course, the conversion from film to Digital and Computed Radiography (DR and CR).

CT is a different but related X-ray animal. Click on the animation below:

You don't want to hear about the math (which has been around since discovered by an Austrian named Radon in 1917), but basically, passing a beam of X-rays through an object from various perspectives yields data that can be reconstructed into an image of the original object. Here is how it works with a CT of the head:

Ever since CT came about, there have been attempts to lower the dosage of X-rays required to get a decent picture. In the last year or so, perhaps due to scary articles like THIS, dose reduction has become quite in vogue. I don't mean to be flippant, as radiation is something that deserves respect and careful handling, much like electricity, but I just have to laugh a bit about the mania that has taken over. The potential dangers are nothing new, and we really don't need to panic. We've been dealing with this for quite a while.

The main principle of handling radiation in the imaging world is called ALARA: As Low As Reasonably Achievable. That doesn't mean we avoid necessary studies, but we are simply attempting to do what we can to lower the dose, and still answer the question that prompted the exam in the first place. Working within this framework gives us some direction.

So...in very basic terms, we can reduce the dose by decreasing the radiation passed through the patient. We can use higher energy beams which do indeed pass through the patient more cleanly, if you will, stopped by less tissue, and therefore depositing less energy, but, alas, we reach a point where we don't get much detail. We can send fewer X-rays through the patient, but too few and we don't see, ummm, stuff. OR, we can increase the sensitivity of the detector, so we don't need so many X-rays. OR.... we can use mathematics to recover information from a crappy image, thus lowering the dose and "rescuing" the picture later.

You REALLY don't want the details of the mathematics involved here, but the newest scanners use something called iterative reconstruction to this end. Let me just borrow the definition from the Wikipedia:

The reconstruction of an image from the acquired data is an inverse problem. Often, it is not possible to exactly solve the inverse problem directly. In this case, a direct algorithm has to approximate the solution, which might cause visible reconstruction artifacts in the image. Iterative algorithms approach the correct solution using multiple iteration steps, which allows to obtain a better reconstruction at the cost of a higher computation time.

In computed tomography, this approach was the one first used by Hounsfield. There are a large variety of algorithms, but each starts with an assumed image, computes projections from the image, compares the original projection data and updates the image based upon the difference between the calculated and the actual projections.

There are typically five components to iterative image reconstruction algorithms, e.g. .^[2]
An object model that expresses the unknown continuous-space function $f (r)$ that is to be reconstructed in terms of a finite series with unknown coefficients that must be estimated from the data.
A system model that relates the unknown object to the "ideal" measurements that would be recorded in the absence of measurement noise. Often this is a linear model of the form .
A statistical model that describes how the noisy measurements vary around their ideal values. Often Gaussian noise orPoisson statistics are assumed.
A cost function that is to be minimized to estimate the image coefficient vector. Often this cost function includes some form of regularization.
An algorithm, usually iterative, for minimizing the cost function, including some initial estimate of the image and some stopping criterion for terminating the iterations.

Aren't you glad you asked? Basically, you keep plugging your image back into the computer until it looks good. The major vendors all have iterative recon in one form or another. Now, I must give credit to GE, whose new VEO system (which just won FDA approval) goes this one better, and I'll let my friends from Medgadget tell you how:

For decades, the standard CT image reconstruction algorithm has been filtered back projection, which uses mathematical methods to reconstruct tomographic images from the projections that are obtained by the circling detectors. More recently, a new reconstruction algorithm, adaptive statistical iterative reconstruction (ASIR), has been introduced that performs modeling of the noise distribution, cutting radiation dose by up to 80% for many applications.

Model-based iterative reconstruction (MBIR), employed by Veo, goes a step further by incorporating a physical model of the CT system into the reconstruction process to characterize the data acquisition phase, including noise, beam hardening, and scatter. It has the potential to cut radiation doses even more but is computationally more demanding, leading to longer reconstruction times (which will gradually become less of a problem with ever increasing computing power). It may potentially deliver lower noise, increased resolution, improved low contrast detectability and fewer artifacts. Veo is available on the GE Discovery CT750 HD system, and is suitable for use throughout the body.

This is really, really clever. The resulting image (bottom pane) looks pretty good as compared to standard reconstruction (top pane):

I'm assuming the modeling has to be done for each individual machine, because there are variances in even the most precisely-made product. No doubt there is scanning of some some standard phantom followed by back-tracking to form a mathematical version of what the scanner looks like to the average photon. Keep in mind, though, this is all done in software, not in hardware, and software can be reverse-engineered. Thus, I doubt GE is going to have this exclusively for much longer. Still, credit where credit is due. This was a rather brilliant innovation. It does seem to take a LOT of computing power to run these numbers, however, and the reconstruction is far from instant. I'm thinking GE needs to set up something like the old SETI desktop program wherein concerned individuals could donate their computers' idle time to the processing of medical images.

No one has mentioned applying the above techniques to old scanners, but there are a lot of them out there, and they need some low-dose love, too. I've encountered two vendors who promise to provide that love. For a price, that is, and substantially more than what love goes for on the street corner not far from one of our hospitals.

The good folks from Sapheneia in Sweden are very anxious to sell you this:

The Sapheneia product Clarity Server is a software providing image quality enhancement optimized for greater diagnostic confidence. Clarity image processing algorithms enable radiologists to lower radiation dose exposures during image acquisition.

Clarity directly addresses the continued medical community concerns of increased radiation exposure to primarily pediatric and female patients and safety concerns for the clinical staff.

Clarity incorporates image-filtering techniques that are configurable based on medical modality and medical observer. Clarity utilizes 3D information for the image optimization and enables both noise reduction and edge enhancement in the same image.

Clarity is applicable to current CT modality technology and supports older generation technology, extending the lifetime of existing instrumentation.

To be characteristically blunt and pugilistic, the Clarity Server is a computer that sits between the CT and the PACS, massaging the data, and prettifying the images that you have deliberately scanned at suboptimal parameters, in hopes of recovery to robust diagnostic status. I'm not so sure about this approach. (Could you tell?) While I haven't confirmed it, the third paragraph from Sapheneia suggests to me that all they are doing is simple digital filtration of the images, smoothing (Gaussian noise reduction) and then edge-enhancing, as you can do with the free Photoshop clone, Gimp2. This should be something that is built into your PACS viewer, and so it has been, at least partially, in AMICAS PACS since version 3.x. OK, AMICAS just gives you a few steps of edge enhancement, but it proves the concept. One press of the "S" key sharpens every CT slice in your study.

Here's a single slice with progressing grades of edge enhancement:

Original

Mild Enhancement

Moderate Enhancement

Too Much Enhancement!

Now, let's try an experiment with Gimp...We'll take the mildly-enhanced image and smooth it and then sharpen it a bit..

Mild Enhancement

Mild Enhancement with Smoothing and Resharpening

I didn't spend a lot of time on the processed image, but you get the idea...you can, to some extent, ~~decrapify~~, I mean denoise, a suboptimal image.

The real question we have to ask is whether or not data gets lost in the process. Sapheneia shows charts and so on that show various parameters are improved, mainly SNR and CNR (signal and contrast to noise ratio, respectively) but that doesn't necessarily mean that some details aren't smoothed out in the process. I haven't yet found a paper that proves or disproves my paranoia, but I'm going to keep looking. In the meantime, Sepheneia has apparently jacked up the price on the magic box considerably in light of the dose mania over here in the States.

Another vendor offers similar denoising as part of their advanced imaging suite. Vital Images, now owned by Toshiba, has made it through my door in spite of misgivings from way back, not to mention the fact that Larry D. still works for them, and the new Vitrea looks pretty good. It includes a denoisify function which applies similar filtering to legacy CT images. It can be toggled on and off, something which I'm not sure the Sapheneia box can do. From Vital:

The Noise Reduction menu
Most of the Vitrea protocols contain a new menu button in the bottom right side of the MPR viewer and the 3D viewer to open the menu for the Noise Reduction settings.
The menu contains a list of predefined filters and tools to create, save and modify custom filters

Applying an existing filter
To apply an existing filter in both MPR and 3D viewer, open the Noise Reduction menu and select one of the available filters. The filters are sorted from more conservative – on the top of the list (Preserving the small details - less blurry but with limited noise reduction) to the most aggressive filters at the bottom of the list (strongly reducing noise but they may blur the thin details in the images).

The Classic filters
2 numbers (Classic) or 3 numbers (Advanced) follow the custom filter names they also appear in any filter annotations in the MPR or 3D images. Example: Smooth_25x30.

The first number (here: 25) is the smoothness of the result. Small smoothness values (such as 4 or 8) will preserve the image sharpness but with limited noise reduction. Larger values (12-40) strongly reduces the noise with increasing compromise in the image sharpness.

The second number (here: 30) is the Contrast. A low contrast value will make the filter more sensitive to the orientation and strength of the images edges. In other words, it will preserve structures with a low contrast but it will limit the denoising strength.

Higher values for contrast will preserve only stronger structures and will strongly reduce the noise at the expense of blurring low contrasted details.

The Advanced filters
The Advanced filters have 3 values: Smoothness, Contrast and Structure.

The Smoothness and Contrast are discussed earlier in this document (see Classic Filters).

The Structure number indicates how much 3D structure (like small vessels, focal lesions, etc.) you want to preserve at the expense of a reduced noise reduction. Low values for Structure preserve the details but may preserve speckles in the images and reduce the denoising strength. High values for structure will remove speckles but may preserve fewer edges.

Sure sounds like simple image filtering to me. These can be applied to 3D renderings, a nice touch.

Now, there are far more advanced methods to denoisify than simple filters, and if you really want to punish yourself, have a look at THIS thesis about using wavelets (the same stuff used in teleradiology compression) to do the job. I'm not going there, but you'll be glad to know that there is a GIMP denoisifying wavelet filter app for that.

In the end, we have a few choices to achieve dose reduction. We can all go out an buy new scanners with the most efficient X-ray tubes and detectors, and the best iterative reconstruction. These babies bring in the dose for a cardiac CT, for example, below 1mSV, which is very, very low indeed. But if you don't have a couple of million lying around, should you invest in one of the after-the-fact denoisers? I'm not yet certain. They can definately give you a prettier picture, but will they obscure important findings in the process? That is indeed the Million Dollar question.

Of course, the most-overlooked path to dose reduction, like the best but least-respected contraceptive, is abstinence. Think before you order a scan.

Nahhhhhh. Never mind.

Oh, SPECT/CT Vendors...

2011-09-15T23:20:00.000-04:00

I've got a little money burning a hole in my pocket...

We need a SPECT/CT, and last year, at RSNA, I had the chance to evaluate the main contenders, which are discussed in THIS post. The Siemens Symbia T-16 and the GE Discovery NM/CT 670 appear to be good machines, although I was not that impressed with the sample SPECT data from either one. Siemens probably has the better gamma camera and GE has a newer flavor of CT. Decisions, decisions.

But Houston (or Milwaukee/Erlangen), we have another problem: To justify spending what we have to spend on this thing, we will need to use it as a stand-alone CT at least some of the time. So I need a real workhorse CT, one that can do bread-and-butter scanning. Which in this day and age includes cardiac work. Thus, I need a 64-slicer attached to my SPECT.

Right now, the only 64-slice SPECT/CT is the GE Discovery NM/CT 570c:

The "c" is for Cardiac, and you'll note that the heads are fixed at 90 degrees, with relatively small detector-faces. But it demonstrates the principal I seek.

So, dear vendors, if you are really interested in selling me a SPECT/CT, bolt one of your fine 64-slice CT scanners to your best SPECT camera, and we'll talk.

Is there a discount for cash?

You Can't Make This Stuff Up...

2011-09-13T22:17:00.001-04:00

Be prepared to cringe...From Metro.co.UK comes this whale (or eel) of a tale....

Eel removed from man's bladder after entering penis during beauty spa
An erratic eel wriggled its way up a man's penis and into his bladder following an accident during an unorthodox beauty spa in China.

Zhang Nan was bathing with live eels to cleanse his skin when one rogue serpent took a liking to his manhood.

Thinking that the eels would make him look ten years younger, Nan dived into the water and let them feast upon layers of dead skin.

The eel treatment in question is a similar concept to the popular London spas that offer fish pedicures.

But after laying in the spa bath, Nan felt a sharp pain and realised a small eel was working its way up his urethra and into his bladder.

'I climbed into the bath and I could feel the eels nibbling my body. But then suddenly I felt a severe pain and realised a small eel had gone into the end of my penis,' the 56-year-old from Honghu, Hubei province said.

'I tried to hold it and take it out, but the eel was too slippery to be held and it disappeared up my penis.'

(OK, that's enough cringing now... it's horrible, though, we know...)

Rushing himself to hospital, the man underwent a three-hour operation to remove the six-inch eel which was dead by the time doctors found it.

Surgeon Jin Wang said that, because of the eel's slippery nature, it was able to make a smooth entry into the genitals of Nan.

'The diameter of the urethra in a man's penis is just a little narrower, but because eels are quite slippery, its body worked as a lubricant and so it got into the penis smoothly,' he said.

(Really - stop cringing - we can see you...)

Believe it or not, Nan's case follows a similar incident when a 14-year-old boy in India had to undergo emergency surgery.

In a case study published by urologists Dr G Vezhaventhan and R Jeyaraman, they described how they removed a 2cm-long fish from the boy's bladder.

The teenager said that while holding the fish he had gone to the toilet and, while urinating, the fish had 'slipped from his hand and entered his urethra'.

Hmmm...

Yup. You can't get this news on Fox, now can you? Hat tip to Drudge, by the way.

Dalai's First Law Strikes Again!

2011-09-09T10:40:00.001-04:00

It's been over a year since IMPAX last crashed, as documented in THIS post.

Today, however, we have a new crash, something with the Application Servers I'm told, taking down the Radiology Departments of three hospitals on the common network, and idling several rads who need something to do, not to mention inconveniencing (or worse) dozens and maybe hundreds of patients.

Lest you forget Dalai's First Law:

PACS IS the Radiology department.

This is never more apparent than when you lose functionality. I'll let you know how long this one lasts.

ADDENDUM

We're back online after only an hour and about 100 studies. It seems that some SSL certificates didn't go in properly... Amazing how something relatively minor can disrupt everything.

Many thanks to our intrepid PACS admins and service personnel for solving this conundrum!

Why 6.5?

2011-09-08T16:25:00.003-04:00

To The Gentlemen From Invivo And Philips

2011-09-07T22:22:00.001-04:00

Yes, that was me. Excellent presentation. Thanks for your time. Looking forward to seeing more!

Dalai

Dalai Loves S&M, I Mean SNM!!!

2011-09-05T17:47:00.001-04:00

In this economy, one has to try to save a buck wherever possible. So, if there is a way to use my perverse talent for profit, I'm always game to try it.

Just after I diligently paid my annual dues to the Society of Nuclear Medicine, I discovered the following contest, sponsored by SNM:

We Want to Hear (and See) You!Send SNM a video telling us why you love being an SNM/SNMTS member.
You might win a free one-year renewal!As a SNM/SNMTS member, you already know about all the great benefits you receive:
A growing network of 16,000 diverse professionals in the field…
across the globe and in your backyard through 14 state and regional chapters. Plus, SNM’s member directory makes contacting peers a breeze!
Resources to help inform, educate and advance…
through leading professional development options, including the ability to evaluate your CE activities and view your certificates in the CE Center, molecular imaging resource library and web access, advocacy presence, and research and publishing opportunities.
Ongoing support through grants, scholarships, and awards…
helping to support, sustain, and reward the best and the brightest in the field of nuclear medicine and molecular imaging.
And so much more…
including heavily discounted registration to SNM’s Annual Meeting, valuable member discounts on publications and products, and enhanced functionality on the SNM/SNMTS Job Bank!
Now, we want to hear why YOU value SNM.Is it the networking? The research? Leading publications like JNM? Premier educational events?
Record yourself telling us your reason in 60 seconds or less. Then upload your video to SNM’s Facebook Page by September 9, 2011.The Top 5 videos (voted on by SNM Staff) will receive a free one-year SNM renewal.
What are you waiting for? Put on your best smile, then Lights! Camera! Action!

So without further ado... If this isn't worth a year's membership, I don't know what is. Maybe they'll give me two years worth if I erase the whole thing!

Distorted Reality?

2011-08-30T23:05:00.000-04:00

Anonymous, who I think is from BDM Information Systems, a division of GE, left the following comment on my Buffett post after spending almost an hour perusing my site:

Your perception of reality is distorted. This is true for us all, but in your case it is pretty bad. If you are born with a lesser brain, raised poorly given poor education then you will not fare as well as your neighbours who were dealt better hands in life. You were lucky to become who you are. A decent brain, good upbringing (I assume). Now you don't want to share your luck with those less fortunate than you, and you insist on calling it hard work - not luck - failing entirely to recognise the gifts that made you work hard.

So here we are. The narcissistic Leftist generosity rears its distorted head. So...there are those who are just so far below us, so "unlucky" that we OWE it to them to share our "luck". A slightly different twist on the same old stuff. But stand and take notice, folks: Anonymous declares that these "unlucky" people have "lesser brains", the first time I have EVER heard this blatant discriminatory phrase come from the Left...or the Right, or anywhere else! Ten points for honesty, and by that I mean Anonymous has stated what he really thinks. If I were one of those "unlucky" folks, I might be offended. Of course, the Left has trained the "unlucky" to expect and demand that the "lucky" share their luck.

Notice that Anonymous removes ALL responsibility from the "unlucky". They are simply "unlucky", I guess. Their meager brain-power cannot process the consequences of their bad choices. And thus, we should "share the wealth" or the "luck" if you prefer. There is not thought of helping them improve themselves or their lot. All we EVER hear is that the greedy "rich" won't help anyone. Siffle, sniffle.

Clearly, Anonymous didn't read the post, but assumed it said what he wanted it to say. Greedy, selfish Conservatives. Which is not what I said at all. Behold what the figures bear out: the "rich" or "lucky" are already paying all the federal taxes. I guess this isn't enough for the Left. The "lucky" apparently are expected to give everything to the unlucky until everyone's lot is equal. And the "lucky" are supposed to keep up the hard work, which apparently is a gift and not something they earned, so as to keep funneling adequate funds to the "unlucky".

I'm sorry, Bunky, but I think I do close to my share. Between federal, state, local, sales, capital gains, and whatever other taxes, I pay well over 50% of my income out to some government agency or another. That's a lot. In addition, My group writes off 10-15% of its income as bad debt, serving the underserved, or "unlucky", who cannot pay.

This argument played out on AuntMinnie.com recently. My friend Dr. Sardonicus pointed out:

I, and basically all of my radiology colleagues, give away 25-30% of our services. Give away, as in free. And then on the 70% that we do collect on, we lose about half of that in taxes. If you were radiologists, then you would know this.

My personal contribution to the poor through free care is many miilions of dollars (I am an experienced radiologist). So, I am pretty much immune to anyone trying to lay a guilt trip on me.

Now, if you personally feel guilt, then please take care of your guilt yourself, and leave me out of it. There are many opportunities to volunteer, and, I guarantee you that volunteering at a free clinic will be much more economically efficient than contributing the money you make at work to the government in the form of an additional check to the IRS. If you were to donate a days work worth of money to the IRS, I guarantee that by the time it got to any poor people it would be 1% of what you gave them, after all the bureaucratic friction in the system burned up the rest.

But my friend Thor, who is a Leftie academic rad, poo-poo'd the thought of generosity:

Well goodness me gracious...how silly of me not to congratulate you on your many contributions to society. Now stop being so pious. You say all this yet I am sure you are not starving or wanting for anything, correct? You knew this was the situation when you went into Radiology correct? You do know that others pay higher fees to make up for your charity care and if everyone could pay your price would be lower so your not really "giving anything away", correct?

Sardonicus responded:

Disagree.

Hospitals are not the same as professional corporations. They can manage the amount of indigent care they give. (particularly for profits). Indigent care is often compensated by increasing fees in other areas, as I am sure you know. . .The hospitals are fat, they do not suffer from indigent care, they pass it on. Meaning - in the face of this vicious recession, in towns where other industries are failing, hospitals are complaining because their profit is somewhat lower.

On the other hand, physicians can't simply raise fees or divert indigent care to counter cuts in reimbursement. When people don't pay (like in the last two years), my pay goes down, while I am working longer hours than before. The decrease in my pay and increase in work is essentially an increase in contributions to charity care. The primary cares are in worse shape, and have been decimated over the past 10-20 years. They can't simply jack up their fee to insured patients. Not allowed, controlled economy. That is why you see many of them becoming employees of hospitals, or becoming essentially the overseer of an army of physician extenders, or refusing to accept medicaid/medicare.

So while you may have to pay higher insurance rates to cover the indigent, I also have to pay higher insurance rates, and my income is significantly down as well.

Thor: spare us the condescending, supercilious tone.

I rather expected someone would attack. I am not expecting beatification. I rarely talk about this, and yes I did expect to do charity care and it is part of the job. I have no problem giving away my services to those who need it. In fact, I have tried many times to give away my services to someone I knew was in need, only to be told by attorneys that it would be insurance fraud and I couldn't write it off, I had to bill them. I couldn't even whisper to them to ignore the bill. Did it anyway.

Here is the point you missed: Most people don't understand that we give away our services on a regular (like every hour of every day) basis. Mostly I don't care if they don't know. BUT when people start slinging mud about high earners taking and not giving, some education is in order.

And, as above, NO ONE pays higher fees to make up for my donated professional time. We cannot raise our fees. We are in a constant battle to reduce the amount they will be reduced by. (see thread on the new CMS rules which are designed specifically to pay radiologists less for their services). I know a surgeon in a small town in our state that was hit with high layoffs. Suddenly, her "no pays" became so high she was insolvent and had to close her practice and move to another town. The hospital, by the way, seems to be making it OK. In this situation, Thor, your assertion is that other patients would pay more and that would keep her income stable. Do you see that it doesn't work that way? (By the way - our group stayed in that hospital and is taking a big hit on the no pays. It is costing us money to stay in that hospital, we can't recoup the salary paid to the people we staff it with, so I feel it directly in my reduced paycheck. Again - your idea of how this works is incorrect).

I expect no sympathy, but I expect greater awareness. I expect not to be beaten up by those with a limited understanding of the real situation. What I would like to see is an understanding that every PP radiologist (OK, every PP physician) donates substantial amounts of his/her time to the cause of indigent care. Can we have a cessation of the discussion that doctors do not contribute enough? I know of no other profession, no other business that gives away as much as we do.

Anonymous, in his Leftist, narcissistic zeal to show what a wonderful, caring guy he is, disses the "lucky" for not wanting to do even more than they already do. I'll wager he doesn't pay the amount of tax I do, nor does he donate the services given away by my group. And as Dr. Sardonicus clearly points out, we DO give them away. I can pretty much guarantee that if Anonymous got really "lucky" and won the lottery, he wouldn't give the proceeds to charity, and he would complain loudly about the 50% bite Uncle Sam will remove from the winnings.

All I can do is wish everyone "Good Luck"!

GIDI-Up!...and OUT!

2011-08-30T16:00:00.000-04:00

A golden oldie post from 2007. We now have integrated digital voice recording, which magically crashed following server upgrades. Seems the XML codes from iRecorder aren't being heard by IMPAX. My partner Dr. Killer longs for the days of the GIDI. How nostalgia clouds our memories...

Image courtesy of: http://www.kinkelder.org/

Just about every medical student has read Sam Shem's novel, "The House of God" and most can recite the 13 Laws by heart:

GOMERS DON’T DIE.
GOMERS GO TO GROUND.
AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
THE PATIENT IS THE ONE WITH THE DISEASE.
PLACEMENT COMES FIRST.
THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14 NEEDLE AND A GOOD STRONG ARM.
AGE + BUN (Blood Urea Nitrogen) = LASIX DOSE.
THEY CAN ALWAYS HURT YOU MORE.
THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
SHOW ME A MEDICAL RESIDENT WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

I can attest to the fact that these laws are really fairly accurate. But I wanted to bend one of the laws a bit as an introduction to today's topic, the GIDI.

The GIDI is an example of Dalai's version of the 11th law: SHOW ME A PROGRAM OR TECHNOLOGY DESIGNED BY ENGINEERS FOR I.T. WITHOUT PHYSICIAN INPUT THAT ONLY TRIPLES MY WORK AND I WILL KISS IT. This will make sense shortly.

You are naturally asking, "What is a GIDI?" Well, the official title of this software extravaganza is "Generic IMPAX DTMF Integration," and it was designed to help us communicate reports to the outside world. It was a good idea, with all the right intentions, but we all know what the road to Hell is paved with, don't we?

Here's the problem the GIDI was designed to solve: We have Agfa Impax PACS, as if you didn't know, and we also have an older Dictaphone analogue voice dictation system. As we dictate happily along, there must be a way to enter the patient into the system for the transcriptionist to know whose report she is typing. Prior to the GIDI, we had the option of simply reading the patient ID, or the accession number, or something like that into the mike as the beginning of the dictation. There is also the option, if it is set up to do so, of keying in that same number with the pad on the dictaphone head-unit. From the Agfa GIDI manual:

GIDI was written because tones describing the images must be manually dialed into the dictation system. This is slow, tedious, and error prone.

I'll agree with that. So, Agfa was commissioned to write the GIDI!

GIDI introduces a more efficient workflow. The application automatically starts at boot time with Impax and waits for a user to press the "start dictation" button on Impax. GIDI is aware that the button has been pushed and uses the modem to dial into the dictation system a series of tones based on Impax study information and user specified settings. The radiologist then makes their recording. GIDI is also aware when the user presses the end dictation tone, which causes the Impax study to be updated such that the dictation is complete.

If you're interested, this is the control panel for the GIDI set-up.

On our particular Dictaphone implementation, The GIDI buys us two things: first, we don't have to enter the accession number (although we usually dictate it anyway), and second, the voice dictation can be called up by telephone from the system if you know the patient's ID. This allows for instant gratification when transcription turn-around just isn't good enough.

To this point, everything sounds great. Now, here's how it works in practice. A SoundBlaster board is placed in your workstation computer if there wasn't already one there, and it is connected to a modem output. The modem AND your dictaphone are connected in parallel to the telephone line. You start the GIDI by double-clicking its icon, if it didn't start by itself, or if it shut off, and then you activate the Dictaphone, which dials into the tank. When you begin a dictation by clicking the proper button, Mr. GIDI transmits the tones over the phone line, Dictaphone gives a voice prompt, and off you go. When done, you click the "Dictated" button, the termination tone is sent through, just like pressing "end" on the mike, and you are ready for the next victim.

Sounds pretty straight-forward, right? This should be a labor-saving device for all involved. Except for one little problem. It is a true pain in the backside to use. It was overengineered and undertested. In actual use, the tones are transmitted VERY SLOWLY. Yes, an extra 6 seconds per study is no big deal, unless you are reading 200 studies a day as we do some weekends. That would be 1200 seconds, or 20 minutes. Let's see...even an extra 10 minutes per day, working, say, 200 days per year, adds up to 2000 minutes or 33 hours. That would be just under four 9-hour working days per year. You get the idea. All that time wasted because of a program that is supposed to be helping me.

As Ron Popiel says, "Wait! That's not all!" The thing has a bad habit of hanging up the dictaphone, crashing IMPAX, or decoupling itself with the dictation system, requiring restarting of the GIDI, redialing into Dictaphone, and sometimes rebooting the computer altogether. So, add another 10-20 minutes to the daily toil. The system only allows dictating one exam at a time, so we have to re-GIDI every study on a multiple trauma patient. (And I'm talking about a CT of the head, C-spine, T-Spine, L-spine, chest, abdomen, pelvis, and at least one extremity, as well as CR's of all of the above, so there could be 10-20 different clicks for one patient.)

And, there's more! Occasionally, when the GIDI blows up, the study that was on the screen disappears, and if you weren't paying very close attention in those first few seconds, it is rather difficult to know who just left your screen. Thus, a number of studies are accidentally lost from the worklist, only to be rediscovered hours or days later.

The punch-line is that we don't even need the damn thing. Our human transcriptionists are rarely more than 10-20 minutes behind our dictations, and they are very good about getting STAT reports online, well, STAT! And, we type in our preliminaries for the ER, so they are not in desparate need of this technological tour de farce either. But no one will let it go.

Sadly, we have in the GIDI yet another example of a solution designed without regard to the actual workflow of the actual human being that actually uses it. Again and again and again, we are delivered products that the engineers (keep in mind, I am an engineer by training as well) think we should like, but never asked us if we actually do. Maybe it all boils down to communication. Somehow there needs to be dialogue between the end-users of these things and the folks that create them. Don't go looking for something you can patent, guys, but try to come up with something that will truly help me do my job. And please listen to me when I tell you how I do my job, don't just show me newer and shinier gadgets that you think will enhance my workflow. Most of the time, they just get in my way. Like the GIDI. Which really has to go. Soon. Very, very soon. Like today.

GE Moves To China Anyone For A Linglong?

2011-08-23T20:01:00.001-04:00

GE, in a vote of confidence for China, has moved the headquarters of its X-Ray division to Beijing. The Wall Street Journal says:

General Electric Co. said it is moving its X-ray business headquarters to China to accelerate sales in the country's fast-growing health-care market, the latest sign of China's growing importance to the giant U.S. conglomerate.

The X-ray unit will be the company's first business to be based in China. The business has already begun the move—which includes the unit's chief executive and three other members of its executive team—and expects to complete the process by year end, said Anne LeGrand, vice president and general manager of GE Healthcare Global X-Ray. The senior leadership team's move to Beijing is aimed in part at helping develop more medical equipment specifically for the Chinese market, Ms. LeGrand told a news briefing Monday.

GE said it doesn't expect the move to result in any job losses in the U.S., where the unit has been based in Waukesha, Wis. The Wisconsin X-ray division has 120 employees. The company also said it is too early to say how many employees it will hire for the unit's new Beijing headquarters.

"As the company grows more global, it's increasingly important for us to become close to our customers," Ms. LeGrand said, adding that she expects 20% to 25% of GE Healthcare's X-ray products to be developed in China during the next three to five years for sale around the world. . .

GE has long placed high hopes on China, with CEO Jeffrey Immelt in 2008 calling it the company's "second home market." In January, the company finalized a deal with state-owned Aviation Industry Corp. of China to inject much of GE's civilian avionics business into a 50-50 joint venture based in China. . .

Last year, GE invested a total of $2 billion in China, $500 million of which was allocated to what it calls customer innovation centers. Ms. LeGrand said most of that chunk was for the X-ray business. GE Healthcare last year launched the Brivo CT, a scaled-down CT scanner for use in China's less-developed primary-care hospitals, and in 2009, it rolled out a lower-cost digital X-ray device called the Linglong for China.

I'm gonna get me some Linglong, that's for sure. By the way, Linglong seems to be the name of a major tire company in China, based in Shandong (you can't make this stuff up, folks):

GE has fallen down the same hole they dug when they named their latest PET/CT after the Kia Optima ~~cheapo~~ inexpensive sedan from Korea. No offense to Linglong, or to Kia for that matter.

I'm not sure if GE will produce any PACS software in Beijing, although I assume PACS is used over there. I do hope the Chinese can improve upon some of the current product line, such as our wonderful Centricity Web viewer. As you can see in the little clip below, when you scroll through a study using the mouse wheel, you risk seizing (or wondering if there is an earthquake, which there indeed was on the East Coast today):

Since the US division can't seem to fix this, maybe Beijing can do something. We can only hope.

I guess Mr. Immelt has found yet another way not to pay US taxes. Maybe GE will invite ME over to the new HQ...wait...Dalai in China? Probably not.

New iPad 3 Well-Suited For Radiology

2011-08-20T22:48:00.001-04:00

Apple never, ever, EVER reveals details about its new products, but sometimes its suppliers are a little more loose-lipped.

The Wall Street Journal reports that Apple is buying up components to build the next generation iPad 3, due for release sometime in 2012. Most importantly:

The next generation iPad is expected to feature a high resolution display - 2048 by 1536 compared with 1024 by 768 in the iPad 2 - and Apple's suppliers have already shipped small quantities of components for the sampling of the iPad 3. Suppliers said Apple has placed orders for a 9.7-inch screen device.

BINGO! As I had hoped in my pieces about the original iPad, Apple has finally ported the Retina Screen, or something similar, to the iPad 3. Note that the resolution of the new screen is close to that of a 3MP monitor, and so at least that parameter will suffice for review of computed radiography. Of course, we don't know the luminance of the new screen (probably less than your current Barco) or the bit-depth and so on, but...

Vendors, mark my word...the iPad 3 will be THE new mobile viewing platform. Bank on it, plan for it, and be prepared with software and/or server-side products ready to handle it. Trust me. Have I ever let you down?

Tax Envy

2011-08-20T17:00:00.000-04:00

Warren Buffett, the Oracle of Omaha, came out recently with a rather controversial statement:

But for those making more than $1 million — there were 236,883 such households in 2009 — I would raise rates immediately on taxable income in excess of $1 million, including, of course, dividends and capital gains. And for those who make $10 million or more — there were 8,274 in 2009 — I would suggest an additional increase in rate.

My friends and I have been coddled long enough by a billionaire-friendly Congress. It’s time for our government to get serious about shared sacrifice.

Ummm, OK. That's nice of you to offer, Warren. I wonder how many of your millionaire/billionaire friends are on the same page with you on this.

Sadly, Warren doesn't put his money where his mouth is, making him a very rich hypocrite with wonderful-sounding but ultimately empty rhetoric. David S. Logan, writing on the Tax Foundation's Tax Blog, notes:

Mr. Buffett chose to leave most of his fortune to the Bill & Melinda Gates Foundation and, thus, avoided an estate tax that could potentially give 55 percent of his wealth to Uncle Sam. Moreover, keeping that wealth actively working in the private sector would generate deficit reducing tax revenues indefinitely.

Logan goes on to deconstruct the faulty thinking behind Warren's generous offer:

Mr. Buffett seems to forget that capital gains and dividends taxes are a double tax on corporate income. Before it gives out a dollar in dividends, Berkshire Hathaway - like all U.S. corporations - must first pay a 35 percent federal corporate income tax, one of the highest in the world. Then, shareholders pay the individual tax rate of 15 percent on their dividend income or the gains from appreciated stock. As a result, the combined tax rate of 50 percent is the 4^th highest combined dividend rate in the industrialized world. Ironically, we had the 8^th highest combined rate under Bill Clinton.
In his op-ed, Mr. Buffett suggests that increasing taxes on the rich ensures that they pay their fair share. Perhaps, but while the top 1 percent of taxpayers earn 20 percent of the nation's income, they currently pay nearly 40 percent of the income taxes. That's a greater share of the burden than the bottom 90 percent combined (that's everyone earning under $100,000 by the way).
Let's not forget that when the top marginal income tax rate was 70 percent in 1980, the rich paid 20 percent of all income taxes. Yet now, when the top marginal rate is 35 percent they pay twice that.
Finally, while the tax burden on the rich has been growing, the burden on low and middle-income Americans has been shrinking. By most accounts, roughly 50 percent of American households pay no income tax at all. Indeed, the IRS will give out roughly $110 billion in "refundable" tax credits this year to households that pay no income taxes.
Contrary to Mr. Buffett's and President Obama's perceptions, America's wealthiest taxpayers are paying a disproportionate share of the income tax burden. Before we ask the rich to pay more, perhaps we should ask those who are paying nothing to contribute at least something to the basic cost of government.

Scott Hodge, also writing for the Tax Foundation, elaborates on the notion that the "wealthy" aren't paying enough:

Recently released IRS data for 2009, shows that taxpayers earning over $200,000 paid 50 percent of the $866 billion in total income taxes paid that year, or $434 billion. Skeptics will say, "That's because they earn the majority of the income in America. Not so. These taxpayers earned 25 percent of the $7.6 trillion in total adjusted gross income in the country that year.

The 2009 IRS data also shows that a record 58.6 million tax filers had no income tax liability that year. This means that 42 percent of the 140 million Americans who filed tax returns that year contributed nothing to the basic cost of government.

I have to believe the "rich" are doing more than their fair share. In fact, they are covering the nearly half of the country that pays nothing at all. How much more should they pay? Review the facts above before you answer that.

But the nation is in dire straights, with horrendous debt, and the "rich" ~~are holding out on us~~ need to do their fair share to help the nation. Sadly, the United States has hemorrhaged so much money so quickly, the "rich" could not even begin to bail her out. Again from the Tax Foundation's Logan:

So taking half of the yearly income from every person making between one and ten million dollars would only decrease the nation's debt by 1%. Even taking every last penny from every individual making more than $10 million per year would only reduce the nation's deficit by 12 percent and the debt by 2 percent. There's simply not enough wealth in the community of the rich to erase this country's problems by waving some magic tax wand.

Finally, to put everything in perspective, think about what would need to be done to erase the federal deficit this year: After everyone making more than $200,000/year has paid taxes, the IRS would need to takeevery single penny of disposable income they have left. Such an act would raise approximately $1.53 trillion. It may be economically ruinous, but at least this proposal would actually solve the problem.

But, we're missing something. Those to the Left of center, whose numbers include hypocritical billionaires, it seems, aren't interested in fixing anything, such as paying off the debt. Just what do they want?

Here's one possibility:

. . . First place aversion arises from progressives’ moral view that requires them to help everyone– you can never reduce carbon emissions enough, donate to the poor enough, elevate support minorities enough, etc– and holding themselves accountable for failing their moral obligations. And they fail all the time because progressives like nice, expensive cars, clothes, food, yoga studios, Martha’s Vineyard, etc, much too much to abide their moral world view. That moral deficiency causes them to:
Appoint others who force [others to pay taxes] and contribute to ending every harm; forgiven and made worthy, they ignore that their appointees often harm the poor and force others not afflicted by First Place Aversion to pay; and
Steal and sully the poor’s lack of culpability for all the wrongs that rich progressives can’t fix by paying them off with other people’s money.

In other words, rich progressives need to feel good about themselves, perhaps to assuage their guilt over being wealthy in the first place. But instead of getting down and dirty themselves, they do their "good" by forcing others to cough it up. In the meantime, they totally ignore what makes the poor, ummm, poor.

It is beyond the scope of this post to discuss the latter issue. Suffice it to say, in many cases (but certainly not all), those in poverty have landed there by making incredibly bad decisions. Alcohol and drugs are big players in this, but simple lack of discipline is right up there, too. You've seen people in line at the grocery paying for food with their WIC card, while chatting away on their iPhones, wearing $200 sneakers, and draped in gold. These people can be white, black, Hispanic, or whatever, so don't accuse me of racism. And don't accuse me of lying, either, as you've seen this, too. These people are "poor" because they can't stop spending money on the non-necessities of life, and they have been trained by the sympathetic, hypocritical Left to expect the rest of us to cover their chit in life.

I believe strongly in charity, in helping those who NEED help. I tried to cast my views in the light of the Jewish approach to charity relative to the Health Care Abomination in THIS post, and my feelings haven't changed. The approach of the Left has nothing to do with helping anyone. It is simply a drive for power and control. It pits rich against rich and rich against poor in hopes of confiscating from the former and buying off the latter. There is no thought of raising the poor out of poverty, but rather keeping them just happy enough that they don't realize what has been done to them.

I've heard angry Leftists rail against the "rich", with the implication that the rich got that way off the backs of the poor, and that they owe it to the poor to take care of them. Perhaps this is true in a few situations, but these are few and far between. Buffett himself became very wealthy by making shrewd investment decisions, evaluating the companies he bought with data available to anyone who can read, especially in this day and age of universal information brought to you via the Internet. Who did he steal from? No one. Why is he wailing about the low tax rates of the ultra-rich? I guess it makes him feel better. Old Warren may not have been the most moral fellow in his younger days, and he might think he has to make things right with God. Whatever floats his boat. But it's very hard to get around his hypocrisy. He bleats from his bully pulpit, all the while avoiding every last bit of tax possible. If he feels so strongly about this, he could make a much more powerful statement by writing a very large check to the IRS. (If you are so inclined, go straight to Pay.gov, and give until it hurts. Hurts YOU, that is.)

I've noticed that Warren's Berkshire Hathaway hasn't done so well lately:

Maybe Warren is worried about joining the ranks of the poor himself?

Captain Kirk Sings Cee-Lo's Song...

2011-08-19T22:47:00.000-04:00

Yes, that IS William Shatner's voice (mostly):

If you haven't heard it yet, here is the incredibly talented Cee Lo Green with the original (WARNING---EXPLICIT LYRICS NOT INCLUDED! THIS IS A FAMILY BLOG!!):

I had to get one last shot at Xtranormal's "Totally Trekkie SciFi Movie Contest" and you'll note mine is indeed the final entry. Wish me luck!

ADDENDUM

Well, this cartoon received an honorable mention from Xtranormal, but didn't win the contest. It went a few seconds over the two minute limit, and "rules are rules"! I'll do better next time. This is what happens when you slap something together five minutes before the contest ends!!!

TabCo...er...Grid Tablets Launched!

2011-08-17T20:44:00.001-04:00

I recently posted about some stealthy company named Tabco with some new take on tablet computing. Like every other new product, this was supposed to be the NEXT BIG THING, rendering iPads, Galaxy Tabs, and so on to the garbage heap (as well as their lemming-like owners, according to the ad.)

Well, as reported in Techie Buzz, it turns out that TabCo is REALLY FusionGarage, based in Singapore, and their new product line includes the Grid 10 tablet, and the Grid 4 phone. Yes, phone! These little gems utilize the new Grid OS:

GridOS is a groundbreaking operating system that features many first-of-its-kind functionalities. It reinvents touch computing from the ground up. Its user interface is unlike anything out there. It’s a groundbreaking, visceral experience. GridOS is stunning, smart, social and transportable. It features a groundbreaking animations engine. Every feature had been rethought and made better. Web Surfing, Email, Video, Music, Photos, Home Screen Navigation and more. It’s like nothing you have experienced before and it’s what makes Grid10 an exhilarating experience.

GridOS user interface is fresh and intuitive. Its grid layout is fluid, easy to use and unique compared to any other device. User interface innovations extend across all its functionalities. Even the way you interact with a volume dial has been rethought and delivered.

GridOS was built leveraging an android kernel. It was built on top of Android. Similar to how Apple built Mac from Unix BSD. GridOS is highly secure and scalable.

GridOS supports Android Apps. Android Apps runs on GridOS without requiring and redevelopment or new code. With thousands of apps available, you with never be bored with GridOS.

One key to GridOS appears to be the reinvented wheel:

This is no vanilla UI. It fundamentally changes the way you will experience a tablet. Completely gesture-based and button-free, Grid10 lets you navigate naturally, easier and without restriction. We’ve even eliminated the boring slide bar to access Grid10. You sign on – literally – with your signature. Sounds like we have reinvented the wheel, doesn’t it? Well, we have with our wheel-based interaction. A finger tap brings up the wheel and its spokes offer a multitude of functions. Just slide your finger around the wheel and choose the desired function.

I might have chosen another example than Lady Gag Gag, but you get the idea.

The Grid10 is a nice-looking monolithic slab with a 10-inch screen:

Under the hood, or screen, or whatever, it's pretty advanced for a tablet (from Techie Buzz):

Some other technical aspects of note is that it packs a Nvidia Tegra II 1.2Ghz Dual Core processor, 512MB RAM, and 16GB of storage. It runs on the GridOS. It is Wi-Fi and 3G capable. It has a front facing camera that will work with its video calling feature that boasts one to one, and one to many, video calls. It also allows for HDMI connectivity.

More specs here. The WiFi version is $499, and the 3G (no 4G, I guess) is $599.

The Grid4 phone looks like a squared off version of the iPhone 4, but with no home-button:

FusionGarage is rather proud of the minimalist design:

It will be hard to look away from a Grid4. It’s amazingly sexy. It’s amazingly sleek. There are no buttons. There are no curves. Its just 4 inches of all screen. The straight edges scream simplicity. It’s a triumph of honest design. The all-aluminum back is a nice touch. It’s shaped around the function with no artificial design. You will turn heads with a Grid4 in your hands.

The 4 inch screen has resolution of 800x480 pixels, as compared to the iPhone 4's 960x640 pixels on its 3.6 inch diagonal screen. Sorry, Verizon-lovers; the Grid4 has a quadband GSM chipset.

In rather amusing fashion, all the accessories, such as the adapter plug below, are done up in Grid Red:

Are the Grids iPad/iPhone killers? Hard to say at this point. Frankly, based on the very limited views on the FusionGarage website, they have more potential to be Android killers. They seem to build nicely upon the Android kernel, with what seems to be a far more pleasing interface. But the market will decide.

If this all sounds a bit familiar, you may be remembering the last production from FusionGarage, the rather unfortunately-named Joo-Joo, which was formerly known as the Crunchpad. It ran Linux, and barely saw the light of day. I expect FusionGarage will have significantly more success with the Grids. Seems to me they will appeal to those who don't want to give Apple (and Steve Jobs) their due, but are looking for something beyond the Androids.

I would love to hear from any bleeding edgers who've actually purchased one of these things...

My Big Fat Greek Vacation

2011-08-16T15:20:00.004-04:00

My loyal readers have no doubt noticed a paucity of postings here on the blog. There are several reasons for this:

I'm tired and lazy
I was in Greece with my family for part of July
It's hot here (and in Greece)
We're trying to get Dalai, Jr., to work on his college applications, and the daily whippings take a lot out of me

Most of these are self-explanatory. The trip to Greece had been planned for the better part of a year, but was almost scuttled by the troubles reported over there, mainly in Athens. However, we never saw a hint of riots or other nastiness, although most of the shopkeepers, and the captain of our little boat, were rather disheartened by the whole economic situation, and blamed Germany for charging Greece 7% interest when everyone else gets 3%. Apparently the concept of being a bad risk doesn't translate well. But life goes on over there, and the Greeks seem proud and happy none-the-less. Personally, I would be depressed at paying over $10 for a gallon of gas, but they seem to be used to such things.

I would post more photos, but our group had five cameras going more or less simultaneously, which produced well over 3,500 images, so it will take a good while to pare all that down to a usable level.

Anyway, be prepared for more PACS news. If there's a topic you feel deserves attention, or if you've heard something especially juicy, please drop me a line at doctordalai(AT)gmail.com.

Ευχαριστώ!!

Some Docs I Know And Their New Mouse...

2011-08-09T13:31:00.000-04:00

The Final, Final, FINAL Frontier

2011-08-07T19:37:00.003-04:00

My entry for the Xtranormal Totally Trekkie SciFi Movie Contest...Wish me luck!

TabCo?

2011-08-04T13:41:00.002-04:00

Attention tablet users! Apparently, you are all a bunch of lemmings, satisfied with the mediocre performance of the available devices, iPads, Galaxy Tabs, and so on.

Enter TabCo. Here's what I know about them: NOTHING.

Here's what All Things D knows about them: (Hint: not much...):

The big reveal for TabCo is set for Aug. 15, but AllThingsD has managed to gather a few facts on the company’s forthcoming product.

On the hardware side, TabCo’s product will have many of the usual features, including Wi-Fi and optional 3G connectivity, support for Bluetooth and USB, as well as its own suite of apps for editing and viewing documents, photos and videos.

The big thing that sets it apart, I’m told, is its software and what insiders call a “predictive user interface.” The design is said to anticipate user needs to help perform tasks such as Web searches, buying products or getting directions.

OK, I'm intrigued, but we've all been disappointed before, as ATD notes:

I can say that the company is playing a high-risk game with all of its antics. Such activities can — and have — built buzz for new technologies even before anything is known about the actual product. That said, such pitches often spin out of hand, with the hype building so much that the eventual product can hardly help but fail to meet expectations.

Microsoft tried such an approach in the middle of last decade with Project Origami, which was later revealed to be a pricey handheld touch computer. Though in many ways aprecursor to the iPad, the initial batch of Origami devices were too expensive, hard to manipulate via only one’s fingers, and had embarrassingly short battery life.

Perhaps because the Origami devices were so far short of expectations, Microsoft essentially dropped the project rather than continue to iterate and plug away — a decision that the company might be regretting after seeing Apple enjoy the riches from a tablet market that Microsoft spent years working to create.

The Segway, too, was built up to legendary proportions before it was revealed, with leaks suggesting that luminaries like Jeff Bezos and Steve Jobs believed the product could change the world and cause cities to be designed differently. In the end, the Segway proved to be a niche success, at best, as a platform for security guards, mail carriers and tourists looking for a unique way to see the sights.

So, TabCo — or whoever you are — you’ve got our attention. Now it’s up to you to deliver something that keeps it.

We'll be watching. 8.15.11. At least it's not set for 4.1.12....

The End Of An Era

2011-08-02T15:37:00.001-04:00

Everyone who is anyone in the PACS business knows Mike Cannavo, the One and Only PACSMan. I'm very sorry to report that the PACSMan is no longer with us. But don't grieve...Mike is still alive and well. He simply had to move on to greener pastures, given the current economic troubles with PACS and everything else, leaving the PACSMan entity behind. Mike posted this message to AuntMinnie's PACS forum:

After 28 wonderful years it’s time for the PACSMan to finally hang up his shingle and just become just plain Mike again. It’s been a blast but change is necessary for growth and my life is changing in so many ways.

My sons have grown into wonderful young men, men I am exceptionally proud of, and my role as a dad has slowly evolved over the past few years. I am now more of a confidant and mentor than taskmaster and taxi driver. Soon, all too soon, my house will be emptier as my baby heads to Rhodes College in Memphis to start college. My oldest attends college locally and still lives at home but between school and work (both at the Apple store and as a top notch web-site developer) I don’t see him nearly as often as I used to either. So it’s really just me and Elvis, the world’s wackiest beagle, and sadly soon he too will no doubt be headed down the road to a new home since my new job requires a bit of travel.

New job? Yes, after years of being on my own I have indeed elected to join the racks of the steadily employed and it’s not heading up Merge or Iron Mountain either . I have loved being a PACS consultant- no position could have been better given the requirements I had when my kids were growing up- but the position I was recently offered allows me to help more than just a handful of clients a year. That is very important to me- sharing the knowledge- just as it has been over the past several decades in the 350+ articles I’ve written and in the countless presentations and Webinars I’ve given. I have been given the chance to take on a phenomenal position in a phenomenal company with a phenomenal leadership team and frankly it’s just too good to turn down. So it’s my turn now.

Know I am really going nowhere and will still be very actively involved in the radiology community, just not as the PACSMan. . . I’ll probably change the blog title to something like “Confessions of an Ex-Altar Boy” or something equally reverent. You will also see my comments in the PDF now and then but under a different moniker. And who knows, someday the PACSMan might indeed make his triumphant return, probably doing it just like Jesus did by riding in on a donkey to Jerusalem, but instead my riding onto the floor of the RSNA on one instead . We’ll just have to see what the future brings.

To Brian Casey, Erik Ridley and rest of the AuntMinnie staff, thank you for giving me to the chance to share what I have learned over the years with our readers. To the AM readers, thank you for making my articles number one each time they were published, and especially the ever politically-correct PACSMan Awards® which I will miss writing more than anything else I’ve ever done. To my clients, end-users and vendors alike, you are the very best and your kindness and support will never ever be forgotten.

When my son graduated high school a month or so back (Summa Cum Laude no less) it was a bittersweet moment for me. It signaled that my role as a dad was pretty much over. I’m still not sure how to deal with that- empty nest is hitting me a lot harder than I ever expected- but Matt’s class motto put things in its proper perspective for me. The saying is attributed to Dr Seuss and goes “Don’t cry because it’s over, smile because it happened.” And so that is what I will do and hope you will as well.

Thanks for 28 years of smiles. Until we meet again I remain.

Mike Cannavo- The One and ONLY PACSMan

Well, there you have it.

I've been in communication with Mike since 2003, when I first started dabbling heavily in the PACS field as a semi-educated consumer. Our corresponding friendship started with my wondering how to handle some nasty trolls who were attacking me on the PACS forum. Mike responded:

A lot of these folks making the postings suffer from a disease known as LDS, and I'm not talking about the The Church of Jesus Christ of the Latter Day Saints either. It's Little D*ck Syndrome- where you have to make up for your "shortcomings" somehow so you mock on the first person who seems to know what the hell they are talking about. I live it every day.

Classic Mike.

I'm expecting him to keep his promise, and appear to us in unexpected ways, be it on a new blog or in some clever new persona on AuntMinnie. In the meantime, if you want to know the Mike I know, head to his blogsite before it goes away- http://thepacsmanpontificates.blogspot.com/. We share a lot more in common than most would imagine. Mainly our warped sense of humor and love of filet.

But maybe, just MAYBE, the annual PACSMan awards can morph into the DoctorDalai awards? Would anyone mind very much?

Godspeed in your new career, Mike!

A Challenge to GE and AGFA

2011-07-15T16:38:00.002-04:00

Yes, GE, and AGFA, I'm throwing down the gauntlet. It's time. It's really way past time I do this.

Here's some background. My group covers a number of hospitals. The two largest in our system use AGFA IMPAX 6.5. We also cover a very busy oncology clinic that uses Centricity 3.1. As you might imagine (and one of you claims to have a Healthymagination) patients bounce back and forth between the clinic and the hospital. Mr. Jones might have had is last three CT's at the clinic, but now presents the the ED with intractable pain, and must of course be scanned STAT! Mrs. Smith's tumor was discovered on scans at the hospital several months ago, and now is a patient at the clinic where her followup imaging will take place.

We deal with this scenario about ten times per day. The problem is, we don't always know that the patient has had an old study, and more often than not, the oncologists call us, boldly telling us that we didn't go where the patient had gone before, and would we please be so kind as to re-read the rather complex CT's of the head, neck, chest, abdomen, pelvis, spine, and extremities now that we know about the comparison studies. This comparison has to be done on two different systems, which is a pain in the gluteus maximus even if I knew about the old study in the first place. It's enough to make me drink...more than I already do. This is a patient-care issue, and a rather serious one at that.

Your mission, Vendors, should you decide to accept it (and I'll bet you won't...) is to solve this problem for me. WORK TOGETHER and create a solution. I need some form of Enterprise viewer to link or overlay or somehow mate the two systems, something that will find a patient's exams performed at either site, and let me know, and more importantly, let me read them side by side as if they were done at the same institution.

I really don't care which viewer ends up doing the job, although if GE wanted to do this right, they would leverage in the Centricity IntegradWeb client somehow. Otherwise, IMPAX 6 would probably be the next best choice. (Don't anyone get a swelled head; I still don't much like IMPAX OR Centricity 3.)

This is not rocket science, boys and girls. Smaller companies like Intelerad and eRad, and bigger folk such as Carestream can do this. AGFA advertises their enterprise capability. So. It can be done. Now, figure out the way to do it for me.

Please?

RIM-Shot: Lessons From BlackBerry Hill

2011-07-13T21:35:00.005-04:00

RIM, Research-In-Motion, was once THE smartphone company. Anyone who was important, or wanted to look like they were, had a BlackBerry phone. I personally never succumbed, but my brother-in-law, who truly is important, by the way, had one of the early black-and-white models, which he used extensively. Many of my partners dabbled with the various RIM offerings, as I bemoaned in this post.

But today, RIM is on the road to extinction, a victim of the usual ignorance, arrogance, and hubris I often cite on these pages. The lessons to be learned are simple enough...know who your customers are, and give them what they want and/or need. It really is that simple.

Jonathan Geller wrote what may prove to be RIM's obituary on BGR.com, dateline today. In his "exclusive look" Geller tells ". . . a story filled with attitude, cockiness, heated arguments among the executive team and Co-CEOs, and paranoia." Sounds familiar.

Geller interviewed a number of former RIM execs for his piece, and the revelations are multitude:

Jim Balsillie and Mike Lazaridis are two irreplaceable leaders who were largely responsible for RIM’s success, our source continued. But as time progressed, Mike did not listen to the marketplace. This is obvious from the outside view, though the details surrounding why RIM is no longer a market leader — and why RIM will most likely not be able to regain its leadership position in the near future — are most interesting.

Let’s rewind a few years. Picture yourself sitting in an executive briefing at Research In Motion. You’d hear Mike Lazaridis unequivocally state time and time again that BlackBerry smartphones would never have MP3 players or cameras in them because it just does not make sense when the company’s primary customers were the government and enterprise. “BlackBerry smartphones will never have cameras because the No. 1 customer of ours is the U.S. government,” Mike Lazaridis would say in meetings. “There will never be a BlackBerry with an MP3 player or camera.”

The fact is, that RIM didn’t only miss the boat in terms of product features and device trends as we now know, but the underpinnings of the company’s consumer failure began all the way back in 2005 with bold statements like these, combined with a lack of research and development in numerous key areas. . .

The three-year roadmap for RIM products focused on refining the technology in phones had already been released, rather than looking at where to add major new componentry or trying to identify or even shape future trends.

“When you hear Mike talk about the latest and greatest, it’s been the same thing for ten years: security, battery performance, and network performance. RIM has positioned battery life and network performance for years. People are not concerned with iPhone battery life,” one source told me. Network performance, to Mike, trumps any innovation a device like the iPhone offers. “Mike is convinced people won’t buy an iPhone because battery life isn’t as good as a BlackBerry,” a different source said. Mike apparently is in disbelief that people can use over 15GB of data on their iPhone and Android devices, and he feels that people will buy smartphones based on network efficiency, even though carriers with tiered data plans in developed markets love customers who use monstrous amounts of data.

Yup. The surest way to alienate your customers is to tell them what they want, rather than listen. The next-surest mistake is to compound the first mistake by doubling down on a product that no one liked in the first place.

Of course, you need to identify just whom your customers really are:

While RIM has always viewed carriers as customers rather than end users, carriers have long been trying to find a different partner that doesn’t charge network fees.

RIM saw the gravy-train as hooked to the carriers, and not to the folks like me that would actually have to use their devices and services. Bad move, at least in the end.

Speaking of mistakes, it is generally bad form to promise a feature and then renege or require some additional part or fee to make said feature function:

. . .Jim Balsillie told the carriers at the 11th hour that the PlayBook wouldn’t have native email and would require the Bridge app in order to receive emails and provide calendar functions. “RIM is notorious for dropping these bombshells at the 11th hour on the carriers, and the PlayBook not having native email was a shock to the carriers.” They were all expecting a BlackBerry with a bigger screen. RIM was hoping to blow through the 500,000 units and have carriers take orders for millions of additional PlayBooks, but that has not happened yet. Mike Lazaridis looks at it as, why aren’t people buying this tablet when it has the most powerful engine with respect to multitasking, and supports Flash? But consumers have spoken pretty loudly a number of times, and Mike unfortunately leads the product side and continues to miss the mark with the masses, a former RIM executive told me. “I don’t even see anyone in Waterloo walking around with a PlayBook that doesn’t work for RIM,” another former RIM employee said.

I think my point is pretty clear. What is happening to RIM is not unexpected, at least by those on the outside. Here was a company that had "lightning in a bottle"; they should have been the premier smart-phone maker on the planet. BUT THEY DIDN'T LISTEN TO THEIR CUSTOMERS. RIM's masters had no clue or care about what the great unwashed masses wanted in a smart-phone. They wanted to dictate what was important and what wasn't. They wanted to tell us...because they thought they knew better than their customers what was needed. Throw in the disconnect between the perceived customer and the actual customer, and you have the recipe for the slow-research-in-motion train-wreck we are now witnessing.

The lesson is complete when one substitutes the name of a PACS vendor and their product for RIM and BlackBerry, respectively.

Did someone say Waterloo?

It's Heart-Attack Friday

2011-07-08T16:32:00.001-04:00

Dalai's note: A few years ago, our most senior partner was stricken with an MI on a Friday after working a twelve-day shift including weekend call. Today is my 24th day of work with only one day off in the middle, due to some scheduling problems in the front office. Thus, for me, this is a triple "Heart Attack Friday." With some luck, I'll make it past midnight tonight....

With apologies to Jimmy Buffett and Alan Jackson....

Dalai:

My head is hot and my ST segments are depressed

And so am I

Angina passes like molasses in wintertime

But it's July

Got more pain by the hour and older by the minute

Damn call days just pushed me over the limit

I'd like it to be indigestion

But think I'll just call it MI

Chorus:

Draw me up some TPA

Get that needle parked before my heart infarcts

I've only been at work for twenty five days

It's Heart-Attack Friday

Dalai:

This cardiac cath is going to take all day

And half the night

Tomorrow morning I know there'll be hell to pay

Hey, but that's all right

I ain't had much time off in this part of the year

My cardiac event is gonna start right here

If the phone's for me

You can tell 'em I've just gone off call PERMANENTLY

Chorus:

Draw me up some TPA

Get that needle parked before my heart infarcts

I've only been at work for three weeks and four days

It's Heart-Attack Friday

Dalai:

I could have retired young

And had some fun, and always be in bed before 2

At a moment like this, I can't help but wonder

What would Jimmy Buffett do?

Jimmy Buffett:

Funny you should ask, Dalai....

I'd say,

"Draw him up some TPA

Get that needle parked before his heart infarcts

He's only been at work for three weeks and four days

It's Heart-Attack Friday

Yup, Draw him up some TPA

Get that needle parked before his heart infarcts

He's only been at work for three weeks and four days

It's Heart-Attack Friday"

He don't care

And I don't care

It's Heart-Attack Friday

Hey, how's his EKG?

What hospital is he in?

Dalai:

It doesn't matter

It's Heart-Attack Friday

Jimmy:

It's always Heart-Attack Friday when you're on call

Dalai:

I heard that

Jimmy:

You've been there haven't you?

Dalai

Not yet, Jimmy

Jimmy:

I've seen your name on the chart

Dalai:

I need to go to Margaritaville, STAT!

Jimmy:

All right. That's good

Smother Down Under

2011-07-04T10:54:00.000-04:00

I haven't heard much from my friends in Western Australia lately. When I asked about their languishing PACS, I was told, "Not much new. Nothing to see here." This, of course, piqued my curiosity, but no one had much else to say about PACS, or much of anything else beyond the lovely weather there on the coast of the Indian Ocean.

Nature abhors a vacuum, so it is said, and I sense a vacuum of information. Trolling the internet was not particularly revealing, although I did stumble upon a few tidbits on the official website of the Department of Health from the Government of Western Australia. I have to say that the website is very nicely done, and it is at least a little cleaner and more user-friendly than ours, for example.

Within the WA site, I found the following passages, which strike me as a bit odd. First, we have the "Policy on Use of Official Information and Public Comment" which was released June 8, 2011:

PURPOSE

WA Health employees are not permitted to use official information obtained through the course of their employment to provide public comment or communicate in writing or online without the express authorisation of their Chief Executive Officer. Public comment includes, but is not limited to, verbal comments to the media, written communication such as letters to the media and online communication by email, blogging and posts via social media sites. Unauthorised disclosure of official information is a breach of an employee’s duty of fidelity and good faith which will result in disciplinary action and in some cases termination.

SCOPE

This Policy applies to all employees within WA Health entities including:
Department of Health
Metropolitan Health Service
WA Country Health Service
POLICY

This Policy covers all verbal, written and online communication by employees using official information obtained through the course of their employment. This Policy applies to communication during and outside of work hours.

Part 2 Division 1 Section 9(b) of the Western Australian Public Sector Management Act 1994 (as amended) (the PSM Act) states that all employees of public sector bodies:

“Are to act with integrity in the performance of official duties and are to be scrupulous in the use of official information, equipment and facilities.”
Accordingly, WA Health employees are not to:
Release any information made available to them in the course of their duties, or in response to a statutory or legally empowered enquiry, without proper authority.
Make use of any information gained in the course of their employment for their personal benefit or gain.
Make any statements on official Departmental, Area Health Service or Ministerial letterhead or the internet that conflicts with official policy or legal and administrative precedents.
Further, the PSM Act, Administrative Instruction 278 – Media & Public Communications states:
“Selected public servants may be called on, as part of their official duties, to explain or provide information to the media or the general public on their agencies’ policies and activities. Chief Executive Officers will determine which officers shall be authorised to make public comment.
Those public servants who are empowered to make public comment should confine themselves to providing such information as is necessary to explain government policy or to provide factual, explanatory and background material pertinent to the question at hand.
In doing so, they should avoid making any comment which could undermine public confidence or disrupt the everyday administration of either the Public Service or the Government of the day. To this end, they should:
Not give their personal views on matters of government policy or administration, or on advice made to government.
Not speculate on future policy directions.
Not publicly criticise any political party, its actions or its policies.
Not prolong discussion or debate on an issue once a decision has been made, or a policy adopted.
Accordingly, WA Health employees are not permitted to:
Disclose official information obtained through the course of their employment to the public through verbal comments to the media, or by written communication such as letters to the media, or online communication by emails, blogging and posts via social media sites, without the express authorisation of the Chief Executive Officer;
Disclose official information obtained through the course of their employment to engage in verbal, written or online communication to disparage, discriminate and/or defame WA Health and/or colleagues;
Compromise or be perceived to compromise the employee’s ability to carry out his or her duties including the duty of fidelity and good faith.
In addition:
When delivering conference papers or discussing issues related to WA Health or on their professional, scientific or technical findings, it is acceptable for staff to use official information that is not confidential. However, in doing so, employees must issue public disclaimers stating that the views are their own and are not necessarily those of the government of the day or WA Health.
Relevant Public Relations / Public Affairs areas within the Department of Health or Area Health Services are to be advised of any conference papers or presentations likely to be contentious or which may attract media attention.

CONTACT WITH THE MEDIA:
Generally, public comment to the media is made through the relevant Department of Health or Area Health Service Public Relations / Public Affairs areas. The following should be noted:
WA Health employees are not to comment or provide information to the media without proper prior authorisation.
Some WA Health employees may be called upon by the Public Relations / Public Affairs area to explain or provide information to the media or to the public on the policies and activities of government.

OTHER POLICY AND LEGISLATIVE OBLIGATIONS:
Prohibited Use of Official Information and Public Comment may also be in contravention of:
WA Health Code of Conduct;
WA Public Sector Code of Ethics;
Public Sector Management Act 1994;
WA Health policies, including the Prevention of Bullying, Harassment and Discrimination in the Workplace Policy, Use of Social Media; and
Health Services policies, including Confidentiality policies.
.....
Breaches
Any staff member who breaches the provisions of this Policy will be committing an act of misconduct and may be subject to the procedures outlined in the WA Health Misconduct and Discipline Policy, the Public Sector Management Act 1994 or to other action or provisions relevant to the management of conduct.
Kim Snowball
DIRECTOR GENERALDEPARTMENT OF HEALTH WA

And here's another, the "Policy on Use of Social Media:"

PURPOSE

The purpose of this policy is to ensure that employees do not engage in online communication that is disparaging and/or discriminatory towards the WA Health and/or colleagues. Communication may include, but is not limited to emails, blogging and posts via social media sites such as Facebook, MySpace, Twitter, YouTube and Flickr. Disparaging communication includes negative, adverse, inappropriate, offensive, discriminatory and abusive blogs/posts that criticises WA Health and/or colleagues in a public way.
The use of online communication via social media to post or blog disparaging comments about WA Health and/or colleagues is a breach of an employee’s duty of fidelity and good faith which will result in disciplinary action and in some cases termination of employment.

SCOPE

This policy applies to all staff within WA Health entities including:
Department of Health
Metropolitan Health Service
WA Country Health Service
POLICY

This policy covers all online communication via social media sites made by an employee, whether during work hours on a work computer, or during work hours on a personal electronic device, or outside work hours on a personal electronic device. Online communication via social media sites that is prohibited includes, but is not limited to, communication that:
Mentions the WA Health by name, its business operations or confidential information;
Is defamatory;
May be construed as discriminatory or bullying;
Bullies, harasses, discriminates or vilifies work colleagues;
Includes abusive status updates and/or blogs that criticise work colleagues, offends others and/or breaches their employment obligations in public ways; and
Publicises or comments on workplace disputes.
Prohibited online communication via social media sites may also be in contravention of:
WA Health Code of Conduct;
WA Public Sector Code of Ethics;
Public Sector Management Act 1994;
WA Health policies, including the Prevention of Bullying, Harassment and Discrimination in the Workplace Policy, Use of Official Information and Public Comment; and
Health Services policies, including Confidentiality policies.
An employee that engages in online communication to make disparaging comments about the Department, management, colleagues and/or patients will be in breach of their duty of fidelity and good faith. Such conduct will be found to be misconduct which will result in disciplinary proceedings and may lead to termination of employment.
Any queries regarding this directive can be sent to industrial.relations@health.wa.gov.au.

Kim Snowball
DIRECTOR GENERAL
DEPARTMENT OF HEALTH WA

Well, I think the message is pretty clear, and I have to wonder if my foray into investigative journalism from last year had anything to do with these policy revisions. Anyone taking bets?

My first thought when reading these policies, which are posted right there on the internet for all to see, was, "What about Free Speech????" As it turns out, Oz has some different rules about that than we do here in the States. From the Wiki:

Australia does not have explicit freedom of speech in any constitutional or statutory declaration of rights, with the exception of political speech which is protected from criminal prosecution at common law per Australian Capital Television Pty Ltd v Commonwealth.

In 1992 the High Court of Australia judged in the case of Australian Capital Television Pty Ltd v Commonwealth that the Australian Constitution, by providing for a system of representative and responsible government, implied the protection of political communication as an essential element of that system. This freedom of political communication is not a broad freedom of speech as in other countries, but rather a freedom whose purpose is only to protect political free speech. This freedom of political free speech is a shield against government prosecution, not a shield against private prosecution (civil law). It is also less a causal mechanism in itself, rather than simply a boundary which can be adjudged to be breached. Despite the court's ruling, however, not all political speech appears to be protected in Australia and several laws criminalise forms of speech that would be protected in other democratic countries such as the United States.

In other words, Western Australia's policies are perfectly legitimate and enforceable, although rather surprising for a nation which prides itself on being cantankerous and disrespecting authority. It therefore seems unlikely that I will ever hear much more about PACS or any other trouble that might possibly disparage the WA government.

Fortunately, there seems to be no proviso to punish the recipient of such information, especially a foreign national such as myself, so hopefully, I'm still allowed to travel to Australia. I would be devastated if they took that privilege away.

In the meantime, I guess it's up to Crikey to find out if anything is going down Down Under.

America Thinks It's Got Talent

2011-06-23T16:14:00.000-04:00

I avoid many of the "reality" TV shows, as they are generally about as unrealistic as it gets. Of course, Mrs. Dalai is quite absorbed in the Bachelor/Bachelorette series, so I have the joy of watching Ashley make a fool of herself chasing Bently, who isn't interested. Women....

Anyway, I do happen to enjoy NBC's "America's Got Talent" which is a little different than some of the others. Basically, it's a throwback to another age, when song and dance ruled the airwaves. The three interpid celebrity judges (Pierce, Sharon, and Howie) travel the nation, looking for the next Million Dollar act, and every so often, actually stumble upon a diamond in the rough. Take Landau, for instance:

Here is a 30-something hair-braided, gum-smacking ex-car wash attendant, who came to the stage on a lark, having no preconceived notion of what would happen next. But the moment the music started, Landau channeled Frank Sinatra and blew the judges and the audience away with his talent. And when the judges actually told him just how good he was, he broke down in tears in front of the audience and the world.

Contrast Landau with these clips of the worst of the auditions on the New York City stop:

While NBC does kindly make the clips of the performances available on its website, you had to be watching the show to see the pre-game interviews with some of these folks. To me, this is the most disturbing part of the story. Landau was quite humble before he went onstage, which is as you might expect. However, some of the purveyors of the worst acts ever to be seen on national television were quite convinced that they had tremendous talent, that once they got their national debut, stardom was just days away.

This may not be an ominous sign, but I do think it tells us that there is something wrong with our society, and ourselves. I occasionally try to sing. I won't shatter glass, but I'm not too bad. However, I grasp totally that I am not very good, either, and I would NEVER subject anyone else to my singing. But here we have people literally making fools of themselves, thinking they are far more talented than they really are (a vast understatement if there ever was one.) There is nothing comparable to the look of utter amazement when they are told in all honesty that their act sucks and they have zero talent.

I wish Dr. Sanity was around to analyze this, but since she has quit blogging, I'll have to wing it. Basically, this behavior represents a form of narcissism. The victim (not the audience, the other victim) believes himself or herself to be worthy and deserving of the attention of the masses, not to mention the million bucks. You'll notice that most of these fools are thirty-somethings and younger, which means that their narcissism was trained into them. This is the result of decades of discouraging discipline, of telling every kid that they are winners, giving trophies to everyone who even shows up to something resembling a competition. This is what we get for ditching the rules, for delving into political correctness at every possible turn, for never saying "no".

OK, OK, I understand that a few nut-jobs on a television show don't signal the downfall of society. But sadly, they are indicative of the way a lot of people think. It borders on delusional, and it has the potential to be dangerous. Especially when these folks vote on the basis of what makes them feel important and powerful. When they buy into a meaningless feel-good slogan to select leaders. And so on. Yup, I think we're in trouble.

By the way, I have no illusions about my writing talent, or lack thereof. Fortunately, Pierce doesn't judge blogs.

Doctor "Hunter's" PACS

2011-06-19T14:29:00.000-04:00

Image courtesy Destination360.com

I have the joy and educational opportunity to be on call on Father's Day, as I was on Mother's Day, and as I will be on July Fourth. I must be living right.

The good news here is that I got the chance to talk at leisure with one of my partners who has the wonderful fortune to be on IR call this weekend. Dr. "Hunter" as I will call him is a damn good radiologist, although not as computer-savvy as some of the guys. Fortunately, he isn't quite as bad in this regard as another partner, the inspiration for Dalai's Twelfth Law, "The PACS needs to be operable by the least technically-savvy radiologist on staff." That would be Dr. Bill, who is also an absolutely superb interventionalist, but not so good with computers:

Anyway, as you might guess, Dr. Hunter's favorite hobby is indeed hunting, and he can discuss guns and hunting trips until the cows come home. (He doesn't hunt cows, fortunately.)

Hunter is based at our smaller, AMICAS hospital. He has been exposed to the new AMICAS PACS more than the rest of us, and has had some problems with it. When this morning's conversation rolled around to the topic of PACS, I was expecting the worst, a tongue-lashing about "my" PACS. Surprisingly, I found Dr. Hunter to be quite insightful on the current and future state of our enterprise. Let me elaborate.

AMICAS PACS, or AMICAS 6, or Merge PACS 1.0, is a considerably more powerful product than its predecessor. With power comes more buttons and settings, most of which are in the background. Sometimes, those settings don't get set right, or at all, for that matter, and that has been our problem. The hospital in question has had some transitions, and in fact just let go the PACS admin who had been trained up on AMICAS 6, but never had time to go through and customize it for us. The formerly junior PACS admin, who is now the Senior PACS admin, as well as a bunch of other things, has not been to training. Fortunately, he is wise enough to know what he doesn't know, and gave me super-user access. Thus, I've been able to do some fine tuning and improve the experience for my mates at work.

I'm not going to diss AMICAS 6, as I had a little to do with its creation. I can (mostly) honestly say that the parts of the program my partners dislike are those which were "inspired" by other systems, and which some other members of the now-defunct Advisory Board insisted be included. One particularly despised function is a more elaborate history listing that superimposes itself above the Real-Time Worklist, and basically takes up space that would be better devoted to the worklist itself. This, I believe, was modeled after Stentor/iSite. I didn't like it there, and I don't like it here. I've asked Merge to put in a control that will let us big-time super-dooper-pooper-scooper-users turn it off. The drive to appeal to a minority user (not a racist statement, I promise) illustrates the situation described in Dalai's Fifth Law: "Workflow is inversely proportional to the number of buttons on the PACS desktop." The desire to please everyone can ultimately lead to the Lego-PACS syndrome of hyperconfigurability. Even Dr. Hunter gave in to this rationale, wondering if the PACS shouldn't just start out as a plain vanilla framework, to which one could add various modules. He used the example of a white Ford pickup, of all things. "Some want bucket seats, some want flame decals on the side, some want brush guards. Let 'em build it the way they want it." Personally, I would never buy a Ford anything, but you get the point.

Dr. Hunter bemoaned the loss of simplicity (if not innocence) we had with AMICAS 5. But I can tell you that the advantages of the new program compensate for this, once the program is configured properly. Still, I hear what he's saying, loud and clear. I used the example of Hunter's new iPhone to illustrate. Apple takes the old AMICAS approach. The iPhone has some configurability, but not so much as, say, an Android phone. But the iOS works really, really well for the vast majority of people, and they flock to Apple so as to have something that works, and work well, right out of the box. Android requires a significantly greater degree of fiddling to get to where you want to be, and I understand that Blackberry's are sheer drudgery in this regard, which probably explains why RIM sales are plummeting. Most of my partners who suffered through various Blackberries now have either iPhones or some Android variant. AMICAS 6 tends to resemble the Android end of the phone spectrum. It works quite well, don't get me wrong, but it isn't as simple as it used to be. There is always a trade-off between usability and power.

Hunter then shocked me with the his home-grown ideas for where we need to go with PACS. In his own way, he has figured out a few things that took me quite a while to realize. He has some inkling of how an enterprise-wide system might work, inspired by the fact that some of our partners never seem to get around to helping with the lists at other sites. "Why not have some sort of window on your computer, or even something you could pull up on the iPhone," says Hunter, "so everyone can see which sites need help? And make 'em link to the PACS programs so I can go right to where I need to be!" Good idea, although my personal thought is to simply (not really) connect all sites to one single unified worklist. Let everyone chip away at everything. Frankly, though, Hunter's idea would probably be easier to implement, requiring fewer permissions from IT and security types. He had a similar idea for report sign-out amongst the various RISes we use. Not a bad thought, really.

The lesson to be learned this Father's Day is of course not to be on call if you can avoid it. Seriously, though, my chat this morning illustrates what I've been saying for a very long time on this blog and elsewhere: PACS designers need to listen to how bread-and-butter, front line, out-in-the-boonies radiologists do things. We use the stuff every day, day in and day out, and we have a reasonably-good idea of what we need the PACS to do and how we want it done. Unfortunately, every PACS vendor feels the need to appease outliers sometimes, adding stuff that only a few really want, or even building something just to please the IT folks who hold the purse strings, and not the radiologists who actually use the damn thing. The disconnect is just something that has emerged over time, but doesn't have to be the way things are done forever more.

In the meantime, I'm jealous of Dr. Hunter. He'll be off duty soon, and I'm sure he's going to go out and kill something. Sounds pretty good after a weekend of call...

The Library of the History of Human Imagination

2011-06-16T14:33:00.000-04:00

The Walker Library from Walker Digital on Vimeo.

Behold the most unique and amazing 3600 square feet on this planet, the Library of the History of Human Imagination created by Jay Walker.

From the Walker Digital Website:

Jay Walker, one of America’s best-known business inventors and entrepreneurs, has founded multiple successful startup companies that today serve more than 75 million customers in 15 different industries.

Mr. Walker is chairman of Walker Digital, a privately-held R&D lab founded in 1994 and based in Stamford, Connecticut. Walker Digital has invented hundreds of solutions for a wide variety of business problems. Since its founding, the company has funded an R&D budget well in excess of $100 million. The company has specialized in creating innovative applications that work with large-scale networks such as cell phones and the Internet.

Mr. Walker is best known as the founder of Priceline.com, which brought a new level of value to the travel industry. Today, Priceline is a highly profitable, billion-dollar public company with tens of millions of active customers. The business processes that guide Priceline’s success were created in the invention lab of Walker Digital...

The Walker Library of the History of Human Imagination celebrates humanity’s intellectual and emotional adventure of discovery, learning, and creativity by showcasing thousands of rare books, artworks, maps and manuscripts as well as museum-quality artifacts both modern and ancient.

Constructed in 2002, the 3,600 sq. ft. facility features multilevel tiers, “floating” platforms, connecting stairways, glass-paneled bridges, dynamic lighting and music, and specially commissioned artworks that celebrate major achievements in the history of human invention.
Invited guests to the Walker Library range from schoolchildren to business leaders, government officials and scholars, as well as librarians from around the world.

Just a few of the many remarkable artifacts in the Walker Library include:
An original 1957 Russian Sputnik, the world’s first space satellite (one of several backups built by the USSR) and the U.S. response, a Vanguard satellite made from surviving parts of the actual American satellite that blew up on the launch pad.
One of two known Anastatic Facsimiles of the original 1776 Declaration of Independence (made directly from the original using a wet-copy process).
A 1699 atlas containing the first maps to show the sun, not the earth, as the center of the known universe. ("This map, by far the most important map in history, divides the Age of Faith from the Age of Reason,” says Jay.)

When confronted with something this overwhelming, the first question might be, "Why?" From a Wired.com interview with Mr. Walker:

"I started an R&D lab and have been an entrepreneur. So I have a big affinity for the human imagination," he says. "About a dozen years ago, my collection got so big that I said, 'It's time to build a room, a library, that would be about human imagination.'"

Walker's house was constructed specifically to accommodate his massive library. To create the space, which was constructed in 2002, Walker and architect Mark Finlay first built a 7-foot-long model. Then they used miniature cameras to help visualize what it would be like to move around inside. In a conscious nod to M. C. Escher (whose graphics are echoed in the wood tiling), the labyrinthine platforms seem to float in space, an illusion amplified by the glass-paneled bridges connecting the platforms. Walker commissioned decorative etched glass, dynamic lighting, and even a custom soundtrack that sets the tone for the cerebral adventures hidden in this cabinet of curiosities. "I said to the architect, 'Think of it as a theater, from a lighting and engineering standpoint,'" Walker says. "But it's not a performance space. It's an engagement space."

Walker shuns the sort of bibliomania that covets first editions for their own sake—many of the volumes that decorate the library's walls are leather-bound Franklin Press reprints. What gets him excited are things that changed the way people think, like Robert Hooke's Micrographia. Published in 1665, it was the first book to contain illustrations made possible by the microscope. He's also drawn to objects that embody a revelatory (or just plain weird) train of thought. "I get offered things that collectors don't," he says. "Nobody else would want a book on dwarfs, with pages beautifully hand-painted in silver and gold, but for me that makes perfect sense."

What excites him even more is using his treasures to make mind-expanding connections. He loves juxtapositions, like placing a 16th-century map that combines experience and guesswork—"the first one showing North and South America," he says—next to a modern map carried by astronauts to the moon. "If this is what can happen in 500 years, nothing is impossible."

Dr. Gene Ovstrovski of MedGadget.com recently had the chance to tour the Library and filed this report, which contains several fantastic photographs of the non-collection. (Hat tip to MedGadget, by the way...)

I'm hoping someday to tour the Library myself, should my fame ever reach the notice of Mr. Walker. I wonder if he has any slide rules in the Library...

Could This Be Why I Blog?

2011-06-09T15:54:00.000-04:00

Nah. I managed to catch Mrs. Dalai without being a country-music star. But it could be interesting having William Shatner for a father.

Hat Tip to Dr. Sanity...

Watson, Go Away! I Don't Need You!

2011-06-01T18:26:00.002-04:00

Eliot Siegel, M.D., schooling IBM's Watson at the University of Maryland; Image courtesy RSNA.org

Surely you've heard by now of Watson, the IBM conglomeration of 90 servers and 360 microprocessor chips that whupped the pants off the former Jeopardy champion. Watch out, boys and girls, Watson is headed to a hospital near you, and he (it?) may challenge you as much as he did Ken Jennings.

Eliot Siegel, M.D., professor of Diagnostic Radiology and Nuclear Medicine at the University of Maryland is taking the lead in teaching Watson about Medicine.

From the RSNA News:

Well before Watson's gameshow victory, experts at the University of Maryland (UM) School of Medicine in Baltimore and Columbia University Medical Center began working with IBM to apply Watson's analytics capabilities to healthcare. Specifically, Watson is being developed as an assistant capable of reading electronic health records (EHR) and providing instant feedback to physicians in ways not always available from doctors and nurses.

"This breakthrough in computer science will allow us to explore this technique for medical diagnosis,"

It seems we have achieved a computer that learns heuristically, although 10 years later than Arthur C. Clarke predicted in "2001: A Space Odyssey."

Earlier attempts at artificial intelligence required every possible question and answer to be hard-coded into the system, a time-consuming process with little value in healthcare, said Martin Kohn, M.D., Chief Medical Scientist, Care Delivery Systems, IBM Research.

"Watson uses a probabilistic, evidence-based approach," Dr. Kohn said. "It generates and scores many hypotheses using an extensible collection of natural language processing, machine learning and reasoning algorithms. Many previous such efforts relied on programmed decision rules. Watson is a self-learning system that does not rely on such rules. It gathers and weighs evidence to refine its hypotheses."

Watch this clip (sorry, I couldn't embed it) of an interview with Dr.Siegel, and you'll get a taste of the future, and perhaps a bit of a chill up your spine as well. Early on in the interview, Dr. Siegel quite matter-of-factly describes how the U of M team will guide Watson through medical school, then internship, and then residency. Say what?

Watson is currently in the testing phase in that learning process, said Dr. Siegel, who pointed out the similarity to real-life students progressing from medical school to residencies.

The first step—acquiring book knowledge—is already under way. Watson's database already includes information from medical journals and textbooks such as the Merck Manual of Diagnosis and Therapy, Harrison's Principles of Internal Medicine, the American College of Physicians Medicine and Stein's Internal Medicine.

Next, experts will work to develop Watson's understanding of the physiology of the human body, followed by the third step: gathering experience.

"Watson not only needs the general knowledge that made him so successful on 'Jeopardy,' but also information from the databases specific to medicine," Dr. Siegel said.

This isn't fair! If I could just take a text book, stick it up my, ummmm, brain, and have it instantly memorized, I would be whiz, too!

The ultimate goal is for Watson to be a helper to physicians and to serve man:

Radiology stands to benefit tremendously from Watson's capabilities, experts say.
"The technology has the potential to provide decision support on a scale not dreamt of prior to this," said Nancy Knight, Ph.D., the director of Academic and Research Development and a founder of the Maryland Imaging Research Technologies Laboratory at UM.

"Watson can supply the radiologist at the point of care with complete patient information from the electronic health record, including imaging history, allowing the radiologist to mine an often exhaustive number of records to identify the most important points," Dr. Knight said. "It also provides the latest and most extensive scientific knowledge and clinical experience that can be used to inform decisions about diagnosis, additional tests, management and likely prognoses."

Phew. The damn thing isn't going to read scans. Yet.

My congratulations to IBM and Dr. Siegel on a huge step into the future. But I am very, very worried about one facet of this program:

IBM is also working with speech-recognition software developer Nuance Communications to give Watson the analytics capabilities necessary for physician-patient consultations.

I think we humans just got a break.

You Know You're Getting Old When....

2011-05-31T16:18:00.000-04:00

Inescapable...Seen Downtown, Far From Maine

2011-05-27T22:38:00.000-04:00

Doctor Dalai Visits Larry's IT Department

2011-05-18T22:13:00.000-04:00

Dalai Beats GE!

2011-05-12T14:50:00.000-04:00

Oh, Vital...Who Is Larry D?

2011-05-11T19:00:00.000-04:00

Just wonderin'...

The Need of the Few to Annoy the Many

2011-05-10T22:07:00.003-04:00

My last post was controversial and even provocative, and maybe I made it so deliberately. Obviously, there is a huge gap in attitude between my outlook and that of some in the IT world. I would like to thank the gentleman (or lady?) from Vital Images (read my Privacy Policy...I DO track visitor's IP's) , who added the following comment to the preceding post, quite nicely clarifying the divide:

"You are assuming that EVERY disk has a virus on it that will bring down your precious system, and I'm assuming that every disk has life-saving information on it. I win. Period."

I am assuming no such thing. You are simply too narrow-minded to understand that there is a middle ground. It's not black and white. There are solutions that best serve the patient first and foremost, the radiologist second, and IT third without creating undue risk.

You're arrogant like most doctors. You can't see that there are options out there that accomplish your goals through a different method. If you want to be head of IT, do it. But being an arrogant armchair quarterback who thinks he knows better like a teenager doesn't serve to better patient care, it just serves to inflate your already large ego.

My dealings with Vital Images have not been stellar over the years, as mentioned in this old entry, but I'm still a bit surprised that this shot across the bow comes from their Minneapolis HQ. Perhaps my favoring of TeraRecon over Vital has earned me a little animosity, but I think VitalMan has a bit more deep-seated resentment. I wonder if Toshiba will embrace and encourage this attitude in their new employees.

Read the post and my comments. I am in favor of safe-PACSing. I want to use those "solutions that best serve the patient first and foremost, the radiologist second, and IT third without creating undue risk." But where are they? VitalMan, as well as Comrade Stonn, offer only the vaguest suggestion of a fix for this, but they have no shortage of indignation over a the thought of interference with their domain.

"You're arrogant like most doctors." Here it is in all its glory. THIS is the core of the problem. When some folks don't like what is being said about our current President's policies, they bellow "RACIST"! I suppose the next best epithet would be "ARROGANT". Sadly, VitalMan probably does hold us docs in such low regard. Which is really funny, as those who know me will tell you that I am about the least arrogant doc they've ever met. But I am a fierce advocate for my patients, and a bit of an S.O.B. when it comes to false bravado and empty rhetoric.

We "arrogant doctors" with "large egos" are responsible for patients' lives. I hate to remind everyone of this, but it is so. The information coming in on foreign CD-ROM's is critical to the health of the patient involved. It MUST be made viewable. Quit carping about how there might possibly be viruses on the disk and therefore we shouldn't load them. And don't demonize me for pointing out the obvious. Rather, acknowledge the necessity of acquiring this data, and work together with us to find a safe way to do so. But as Dr. Sardonicus commented on the last post, many would rather just say, "We don't do that," and go out for coffee.

The real answer to this particular problem is direct connections between hospitals, and a safe way to import data from foreign PACS, limiting the need to fool with CD's. As an aside, I think LifeImage has a good beginning on the solution. But the problem of IT's resentment of physicians is going to take some stronger medicine to solve.