Killer SPECT/CT?

OK, wrong Hawkeye, but the title is correct.

To keep at the bleeding edge of nuclear technology, my hospital is in the market for a hybrid SPECT/CT. This latest and greatest idea in nuclear medicine recapitulates the brilliance and innovation that brought us PET/CT, and applies it to PET's cousin SPECT.

I'm going to assume that you know what these modalities are all about. PET uses positron-emitting radioisotopes to produce an image, while SPECT, Single Photon Emission Computed Tomography, uses more conventional radiopharmaceuticals, generally labelled with Technetium 99m, or Indium 111, or Gallium 67. PET is acquired with a ring detector, and SPECT uses two rotating gamma camera heads (sometimes one, rarely three) to produce an image. You really don't want me to get into the mathematics of the process, not that I really could; suffice it to say that by rotating all around the radiation source (the patient), the radioactivity detected by the heads is reassembled into a series of slices. This technology has been around for a long time.

In the early days of PET, there were attempts to modify gamma cameras to act as cheap PET scanners. We had one, the ADAC Vertex, which used thicker NaI (Sodium Iodide) crystals to stop the higher energy annihilation gamma rays (511 KeV vs 140 KeV for the main gamma emission from Technetium). It was a good way to get our feet wet, but the images weren't great.

One of the SPECT gamma-cameras that was marketed as having PET capabilities started life as the Elscint Varicam:

This was a camera well ahead of its time, with body cowling designed by Jaguar (or was it Porsche?). Its computer was a little esoteric, and I'm not sure many were ultimately sold. But with thick crystals, it could be made to do PET imaging.

In 1998, GE bought Elscint, and assimilated the Varicam into its collective product line, where it became the Hawkeye. (As an interesting historical aside, I was actually talking MRI with some of the developers at Elscint HQ in Haifa, Israel, the very week everyone else at Elscint was in Milwaukee completing the deal.)

I think the innovation to put a CT in the same machine as the SPECT gantry came from UCSF, where an old GE 9800 and a GE 600 XR/T SPECT were sort of loosely combined:

I suppose I should stop at this point to answer the question of why one would want to do this. As with PET and its marriage to CT, there are two reasons. First, the human body is inhomogeneous, i.e., it is full of things that block x-rays to varying degrees. Bones block more than watery structures (like organs), which block more than air in the lungs. To properly reconstruct a tomographic, SPECT image, the computer should know what the anatomy looks like. Most of the time in SPECT we ignore this, although in cardiac work, where chest wall or breast or diaphragmatic attenutation (blocking) could create false defects in the image of the heart, attenuation correction is critical. This correction can be accomplished by sweeping a radioactive source across the area in question, sometimes during the scan itself, or one could use CT. CT actually works much better, because it is designed to look at anatomy, not physiology. Second, linking CT and SPECT gives me a better chance to localize those pesky little hot-spots, just like we see with PET/CT.

Anyway, under GE tutilage, the Varicam became the Infinia. A bit later, a low-resolution CT was added to create the Hawkeye:

The "bump" to the right of the ring holds the x-ray tube, and the black strip to the left, inside the ring, is a detector. Thus, a rather limited CT is created. GE continues to sell this device today, and it now has 4-slice capability (Hawkeye Infinia 4).

Philips and Siemens have gone more traditional, with offerings hearkening back to the original UCSF design with a real CT scanner. The Symbia from Siemens uses their Emotion CT scanner (in various slice increments, either one, two, or six, and soon 64) mated with a dual-head gamma camera. Very pretty cowling; you have to love that Bondi-Blue made famous by the original iMacs.

Philips Precedence SPECT/CT mates a Philips CT (which is coincidentally a descendant of an Elscint design as well) to an ADAC (I mean Philips) Skylight gamma-camera:

I've heard that the Skylight, a room-sized framework suspending two gamma camera heads, was commissioned to do bone scans on racehorses, and having two in my lab (Skylights, not racehorses), I can see where this might have been the case.

So, once I get my hands on one of these, what will I do with it? The possibilities are really endless. Anything we do with SPECT, we can do better with SPECT/CT. A lesion on a bone scan can be precisely located with the CT component. The blobs of activity that are almost unreadable from a ProstaScint scan suddenly become diagnostic of nodes invaded by prostate cancer when I can see where they actually lie. Cardiac scans gain accuracy with the improvement in attenuation correction. And so on. But there is one theme common to these new and exciting applications: They depend heavily on the CT component. The nuclear literature is chock-full of reports of improvements in diagnosis when using SPECT/CT, especially with diagnostic quality CT's done with IV and oral contrast.

Which leads us into the editorial part of this opus.

The Medical University 100 miles down the road is getting four Symbias. Yes, I said FOUR. Our community hospital here in the boonies has to be competitive, but with luck, I will get one SPECT/CT scanner, so I had better choose the right one.

Equipment vendors are in the business of selling equipment, oddly enough, and they try hard to convince you that their machine is the best, and the other guy's is trash. When I was looking at PET/CT scanners, GE sent me at least a dozen articles that "proved" their older BGO crystals were better than Siemen's LSO crystals. I didn't fall for it, and I'm happy with my PET/CT choice of the Siemens Biograph. (However, I'm very UNhappy with the fact that Siemens released their higher resolution TruePoint machine within a year of our system's purchase, which can't be retrofit our older model.)

GE knows very well that I'm not a Hawkeye fan, but they continue to try to convince me of the error of my ways.

I'll make the assumption that the gamma camera (i.e., the SPECT) components are similar, and that the attenuation correction on each will yield good images. The only reference I could find indicates that the Hawkeye's SPECT resolution is slightly better than that of the Symbia series.

But.... When my Chief Tech asked about the quality of the Hawkeye's CT, she was told, "Why would you need more than attenuation correction?" Excuse me? Obviously, there is a little lack of understanding of one's product here. Attenuation correction is only part of the story, and as the interpreting radiologist, it is the lesser part. When I see hand-waving like this, I know there is something to hide. And it is indeed the CT component.
The Hawkeye's CT (we'll be generous and call it that) can acquire 4 slices simultaneously, although I'm not sure how fast it rotates. You sure as heck wouldn't want the open gantry rotating beyond a snail's pace, or someone is going to get hurt. Slice thickness is (per RT-Image) 5mm. OK, but the darn thing puts out only 1-2.5 mA with a 350 Watt generator! Compare this to the Symbia T6, with a 6-slice CT, that has a 50 KW (50,000 Watts), that can develop 20-345 mA. The Emotion CT platform can scan down to 0.63 mm. That's a real CT, with diagnostic images for correlation. In a departmental pinch, a Symbia can even be used as a stand-alone CT.

Why do I need more than attenuation correction? Because CT is what SPECT/CT is all about, folks. Yes, attenuation correction is important, and it greatly improves the image. But I need the diagnostic CT, and it needs to register perfectly with the SPECT image. In this way, I can match the anatomy to the physiology, and that is what I need to do. Sadly, GE doesn't want to acknowledge this, mainly because its product doesn't have a diagnostic CT component. No doubt they will couple their gamma camera with a proper CT someday, but until then, this little deficiency doesn't seem to bother them. In fact, their strategy takes a rather different turn:

The following link is to an article regarding the possible link between multiple CTs and cancer risks, especially in children. Aiding us in our cause for our low-dose SPECT/CT Infinia Hawkeye 4 system. Maximum patient dose with the Infinia Hawkeye 4 is 2.5ma. Why more dose for Attenuation Correction and Anatomical Mapping in Nuclear Medicine environment?

http://news.yahoo.com/s/time/20080630/hl_time/howdangerousarectscans

Maximum patient dose is 2.5 ma? I'm not quite sure what that is supposed to mean. The initials "mA" stand for milliamperes, a measure of current, or loosely, flow of electricity. The Hawkeye's tube current is indeed rated at 2.5 mA. Yes, this lower-powered tube does yield a lower radiation dose.

The article in the link discusses the supposed danger of too much radiation from too many CT scans, and was inspired by a now-infamous New England Journal article. There has been tremendous debate in our literature, both before and after this somewhat inflammatory piece, concerning the carcinogenic potential of diagnostic radiological procedures in general, and CT in particular. I won't rehash that now. But most agree that it is desireable to keep the amount of radiation to the lowest reasonable level.

GE deserves accolades for its attempts to reduce radiation exposure from its devices, especially in the realm of cardiac CT. But in the SPECT/CT venue, the argument is hollow at best. Because the Hawkeye's CT images are not diagnostic, the patient will have to undergo another CT, and the dose will be added to that from the Hawkeye. In other words, the total dose will exceed what the patient would have received had he or she been scanned on a SPECT/CT unit that had a diagnostic CT in the first place.

Now, being board-certified in both Nuclear Medicine and Radiology, I rather take offense to that last line in the quote from GE about the "Nuclear Medicine Environment". The implication here is that Nuclear Medicine doesn't need diagnostic images. Well, sorry to disappoint you guys, but likely the majority of nuclear medicine exams are read by diagnostic radiologists, and because of PET/CT, most pure Nuc Med physicians are now pretty well versed in reading CT's, so don't even think of going there.

One simply cannot justify the purchase of a SPECT/CT camera on the basis of attenuation correction alone, and that seems to be the majority of what the Hawkeye offers. So, let's not play the radiation dose card, when ultimately a patient scanned on the Hawkeye might get a higher dose than someone scanned on a Symbia or a Precedence. If the extra radiation is so dangerous, and it needs to be limited as much as possible so the scans don't turn out to be harmful (or maybe fatal?), then we need to do only one CT scan and not two, yes?

I'm anxiously awaiting the day that GE delivers a SPECT/CT camera with a real CT in the box. No doubt this will occur. But you will forgive me if I have to pass on the Hawkeye. It just isn't going to be my "killer app".

ADDENDUM

Several comments to this post have led me to look further into the Philips BrightView XCT SPECT/CT device, which will be available early 2009. From the Philips website, we learn that this device differs significantly from the other contenders:

CoPlanar FP uniquely integrates Philips BrightView SPECT in a co-planar design with advanced Philips flat-detector X-ray CT technology.

This is the only application of flat-panel detectors in this realm that I could find. Sadly, I didn't look closely at this machine at SNM, but RT-Image gives us the CT specs for the Hawkeye, the BrightView, and the Symbia T16:

I don't know how the flat-panel detector will change things, but physics is physics, and the CT appears underpowered relative to the Symbia, although it is significantly better than the Hawkeye. I'll post further when I get to see some images.

Agfa's TWO Suitors

The Slaying of the Suitors, image courtesy of http://www.mainlesson.com

I've written before about Agfa being for sale, and Siemens needing a PACS product. In an article yesterday, AuntMinnie.com put these seemingly disparate facts together like chocolate and peanut butter in a Reese's cup:

Agfa-Gevaert of Mortsel, Belgium, reportedly has spoken with Erlangen, Germany-based Siemens about the possibility of selling Agfa HealthCare as part of its strategic review process, according to published reports.

The Financial Times reported that Los Angeles-based equity group Gores Group also has shown interest in acquiring Agfa HealthCare. If Gores were to acquire the division, the story added that Gores is likely to leave management of the healthcare operations in place.

Gores already has holdings in the healthcare market. In July 2007, the group purchased the diagnostic imaging division of HealthSouth of Birmingham, AL. The new company, Diagnostic Health, is one of the larger imaging center chains in the U.S.

The report also noted that an acquisition of Agfa HealthCare by Gores could generate opposition from organized labor in Belgium, adding that the transaction would result in some short-term layoffs.

In 2007, Agfa HealthCare posted net sales of approximately $2.2 billion (U.S.).

Representatives for Agfa and Siemens Healthcare of Malvern, PA, declined to comment to AuntMinnie.com on the report.

Just remember, boys. As the Mossad (the Israeli equivalent of the CIA) puts it, "Never say 'No comment.' 'No comment' is a comment."

Dead Green Servers

In a recent post, I relayed the information that the GE migration to the Linux server had to take place because the Sun Solaris servers upon which Centricity had been based were now at end-of-life status. In particular, the most recent version used for Centricity, the SunFire V480, is "retired and no longer orderable" according to Sun's website.

But wait, all is not lost! It seems that the SunFire V490 is now available to meet all your Solaris needs, and you can get it from $30,995.00 (US). Could it have done the job for Centricity? More than likely:

Pack your racks with UltraSPARC IV+ processors driving this 5 RU server and get over 5x faster performance compared to UltraSPARC III based Sun Fire V480 servers. Up to four processors per box with eight threads and 64GB of memory make it ideal for securing and delivering multiple applications and business processes or distributed databases.

Yeah, I think the V490 is probably beyond the V480's capabilities:

The Sun Fire™ V480 server is designed to deliver compute density and enterpriseclass RAS features at an affordable price. Its space-efficient, rack-optimized 5RU, 24-inch-depth enclosure provides excellent value per rack unit and contains up to four 1.05/1.2-GHz UltraSPARC® III Cu processors, each with 8 MB cache(L2), up to 32 GB of memory, integrated dual 10/100/1000-Mb/sec. Ethernet, and the Sun Fireplane Interconnect operating at 9.6 GB/sec.

OK, so what's the real reason behind the upgrade? Well, I dunno. To be fair, GE has been selling the Linux servers for several years, well before the Dynamic Imaging acquisition. And far be it from me to criticize them for being willing to change some software that I was not terribly pleased with in the first place. But was it the server reaching end-of-life that forced the issue? Or the software?

Dalai Does Dallas

I had a rather quick turn-around last week. I arrived back home from New Orleans at 5 P.M., and had to fly out to the West the next morning. We were booked on American Airlines, and we knew this was going to be problematic when the ticket agent predicted American's bankruptcy within the next 6 months. Always reassuring before a flight. To make matters worse, I used my smartphone to check for the connecting gate in Dallas, and lo and behold, it had been cancelled. Fortunately, we were able to rebook on US Air to our destination, and all was well.

American blamed the cancellation on weather in Dallas, and truly there was a big storm there that day. However, the storm lasted less than an hour, and I personally think American was looking for excuses to suspend flights and save fuel. Maybe that's why they tell some of their gate agents to be nasty to the flying public; one less customer, one less gallon. However, given their rather unfortunate habit of letting their planes sit idling with the engines running while waiting for their gates to clear probably eats more fuel than they save with cancelled flights and lost customers. Scratch one more airline.

I actually wasn't planning to travel again quite so soon, but I received a call from Amicas asking me to fly out West to speak with some potential customers. They thought the doctor-to-doctor thing might be helpful, since the group was somewhat similar to mine, and what they wanted to do with the product was rather close to the way we use it. So, off I went. Lest anyone dare call this a junkett, I'll reiterate that I really didn't want to go anywhere at that time, and I certainly wasn't interested going West where the temperatures were well above 100 degrees. But faith in the product, and maybe a little vanity, made me decide to do it anyway.

The radiology group in question is sort of like mine, about the same size, with a few guys older than I am, and more that are younger. They are rather spread out, covering several towns rather far from their base, as do we.

Now, I won't reveal the particulars this group sought, but portability was a critical factor. They had narrowed their choices down to Amicas and another company, and they were having some trouble deciding beyond that. On the advice of my very wise, and occasionally politically-correct friend, Mike Cannavo, the One and Only PACSMan, I won't name the other company, but suffice it to say they are definitely one of the BIGGER players.

I had the chance to speak briefly with some of my counterparts in this Western group, as well as their IT guru. It became clear that they saw the viewers of both PACS as equal. They made the assumption that both could serve their needs, but they still had some hesitation about Amicas as a smaller company vs. the "security" of the BIGGER company. I'm not sure I got all of my points across in person, but I'm told that many of them read this blog, so here is everything I should have said, just in case I didn't.

First and foremost, Amicas is a scrappy little company that isn't going anywhere. I'm always seeing something on AuntMinnie.com about how little PACS companies are going to either die or be taken over. That's true for some, but I don't include Amicas in that pile. They have a great deal of money in the bank, the company is buying back its stock, and 20% of revenue goes into R&D. It is acquiring new technology such as RadStream (the acute-event reporting software from Cincinnati Children's that I have discussed elsewhere.) Sure, if some company like Siemens offered them double what they are now worth, I'm sure they would sell out (I would), but I don't see that happening any time soon. Let's put this takeover idea to bed for today, shall we?

Somehow, there has emerged the illusion that there is safety with purchasing from the BIGGER company. Hmmmmmm... Just ask anyone who bought Centricity in the last few years how safe that is. Or the old Philips PACS made by Sectra. Sadly, the BIGGER folks have an easier time of buying some new technology and requiring a forklift upgrade (usually hardware needs replacing as well as software in these circumstances) for you and me to get it. And, they are not worried (at least not as much as they should be) about whether or not you and I will pony up the charge for the next latest and greatest. After all, the BIGGER company was the safe bet, wasn't it? I can't see that we are particularly worse off dealing with a smaller company that isn't looking to swap out its product for something new, rather than improve and grow what it has. There are those who still believe the old "no one gets fired for choosing BIGGER" philosophy, but I guess I'm not in charge of their particular operation.

Only a few of the BIGGER folks have totally web-based technology, but most don't, and that is the case with the BIGGER company in question here. Is that a problem? Well, it depends upon how many software clients you wish to play with. Amicas has just one GUI, called LightBeam, which is deployed over the web to anywhere you happen to have a computer and broadband. To be totally accurate, there is a second client called LightView, that is simply LightBeam without a couple of features such as spine labelling. Which client and features are activated depends upon your status as a radiologist, clinician, tech, etc. Our friends at the BIGGER company seem to use several clients, some thin, some thick, and as I understand it, I could not put the thick client on my computer myself without help (authorization, I guess) from IT or the PACS team. Hmmmm.

How does the system distribute images? Most everyone is now going to a central repository. Amicas basically ties a web-server to a SQL database. (Note: Amicas now uses the IBM DB2 database which in turn runs SQL.) Why reinvent the wheel? This architecture works pretty well for other web applications, so why not use it? Is this what the BIGGER company does? Well, to some extent, but there seems to be a lot more complexity added, without necessarily getting a lot of additional advantage. This could be quite critical to my new friends out West, as their enterprise spreads far and wide, and the way the system deals with connectivity (or the lack thereof) could make or break the system. Amicas will allow a modality to automatically resume sending once a broken communication line is repaired. It seems that the BIGGER company requires a manual resend in this situation. Could be a problem.

Service should be a given. I've had a few glitches with Amicas service, but our downtime on our group's system has totaled only an hour or two in two years, and most things get caught before they cause chaos. I sure can't say that about some of the BIGGER companies I deal with daily. As for the BIGGER company I'm referring to here....well, I'll let someone else answer for them.

To me, the background operations don't matter as much as the actual interface, the client, the GUI. I like the way Amicas works. It doesn't get in my way, and it lets me bang through studies as fast as I feel comfortable doing so. Can we say this about the BIGGER GUI? I guess it depends upon which one of the options you actually use in practice.

Bottom line here is that BIGGER is not necessarily better. Look honestly at the products themselves, with no preconceived notions about BIGGER companies being safer than smaller companies, and the like. See what works for you and your group, and be sure they all get time on the GUI before you sign on the line. You might find that smaller works for you. I have lived through situations where the purchase was directed to the BIGGER, "safer" choice, and for three times the expenditure, we got half the product.

And no, I don't get a commission, so I have no vested interest in which way my friends out West decide to go. But I'm sure they will make an informed choice. They DO read my blog, after all!

P.S. No, the BIGGER company in question is not the one you think it is. I would have said bigGEr were that the case.

NO RIP for eRAD

According to a very reliable source, eRAD had given up the corporate ghost. HOWEVER, I just heard from a friend at eRAD that they are alive and kicking, so word of their demise is premature. Glad to hear it! My sincerest apologies to eRAD and my friends there, but I promise my source was trustworthy in the extreme! Perhaps his/her unimpeachable source needs to be impeached.

It seems that I have more readers than I ever will admit to myself, and it seems that a bunch of them were burning up the lines to eRAD. I've learned my lesson, I think, about posting unsubstantiated rumours.

To further my mea culpa, I will reproduce an e-mail from Seth Koeppel, eRAD's Senior VP of Sales:

All is well at eRAD, no danger of going out of business. With roughly 220 customers (300+ sites) of various shapes and sizes we're fortunate to be able to sustain ourselves (at a pretty full staff I might add) on residual support contracts, upgrades, expansions and add on sales from existing customers.

With this said I will tell you it's a tough market. Lots of opportunity but not a lot of checks being written right now. So we took the painful step a few weeks ago of reducing staff by a whopping 4 heads (2 direct sales, 1 apps and 1 field support) to ensure we can run at a 'zero footprint' or break even. One of the sales guys went back to work for our best reseller where we originally hired him so no real loss there and a better fit for him. If sales pick back up we'll add the heads back.

We continue to see steady activity from our network of resellers which has been erad's primary sales vehicle. While distributing through resellers can be a challenge it does have some advantages in a down market. If you stop and consider where much of the spend is in pacs right now its the small community hospitals and non-critical care access providers that haven't yet gone digital. There are literally thousands of ortho, multi-specialty, urgent care, etc. Clinics and small imaging centers that have yet to go digital and these are best served by the resellers who've been supplying film, chemistry and service to them for years. I just don't see how a company can afford a direct sales force to reach this market? Particularly with the cost of fuel/travel being what it is I think the regional guys have a huge advantage from a 'cost of sales' perspective and the margin on the low end systems aren't all that appealing for the big guys.

Then there's the replacement market. Talking to Ben Brown from KLAS at SIIM (you were missed by the way) he shared an interesting bit of info with me. He indicated they surveyed both the vendors and the hospitals on what they felt the replacement market is. The vendors weighed in at 40%+ and the hospitals 10%. I think there is some merit to this disconnect. The pacs the hospitals paid big bucks for just a few years ago does what they need it to do. Its the rads and the referrings who are beating the drum for web-based and remote reading to become more efficient and frankly I don't see the hospitals giving a hoot. Certainly not enough to spend the big dollars to make the rads more efficient so they can make more money.

This brings me back to my hot button of 'enterprise reading' or 'worklist consolidation'. I think the market is going to realize that A) hospitals aren't going to rush to upgrade and B) if they do the rads are still left reading from multiple disparate systems which doesn't allow for maximum efficiency of the most expensive resource in the production line. I've seen enough large groups pursuing purchasing their own system and requiring images be sent to it to know this is not just a passing fad but a reality of how groups will need to work in order to grow their reading base and improve efficiency.

This is where our direct sales efforts come in to play as the HL7 interfacing and complex workflow require a certain acumen and experience.

ERAD's technology is very progressive and very configurable so we have a big advantage in this space with some experience vis-a-vi our telerad providers and others whom have endeavored.

Then there are still some of the big guys who need a web based system (Cerner, McKesson, Siemens) to name a few not to mention companies like Sage/Medical Manager who still sell DI integrated to their RIS which is now owned by GE.....a direct competitor. Than there is the whole world of EMR companies who will no doubt want a web based image management component for their customers who do in office imaging and want to access images directly from the EMR in the context of the patient record and not have to go search a pacs worklist. Our API web interface allows this and we're seeing growing interest.

So I see lots of opportunity for a company with a solid platform, good developers, support infrastructure and 9 years of operating history.Everyone is feeling the pain with GE announcing a reduction of 400 heads in their imaging division today and Emageon's management losing its proxy fight with its investors which will no doubt result in a sale to the highest or for that matter any bidder.

So we're still here and will be for the foreseeable future. Hard to convince the world a small little company in Greenville SC can challenge the big guys and win but if anyone stops long enough to dig into the details they too will learn what several others have.

Hope to see you soon!

Seth

And that's all I have to say about that.

A Nuclear Oasis

I told a minor mistruth in the last post. It seems that a company called Segami has a product called Oasis that does much of what MIMVista's fusion product offers. I'll let you peruse their literature via this link.

Seeing it in action is impressive, but somewhat less so than the MIMVista product. Yes, it would link two studies, but some of the landmarks did not quite match as well as those on the MIMVista demo product. Could MIM have used better scan data? Maybe. Some of the tools on Oasis were a bit less intuitive at first blush, especially those that are used to alter the registration that I would have hoped to have been perfect when performed automatically. It did propogate ROI's from the old study to the new, as does MIM's, but not quite as well. There seems to be no deforming option, nor is there use of gradient-based edge detection.

I was told the system was web-based, and if you have more than one user, it is sold as a client-server operation. I didn't get a price on the PET module itself.

However, as it turns out, Segami writes the software for the Philips JETStream computer, which replaced the venerable ADAC Pegasys machines. We need a bunch of them, as our Pegasyses (Pegasi?) are rather old and decrepit at the moment, and Sun Workstations are just so 1990's. I was quoted a price for the client-server software, an adequate number of licenses, and the PET/CT product thrown in which was less than the price of one and one-half JETStream workstations from Philips. Now, whether the Segami product can do some of the special things offered by Philips, such as the rapid-acquisiton ASTONISH protocol, is yet to be determined.

As for PET/CT, I'll give MIMVista a 9.5, and I'll give Oasis an 8.5, based on limited exposure. You can rest assured, there will be more to come on this topic.

(MIM)Vistas of New Orleans

The annual meeting of the Society of Nuclear Medicine is held in various cities, including New Orleans, San Antonio, Philadelphia, Orlando, and Toronto. This year's meeting is rather poignant, as this is the first time the SNM has returned to New Orleans since Hurricane Katrina. The Morial Convention Center is in great shape; you would never know of the tragedies that occured within its walls and nearby. However, within a few miles of the convention center, and only a mile or so from the French Quarter, lies the Ninth Ward, and there we found that all is not well with New Orleans. Much destruction remains, and rebuilding is slow and patchy. Further north, near Lake Ponchatrain, there is even more devastation, and three years after Katrina, little has been fixed. Locals tell us that over 60,000 people left New Orleans, never to return, and their homes will sit barren for the foreseeable future, testaments to a complete failure of government at all levels, especially local.

Bourbon Street is as lively as ever, perhaps slightly cleaner than it was on my last visit several years ago. Alcohol flows freely, and the strip clubs dominate the landscape. My fourteen-year-old son (who looks fourteen) was offered Jello-shots, among other things, which he wisely declined, as Mrs. Dalai and I were looking on. One of the street hawkers asked me if I wanted to buy my son his first lap-dance. I smiled and didn't respond, but I reviewed the possible answers: "No, he's only fourteen." Or, "No, but when do I get my first lap-dance?" Or, "Let him buy his own!" Mrs. Dalai was not amused. She was even less amused when a stripper outside a club called to her, "Hey, I'll play with you too, baby-doll!" There is no place like Bourbon Street. I like to come here every five to ten years just to remind myself why I don't want to come here any more often than that.

I'm somewhat surprised that this city exists at all, let alone the fact that it survived the one-two punch from Katrina and Rita. There's a joke around these parts: "Look up. What do you see? Sea level." Yes, New Orleans sits anywhere from 1 to 15 feet below sea-level. Minor problem, eh? But, the spirit here is strong, the levees and pumps have been repaired, and the rebuilding goes on. Eventually, I predict New Orleans will return to its former grandeur.

But now, back to things medical.

I had the chance to speak with several folks from MIMVista, including the fellow that wrote the software for the iPhone 3G application. The company was kind enough to give me the link to the presentation at WWDC08 in San Fransisco:

As it turns out, the iPhone app cannot be demo'ed at this point due to some pesky NDA's MIMVista signed with Apple. But as per the last post, the software should launch with the iPhone 3G itself.

The real news here is the core MIMVista software itself. For us PET/CT readers, what they offer is nothing short of revolutionary. To understand this, you have to realize what it is I do when I read PET's. If I'm looking at a new study, I try to find the "hot spots," and determine if they are physiological or pathological. If the latter, I need to determine how hot they are, a measurement called SUV, or Standard Uptake Value, which is a ratio that tells us how hot the lesion is relative to the total distributed dose. A somewhat arbitrary value of 2.5 has been assigned to badness; in other words, if a lesion is 2.5 or more times hotter than the "average" activity in the body, we should worry that it is malignant, or at least infectious or inflammatory.

MIMVista's software won't actually find the hot spots for you (no doubt they are working on that) but once you locate them, MIM does the rest. Simply focus in on the lesion, and let the PET edge tool take over. It will find the contour of the lesion in three dimensions, and report back all the needed statistics such as minimum and maximum SUV, HU's (density from the CT component), and the volume of the lesion. MIMVista uses a unique, proprietary edge detection system that uses a gradient-based algorithm as opposed to the constant threshold algorithm used by everyone else in the business. See this paper if you want the details.

This would be adequate in and of itself. But as Apple's Steve Jobs himself says, "Oh, and one more thing...." The bane of my existence as a PET/CT reader is the comparison of the current study to one or more priors. MIMVista has attacked this problem, and has the only real solution I have encountered. This is multi-faceted, and very, very well thought-out. The system will automatically match the old study to the new. Voxar told me years ago that they were working on this, but they have yet to deliver it. In addition, the system will propagate the contours around the lesions from the prior study to the lesions on the current study. That may not sound like much, but trust me, this could be an absolute miracle for us readers. The lesion contours can be transferred rigidly, or can be deformed, and will automatically adjust to the new pattern of the finding. This is what the clinicians (and sometimes the patients themselves) want to see. Tell me the progression of the SUV and the size of the lesion. Measuring all of this manually for every lesion for every study is incredibly tedious and prone to error. I'll take every bit of help I can get, and MIM is offering me a heck of a lot of assistance.

MIMVista's system is made up of modules,

which as I understand it can be used separately, or together, with or without the "PACS" storage server. The "viewer" is a thin client, but supposedly not for diagnosis. However, the "thick" fusion module should work on all workstations with a fairly open license agreement. As of now, there is no integration to Agfa, which I would need for reading PETs done at my Agfa. Let's get to work on this, Agfa and MIM. Quickly. I really, really want to get my hands on this software.

I looked briefly at the Cardiac package, which would be great for those doing multimodality PET perfusion/CCTA scans. At the moment, it doesn't have the high-level CCTA angiographic controls and so forth that we need for readout of CCTA alone.

I didn't demo the Neuro package, but I have been told by other docs that it is quite advanced.

I was asked not to mention numbers, but I can say that the value for the price is absolutely phenomenal. This is a bargain folks, and I don't say that often. PET/CT readers, have a look. You'll be glad you did.

Disclosure statement: The folks at MIM gave me a UniBall pen, worth approximately $1.

I Have GOT To Have This!!!

The definition of "killer app" is different for everyone, but to me, it signifies a piece of software that is so good, you have to go out and buy it (and the platform it runs on if you don't already have that) yesterday.

MIMVista, creater of advanced imaging software, has produced the MIM iPhone Application, and this is my killer app, my excuse to run right out and buy the new iPhone3G, scheduled for release on July 11.

The MIM iPhone Application provides multi-planar reconstruction of data sets from modalities including CT, PET, MRI and SPECT, as well as multi-modality image fusion. Using the multi-touch interface, users can change image sets and planes; adjust zoom, fusion blending, and window/level; and measure dimensions and SUV.

Lemme at it! Now, my contract with AT&T says I'm due for a new phone sometime in December, but....there are ways, there are ways.

The iPhone3G now uses AT&T's faster 3G system, and has GPS chips built-in.

It's definately prettier than my Blackjack II. Now whether it's actually more functional remains to be seen. Look for my report sometime in July. Or December.

I just received an email response to my query about MIMVista and the iPhone3G. The text follows. There was actually a brochure attached, but I can't open it on this convention computer I'm borrowing....

Q: When can I test drive the MIM application?

A: Apple said it will be releasing the iPhone 3G on July 11th and launching the App Store in "Early July". So, the exact date is unknown. Mobile MIM will only be available through the Apple App Store or iTunes.---------------

Q: What will be the cost of MIM?

A: The first Mobile MIM (for referring physicians & hopefully patients) will release at no cost, free.---------------

Q: What features will be in the first MIM application?

A: The features made available in the free Mobile MIM (for referring physicians) will likely be image display, fusion, blend, window/level, zoom, and a few other items. This release of the free Mobile MIM is not intended for diagnostic purposes.---------------

Q: What about the measure mode and other features I see on the internet?

A: Another fully featured MIM application is in the pipeline and will be released Q4 2008.---------------

Q: What about security and HIPAA?

A: To ensure patient privacy, all communications between the Mobile MIM and the MIM Workstation/Server software will be transmitted over a secure encrypted connection. The MIM application will also make use of password locks, tamper-prevention features and will encrypt the patient data on the iPhone / iPod touch.---------------

Q: Will MIM support DICOM Query/Retrieve or DICOM Send?

A: No, we do not plan on implementing this for two reasons: Security & Simplicity.---------------

Q: How does patient data get onto my device?

A: Patients are transfered from a MIM Workstation and/or Server.---------------

Q: What if I do not have the MIM Workstation / Server Software?

A: You will need to buy or demo the MIM Workstation / Server Software. For the time being, only sites that have MIM Workstation/Server software can send data to a iPhone / iPod touch. The free Mobile MIM will install on the iPhone & iPod touch with 1 or 2 pre-loaded patients, so users can experience the Mobile MIM application.---------------

Q: What happens next? and who will contact me?

A: All feedback has been assigned to a sales rep and/or engineer at MIMvista. Mobile MIM should be on the App Store when it is launched by Apple. Please contact us with any questions.-- The MIMvista Team

I'm currently in New Orleans getting some SNM....that's the Society of Nuclear Medicine, perverts! No doubt MIMVista has a booth here. I'll report more tomorrow.

Following The Green Brick Road Yet?

I'm getting a lot of traffic from BDM Information Systems, the software arm of GE, looking particularly at my posts on the Centricity/Dynamic Imaging upgrade paths. I'm glad to be of service to all my friends at GE. Let me know if there is anything else you guys might need!

More PACS Ownership Follies

On the heels of the last post comes an interesting incident illustrative of how the process works.

IT informed the PACS team at 12:26 PM yesterday that there will be a planned internet outage from 2AM through 4AM tomorrow morning, and PACS informed Radiology of this via email at 4:17 PM. Supposedly, services within the enterprise should continue to function (i.e., the LAN's will still be functional), but there will be no outside access. This is a bit of a problem, as we have nighthawk radiologists that sit at one site and read for all of our sites. Scans from other hospitals are piped in via.....Internet!

Yours truly complained (very respectfully, I might add):

As you know, our night radiologists are completely dependent upon the internet connection to the outside which allows them to serve (our outside) hospitals. While we appreciate the advance notice, I hope it is understood that this planned outage represents a significant impact upon our ability to provide patient care. Therefore, I respectfully request that this outage be postponed until such time as (we) can together formulate an alternative conduit to allow for us to provide uninterrupted service.

Your understanding in this matter is greatly appreciated.

PACS responded:

Due to the necessity of this planned system outage, we can not postpone the outage. We understand your concern for patient care, which is why we had hoped that with enough prior notice alternate means of access could be arranged.

Thank you for bringing this to our attention and we will work together to minimize situations like this in the future.

OK, I do hope we can stick to that last sentence. Is 34 hours enough prior notice? I don't think so, personally. But, since IT owns the network, IT triumphs yet again.

Who Owns PACS? . . . and are they Highly Reliable?

Among the many things I missed by not attending SIIM was a discussion on something near and dear to my heart, the "ownership" of PACS. The debate, as summarized by AuntMinnie.com's Cynthia Keen, pitted Dr. Paul Chang, speaking for IT against Dr. David Channin, pushing for Radiology ownership. Dr. Chang argues for a "matrix" to "enable the experience of one domain to be adopted by another domain." And,

Because PACS is the multimedia component of an electronic health record (EHR), the EHR must be optimized to support radiology workflow. Not only is this a complex undertaking, but it logically fits as the responsibility of the IT department -- as long as the IT department has a global vision and a progressive philosophy, Chang said.

Dr. Channin, whose idea of "Napster PACS" I borrowed for my Portable Patients post and article, counters:

"Radiology has led informatics technology innovation in hospitals and will continue to be the source of informatics leadership in healthcare," Channin said. "Domain expertise must take precedence over IT expertise. Tools don't drive domain innovation."

"If controlled in a central manner, such as a matrix structure, the priorities of a radiology department will be subjected to control by an IT department juggling priorities representing multiple domains in a hospital," he said. "If you don't have budgetary control of your bucket of allocated capital dollars, you have lost control. Your critically needed PACS upgrade will be competing with acquisition of a new laser doodad for OR."

Radiology departments should wield the power they have as cash cows for hospitals, define their IT domain borders, provide access to them with standard interfaces, and demand autonomy, according to Channin. He recommended that radiology departments contract with IT departments for "commodity services" such as networks, virtual operating systems, and data storage.

"As progressive as an IT department may be, it doesn't care about the quality of information that radiologists need," Channin said. "Even if a new capital acquisition is approved in February, you may be told that you can't upgrade XYZ until the department synchronizes something else in August. It is imperative that radiology departments be able to control their own domain."

I have to side more with Dr. Channin, and not just because I stole, I mean borrowed, his earlier ideas. As a radiologist, my patients come first. Period. End of story. There should be nothing between me and my patients' images, because it is my job to interpret these images and do my part for patient care. Now, if you will all turn to the Book of Dalai, Chapter 3, Verse 3, you will take reverent note of the first two Laws of PACS:

I. PACS IS the Radiology Department.

II. PACS exists to improve patient care. Its users are the radiologists and radiologic technologists. The entire goal of the PACS team is to optimize PACS function for its users.

Not to toot my own horn (like Bill Clinton does), but I think I figured this out a while back. Nowhere else in the hospital is the most critical piece of equipment farmed out to a different department, and why should this be so for PACS and Radiology? Well, that gets into politics. PACS, after all, is a tangle of wires and computers that we lovingly refer to as networks, servers, and workstations. Amazingly enough, that's what IT deals with, too! Therefore, they want to claim ownership of the PACS package, too. Why do they want to take on more headaches, including middle-of-the-night calls, and blogging radiologists that quote them in embarrasing statements? It's called territory. A department's budget is its club, or its reputation. (I will refrain from using crude, coarse, peurile male anatomic references in this discussion, but you know where I'm going.) The more stuff under their domain, the higher their budget, and the greater the power the department commands. So, it is to IT's advantage to engulf PACS, and they aren't about to let it go.

So what's the problem? Since the IT wonks are supposed to know everything about computers, aren't they the logical masters for PACS? In the discussion that followed the AuntMinnie SIIM recap, AM member Frumious says:

This is going to sound like a rant and in some ways it is. My experience is that with 1 exception, most Hospital's IT, including large ones with large budgets and multiple campuses and connections to remote sites are not exactly bleeding edge and performance and service is adequate at best. They are indifferent to Radiology's needs and generally see the email system as more important than the clinical systems. . .

Also, how many IT departments seek out clinical input or have staff with clinical background in the department at the decision level? And what of accountability? Do you all rely on your IT Dept to quickly respond to your issues, whether troubleshooting and resolution or your needs? My experience is that the Hospital doesn't hold the IT dept in high esteem either. They don't understand that Radiology creates revenue and provides a large add-on service to many different disciplines. . .

How many of you had your PACS selected for you by IT or by Administration because GE or other vendor made them think they got a great discount & the vendor would take care of everything, all without your clinical input?

. . . Paramount is the workflow. Everything else is a tool to improve the workflow. Use tools, don't hire them.

But it goes beyond a mere turf war between radiology and IT, it goes into service & the concept of taking care of the customers. Radiology's customers and concerns are imaging the patients and providing the referring physicians access to the images and results quickly and collecting the revenue to stay in business. Getting IT to understand that concept is usually an uphill battle (go figure). For example, it's often radiology who is "pushing" IT to improve things such as the network because pushing images makes network needs just so much greater; reliability because RIS/PACS and the network are mission-critical. IT sees radiology as too demanding and would prefer to see radiology as just another customer of IT and deal with everyone's needs FIFO.

My personal experience has varied. Much depends on the individual members of IT one works with. I have met some over the years who repeat the mantra over and over, "That won't work, we can't do that, let's have a meeting in six months to decide if we should talk about that later." Most, however, do have an inkling about what is important to keep the department running, and they are certainly our allies in doing so. Not that we haven't had some glitches. I remember the time IT refered all of the rads to the Help-Desk to change passwords after some particular change, and the Help-Desk didn't answer the phone after 10 rings after 5PM because there was only one staffer. Great situation for the nighthawk coming on that night. And we won't even talk about IT-driven PACS selection processes.

A fellow named Mike O'Meara posted his views on the AuntMinnie thread, and I think he's on to something. Mike is president of ORQA, whose mission is to "Reduce risk for ancillary health care services by providing enabling technology to promote a culture of collaboration, open communication, and mindfulness." Um, OK. Well, have a look at their website if you're interested in further information.

Mike suggests a more middle-of-the-road approach for PACS stewardship, one that has great potential. It seems that there is a new bureaucratic or organizational or whatever concept called High Reliability Organization tenets, brought to you by the Agency for Healthcare Research and Quality, a proud member of Health and Human Services, i.e., they are from the Government, and they are here to help you. Now, I don't have the patience to wade through the 40 pages of governmentalese, but the executive summary on page 1 says:

At the core of high reliability organizations are five key concepts, which we believe are essential for any improvement initiative to succeed:

Sensitivity to operations. Preserving a constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them.

Reluctance to simplify. Simple processes are good, but simplistic explanations for why things work or fail are risky. Avoiding overly simple explanations of failure (unqualified staff, inadequate training, communication failure, etc.) is essential to understanding the true reasons why patients are placed at risk.

Preoccupation with failure. When near-misses occur, these are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than viewing near-misses as proof that the system has effective safeguards, they are viewed as symptomatic of areas in need of more attention.

Deference to expertise. If leaders and supervisors are not willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face, you will not have a culture in which high reliability is possible.

Resilience. Leaders and staff need to be trained and prepared to know how to respond when system failures do occur.

How does this bureau-speak fit in? Mike thinks they will

. . . hopefully create a culture where the organization as a whole has "ownership", but different stakeholders in their area of expertise have the accountability for the success of PACS. The IT folks should accountable for ensuring the Imaging IT systems (PACS, RIS, VR, etc) are available as close to 100% of the time as possible, and work to remove all techological barriers to successful operation of the system.

The clinical folks should be accountable to ensure the workflow meets their needs and that the system is used to its full potential.

The business managers in radiology and administration need to be accountable for quantifying how they will realize a return on their investment in PACS.

The goals of each domain inherently contradict each other and it's up to the collective team to compromise on solutions that work for everyone. In most truly successful PACS implementations I've come across, a formal team consisting of stakeholders from each domain of expertise is who "owns" PACS, and that team is held accountable to the CXO/Board of Directors of the organization. If hospital politics or hidden agendas prevent the formation of an effective cross-functional team, then there are much deeper organizational issues than "who owns PACS"...

Frankly, I like it. The High Reliability factor for this purpose will definately be the Sensitivity to Operation thing. Everyone has to realize the mission-criticality of PACS. That's just the way it is. Emergent patient care trumps everything else. However, the key problem, as Mike points out, is that indeed some of the goals of each department might conflict with those of the other divisions. Then you get into a urinating contest which is often won by the folks with the greatest political clout. But that isn't how it has to be. There has to be compromise between the departments, but not of the ultimate goal, which is using the PACS system, that IS the department, to further patient care. The minute that gets disrupted, heads need to roll until those that are left understand the mission.

If I had my own way, PACS would be completely under Radiology's domain. However, we have to be practical, and not reinvent the wheel. It makes much more sense to utilize the hospital network rather than install a second LAN in our department, and so forth. But it all works if and only if everyone cooperates, and understands who really runs the show. Which is me, of course. Funny how every member of the team seems to think that of themselves as well.

A Clock For The Industrious

From Yugo Nakamura:


Many thanks to the One and Holy PACSMan! (I gave him a promotion!)

PACS Synergy Takes Energy

My fellow author Erik Ridley (OK, Erik, you can stop laughing now) reports today on AuntMinnie.com about the use of Synergy, an open-sourch program from SourceForge, to control multiple PACS apps from one computer. This was based on a SIIM presentation by Stuart Pomerantz, M.D., from Mass General.

"Many of the ergonomic benefits of a 'one-box' radiology solution can thus be achieved in a multi-PC environment with keyboard-monitor software at no additional cost," Pomerantz said. He discussed the MGH researchers' experience with an open-source, virtual "one-box" system during a scientific session at the meeting.

A "one-box" approach with all applications running on one workstation would offer ergonomic advantages, allowing users to use a single PC (and keyboard and mouse) to drive all applications, he said. A virtual, network-based "one-box" model would also have this benefit, yet it would retain the flexibility to split into two separate simultaneous input modes for two-person navigation and data entry, according to Pomerantz.

"It's important that the virtual 'one-box' is not through a switching device, through a manual switch where one keyboard and mouse controls a different on-screen connection to one PC or the other, but rather a fluid connection across all PCs with simultaneous control," he said.

This is an interesting idea, and actually one I have encountered before. One of my partners bought a second computer, and connected it to the same monitor, mouse, and keyboard as his first computer via a hardware KVM switch. He did this to allow different (and at that time somewhat incompatible) PACS clients
to run on the different computers, but to still be controlled from the same perch in his office. Personally, I thought it was overkill for the purpose.

Pomerantz's approach does not use hardware KVM switches, but rather networks control via the Synergy program.

With synergy, all the computers on your desktop form a single virtual screen. You use the mouse and keyboard of only one of the computers while you use all of the monitors on all of the computers. You tell synergy how many screens you have and their positions relative to one another. Synergy then detects when the mouse moves off the edge of a screen and jumps it instantly to the neighboring screen. The keyboard works normally on each screen; input goes to whichever screen has the cursor.

In this example, the user is moving the mouse from left to right. When the cursor reaches the right edge of the left screen it jumps instantly to the left edge of the right screen.

OK, this has potential, but for many of us, the potential is that of confusion. I would be rather concerned about realizing which computer it is that I'm operating.

Is this all really necessary? I'm not so sure of that either. Most desktop workstations have the horsepower to drive the PACS client, SR window (if you are so unfortunate as to need one), RIS client, and some level of advanced visualization software. If you are using an integrated thin client, there is relatively little impact on your CPU.

I'll probably try this at home, and amuse my wife and son no end as I scoot my cursor over to their screens while they are trying to do something productive. I might have a different opinion of the efficacy of using this with PACS if I were to see it in action at Mass General, but short of that, this seems to represent about the same level of overkill as the old KVM switch idea. Just my humble opinion, of course.

80K Hits . . .and some interesting software

Image courtesy of: http://www.predig.com

Visit 80,000 was from a Sprint/United Information Service customer in Kansas City, Missouri, who found me via Google. They were trying to find out "who's going to buy GE business". . . I guess that remains to be seen, eh?

In the meantime, I just read about an interesting piece of software from BridgeHead Software. The product is called PACStore, and it supposedly

. . . helps healthcare organizations reduce the accelerating storage hardware and management burden imposed by the long term retention and protection of PACS (Picture Archiving and Communications Systems) medical image data.

The function that grabs my eye has to do with the old problem of uniting disparate PACS:

PACStore effectively unifies PACS data by enabling clinicians to search across stored medical images from different proprietary PACS systems. It does this through a search facility based on the Digital Imaging and Communications in Medicine (DICOM) standard used by most PACS vendors.

PACStore is storage agnostic, providing unlimited flexibility for selecting and deploying different types of storage media throughout the evolution of your data lifecycle management strategy. Storage costs are reduced as PACStore automatically moves data onto the appropriate storage media based on how available it needs to be. The most current, active PACS image data stays on the most highly available primary storage, while static data, which is viewed less frequently, is moved to alternative, lower cost media in line with compliance and protection requirements.

Sounds pretty good. I would remind the folks at BridgeHead that radiologists like to search too, not just clinicians. In fact, I think our needs are more important! And, they are a little too IT centric in their approach, or at least in their advertising:

The PACStore Solution

Traditionally, PACS vendors have provided internal standalone backup and offline archiving capabilities to address PACS data only. This created stovepipes within the organization, resulting in redundant technology assets outside the control of IT.

With a single complex study soon expected to consume upwards of 1TB of disk space, you can no longer afford redundant systems for medical image management.

PACStore from BridgeHead allows you to leverage your existing IT infrastructure, putting IT back in control of all your data.

Hey, wait a minute! I don't want IT in control of my data! But I get where they are coming from. This seems to be more of an internal fix than something to truly bring several external PACS together, but the idea could perhaps be redirected to that end.

Did they say 1TB per exam?

Indiana DalaiAnd The Archive Of The Lost RAID

Follow The Green Brick Road. . .The Official GE Version

I've been fortunate enough to make some good friends in the PACS business over the past few years. One of them is a great guy by the name of Brad Levin, whom I met while he was working for Amicas. Brad later joined Dynamic Imaging, and now, of course, works for GE.

Brad read over my previous post about the upgrade path for Centricity, and was kind enough to pen the official GE response, which follows unedited below:


I hope everything is well. On behalf of my colleagues at GE Healthcare IITS, I wanted to follow up on your comments from, "Follow the Yellow Brick Road ", posted on April 18, 2008. Per your inquiries, we wanted to provide additional detail and also clarify a few items referenced.

1. Centricity PACS version 3.X - As mentioned, our upgrade program for Centricity PACS 1.X/2.X has been offered for nearly three years, and (other than users running the latest Solaris hardware (V480)), requires a Solaris to Linux upgrade due to hardware end-of-life from Sun Microsystems.

2. To be clear, the advanced visualization solution you are referring to is marketed as “AW Suite” and is now available via software integration to Centricity PACS 3.X. Presently, the AW Suite embedded integration includes the following applications: CardIQ, AutoBone , CT Colon , Advanced Vessel Analysis, and Advanced Lung Analysis.

3. Since the acquisition of IDX by GE Healthcare, the ImageCast (IC) radiology information system has been marketed as Centricity RIS-IC. Presently, RIS-IC is ranked the #1 RIS by KLAS (Radiology (large) category, 2007 End of Year Report, 12/07, http://www.klasresearch.com/). As an integrated solution for RIS/PACS, this is marketed as Centricity Radiology. As a point of clarification, the Centricity PACS worklist is not changing to the interpretation worklist used by RIS-IC; however, customers using Centricity Radiology may choose to implement a RIS-driven workflow. Only in that case would the RIS-IC worklist be used. One last note about RIS-IC, the upgrades to Centricity PACS 3.X have no relation whatsoever to RIS-IC. Accordingly, Centricity upgrades do not include RIS-IC, and therefore, your comment about RIS-IC being “….included with the purchase of Centricity 3.0 Linux server…” is not accurate.

4. Regarding the new Centricity PACS-IW, similar to our naming structure for RIS-IC, the “IW” stands for “IntegradWeb”, based upon the recently acquired IntegradWeb PACS from Dynamic Imaging. Centricity PACS-IW is presently the #1 ranked PACS by both KLAS (PACS-Acute Care (large) Report, 4/08, http://www.klasresearch.com/) and MD Buyline, for the past two years in a row in the MD Buyline Intelligence Report for PACS, http://www.mdbuyline.com/.

Also, just to clarify a few items related to your upgrade discussion:

1. Your first upgrade alternative is a status quo decision to remain on the Solaris platform of Centricity 1.X/2.X. As you are aware, all hardware has a similar cycle – in just a few years, hardware that was once state-of-the-art eventually turns end-of-life. The decision by Sun to move their server hardware to end-of-life was made independent of GE Healthcare; however, it does have a significant impact on Centricity customers, and the solution is to upgrade to Centricity PACS 3.X. By moving from Solaris (a proprietary platform) to Linux, GE is moving to a more mainstream technology that in the long term provides Centricity customers more performance, choice and flexibility.

2. The second upgrade alternative you mention concerns an upgrade to Centricity PACS-IW. Any upgrade to Centricity PACS-IW would include a traditional PACS migration of images and results. While migration is rather commonplace in the replacement PACS market today, you are accurate that many of the unique data elements (e.g., annotations, key images) from Centricity PACS would not be able to be migrated to Centricity PACS-IW. This consequence of migration is the same when migrating from just about any PACS to Centricity PACS-IW, as well as the consequence of migrating Centricity PACS to any other PACS sold today. Considering this limitation, we do not recommend this as an option. Whether in the future GE will be able to export all the unique data elements is unclear at this time, thus, we are taking the most conservative approach by not committing to it and not recommending it. The only way to ensure the protection of these data elements is to upgrade through the Centricity PACS (not PACS-IW) product family.

3. The third upgrade alternative you discuss protects your investment in Centricity PACS by upgrading from Solaris to Linux, upgrades you to the latest Centricity 3.X platform complete with the new features you explained to your online audience (nice, thorough list, thank you), while also leveraging the diagnostic capabilities of the IW viewer anywhere over the Web. Currently there is a worldwide engineering initiative leveraging the strength of the IW diagnostic viewer and Centricity PACS 3.0 [Note: Prior versions of Centricity will not be able to take advantage of this new product]. This new product, Centricity Web DX Viewer, which we announced at the SIIM 2008 conference just last week, is a work-in-progress (WIP). This diagnostic capability will enable diagnostic interpretation anywhere over the Web, powered by the IW viewer. The Centricity Web DX Viewer will directly connect to the Centricity PACS 3.0 database and enable radiologists to perform complex image manipulations to include 3D (MIP/MPR) along with all of the other features of the IW viewer, change study status directly in the Centricity PACS 3.0 database, while also being assured the appropriate study locking mechanisms are in place. As this effort was scoped earlier this year, our Centricity PACS beta partners have already been identified and engaged. Keep in mind that Centricity Web DX Viewer is not meant to replace any of our existing client technology, as we are continuing to invest and support those programs. The Centricity Web DX Viewer is an additional capability that our Centricity customers can soon choose to add to their Centricity PACS environment, without compromising the investments they've made to their Centricity PACS infrastructure.

4. In terms of next generation development, we have indeed brought together our research and development teams from Centricity PACS and Centricity PACS-IW, leveraging the best innovations from each team into a single next generation effort. The current iteration of the next generation solution was demonstrated at the GE SIIM Customer Event last Thursday evening and was extremely well received.

In closing, GE Healthcare looks forward to helping you and your colleagues leverage your investment in Centricity PACS for not only today, but for the future. We pledge to all of our customers that we will continue to ensure an upgrade path for Centricity PACS, as well as integrate and make available the best available technology in the GE Healthcare product portfolio. And lastly, GE Healthcare will continue to develop innovative technology, as well as canvass the marketplace for potential acquisitions of technology that both deepen and enrich today’s product mix for the benefit of our customers.

I hope this has been helpful, but it is only intended to provide a brief overview. I encourage you and your online audience to contact their GE Sales Executive to learn more since every customer has different needs and requirements. We will also be discussing more about the Centricity Web DX Viewer over the coming weeks and months, to include presentations at the GE Healthcare User Summit, August 18-21, 2008, in Washington , DC .

If you or your audience has any questions about the above, please have them contact me at brad.levin(AT)ge.com and I will see that their questions are answered.

Regards,


Brad
Brad Levin
VP, Marketing, Dynamic Imaging Solutions
GE Healthcare IITS

Kroger Becomes EMR Vendor

You know technology has progressed when you can buy it at the grocery store.

From the Enquirer (the Cincinnati paper, not that other Enquirer) comes word that the grocery chain Kroger will be selling this MedFlash device, a USB drive that will "store all of a patient's personal health records." This is not yet nation-wide, but will be offered in Kroger's 103 stores in the Greater Cincinnati and Northern Kentucky market. The little drive costs $29.95.

The Med-Flash device is made by a company called Connectyx. They appear to be primarily concerned with medical and billing software. While the Med-Flash could end up to be their biggest seller, their website touts other things such as the "Medical Revenue Manager" or

MRN Manager(tm) (which) provides a remarkable return-on-investment, accelerating your evenue cycle by putting you in charge of Medicare and insurance denials.

The easist and most effective tools to manage your denials are in the MRN Manager(tm) suite of tools! Over TEN-MILLION claims processed in last 12 months.

They seem rather sure of themselves. Anyway, Med-Flash stores your entire file, according to the website, and even comes with a "free Rx Card that can be used at any participating Pharmacy to help you save 50 to 80% on Generic Drugs." All this for $29.95!


And just how do you get your information into Med-Flash? Basically, you go online to MyMedflash.com and enter the information. Presumably, the patient himself takes care of this. Here is the on-line form:




Supposedly, "thousands" of images from MR's or CT's can be uploaded "via Internet Explorer," but I'm not sure how that works with respect to PACS. The site notes: ". . . the program includes a picture/document uploader that enables the owner to upload MRI/EKG/X-rays photos." Just where the average patient is going to score these images in a form they can upload is not specified. They could at least upload reports if they have a document scanner, and who doesn't these days?

I'm wondering if Med-Flash is more of a Flashy gimick at this point in time. Carrying a laminated piece of paper might accomplish the same thing for most people. However, I can certainly see the potential in carrying one's full medical dossier, especially for those with complex histories. I'm still wondering how Joe Patient is going to get his CT from the hospital PACS into the Med-Flash site and drive, but I'm sure someone over at Connectyx is working on that as we speak.

I guess the next step is an implantable RFID chip that the hospital reads by passing your head under the barcode scanner.

GE Sells Out ...Their Appliance Business

After 100 years of GE appliances, GE plans to get rid of this flagship division. It seems that the giant conglomerate is looking to improve stock prices after a rather rocky first quarter.

From today's Wall Street Journal:

Shedding the appliances brand would be a symbolically significant move for the Fairfield, Conn., company. GE entered the business in 1907 and boasts of milestones such as introducing the refrigerator, room air-conditioner and toaster oven.

But because the unit is now a relatively small part of the company, a sale might not satisfy investors who are pressing Mr. Immelt to improve GE's sluggish performance. Last month, GE reported an unexpected 5.9% drop in first-quarter net income and lowered its earnings forecast for the year, only weeks after issuing sunnier projections. The move prompted the biggest one-day selloff in GE shares in more than 20 years.

GE's shares finished Wednesday at $32.51 each in New York Stock Exchange composite trading, putting them near levels they traded at in 1999.

Ouch! So who's going to buy the fridge division?

GE has hired Goldman Sachs Group Inc. to run an auction for the appliances unit. It's unclear who might be interested in bidding this early in the process. But possible buyers for the division include appliance makers BSH Bosch und Siemens Hausgeräte GmbH of Germany and Haier Group of China, bankers said. Private-equity firms and GE's Mexican partner, Controladora Mabe SA, could also be interested, they said.

Siemens? SIEMENS? My GE fridge (the one in the garage that actually works unlike my overpriced SubZero) is now going to be made by Siemens? Well, I've never owned any Siemens appliances, except for an old model of their GigaSet cordless phone, which worked quite well.

OK, now, no one needs to blame me for this fiasco. I like my GE appliances. Really. I like my GE stock, too, and I'm pretty worried about where it's going.

Agfa Finds Buyer??

On the eve of SIIM in Seattle comes some good news for my friends at Agfa. According to printweek.com:

Agfa-Gevaert's battered share price, which has fallen around 70% in the past year, recovered slightly last week on the news that it may have found a buyer for its underperforming medical unit.

Agfa's shares rose more than 7% after chief executive Jo Cornu revealed the company had received many expressions of interest since appointing German merger advisory firm Lazard at the end of last month.

The share jump also followed the revelation by US private equity outfit Gores Group that it is interested in Agfa's healthcare division.

Gores said: "We find Agfa an interesting company with some great assets, and we are ready to speak about a partnership or a purchase."

The Gores Group is:

. . . is a private equity firm focused on acquiring controlling interests in mature and growing businesses which can benefit from the firm's operating experience and flexible capital base. Gores' offices in North America and Europe serve its active investment programs in these regions.

Here's a list of their holdings:

Current
Adventa ControlTechnologies
Aptiv Technology Partners
Avure Technologies
CompuDyne
Enterasys Networks
First Communications
Global Tel*Link
Diagnostic Health Corp.
Intelliverse
Lineage Power
Real Software
Sagem Communications
SER Solutions
Somero Enterprises
United Road Services
Wire One Communications

Prior
Anker
Aprisma Management Technologies
Artemis International Solutions Corp.
Brand-Rex
Connection Machines Services
Encore Real Time Computing
Farallon Communications
Goretek Data Systems
Humanic Solutions
Information Dimensions
Inmac
JAMIS Software
MPC Computers
ONEBOOK Financials
Proxicom
QuorTech Global Solutions
QuorTech Solutions
Revere
Select Business Solutions
Silicon Systems and Technologies
SSA Global Technologies
The Learning Company
VeriFone
Vicorp

Gores doesn't have a PACS company as yet, so this could certainly diversify their holdings.

I don't yet know the price tag for this little purchase, but I'm sure it's a good deal for Gores. Whether it's a good deal for Agfa and its users remains to be seen....

Survival of the Fittest . . . Small PACS Companies

Hershey Ice Breaker PACS candy, courtesy http://www.likecool.com/

Any time Amicas is mentioned on AuntMinnie.com, there follows a wave of responses divided into two main camps. There are those of us who love the product, love the company, and will defend it to the hilt. That should gladden Steve K's heart no end. However, there are the usual nay-sayers that generally knock any company with revenues less than the nation of Panama.

So it goes on a recent thread, started by Michael D, who was interested in the latest Amicas offerings. Larry, the Cable Guy from Nebraska, posting as GITRDONE, immediately pounced:

Amicas is a very small, almost regional player in the PACS market, they have a decent product but that is where the positives end. They have very spotty support coverage, and their long term sustainability is suspect. They are still around because of a large infusion of cash a few years ago, otherwise they would be another Merge story right now. They have a me too product though that you can get from 15 or so other companies that all seem to be in the same boat. If you want to buy a simular product for a simular price from a company that will more than likely be around in the next 3-4 years I would look at McKesson, Fuji or Philips. I would guess that Amicas will be purchased or fizzle out in the coming years as they just don't have the scale or talent to play in the replacement market.

Larry later reveals that he works for a PACS vendor, apparently in Nebraska (my old stomping grounds!), and his main competition there is NovaRad. Larry keeps repeating his mantra throughout the thread:

1. Small companies will die or be assimilated.
2. Amicas has a me-too product, identical to 15 others.
3. You are far better-off buying McKesson, Fuji, or Philips.

Now, I'll be the first to agree that there are tremendous pressures on PACS vendors, especially the smaller companies. And yes, some will disappear. Having gone to many, many RSNA's throughout my career, I can vouch for the fact that a number of the products and companies that were there at the last meeting didn't survive to make the next.

Beyond this, I disagree completely and totally with Larry. Amicas' product is very different from the others, and really, it is only when you reach the next tier down from the likes of Amicas, Intelerad, and DI (well, they used to be at this niche) with some of the smaller fry that the GUI's start to look a little more alike. And even those products are unique. The IT types simply don't understand that radiologists don't all work in the same manner, and different rads and different groups will need different approaches. I'm not so much of a Pollyana to say that everyone would love Amicas if they tried it. (I would wager that lots would, but that's beside the point.) Me-too product? Not even close.

The small companies provide innovation that does not exist, at least to the same degree, within the large behemoths. Without Amicas, Stentor, Dynamic Imaging, and even ScImage, to name just a few of the small players, PACS would be probably be stuck back in the state of trying to immitate film, with tiled-displays on $50,000 Sun boxes. I don't think there's much question that the little guys, well, some of them anyway, have led the way in trying to give the customers what they want.

But Larry essentially paraphrases the old IT belief: "No one ever got fired for choosing GE." The large company is safe. It will be there tomorrow, and will always be available for service and to take care of me. Hmmm...sounds a little socialistic to me. Sadly, with this opinion borne out of fear of making the wrong choice and looking bad and/or getting fired for it, comes a complete dismissal of the needs of the folks for whom the product is being purchased. If the big boys understood the needs of the radiologists, and wrote their software with them in mine, there would be no smaller companies in this business. But that isn't the way it works.

With the shrinking number of dollars to spend, the PACS consumer has to be far more savvy than ever before. No longer can an IT committee hijack the decision, insisting on the "safe" purchase from the large company. Been there, done that, and the results are not pretty. Spending, oh, I don't know, 2-3 (or more) times what an Amicas installation would have cost easily bought us 1/2 the usable system. We can no longer afford to blow millions in that manner.

I find it most amusing that Larry repeatedly mentions McKesson, Fuji, and Philips as his "safe" choices. What happened to Agfa and GE? GE is the biggest PACS company of all, and I will absolutely guarantee in writing that they will be here 100 years from now. (And if they aren't, good luck collecting on that bet!) Why doesn't Larry mention them? Could it be that Larry thinks they can't GET'R'DONE? Maybe buying from the large company isn't always the best idea after all. Or does Larry work for Fuji?

Dalai-Less In Seattle

Due to some last minute family stuff, I won't be able to attend SIIM after all. However, my PACS guru will be there, and since he is somewhat less infamous than me, he will be stealthily gathering lots of good stuff that will appear here upon his return.

I would also welcome reports from anyone else attending the meeting. Let me know what you thought of the new toys, what you felt was the most innovative, funniest, etc. I'm counting on all of you to be my eyes in Seattle!

I WILL see you next year in Charlotte!