A Record Month!

As you know, I keep track of visits and such via Sitemeter.com. This month has ended with a bang, showing the most visits ever. I'll keep writing it if you keep reading it!

Falling Down

Image credit: http://en.wikipedia.org/wiki/Image:Falling_down.jpg

A significant portion of my business lately has come from Falling Down. No, not the old Michael Douglas movie, but rather the actual falling down of patients, mainly the elderly. I cannot tell you how many dozen examinations I have read over the past several weeks that were prompted by an old person falling. The average age for this particular problem is creeping up, although the range is widening overall. I'm seeing more and more exams on those in their late 80's and early 90's, although I haven't seen any on those 100 and over for a while.

According to the CDC as quoted by eons.com, falling down is "the leading cause of injury-related death in people over 65, primarily the result of hip fracture complications. (B)y by 2020, medical costs from hip fractures alone—resulting from falling accidents—are expected to cost the healthcare system between 20 and 50 billion dollars." Big problem. Really big problem.

It may be a stupid question, but why do old people fall down? And how can we prevent this from happening? There are several answers out there....

From www.laterlife.com, we find this:

Scientists at the University of Birmingham have been investigating this troubling phenomenon, and they’ve found that vision plays a part.

It seems that the normal thing to do, when walking through cluttered environments, is to look ahead to locate safe places to put one’s feet. But older people need to look much sooner to these targets, possibly through a slow-down of reflexes or a need to make sure that the way is clear.

Result is, they are in danger of looking ahead before they have sufficient visual information to negotiate the step immediately in front of them. And this makes for a higher risk of tripping and falling.

The eons.com article adds:

There are intrinsic changes associated with the aging process. The changes that increase the risk of falling are a degrading musculoskeletal system, sensory function, and gait changes associated with aging.

There are actually many factors that contribute to slip-and-fall accidents in the elderly. Medication side-effects can cause balance problems or dizziness, which can lead to falling. Elderly people have more chronic illnesses. Arthritis, for instance, is one of the major factors in falling. Pain associated with joints can cause falling. Fatigue, osteoporosis, dementia, and all sorts of things that more commonly strike the elderly, can lead to falls.

As my wife's grandfather, who passed away at age 93, used to say, "Getting old isn't for sissies."

So, what can be done about this? There is a long list of precautions to consider, such as these exerpted from the eons.com article:

Minimize changes in walking surfaces, and use slip-resistant coverings

Use lighter-colored floor surfaces to create color contrasts between walls and floors

Increase lighting and reduce the contrasts in lighted areas

Securely install grab-bars positioned for support

Don't wax floors

Avoid climbing and reaching to high cabinets

Always keep a night-light on in your bathroom

Use bathroom rugs with nonskid backing

Install light switches at the top and bottom of stairs

Be sure carpeting is tightly woven and installed so it doesn't move or slide

And so on. Perhaps the most important recommendation for the older generation is to maintain good health, and not to let the fear of falling get in the way of exercising, and enjoying life. You see, there's a lot more to look forward to as we get older than having some cranky radiologist read your hip radiograph!

Sniping for Fun and Profit

Cute, isn't it? But that's actually not the sort of sniping I'm talking about. Rather, I am referring to those low-lifes who are my nemesis on eBay... Let me elaborate.

I love dabbling on eBay. I love to pick up bargains, hard-to-find collectibles, necessities of life, what have you. Now, I'm not addicted or anything; I can quit any time I want to. Really. No, really!

Anyway, for years now, I've been trying to find an affordable piece of the Star Trek universe, preferably one that had something to do with medicine. Perhaps a screen-used scanner, or Dr. McCoy's uniform, or surgical scrubs. These things do appear on eBay all the time, and I have bid on a few. But, I haven't won any of them, and it's all because of the bloody snipers!

So, what's a sniper? eBay itself offers this definition of sniping:

Placing a bid in the closing minutes or seconds of an auction-style listing. Any bid, placed before the listing ends, is allowed on eBay. To protect yourself from being outbid at the last moment, enter the maximum amount you're willing to pay for an item up front, and eBay will bid automatically for you, making sure you're the high bidder until your maximum is reached. This system is sometimes called proxy bidding.

eBay has no problem with this practice, and why should they? The seller is happy, the sniper is happy, it's only the unsuccessful buyers like me that aren't happy! But think about how this works, and you may see it from my point of view.

When an item is listed for auction on eBay, a time limit of one, three or seven days is selected for the sale. Bids trickle in over this period. But, it is at the last possible minute that the sniper swoops in and tries to outbid, leaving others no chance to top him or her. Now, eBay's response about the proxy bidding system is well-taken. If I can only stomach spending $500 for McCoy's old tattered uniform, then that's what I bid as my maximum. But I'm going to feel really bad when Mr. Sniper cuts in 10 seconds before the auction is over and gets it for $501. This is the problem with the system: there is always someone out there willing to pay just one more dollar (or five when things get into the higher priced realm) for the item in question. In addition, some of these auctions end during working or sleeping hours (No, they are NOT the same, thank you), and it is impossible for me to sit on the computer and snipe, or snipe back, as the case may be.

There are those who live and die by sniping, and justify the practice till the cows come home. This site, for example, basically says that snipers aren't doing anything wrong, so leave them alone. Personally, I disagree. There is a certain degree of unfairness, of violating the spirit of the thing, by sitting and laying in wait, ready to outbid the bidder by the smallest increment possible. Why is it unfair? Because there is no possibility for said bidder to "fight back", except perhaps to place a ridiculously high proxy limit. Maybe that is the answer after all.

Technology has provided a solution, or perhaps aided the problem. There are a number of automatic bidding programs out there that will electronically snipe for you. I won't link to them because I think it is a nasty practice, but feel free to Google the concept yourself.

So, since I'm not happy with the status quo, how would I change things? In my bidding travels through the net, I have found a site for guns and knives and such called GunBroker.com. (You would be amazed at the weapons available on the 'net!) They have a little something called the "15 minute rule":

In a typical auction setting, there is always a called out counting that happens to allow buyers time to decide to place higher bids. This 'final call' is reset each time someone places a bid. . . .(B)ecause of delay caused by the Internet and other possible technological speed bumps, we have a 15 minute final call time.

. . .If there is bidding activity on the auction within fifteen (15) minutes of when the auction is scheduled to close, the auction automatically switches into a special mode analogous to the 'going, going, gone' period of a live auction. In this mode, the auction is automatically extended until there have been no bids placed within fifteen (15) minutes. . .The 15 minute rule makes auctions more fair, by allowing all bidders an equal opportunity to place their best bid. In other online auctions where an auction ends exactly at a given time, some bidders will hold their bids until the last minute or so, in the hope of winning an item on the cheap. This is referred to as 'sniping'. The 15 minute rule gives all bidders an equal opportunity to place their best bid on an item before the item closes. This way, no bidder loses an item to sniping, and the seller can be assured that he has gotten maximum value for the item.

In a recent survey, a feature similar to our '15 minute rule' was the #1 most-requested feature addition that eBay (R) users would like to see added to the eBay (R) site.

I'm really not sure why eBay won't do this. It seems a great deal more "fair" than the sniper system. Perhaps eBay is worried about auctions continuing forever, but I really doubt that would happen. At least every participant has a fighting chance, and isn't guaranteed to get away with something based on a loophole. (Remind you of any other practice I've been writing about?)

Oh well, I guess I might as well get hold of one of those sniping programs....

Entertainment in Rome

Observed just off the Piaza Navona. You've seen the white-clad "statues" of friars, and even the "Statue" of Liberty played by street-mimes. Here is something truly different....

The Ultimate Pointing Device

I have posted here and there about the various pointing devices on the market and how they work (or don't) within the PACS environment. They all attempt to translate your thoughts into motion on the screen in some manner. Wouldn't it be nice to eliminate the mechanical middlemen and just "think" your way through a study?

As reported in Medgadget, our friends at Microsoft are working on just such a project. No, their goal is not a new PACS interface, of course, but this would certainly be a great application for such technology.

The project is in a very preliminary state, but the essence is this:

We have built software infrastructure that acquires the signal from our EEG devices, transforms our data into relevant features for our machine learning algorithms to build predictive models, and classifies new data in real time. The system also allows us to easily store, playback, and visualize raw as well as classified data.

They have used this primitive prototype to control various tasks, including playing the video game Halo. That's not bad.

Some comments made on this topic suggest that the technology will be used for mind-reading, and other nefarious purposes. I seriously doubt, however, that such capabilities will be present for quite a while, as in decades at least. Would you trust Microsoft with the keys to your brain? Perhaps, as long as they don't try to apply patches or service releases!

In the meantime, consider the possibilities of powering through your daily stack by concentrating on the images. I guess this means I'll be even more sedentary than I am already. Maybe Microsoft can come up with some virtual muscle stimulation.

Don't Even Ask About Today's Special.....

Up For Bidding... A Fossilized Walrus' WHAT??

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

I should have been able to resist, but I just couldn't let my readers miss this one. This is not a joke, by the way. From the auction site of the I.M. Chait auction house:

Description:HUGE FOSSIL PENIS WITH PRESERVED SKIN

Odobenus species

Pleistocene

Tamyr Peninsula, Russia

This amazing discovery occurred while Russian fossil hunters were combing the defrosting permafrost for Woolly Mammoth fossils. Mistaking this extremely rare find for a badly weathered mammoth tusk, they threw it onto their truck and hoped that it would look better once polished. Luckily, a knowledgeable fossil dealer saw this specimen prior to any cosmetic improvements and realized what it really was; an actual mummified penis from an extinct species of Walrus. Buried in the frozen tundra for tens of thousands of years, the actual skin and muscle tissue which cover the baculum has dried, allowing for this extraordinary preservation.

Among mammals, whales have the largest penis but the walrus has the largest and most robust internal bony penis. So massive is this bony element that Eskimos use it as a killing club during their hunts. The shape of a penis bone or baculum is an important diagnostic feature used to identify species within five orders of mammals: Primates, Rodentia, Insectivora, Carnivora and Kangaroos (marsupials).

This truly one of a kind fossil "member" is among the most bizarre find of ancient erotica to date. Measuring an impressive 4 1/2 feet in length, it comes with a metal display stand.

Go ahead and bid. You know you want to. Estimated sale price for this piece of natural history is $16,000 to $20,000. Size matters, so they say....

Conversation with a Heart Surgeon on Sunday Morning

Dr. Michael DeBakey, THE Premier Heart Surgeon, courtesy of http://www.nasa.gov

Here is a conversation, transcribed verbatim, that I had with one of the premier cardiothoracic surgeons this morning at our heart hospital:

Dalai: Could I speak with the nurse taking care of Mr. X?
Ward Clerk: Dr. Surgeon is rounding, I'll let you talk to him.
Dr. Surgeon: Yes?
Dalai: Dr. Surgeon, this is Dalai. I wanted to let you know that Mr. X has a new, small left apical pneumothorax.
Dr. Surgeon: Do you think I give a shit?
Dalai: Well, I hope so....
Dr. Surgeon: OK, thanks....{hangs up phone before response}

Maybe he was kidding, and maybe he wasn't. That is still what I would call disruptive physician behaviour. Naturally, if I were to write him up, I would get laughed at. But you can bet your last dollar that if the conversation were reversed, I would be on the carpet in front of the MEC and Administration faster than you can say "Chest Tube". You can bet that same dollar that I would be criticised if I didn't let someone know about the positive finding. Damned if you do, damned if you don't.

Oh well, retirement in six years, 4 months, and one week, stock market willing.....

ADDENDUM

Anonymous from a large PACS company just posted this comment:

Hmmm... grouchy customer tears you a new one when you're just trying
to do your best.

Sounds strangely familiar.

Oh, dear, I have trodden on some toes, have I? Well, I do see the analogy Anonymous is trying to make. I have been on the case of the big PACS folks for a while, and some might say I have been relentless in my approach. Now, the situation above directly involved patient care. The patient had a positive finding, and I dutifully reported it. That the surgeon didn't want to know about this is his problem. I have a duty to the patient whose image I am interpreting to relay positive findings. Just ask any malpractice litigator. Had I shirked this responsibility, I would be in big trouble.

Anonymous' implication is that he and his company have done everything they should have in creating their PACS, and that I am being grouchy about their best work. I will grant you that Anonymous and his/her crew have very likely done their best within the parameters they were given by designers or whatever. My problem is that they didn't work with the users (or enough of them, anyway) to create the product that I and my partners want to use.

The purpose of complaining in this venue is to be heard, and with an international audience, I know at least someone is listening to me. I expect the vendors, to whom we pay a LOT of money, will at least listen and occasionally act on my complaints. Here is where I differentiate my situation from Anonymous' plight: The surgeon's b*tching and acerbic behaviour is foolish, because he knows, and I know that I cannot do anything different than what I did. He MUST be informed of a positive finding, whether he wants to hear about it or not. With my b*tching and acerbic behaviour, I do expect a change. That is the difference.

Things could be worse; one of my partners emails our CIO and PACS administrator with each and every glitch and hiccup of the system. Posting that sort of thing does no one any good.

Impressions of Compressions

There has been some talk on Aunt Minnie recently about compression, prompted by a Canadian study that showed you don't lose anything with lossy compression. Think about that one for a moment.

This prompted me to see for myself just how compression might affect an image. There is a ton of information on compression in this setting. Try the Wikipedia article on wavelet compression for starters. Frankly, the topic is so complex, I would have had to dust off my old engineering skills as well as my HP 41c, which I loaned to a physicist friend years ago. So, I thought it would be useful to (picto)graphically demonstrate what varying degrees of compression might do to a CT slice. I began with a DICOM image, the original size of which is 514 KB.

Then, using IrfanView, I applied JPEG 2000 compression (which uses wavelets) in varying degrees, with the results depicted below:

The number after "Lossy" is the degree of compression applied, which can range from 1 to 100, rather like the 1-12 selection offered for the original JPEG. IrfanView's JPEG 2000 compression plug-in uses the LuraWave JP2 module from LuraTech, if you're interested. You do have to keep in mind that I had to convert the images into regular JPEG for display here on Blogger.com, but you still get the idea. The image is pretty much unreadable at over 1:100 compression (I probably should have stated that as 100:1, but it's too late now!) However, I defy anyone to tell me that they can tell much difference between the higher quality compressions and the original. In particular, the lossless image is for all intent and purpose identical to the original, at least to my eye.

There are strong arguments made to store only the original full DICOM image, and this makes sense given the plummeting prices for storage. However, bandwidth, while ever less expensive, is still right up there. For example, we are having to consider the use of Metro Ethernet (MetroE) lines to boost the transmission speeds for our self-owned PACS. This will add somewhere from $50,000 to $100,000 to our yearly PACS expenses. Were we to use lossless compression, or even very high-level lossy compression, this would not be necessary. The question always comes down to this: Will I miss something on a compressed image that I would have seen on the full-fidelity original? Frankly, I don't think so.

Agfa Really Is For Sale!

My April Fool's post was just a joke, but it seems that life sometimes does imitate art. From Forbes.com:

BRUSSELS (Thomson Financial) - Ludo Verhoeven, chairman of imaging technology and software group Agfa-Gevaert NV said the company has received interest in buying all three of the businesses which it will be spun off into next year.
Asked whether interest was coming from private equity groups, Verhoeven said 'the only thing I can say is that there has been interest for all three businesses, and that's not bad news'.
He was speaking at a news conference for the group's half-year results.
The group plans to divide into three separately listed companies; Agfa Graphics, Agfa Healthcare and Agfa Materials.
Earlier, the group said it expects the company's demerger into three separate companies to be completed by summer next year, with the group implementing the transaction based on the closing balance sheet of Dec 31 at the end of this year.
The listing of independent companies will also take place before summer 2008.

Are you listening, GE? I'm not sure there is another Big Iron company out there that would be able to afford this little purchase. Or that would be at all interested, for that matter.....

Many thanks to AuntMinnie user Daryl Thompson who spotted this little tidbit.

ADDENDUM

BusinessWeek.com adds this:

Agfa Split Attracts Private Equity Interest
08/1/2007
Agfa-Gevaert NV’s split-up into three separate businesses next year may well lead to the sale of at least one of the demerged companies -- but whilst analysts agree the move is unlikely to take place in the short term, they see a number of possible buyers, including private equity groups and sectoral peers from both Europe and the US. On July 31, group chairman Ludo Verhoeven said the company has received interest from potential buyers of Agfa Graphics NV, Agfa Healthcare and Agfa Materials, but said a deal would have to be done at the right price. Analysts see the demerger as a much-needed move by a company which needs to 'get its act together', adding that it will unlock value to attract potential buyers. Arnaud Goossens at ING Securities sees the sale as a long-term goal: 'These businesses have been up for sale for almost two years,' he said, adding that many potential buyers have now invested elsewhere. Philips NV has been mooted as a possible buyer, but Siddy Jobe at Bank Degroof said the obligation to take on the declining analogue business, as well the digital hospital imaging systems, had put them off. 'If you're interested in healthcare, you have to take it all or nothing,' Jobe said. ING's Goossens, however, did not rule out the break-up of the demerged entities and said Philips could be eyeing Agfa's ORBIS hospital IT system.

Hey, wait a minute...Philips???? Didn't they just buy Stentor and make it their flagship program, ditching Sectra and inconveniencing the users of the "old" platform? I guess I'll have to learn to love iSite, eh?

Addendum 2

And there's even more bad news for Agfa, and potentially us Agfa groupies, from Forbes 7/31/07:

BRUSSELS (Thomson Financial) - Shares in Agfa-Gevaert NV plunged after the imaging technology and software group posted a disappointing set of second quarter results and put back the company's demerger by six months to focus on operational improvements...

'After a decent first quarter that gave hope for more improvement, the second quarter results are a major disappointment. Further... management admitted the major operational weakness and said it would focus more on operational improvement,' the broker said...

'The results show that Agfa is not yet worth any sign of confidence from investors. Management has a lot of difficulties in getting the ship under control.'

Uh Oh... Next thing you know, Agfa will be blaming me for their downturn, although the article suggests that the high price of aluminum is at fault. We'll see.... Actually, they did find someone to blame, acording to Forbes:

BRUSSELS (Thomson Financial) - Agfa-Gevaert NV has announced that Philippe Houssiau will be leaving his role as president of Agfa HealthCare, 'in view of the second quarter results'.

The company added that Carl Verstraelen will join the unit as Vice President Finance and Controlling.

Verstraelen will be put forward for appointment as CFO in Agfa HealthCare's executive committee after Agfa splits next year into three separate listed companies, the imaging technology and software group said in a statement.

He's Back!

I'm back from overseas, having stayed in Italy for a few days following the meeting cruise. We spent a couple of extra days in Venice, and then took the train to Rome for the rest of our stay, with a little side trip to Pompeii at the end. That was my favorite part of the whole trip.

One of the most macabre sights I have ever seen was to be found on the main street of Rome, Via Veneto. The Capuchin Friars have a church with an indoor cemetery sitting right next to hotels and restaurants. But this is no ordinary cemetary. Here is the description of just one of the rooms:

Crypt of the leg bones and thigh bones

The side walls each have four niches occupied by a Capuchin, standing and vested in the habit. Along the rear wall, the central block is a richly imaginative composition: up above, a cross enclosed in a circle; underneath, the Franciscan coat-of-arms: Christ's bare arm crossing the clothed arm of St Francis, surmounted by a crown of vertebrae. In the ground, 18 crosses mark the graves of various friars. The central oval frame in the vault contains an arrangement of jawbones decorated with vertebrae and, on either side, two large flowers made of shoulder-blades, with hangings of vertebrae. The corridor vault has three eight-pointed stars, a massive lantern hanging from the central one.

I have borrowed a photo from the Capuchin's website since they allowed no photography within the crypts. When they say "coat-of-arms", they really mean it.

More photos can be found on the website of someone who took some "forbidden pictures"....http://www.tapholov.com/bones_chapels.htm

At the Vatican we saw the usual stuff, including the cleaner, brighter paintings of the Sistine Chapel, and the innumerable works of art within the Vatican Museum. There is a relatively new tour of the excavations beneath St. Peters, which include a necropolis from before the time of Jesus, and possibly the tomb of St. Peter himself.

I had one particularly unusual experience. Upon first meeting our guide for the Vatican, he looked at me rather strangely. I thought perhaps that he had read my blog, but he didn't seem the radiological type. As we entered the museum, he apologized for starting, and said, "you are about to see yourself inside..." It seems that I bear a striking resemblance to the portrait of the Roman Emperor Hadrian:

Yup, maybe I'm the reincarnation of Hadrian, who wasn't a particularly nice guy. That would certainly go along with a lot of opinions, wouldn't it? Oh, well. Veni, vidi, vici, right?

Euros, Assumptions, and Greek Islands

You may notice some degree of stagnation on the blog, as I have not posted in several weeks. I’ll try to remedy that situation.

I am presently in Rome, Italy, following a cruise of a few Greek Islands, Split, Croatia, and Venice. It was actually a meeting cruise, with a number of lectures on CT by Elliot Fishman, M.D. and other radiological celebrities. I wonder if they realize that they were on the ship with the (in)famous Dr. Dalai… The cruise itself was OK, but I do have to give one warning: Unless you are clinically deaf, avoid the Royal Caribbean ship Splendour of the Seas like the plague. It is an older ship with absolutely no insulation between decks. We could rarely sleep due to the constant banging around and dragging of chairs on the deck above us. Not good. However, there was a great deal of CT knowledge imparted to the participants, and I'm going to try to apply at least some of what I learned to my daily practice. Although the meeting wasn't about PACS, I did acquire a few tidbits here and there. Several of the other participants have Agfa Impax 6 and hate it. One fellow replaced an old (2003) Amicas system with Dynamic Imaging and loves it. Dr. Fishman himself uses Emageon at Johns Hopkins, and complained numerous times that it chokes if they try to load a CT series that contains more than 100 images. That's 100, folks, not 1000. Their solution has been to use Siemens WebSpace, a remote client version of InSpace, for multislice CT studies of more than 100 slices, which is about everything they do there at Hopkins.

There is a thread on Aunt Minnie which was prompted by my recent article, Dalai’s Laws of PACS. This discussion has gone from hashing out what clinicians should expect out of PACS (a major point that I left out of the Laws) to a longer chat about vendor-neutral archives and databases. I don't claim to have all the answers on that one, nor do I begin to understand all the underlying DICOM issues involved. However, two experiences from this trip I'm on may provide some useful analogies.

The issue was rather well-stated by David Clunie (of course!) with this post toward the end of the long thread:

We have talked about the "vendor-neutral image archive", which could be the place in which images and other (standard) composite DICOM objects live; would it also be feasible to discuss a "vendor neutral image database" as a separate entity from the archive, which multiple PACS and/or "Image Manager" actors could access ? I say this, because it is useful to have central and accessible database of the images and various additional information that may not be strictly related to or extractable from the DICOM image headers and have no business in there (e.g., read status, legal name changes like getting married, etc.) - this information is needed by multiple production systems (e.g., different PACS, different RIS, web server, EMR, etc) in addition to the image locations, yet is perhaps separate from the "PACS" functionality per se. Also, during PACS migration, such a database might not need to be changed, or could be serialized in a "vendor neutral image database interchange format" that could be "read into" the next database. In the past various folks have proposed extensions to support PACS migration that serialized a snapshot of this information (even suggesting a huge DICOMDIR for this), but I am not sure that there has ever been a serious attempt to factor out a shared, live, standardized, database. In a sense, the VNIA and the VNIDB would to in-house PACS what the IHE XDS repository and XDS registry are to cross-enterprise document sharing; not that I am suggesting that XDS is necessarily the appropriate technical solution for this. Ordinary SQL access might be an option; another might be Grid Service based queries such as are being developed for caBIG imaging, which also have the benefit of a comprehensive security model.

Early on in the discussion, I think I was mentally considering the archive and the database as one, which is not strictly accurate. For me, the bottom line is this: I want the ability to plug different tools, modalities, and especially workstation GUI's into my database. Simple concept, difficult execution, apparently. But here is where the first European example comes into play. You are all familiar with the Euro, the new currency used by the multiple countries of the European Union. Anywhere within the EU, a One Euro Coin looks like this on the back:

But on the front, the different member countries can display their own design. Here are the coins from Greece, Ireland, and Italy:

My point here is that all these coins are worth one Euro. They look slightly different, but they do exactly the same thing. Such would be my vision for a Vendor Neutral system. I want to be able to buy a database from Belgium, as it has the reputation to be the best. I want to plug in a scanner from Germany, and have it talk to my database from Belgium without any add-ons, extra interfaces, or especially extra charges. I want my interface from Greece, my 3D app from Ireland, and so on. Quite roughly, interchange DICOM for Euro, and you see where I'm going with this. DICOM needs to be the unit of currency for PACS. The only problem with this concept is the vendors' insistence on the use of Private Attributes, factors that make their systems different, but don't translate from PACS to PACS. WindowsPACSMaven proposes a possible solution:

To alleviate the above mentioned issue with Private Attributes I decided with a colleague in 1998 that we would design a PACS using "Native DICOM". Native DICOM is DICOM V3.0 with no Private Attributes! To do this we partnered with a major university to be sure that no vendor attributes got into our design...By using Native DICOM we would be guaranteeing viewability anywhere that DICOM V3.0 is present. So if we can get Radiology to start to use Native DICOM through vendor and/or open solutions the problems with storage and retrieval will be minimized going forward from here. Because the Native DICOM concept is so radical I actually lost my job for promoting this concept and am now an independent software developer for healthcare! Because of my job loss I still have to remain anonymous so that I don't affect my future income possibilities since I do consulting for healthcare vendors.

One would assume that the big boys have something to lose with this approach, eh? Therefore, it must be good! OK, OK, there is a lot more to the issue than I've presented, but the idea is clear, and I think it has a lot of merit.

So how did we get in this situation? The second lesson from my trip might explain it. On the island of Corfu, we were enticed by Royal Caribbean's shore excursion brochure to take a "4WD trip into the hills of the island, where you will see villages rarely visited by outsiders." We were intrigued and signed up for the journey. When we got to the staging area, we found 20 little 4WD vehicles. So far so good. But upon closer examination, there was one little problem: the cars all had manual transmissions! This was a problem because I've never driven a stick, and my wife hadn't done so in over 20 years! But she bravely took the wheel, and skillfully drove up and down the hills, through little passes and treacherous switchbacks like this:

It was worth it, however, to see some of the wonderful, isolated little villages. At least that's what we told my wife when we got back! She was too busy driving, and in particular trying to keep from rolling back into the car behind us in the caravan to see the sights! Here are some typical scenes:

The lesson here is that Royal Caribbean assumed that everyone was OK with their way of doing things, that no one would have a problem with manual transmissions. They were so unconcerned with the needs of their passengers in this venue that they didn't even bother to publish the fact that the cars were only of this persuasion in any of their literature. This is they way it is, kids, it would cost us money to change it, and we assume you will like it and be comfortable with it.

I'm sure you see where I'm going with this. Do I even have to say it? Oh, well, I'm not known for my subtlety. Many PACS companies have done things a certain way for quite a while, and they assume you and I will like it. The fact that we may NOT be comfortable with it, and that we may have to waste the brainpower that we should be using to view the road, I mean the image, on driving the stick instead. The DICOM currency standard would be one way to solve this problem. One could, in theory, use an "automatic" front end to a database that otherwise had a "stick shift" GUI.

Let me wrap this up before I get even further lost in weird car analogies. Ultimately, the only "vote" we have is with our dollars, (or Euros) or those that come from our hospitals. I WANT the ability to do what I have described above, and I expect the market to provide it eventually. Royal Caribbean made what could have been a very dangerous assumption (had I tried to drive myself), and the non-insulated Splendour of the Seas deprived me of valuable sleep. My vote will be to never cruise on one of their ships again. I'll be certain to exercise the same sort of thing with other big purchases as well. Hint, hint.....

Ciao!

The Rocky Horror PET Show

A coronal slice from a PET/CT. Scary, ain't it?

OOPS, I Did It Again....Dalai's Laws of PACS Published!

I'm published again! Auntminnie.com has graciously posted a revised and expanded version of Dalai's Laws of PACS, accessible here. I guess it was a slow news-day.





I'm waiting for the, um, comments from my friends in IT.

Teleradiology Spam

You have to love spam, especially when it comes from unexpected sources. Today, I received this little opus from Dr. Ashish Dhawad, trying to convince me of the joys of using his "Telediagnosys" service operating from India:

Hi,

TeleDiagnosys is a premier provider of offsite Teleradiology/Nighthawk Reporting Services from American Board Certified radiologists.

If you are a Imaging Center / Hospital - We can provide you with STAT and Routine reports 24 X 7 leading to cost reduction.

If you are a radiology group - We can take care of any additional / overflow work that you cannot handle, increasing your productivity

Our advantages -

1) Attractive Pricing - USD 8 for X Ray, USD 35 for CT and USD 45 for MR

2) Reporting by American board certified radiologists with State licenses and malpractice insurance

3) 24 X 7 X 365 coverage

4) Turnaround time of 30 mins for STAT and 12 - 24 hours for routine studies

5) Fully transcribed reports in required formats can be emailed/faxed at no extra cost

6) US telephone number for emergency calls

7) No minimum guarantees, No Setup fees

8) No PACS to send images??? We can provide you with a complete solution

More details are available on our website - http://www.telediagnosys.com

In case you need any more information including references or trials please contact me on dhawad@telediagnosys.com or US Toll Free 800-490-0509.

With Best Regards,
Dr Ashish Dhawad
Chief Operating Officer
Telediagnosys Pvt Ltd
US Tel no: 800-490-0509
US Fax no: 703-991-1426
Email: dhawad@telediagnosys.com
URL: http://www.telediagnosys.com/

I went to the website earlier this morning, and it was quite nicely done, with Adobe Flash titles and the like. However, this afternoon, I find the website is down, perhaps due to much traffic or angry complaints spawned by the spam email advertisement. But, the Google-cached version tells us:

TeleDiagnosys Services Pvt. Ltd. is India's pioneering and premier provider of offsite Teleradiology Reporting Services from experienced and eminent doctors with fast turnaround times. We partner with diagnostic centers, individual radiologists, hospitals, medical groups and other entities requiring remote, off-site reading of diagnostic imaging studies. Using a comprehensive approach, we provide the expertise to configure, install and maintain the digital technology necessary to implement remote reading of imaging studies. We also link our clients with well-qualified & well-trained radiologists who are available to provide remote reading and interpretation services. We have the necessary infrastructure and expertise available to provide round the clock, reliable and efficient service to our clients.

I had thought this sort of thing had not caught on in the US, but in looking around the web, there are dozens of companies in India offering similar telerad services. Most claim to use Board Certified U.S. trained radiologists. Perhaps they do. Rather hard to prove from here, isn't it? Does anyone really know who is on the other end of their teleradiology or night-hawk service? Have you actually met any of them?

No matter. What these companies are selling is cheap, available radiology. Whether all of their readers are rads from Haavaard, or if they are all students at the Bangalore High School for Health Sciences, what attracts their US users is mainly the cost savings. I can tell you that Telediagnosys' prices are lower than many out there, and if you look around, you can do even better.

I don't know about you, but to me, this lowest-bidder concept of Radiology is not a particularly comforting thought. Would you base your choice of a surgeon on who will cut on you for the lowest price? Well, as it turns out, lots of folks would do exactly that. There is a new trend of "medical tourism" that inspires those who cannot afford treatment here in the US to go abroad, often to India. This article from the Providence (RI) Journal tells the story:

The first such travelers were looking for cut-rate cosmetic surgery. But today, many include people seeking necessary procedures, including heart bypasses, hip and knee replacements, cancer treatment and dental work. They are finding clean, well-equipped, even luxurious hospitals that meet accreditation standards and often are staffed by American-trained doctors. Catering to an international clientele, they provide procedures at roughly one-tenth to one-quarter of the cost in an American hospital.

Ouch. American medicine has somehow priced itself out of the market. Where did we go wrong? I have to think it is some combination of greed and fear, relinquishing control of what is still (but just barely) the best health-care system in the world to the government, and to third-party payers. The greed factor is obvious, when one looks at self-referral, and I won't bore you with that discussion again. Fear of loss of revenue is certainly a similar emotion that has driven costs up, and led physicians into areas not their own, such as (surprise) imaging, which leads to self-referral. I'm not certain if the government or the insurance company, or the uneasy symbiosis we all share with them has driven the whole system off the edge. What I do know is that costs are exploding, and if we don't fix it, our friends in Washington and Bangalore will do it for us.

Even as a physician, I'm not immune to the ravages of costly medical care. My son just had some diagnostic procedures (EGD, colonoscopy, small-bowel follow-through) for which the hospital bill alone (haven't got the physician's bills yet) was $10,000. Since his doc is in another state, and out of our insurance company's little local network, I might just have to eat that cost. I would not have taken him to India, but for someone who had no good choice, spending, say, $3000, including the trip to India and a little sight-seeing, would have been a very viable alternative.

All of us involved in the U.S. Healthcare field have to do something about this stuff, and quickly. Otherwise, Hillary-Care AND Bangalore General are going to be our future. Namaste!

Is Speech Recognition a Kickback???

Image credit: http://www.jd-associates.com.au/author/garrydisher

I wish I had come up with this myself, but instead, this comes from one of the many brilliant folks that peruse this blog and otherwise correspond with yours truly. My colleague has suffered through a forced implementation of SR, and notes the following:

Do you know if anyone has ever tried to construe the adoption of voice recognition technology as a kickback to the hospital in violation of federal antikickback statutes? It would seem to me that transcription services are traditionally provided for free by the hospital to hospital-based physicians (except of course the cardiologists and administrators don’t have to use it!) and that the cost of transcription is covered by the technical fee collected by the hospital. In essence we are providing free services to the hospital in return for a hospital contract. I wonder what the lawyers would say.

So do I.

The Inmates Are Running The Asylum

I have stolen my title from a book of the same name by one Alan Cooper. Mr. Cooper is Founder and Chairman of the Board of the Cooper company, which is devoted to leading-edge, customer/user oriented product and software design. From the company website:

For over 30 years Alan Cooper has been a pioneer of the modern computing era. His groundbreaking work in software invention, design and construction has influenced a generation of programmers and business people—and helped a generation of users. Alan is the author of two best-selling books, About Face: The Essentials of User Interface Design and The Inmates Are Running the Asylum, and his visionary ideas and outspoken style make him a popular speaker. Whether you know him as the "Father of Visual Basic," the inventor of personas, or the guy who thinks software should be spanked, we know him as the man whose ideas are the foundation of what we do.

Mr. Cooper has a rather radical outlook on software and indeed other high tech offerings. From his "Inmates" book:

No matter how early in the development process specifications are drafted, they cannot substitute for interaction design. And no matter how hard they try, programmers cannot consistently arrive at a successful design. Not only are their methods, training, and aptitude wrong for the job, but they are caught in a strong conflict of interest between serving the user's needs and making their programming job easier. Yet, in company after company, software engineers are allowed to control the development process, often from start to finish. Sometimes, their control is overt, but more typically it is indirect.

Hence, the inmates (the programmers...no offense!) are running the asylum. This is more or less what yours truly has been saying for a while in reference to PACS. The vendors are allowing their engineers and programmers to create technological magnum opuses which allow too many permutations, and ultimately get in the way of my reading my studies. Why is this tolerated? Cooper compares this to a dancing bear: we are all so impressed with the fact that bear is dancing at all, that we fail to observe just how badly it is choreographed.

So few software-based products have exhibited any real dancing ability that most people are honestly unaware that things could be better-a lot better. Most people using spreadsheets and word processors on modern computers imagine that all the problems that a computer can solve have been solved, and solved adequately if not well...Bill Gates once observed, with uncharacteristic cynicism, that the way you made software user friendly was by making a rubber stamp and stamping each box with the legend "USER FRIENDLY." Unintentionally, his method has become the computer industry's real method.

Mr. Cooper's premier design company will help one create a software product (or hardware, for that matter) that does not suffer from these maladies. The company motto is: "Companies are more successful when their products help users achieve their goals." Accomplishing this gargantuan task takes several steps, including Planning, Research, Modeling, Requirements, Framework, Refinement, and Support. Of these, modeling may be the most characteristic of Cooper's contributions.

Are you frustrated by trying to develop a product that serves thousands--or even millions--of different users? Imagine if instead of trying to please everyone, you could design for three distinct people you knew very well. Wouldn't that make your job easier?

This is the power of personas, a technique for modeling users that we invented here at Cooper. As we interview and observe users in their natural habitats, we look for patterns of behavior and goals shared by multiple people. Each distinct behavior pattern becomes the basis for a persona: a description of an archetypal user.

Personas help everyone from programmers to executives understand users in a way no other tool can: at a gut level. Personas help guide design decisions, end those lengthy arguments about what users need, and get everyone to agree on what product you're building.

You don't need an enormous project to enjoy the benefits of personas. For short projects, personas may just be quick sketches based on limited data. For large initiatives with distributed teams, a well-researched and thoroughly documented set of personas can be an essential reference and communication tool.

In an article about Cooper, Allison J. Head further describes this process:

The gist of Cooper's argument is fairly straightforward: There will be far greater success designing an interface that meets the goals of one specific person, instead of trying to design for the various needs of many. At first blush, though, it may seem downright counterintuitive to design for just one person, whether hypothetical or not. How can designing for a single soul possibly ensure an interface that supports the needs of many users? But as an interface becomes more layered and complex and tries to serve an ever-widening audience base, Cooper's argument holds true.

As long as personas are developed with diligence, the planning and development tool has three key benefits for interface design projects of all kinds. First, personas introduce teams to hypothetical users who have names, personal traits, and habits that in a relatively short time become believable constructs for honing design specifications. Second, personas are stand-ins with archetypal characteristics that represent a much larger group of users. Third, personas give design teams a strong sense of what users' goals are and what an interface needs to fulfill them.

She goes on to describe what may happen if programmers and designers don't user personas:

One of the best arguments for using personas comes from some misguided design efforts at Microsoft. When the software giant geared up to redesign its well-known Microsoft Office Suite for a 1997 release, the research team soon discovered that many of the features users wanted already existed. In fact, four out of five of the features users requested for Office 97 came with Office 95. The outcome of Microsoft's design approach is just what Cooper warns against. In trying to support the diverse tasks of many conceivably different software users, Microsoft cobbled together a product that was bloated with capabilities and ended up satisfying few users.

I think most would agree. I am reminded of some PACS systems I have used....

Anyway, how might this approach be used to create a PACS? Can we assemble a "Joe Radiologist" persona that would cover most radiologists? Well, let's see.... What do radiologists do all day with respect to PACS? We sit in front of the darn things and read studies. That pretty much is all we do, except for the interventional types and the barium-slingers. The real question is how Joe Radiologist wants to interface with his PACS. That is indeed the question. If I were taking this approach, I would talk with all of my partners, and ask them what they like and what they don't like about the PACS systems we already use. In fact, I would post the question here on the blog, and open it up to as many rads as possible. I would then synthesize and distill this wide pool of answers down to a usable persona.

The key to this process is, I believe, to drop all preconceived notions, but not to forget lessons learned. If you are going to build a PACS (or a car, or a toilet-paper holder) you would like to make it usable, and comfortable. There should be adequate features to cover at least 95% of situations that will arise (easy with toilet-paper holders, harder with cars, easier than some think with PACS.) Many products out there are obsessed with how to handle something that Joe Radiologist might have to do once a week, or once a month, and pay little attention to the repetitive grind that makes up 95% of our work. And many vendors are stuck in the rut of doing things the same way, version after version. Therefore, it is critical to see how a wide swath of your potential customers would use your product, and it is very important to understand how they work with your competitors' versions of the same thing. When Saab designs a new car, for example, it is probably wise to determine if the 99% of the world that buys cars other than Saab's would appreciate having the ignition key on the center console, which is where Saab (and no one else) puts it. If you are a PACS company, it is probably not terribly wise to gear your Joe Radiologist persona to those who are mostly users of your PACS, and then proceed to come up with the next generation of a PACS with its ignition key on the center console. I should also add that real radiologists need to be reintroduced to the process; don't go with the stereotyped "Joe" for a prolonged period without a reality-check from the flesh-and-blood version. Trust me, if these caveats to the Cooper approach are discarded, the result will not be what "Joe Radiologist" wants at all.

One of my partners told me in all seriousness that I should create my own PACS system. I wish I had the time and the wherewithall to do so. Of course, out of vanity, my persona would be used instead of "Joe's" which would naturally yield the most wonderful system ever. Absolutely. Guaranteed.

40,000 Hits and Repeat Customers

Image Credit: http://www.scifi.com

This is a first, folks! I think Visitor 40,000 happens to have been number 20,000 as well. I'm assuming that there aren't too many folks in Montevideo, Uruguay who peruse this stuff, so I'm thinking this represents another visit from Rafael Sanguinetti of www.charruasoft.com. Thanks for your support!

A Survivor Of Voice/Speech Recognition Speaks Out

(Dalai's note: I was approached by a colleague, and asked if I would post his VR/SR experiences online, but anonymously so he would not have the vendor in question breathing down his neck. I am more than happy to do so, and here it is....)


I will start by telling of our voice recognition (VR) experience.

About one and a half years ago we launched VR to our hospital system. It was an integrated “front end” VR product that resided on our PACS workstations. You may or may not have preconceived ideas about what quality we might have purchased, suffice it to say we purchased what for all intents and purposes, seemed to be the best VR product on the market. No we didn’t buy some outdated piece of garbage.

It was a planned 6-week launch with training provided primarily by the VR company. Initially, we were expecting things to be a little stormy; how wrong we were. First, we had scheduling problems with training, there were rads that were unavailable for training and the amount of time dedicated to each rad was short, only a few hours. In addition, the rads were learning while still having to attend to some clinical duties, which was a BIG MISTAKE.

So after a few weeks, the trainers left, there were still rads that had almost zero actual training. Our IT/IS support staff tried to help out as much as possible. It was just over a month when things in the department finally caved in. We were chronically short staffed, radiologist wise, and work wasn’t being finished. Those of us who took to VR somewhat well were being completely overrun by those who did not, both in having to field multiple near hysterical calls and a markedly increased workload. There were multiple unexplained system crashes (denied initially but fixed somewhat in a later patch) and a greatly degraded workstation performance.

We had numerous direct meeting between the administration, radiologists, and VR company. Here is what we got, repeated requests for the radiologists to document every occurrence of problems (yeah, right, like we weren’t totally swamped as it was what’s one more thing to do), repeated denials of their software being to blame for workstation slowness and crashes (of course later we would learn that yes it was their software causing crashes and system performance issues), repeated promises to fix the problems.

After almost 2 months of this I, being the “radiologist champion” for VR and about 2 seconds from a complete nervous breakdown, told myself “Either I stop using VR or I hand in my 90 day notice and look for a new job”. I turned off the VR product and told my fellow radiologists that I would no longer be fielding their questions about “how to make VR work”. The rest of the group followed suit immediately. It imploded over night. Problems that still existed at this time were:

1) Random crashed requiring a system reboot
2) Unexplained, or rather un-admitted, slowness of the workstation
3) Consistent patterns of errors in VR, it did not appear to be learning no matter how many times corrected
4) Almost no one in the department (IT/IS included) really knew how to use the advanced functions, macro generation was “trial and error”
5) Lack of advanced support, many question to our IS/IT people generated a response “I’ll send and email to VR company and see what they say”
6) Many errors sent for “transcriptionist editing” came back uncorrected, the error rate of “transcritpionist editing” was far greater than the old system. Many report errors escaped the radiologist review as well and went out finalized. Many, many months later I would learn we had some actual “transcriptionist sabotage” going on and this was NEVER disclosed to the radiologists.
7) A horrific loss of productivity in an already short staffed group.
It died for a long time; of course the hospital had a vested interest in making this work.

We recently had a visit to a “model group” for VR and got to see them in action. The model group watched us and decided to purchase the product anyway. They are a large group; they owned the transcription, PACS, and other things and “contracted” these things out to hospitals. This was a business decision by a group that owned the entire infrastructure. They did things very differently and claim a 90+% “sign off” rate. Here is what we observed and were told:

They began by sending their IT folks to the VR company for intensive training. They refused the VR company's offer to do radiologist training; they were going to handle that all in house. Prior to launch their entire IT/IS support staff had been using the product for “months” and were fluent in its use. This was before a radiologist touched it. After launch they had their trainers go back for additional training to learn to “hack” the word lexicon to overcome pattern of repeated errors. This has worked very well for them and is a process discouraged by the VR company. What we learned, to our dismay, was that VR was not just “appearing” to not learn certain repeated phrases or words, it REALLY WASN’T learning them at all, no matter how many times we made corrections manually. The "model group" placed skilled VR support staff available 24/7, to immediately respond and deal with radiologist problems with VR.

They began by doing a “staged” launch of VR, starting with sections and working 1 section at a time. Each radiologists was initially afforded a full half day of one-on-one training with no clinical duties (no phone calls, no tech interruptions, no exams needing to be read, NOTHING); after that they each received 3 full days of one-on-one training while working (they estimated a total of 24-28 training work hours for each rad). By one on one they mean the trainer was physically in the same room or sitting outside the radiologists door. They had section meetings every morning to discuss VR’s use and share tips; they relied on a lot of “peer pressure” to make things go smoothly. The entire launch was slated to take about 1 year.

The made sure their workstation greatly exceeded the VR companies recommendations. They made sure their transcriptionists were folded into other duties as they lost their need for so many of them. I would add here that prior to VR this groups report turn around was poor, over 2 days for routine stuff.

We were also told the group was now considering “financially penalizing” rads that are using too much transcriptionist editing, this was not implemented yet and the penalties they were considering was not shared with us.

We then got to observe some rads in action. It really wasn’t magic. First, they have employed radiology “assistants”. These folks do a lot of the “scut work”, phone calls and so on; they basically make sure the radiologists are not disturbed and the hospital pays for them. One rad was a “macro master” although he appeared to spend much more time looking at the VR than the exam. One rad absolutely hated the VR system, so all is not roses at this model group. The next few rads showed all the problems we have seen all along, lots of little annoying errors. Every rad admitted it slowed them down but they had “made up” for it through intense training, heavy assistant use, awesome IS support staff and excellent equipment. They did feel, well, most of them, that it was “worth it” for various reasons.

They did confirm many things we radiologists already knew. Things like the software’s inability to learn certain works on its own, or rather the pattern of making repeated patterns of errors. The VR company’s gross underestimation of the training needed and IS support staff needs. The performance issues on the VR companies “recommended” systems. Basically this is something the radiologists need to “buy into”. They did admit to the limitations of VR but that it is improving and “As long as the radiologists see continual improvement they will stick with it”. They also, on their own, identified and developed work-arounds for many conflicts the software was having with other office software products.

Where do we go from here? A few in my group had prior experiences with VR, all universally negative. I had a hope, as did the administration, that “This is such a superior product, it will be different this time”. It was very disappointing to see not only every fear confirmed, but also some new ones learned. Any trust between the VR company and the radiologists has been completely destroyed beyond repair. This experience has certainly made us much more cautious in trusting the word of any vendor, especially software vendors as I feel they may not fully grasp that they are selling a medical product and not a video game (i.e. doctors have zero tolerance for “buggy” software and more than they would tolerate a “buggy” CT scanner). So it stands with my group, many of whom now have the well justified attitude of “Hell will freeze over before I turn on VR again”. I am not sure this can ever be turned around. I hope, if nothing else, this review serves as a warning, to radiologists, administrators and most importantly VR vendors that VR is not something to be taken on lightly.

In a similar vein to Dalai Lama here are my 10 commandments for VR:

1) Voice recognition (VR) exists as only one of multiple possible solutions to address the problem of radiology report turn around time. The underlying problem being the near instantaneous distribution of images through PACS unaccompanied by the radiologist report.
2) VR will only see its maximum benefit (i.e. near instantaneous report generation) IF the radiologists self edit and sign off the majority of reports.
3) VR with or without self editing slows radiologists down. It costs productivity as radiologists are now forced to spend additional time either self editing or reviewing the VR generated reports for errors. Do not assume your radiologists are going to quietly eat this productivity loss.
4) The loss of radiologist productivity can be compensated, to some degree, by the use of radiologist assistants to do some tasks formerly done by the radiologist. Also there is a gain by the lessened need to re-review cases that have been dictated but not transcribed. Despite this there may still be a long term net productivity loss. Again, do not assume your radiologists are going to quietly eat this productivity loss.
5) Poor system performance is a guaranteed PACS/VR killer.
6) VR and PACS are by definition “beta” software. There is no such thing as a perfect PACS or VR software; there are only “acceptable” performance parameters that will improve over time. VR may never be perfect.
7) The hospital shall accept it’s responsibility for supporting VR by ensuring it’s IT/IS support staff are well versed in PACS and VR and available as long as the radiologist are working. The IS/IT support staff shall have a full working knowledge of VR and be capable of training radiologists before a radiologist ever touches the software.
8) VR requires far more IT/IS/training support that the VR companies will admit.
9) VR is not a big money saver if properly implemented. Any savings from transcriptionists will be quickly eaten up by the need for hardware upgrades, software upgrades, training and the needs for additional support staff.
10) Before implementing VR, ask yourself “Am I doing this for the right reasons and am I willing to commit additional resources, possible indefinitely, to the proper launching and support of VR?”

PACS Abuse

An observant AuntMinnie poster found this lovely little item from the Cleveland Clinic:

Sub-specialized medical care is the standard of care today. Only an orthopaedic surgeon would perform an anterior cruciate ligament reconstruction, and only a neurosurgeon would remove a brain tumor. It is still common however, for general radiologists with no sub-specialized training to interpret the images that lead to these procedures.

This lack of sub-specialized radiology interpretations previously was necessary because of the need to have a radiologist in close proximity to the imaging center where procedures were performed. Now, through the use of new developments in information technology systems, Cleveland Clinic’s Department of e-Radiology offers sub-specialized radiology interpretations to referring physicians anywhere in the country. Better quality of medicine is possible through the use of interpretations and protocols developed and performed by Cleveland Clinic sub-specialty-trained academic radiologists.

A number of factors made growth in e-Radiology possible, most notably the imaging explosion of the past few years, which is expected to grow at the rate of 8% to 10% per year into the foreseeable future. Two additional factors are the national shortage of radiologists and the rapid developments in information technology that have allowed image interpretation to occur independent of geographical restrictions.
A large portion of the imaging growth is in outpatient imaging, with an estimated half billion outpatient imaging examinations projected to be performed in 2008. In 2002, 84% of magnetic resonance, 64% of computed tomography and 98% of positron emission tomography scans were done on an outpatient basis, and these percentages are expected to continue to increase over the next ten years. Only 67% of imaging is currently done in hospitals, down from 95% in 1980. Outpatient imaging accounted for $14.8 billion in Medicare revenue for hospitals in 2001 and generated $3 billion in profits.

Radiologist shortages have been significantly resolved through the use of teleradiology. Over the past few years, dramatic advances in information technology and the availability of technology in cost-effective pricing, high-speed telecommunication lines have removed almost all geographic restrictions in interpreting images. It is now possible to send digital images securely over the Internet on a virtually real-time basis to radiologists located anywhere such telecommunication lines exist. The radiologist is then able to dictate the images using voice recognition software so that the images and report are available online for the referring physician within minutes via a HIPAA-compliant Web browser.

This is just plain disturbing on several levels. First off, the piece insults general radiologists, who are for the most part quite good at what they do. Will a super-specialized rad be better for the esoterica of his specialization? Probably, but on a day-to-day and head-to-head comparison, I thing we would find that the generalist can hold his own. I am very distressed in this regard by the use of the term "standard of care." This is a legal term, and the Cleveland Clinic is basically saying that the generalists out in the boonies are beneath that standard and are therefore committing malpractice!

Secondly, there is note of the explosion of imaging, but no decrying the self-referral that is inherant in much of the "outpatient" studies that would be included in this designation.

Finally, the anonymous author of this piece is using the advent of my beloved PACS (technically teleradiology, but they have become essentially one in the same these days) to facilitate and even justify their desire to swoop in and snatch exams away from the lowly generalists.

I always advise my gentle readers to "follow the money," and here, this is not a difficult task. Our friend at Cleveland Clinic is telling you that the lowly generalists out in the boonies can't do an adequate job, but in years past, you had to settle for this because they were the only game in town. But wait, we now have PACS, and so we are finally able to help you poor downtrodden masses who have the bad fortune to live somewhere other than Cleveland. Just sign this reading contract, and pay us our fee, and we'll all live happily ever after.

This drivel should be beneath an institution with the stature the Cleveland Clinic. It is an abuse of PACS technology to generate revenue that really belongs elsewhere. AND, it encourages self-referral in a round-about way. I do hope everyone at the Cleveland Clinic will enjoy Hillary-Care which they are helping to bring about with their greedy approach to radiology and medicine.