Great ExSPECTations

I'm on my way back home from frigid Ann Arbor, having just spent the morning in an amazing Nuclear Medicine department. It's embarrassing, really. Our entire Radiology and Nuc Med divisions would have fit easily within the confines of the U of Michigan Nuclear Cardiology Department alone! I lost count of the number of scanners I saw, and we never even ventured into non-Nuclear territory. Maybe there is something to this academic stuff after all.

I am very grateful to the folks whose schedules we disrupted, in particular Jeff M., and Dr. B., who gave very generously of their time to show us the Siemens Symbia SPECT/CT scanners (several of them...LOTS of them!), discuss their operation and go over images and protocols.

The Symbia series has been around for a few years, which means two things: the bugs have been worked out of the platform, and it may not be at the bleeding edge of technology. At this point in my career, a proven track record tends to trump all else. The CT component is a little long in the tooth, basically the older Emotion platform, but its images are fine. Really, the only thing it really lacks for my purposes is the ability to utilize iterative reconstruction. This could perhaps be added in software, but apparently that is not a likely event. I'm still satisfied with the dose in the setting of a SPECT/CT acquisition.

Symbia does offer IQ-SPECT for cardiac studies, which will allow either a reduction of injected tracer dose, or a significant time-savings. How about acquiring a cardiac scan in 4 minutes instead of 20? Or double the counts with a 6-minute study? Or cut the dose back with a longer scan? I'll let you read the brochure for yourself, but in viewing live studies, I can tell you that the IQ-SPECT scans look about the same as those from the conventional protocol. Key to the process is a focused collimator, the successor if you will of Siemens' old CardioFocal collimators we used to have on our Orbiters from 1990. Everything old is new again, as they say...

The physician (a cardiologist, actually) who had done much of the research for IQ-SPECT was not available today, but I did have a great conversation with Dr. B, a private-practice rad who had returned to academia, and two of the residents. It seems they were not familiar with me and the blog, but I gave them my card, containing my URL. Hope you guys aren't too disappointed in what you find here!

Dr. B and I commiserated on the joys and perils of Private Practice Radiology, not the least of which is having decisions about equipment often made by administrators and vendors, and having no recourse for bad equipment.  I sheepishly mentioned that I have on rare occasions used this blog to hold a vendor accountable (I believe I might have said something like "hold their feet to the fire" but that wouldn't be like me) for bad products. He nodded approvingly, and said, "I think you would fit right in with Academic Medicine." Which I take as an incredible complement.

The two residents were quite impressive themselves, and I wish we were hiring so I could rescue them from the horrendous weather up there in Michigan.

Due to various machinations, we won't be looking at the Discovery 670 NM/CT 670 this time around. However, I will say this now: we will never again buy a conventional gamma camera without integrated CT.  (I can act like a big-shot with other people's money, but it makes perfect sense.) I do believe we are to have a peek at the Philips Precedence before the final decision is made. I hope we have a room big enough for it! 

Doctor Dalai's Ultimate PACS Fix

Confirmed! iPad 3 WILL Have Retina Display!

The folks over at MacRumors were able to get hold of a display module for the upcoming iPad 3, and literally examined it under a microscope.

From the MacRumors story:

Clearly, there are four times the number of pixels on the new display, and this all adds up to a resolution of 2048x1536, as compared to 1024x763 for the old model. The screen is still about 9.7" diagonally.

The Barco 3MP monitor sitting on my desk shows the very same numbers as the new iPad display.

You realize what this means, of course. The iPad has the potential to become the de facto mobile PACS platform. Of course, there are a lot of hoops to jump through before that happens, but trust me, it will happen.

I do have to add my own personal slant. I've got an iPad 1, and I'm not all that fond of it. There are a number of things it just does NOT do well, not the least being the simple writing of a simple blog by a simple radiologist. However, I did get a case with a Bluetooth keyboard, and this may help things. As far as graphic tasks, however, the iPad/iOS approach does seem to work well, and with the new Retina screen, there can be no worries about resolution. Now, contrast will be another story...will we have to only use PACS apps in the dark? Only the Shadow readers know for sure...

And The Winner Is....

I know there is a lot of pent-up desire out there to know which advanced visualization solution we chose. Now, the decision was far from easy, as any of the five contenders would have done the job. Most likely, anyway.

In the end, we gathered everyone's notes and tally sheets, spoke to as many of the attendees as possible, and tried to synthesize their opinions.

All five products have some things they do well, and some they don't. There are actually few glaring deficiencies, such as the one product that won't be able to create AVI movies until the next release. Another requires an add-on bit of software for certain functions supplied by another vendor, and I am told said add-on won't work as a thin-client, and thus must be installed on every reading station.

At the host of this little party, I have been hearing lots of interesting tales... Did I know, for example, that one company did this, another didn't do that, and by the way, this company just got thrown out of a big-name academic center in favor of that company?  Sheesh.

Now, don't bombard me with queries such as, "but why didn't you like X?" It's not that we didn't like X, but we felt that one product would satisfy our needs in a manner better than the rest. Your mileage may vary, and I urge all potential customers to check out the software for themselves.

Many thanks to all of the vendors and all of those who attended our little shoot out.

And now, the winner is....

Wait for it.....

TeraRecon

I'm looking forward to having it up and running ASAP, so I can report on how well we did with our choice. More to come!

PeerVue Purchased By.....

McKesson!

http://www.businesswire.com/news/home/20120208006474/en/McKesson-Acquires-peerVue-Leader-Radiology-Workflow-Solutions

Today McKesson announced that it has acquired peerVue Inc., an innovative provider of solutions that simplify diagnostic medical imaging workflow, expedite communications for improved quality and efficiency, and support customer efforts to improve patient safety. The acquisition extends McKesson’s portfolio of enterprise imaging and information management systems with highly flexible workflow capabilities that address site-specific needs such as critical results management, peer review and emergency department communication for multiple disciplines.
“We can bring together new care coordination capabilities to close the gaps in workflow for clinicians and enable better health in this generation and beyond.”
“peerVue brings world-class capabilities that facilitate care coordination, which is essential for better care and better business as part of our Better Health 2020 strategy,” said Kevan Torgerson, president, Enterprise Medical Imaging group, McKesson. “By addressing critical imaging workflow needs, particularly for radiologists, our combined capabilities empower care teams to more effectively engage with one another and to make better informed decisions throughout the diagnostic workflow.”

Even McKesson folks didn't know. Good security, people!

The Merge PACS Roadmap

When Merge bought AMICAS last year, many of us were quite worried about the path our PACS would follow, especially with the loss of the main developers and programmers. As a customer, I'm happy to say that promises made at the time are being kept, and the future looks pretty good, at least for the next few years.

I had the chance to visit Merge HQ in mid 2010, and I filed this report:

But what I really came to Chicago to discover was the future of AMICAS PACS, and I think the answer here is satisfactory. The Merge people feel that Merge and AMICAS were more complementary than competitive, except in the realm of RIS/PACS. Everyone agrees that AMICAS had a great PACS, and Merge had a good RIS. These two programs, respectively, will be the go-forward products. Everyone at the table wanted to be certain I deliver this message clearly, so I will quote verbatim: "The approach to RIS/PACS will be the consolidation of the best practices of all of the applications into a single platform workflow and viewing solution." Well, there you have it. All Merge RIS/PACS customers, including those using AMICAS PACS, Fusion PACS, or RadStream (from Emageon) WILL BE SUPPORTED, and will have an upgrade path. How much the upgrades will be wasn't mentioned. What I will call AMICAS 7 will ultimately include the best of all worlds, blending the best of the legacy products, and using the ECM as the back-end.

So far, this has indeed been the course of events. In particular, AMICAS PACS lives on. I am somewhat distressed that it is now called Merge PACS, but I suppose I'll get over it. To the victor go the spoils, and all that.

A few days ago, some of the Merge folks gave me an update on their PACS roadmap. There were no huge surprises, but a lot of nice features are here or are at least on the way.

Our AMICAS, I mean Merge Hospital is still back on AMICAS 6.0.4, the first maintenance release by Merge, and there we sit for the moment. But we are behind the times.


Version 6.1 was released early in 2011. The most important change was the option to integrate to a Vulture Vendor Neutral Archive (VNA), preferably the Merge iConnect VNA (formerly known as Emageon AMICAS Merge ECM, or Enterprise Content Management.) 6.1 also offers tagging for teaching-file creation:

If you bought Merge PACS today, and everyone was REALLY efficient at getting it up and running, you would receive Version 6.2, which was released in Q3 of 2011. While previous versions would run in a 64-bit environment, 6.2 is a native-64-bit application, which can use more memory for larger studies or more studies viewed simultaneously. Yes, it will run on 32-bit stations, too. There are several fixes as well; our version has a weird glitch involving the display of some of the cursors, and that is now history. 6.2 also includes  instant messaging via Merge Messenger (do you get the impression that they like the name Merge?) which lets users communicate with each other and link to studies in real time.

DICOM SR reports and other such objects can now be viewed. There are some mammo enhancements such as skin-line localization. 6.2 has been more optimized to be launched from an EMR as an embedded viewer.

We will soon see Version 6.3, expected to be released Q2 of this year, and there will be a number of new features available. First in my heart, anyway, will be PET/CT fusion. Actually, any two modalities can be fused, so maybe I can avoid that PET/MRI purchase after all. (It would be nice if we had PET/CT at the AMICAS Merge hospital...)

There will be even more digital mammo enhancements, with linked magnifying glass and linked binoculars view:

Digital tomosynthesis display will also be included:

One of my partners has been whining about requesting user-customized keyboard shortcuts, and his wish is now granted:

6.3 has some back-end improvements, such as LDAP support, and better study-deletion rules. Its code has been streamlined for faster operation, and improved experience on lower-end workstations.

Sometime late in 2012 we will see the next edition of Merge PACS, Version 6.4. In an attempt to consolidate Stryker Ortho customers, Merge will, umm, merge the functions of Stryker PACS into the mothership code. There will also be teaching file worklist access from iConnect. There will be a new option to upload CD-ROM data.

Sometime in Q1 2013, we should see version 7.0, code named Ability (actually, it's not, but I thought it sounded like a nice counterpart to another version 7.0). We will see native DICOM printing (which now requires an add-on such as ePhlegm eFilm to accomplish, global user preference administration, and EMPI (Enterprise Master Patient Index) support, critical for true enterprise systems. There will be some enhancements to the Real Time Worklist (RTWL) as well.

No word yet on Version 8.0.

I'm personally pleased by what I've seen. Merge PACS remains eminently usable, and continues to evolve and improve.  I'll still put it up against anybody else's software. Now, if I could only come out with a new and better version of my abilities...

Today's Best Exam History

Found on an order for an abdominal and pelvic CT:

28 yo s/p GSW to left thigh on Saturday Jan 28, 2012.  Reports evaluation at (outside hospital) showing bullet lodged in muscle.  States this morning, having BM and heard "clink", dug through stool and found bullet.

This is why I went to medical school, folks.

The Best Part Of The Superbowl

I'm not the world's biggest football fan, but I generally do watch the Superbowl. While I don't really have much skin in the game, so to speak, I am very distantly acquainted with the family that owns one of the teams, so I guess I'll root for them.

But the real reason I watch is for the commercials. It has become a tradition for advertisers to put their best efforts into the VERY expensive Superbowl messages.

My all time favorite is still the FedEx Caveman Commercial from 2006:

Time and technology march on, and the offerings from this year are certain to be even more incredible. The productions from several automobile manufacturers have been posted a bit early to YouTube, perhaps to catch that portion of the audience that actually watches the game and goes to the bathroom during the breaks.

First, we have Ferris Honda's Day Off:

Next, a teaser from Acura, starring Jerry Seinfeld and Jay Leno:

Now, a frosty one from Suzuki:

And something a bit more blood-curdling from Audi:

And finally, let this farce from Volkswagen outwit you:

Lexus just barely got the ad out in time for the GS debut on Friday:

I wonder what the good folks at Bud Light will come up with this year....

DoctorDalai.com Second-Most Read Blog!

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

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

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

(BTW, HISTALK is deservedly number one.)

PeerVue Purchased!!!

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

Sono-Roast

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

From the FDA:

Class 2 Recall GE LOGIQ P6 Ultrasound System

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

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

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

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

Hat-tip to Dasmah of the Kuwait PACS Club.

Dalai Meets The Next President

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

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

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

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

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

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

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

Decisions, Decisions...

Dear Vendors:

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

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

Sincerely,

Dalai

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

Image Courtesy TMONews.com

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

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

Except it doesn't work.

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

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

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

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

How Much Is An EMR?

MediNote EMR, courtesy Carson Doctors Group

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

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

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

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

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

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

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

The Advanced Visualization Caucus

"Glass View" on IntelliSpace, Courtesy of Philips.

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

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

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

Pat, the PACS Goddess!

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

Team Siemens

Team Vital

Team Tera

Team Philips

Team GE

A-Team

Team Techs

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

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

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

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

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

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

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

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

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

Help Dr. Dalai Quiz Advanced Visualization Vendors!

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

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

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

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

ADDENDUM

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

Advanced Visualization Demonstration Questions

General

• Please provide a brief overview of your system. A drawing would be great. Handouts are appreciated.
• How many servers are required for full functionality? Is there a user or a slice limit per server?
• Please outline or provide a table to illustrate.
• What is your licensing scheme for both thick and thin Clients?
• Are there 2 Tiers of functionality, as in Thin and Thick Client? Please elaborate on the functionality available for each Tier.
• Will both clients function well in a Citrix environment?
• What is the client to server ratio for each type of Client?
• Does the thick client require any special hardware?
• How does the user login to either product?
• Does the system have its own user database or can it authenticate to Active Directory?
• What type of auditing functionality does it have?
• Has your product been fully integrated with AGFA’s IMPAX 6.5? Please describe the usual workflow we would experience when accessing a study on your system via IMPAX. (Any images created on your system would be stored on IMPAX.)
• How will we handle routing of separate datasets to your system as opposed to IMPAX? We will likely want to send full thin-slice images to your server but not to IMPAX.

Thin Client

• How do you access the thin client?
• Is it URL based?
• Is it dependant on a specific browser or require any additional software to be installed, i.e. Java, .NET, etc? If so what version?
• Will the thin client work on a MacOSX, iOS, or Android?
• How many concurrent users can it support?
• In situations with low bandwidth (outside the Hospitals) how does the thin client perform?
• What happens if the connection between server and client times out?

Hopefully we haven't missed much.

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

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

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

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

Duh...Importing Outside Studies Into PACS Avoids Repeats

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

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

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

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

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

Hat tip to The Once and Former PACSMan.

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

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

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

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

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

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

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

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

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

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

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

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

Mar-Mar, Misses, and Madness

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

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

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

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

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

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

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

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

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

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