Tuesday, May 30, 2006

PACS, the WIKIpedia, and other musings from the Baltic Sea

At this very moment, I am on a ship traveling up the east coast of Sweden en route to Stockholm. This trip required my son to miss his championship baseball game, but one of the other dads was kind enough to email us the results. (My son’s team lost, unfortunately.) The communications link went something like this: My friend emailed the play-by-play from the field via his Blackberry. The messages went to the Internet, which I picked up in my cabin, where my laptop is also connected to the Internet via satellite. Now my connection is running at dial-up speeds, which gets really frustrating, but, on the other hand, I’m really tickled that I can be on a ship (at that time headed toward Oslo) and get email from someone at a baseball field in South Carolina. Oh, Brave New World.

The Internet probably has done more to unite humanity than any other single factor in history, as illustrated by my little vignette. A more practical and useful example would perhaps be the Wikipedia. This is a collaborative effort, basically involving anyone who wants to participate, to catalogue the world’s knowledge. Anyone can write an article, and anyone can edit the Wikipedia. You do have to be prepared to back up your contribution with facts, and you must credit any photos you submit. I have made my mark on the Wiki by altering the paragraph on PACS architecture to include to concept of Web-based PACS. No doubt it will be edited further, but I feel I have had my 15 minutes of fame.

So far, we have been to Oslo and to Copenhagen. Both are spectacular cities. Oslo is a little more stark in some ways, but I found it to be more compelling. It seems to be overall a more peaceful place, but it’s hard to get much more than just a subjective feeling in a few hours.

Norway has a great deal of oil money from the North Sea fields, and it taxes its citizens quite heavily. Still, the Norwegians enjoy numerous benefits, including socialized medicine. They do have a co-pay for doctor visits, but there is then a major-medical plan that takes over if necessary. There is apparently a growing wait for some non-emergency services, but no one in Norway goes without health care. Period.

I have been a very loud opponent of socialized medicine for most of my career, but I am at the very early stages of thinking it inevitable. I look at the American system, and I see how it is being gutted and deformed and derailed by greed and fear, by self-referral on the part of some doctors, and by gluttony for unneeded services on the part of some patients. We cannot go on forever like this. When I hear about how well a system like that in Norway is working, I have to wonder if theirs is the right way after all.

Forgive my melancholy. It’s a beautiful night on calm seas. I’m going to enjoy it. Thanks for listening. Oh, and by the way, thanks for your ever-increasing readership of this blog. May isn’t even over, and it has topped all previous months for numbers of visitors and page-hits. Maybe I’m at least keeping you guys amused, huh? I’m very grateful for your interest, and I hope you feel your time here is well-spent.

Monday, May 22, 2006

Showdown at the PACS Corral

The second-place winners of the shoot-out at the OK Corral
A rather unusual event took place at the SCBT/MR (the Society of Computed Body Tomography and Magnetic Resonance if you didn't know) meeting last month. Six PACS vendors, Agfa, Amicas, Fuji, GE, McKesson, and Philips were pitted against each other in the first-ever PACS showdown. This is really a mighty feat in and of itself; getting six PACS stations and associated servers to all work at the same time is quite a miracle. I wonder who paid the electric bill.
Several vendors had engineering/apps types running their demonstrations, which consisted of performing a set of typical PACS tasks whilst under the gun. Amicas sent a physician who was very well acquainted with their product, and probably the best choice to show the world how their system works for its intended end users.
According the the Diagnostic Imaging article, there was no clear winner to this little exercise. Sadly, while some vendors (Amicas rep Barry Gutwillig was quoted in particular) wanted the results released, ". . . The vendors with more sensitive concerns. . .won this debate. To ensure a healthy participation at the next showdown, the SCBT/MR will not publish how the audience ranked each vendor." (Italics and implied disgust are mine.)
DI interviewed some of the attendees, and received various responses. Here's one from Dr. Dennis Foley, chief of Digital Imaging at MCW: "Dr. Foley. . . said that Philips, McKesson, and Fuji performed reasonably well in handling large data sets and doing relatively routine daily work. None of these companies, however, had well-integrated 3D solutions in their packages, he said. His nod went to GE for its hanging protocols, exam comparison, access to prior reports, and recovery from interruption." Ahem. It's clear that Dr. Foley hasn't used Centricity in the real world.
I am very disturbed about the "coverup" of the results of the showdown. Let's run an Olympic race and only report the results if the US wins. Obviously, one of the biG vEndors had a problem with how things turned out. Perhaps the small fry were more confident, or at least felt they had nothing to lose. Barry said it best:
“The society asked us if we wanted the results released, and we said yes,” said Barry Gutwillig, executive director of marketing and business development for Amicas. “We wouldn’t be here if we didn’t feel we could rank. I think it’s a testament to the vendors who are here and maybe more so to the ones who are not.”
With all this in mind, here is my advice for prospective PACS buyers: Do your OWN showdown. Either get a bunch of vendors to set up demos at your place all at once (or fairly close in time to each other so the details remain fresh), or get access to a web-based demo that will let you pound on their system at your leisure. I really favor the latter, as you can get a much better idea of how things work in your own hands. Vendors? Can you make this happen?
PACS interface preference is a very subjective thing. I like this approach, you like that approach. In this game, the second-place winner is in no immediate danger of extinction. Perhaps future showdowns can work from some additional metrics, such as: Does the damn thing work? Does it get in my way? Is the interface clean and usable? On second thought, those metrics are pretty hard to, um, meter, aren't they?
I received this comment, which is worthy of being moved into the post itself:
As one of the "big vendors" who was present at the show, we were also actually extremely irritated that the results were not disclosed, wherever we placed. This change in policy occured after we went on site. We may not participate again if that is going to be the way the showdown is run as it seems kind of pointless.We also thought the demonstration script was watered down from the original proposal and would have liked to have seen some of the original more challenging scenarios tackled.BTW: You have a minor inaccuracy in your article. You wrote that "Several vendors had engineering/apps types running their demonstrations". Actually, all of the vendors had a customer radiologist running their workstation. Some just seemed geekier than others.
I'm thinking this is from HBO/McKesson, by the way...
Now I wonder which vendor limited the tasks and then Got Excited about the results and as near as I can tell had them quashed? GEe, who could it have been?
OK, enough innuendo. If the folks at Centricity Central want to comment, I will publish their words here verbatim, just as I have for the Anonymous other Big Vendor. Well?

Sunday, May 21, 2006

Cool is for Losers!

My daughter just graduated from high school this weekend, and she will head to college in the fall, departing my sphere of influence. My son is finishing sixth grade, and will hang on to the Dad payroll for quite a while longer. It is his contemporaries that are starting to really worry me, the little 11 and 12 year-olds that shouldn't have a care in the world. Sadly, there are young kids in my son's class, boys as well as girls, that are incredibly concerned with what others think and say about them. It is very important to be "cool". These days, being "cool" involves not eating, not studying, not listening, showing no respect, and generally not doing anything they should be doing. The consequences of all this for these children's health are the most frightening aspect of the whole mess. When I hear a 12-year-old boy say that he can't drink a glass of milk because it might make him fat, I throw up my hands in horror. Enough is enough, people!

I propose a new campaign to fight this horrible trend, "Cool is for Losers!" When you get right down to it, being "cool" just means that you are doing stuff that makes you popular, but might not necessarily be smart or good for you. Starving yourself, smoking whatever, drinking, doing drugs, piercing various body parts, dressing like a prostitute, dressing like a convict (the droopy drawers look originated with prisoners who wanted to, ummmm, advertise their backside wares to fellow inmates), and so on and so on and so on. A real classy way to act, huh?

Why is it so important to be cool anyway? We've all been teenagers recently (ha!) and we all know the insecurities involved in that age group. To be accepted is more important than being healthy, or looking like a human being. But those whose entire goal in life is to be "cool" are more likely than not those who are petrified that they won't fit in with the "in" crowd. While they might make themselves popular with one tiny subset of society, they ruin their reputation with everyone else, and may cause irreparable physical or psychological harm to themselves. To put it quite bluntly, it is the "losers" that try so terribly hard to be cool, and conversely, the attempt to be "cool" can make these kids losers.

I'm no psychiatrist, and I can't begin to find the solution for all of this. However, sometimes just a catchy phrase will get things started. So, spread the word among the young folks in your lives: "Cool is for Losers!" It might actually make them think about the weird things they're doing, which is at least a step in the right direction.

Wednesday, May 17, 2006

Dalai Busts a Junk Faxer!
Well, Almost....

My fax line at home rang at 3AM the other day, naturally the night before I had to take call. It was a message from my friendly Junk Faxer, and I had received the very same fax about 10 times already. But when someone wakes me at 3AM unnecessarily, watch out!

Some rather brief research on the Junk Faxer's fax-back number disclosed that he is using Global Crossing, and that the long distance provider is a little Seattle company called Threshold Communications. I called Threshold, and was able to speak to Karen, one of their VP's. She was very kind and helpful, and promised to get my number removed from the Junk Faxer's list. But, no, she could not disclose the name of the faxer. And she had been receiving numerous calls from disgruntled members of the public such as myself.

Junk Faxing is illegal, as it turns out, mainly because unlike email spam, it costs money to receive a fax. Paper, toner, ribbon, they all add uup, you know. But some of these guys just ignore the law and keep on faxing. We, the victims have very little recourse. There are some services, such as FaxRecoverySystems, that will handle the prosecution for you. Send them a dozen or so junk faxes, they will do the research, file the claims for the illegal activity, and send you a check for $100 or so. It's probably a good deal, as the footwork gets complicated, but keep in mind that the fine for each illegal fax is about $1500. FaxRecovery is recovering more than faxes! As an aside, they had a message posted asking for information about the rather ubiquitous fax, and I supplied them with Threshold's number. Hopefully, I'll get some sort of reward, although not having the phone ring at 3AM is reward in and of itself.

I am no lawyer, thank Heavens, but I have to wonder if the other companies involved in Junk Faxing have some legal liability. The people at Threshold obviously know that they are providing services to a company that is doing something illegal, as well as distasteful. Why don't they refuse to do so? Karen gave me the clue: the junk faxer has about 300 numbers through their service, "but we only get complaints about 3 of them." Money talks, eh?

It would be unethical for me to suggest that anyone contact Threshold and tell them the error of their ways, or to put the fax number of the Junk Faxer on speed-dial and help tie up his lines, so forget that I said anything about that. But if there are any Threshold customers out there reading this, perhaps they could mention the situation the next time they pay their bill? Just a thought.

Saturday, May 06, 2006

Walk the Line (Placement)

Courtesy of ClinicalCases

Of the many and varied annoyances we endure on call, the CXR for line-placement at odd hours is becoming more common. When a surgeon or internist places a catheter in a large vein, there are some potential complications that should be excluded with a radiograph of the area. These problems include a pneumothorax, hematoma, and aberrant course of the line. All well and good. However, some of our clinicians have gotten into the habit of placing the line, and then telling the nurse to get Radiology to "OK the line" as they walk out the door.

Now, I can exclude the complications outlined above, although if I'm working from home at 3AM, I don't have high-res monitors at my disposal, and I can't really confirm that there isn't a tiny pneumo. But even a Sony Jumbotron would not tell me if the line is "OK", in other words usable. That is a clinical determination. If there was good return of blood through the line at the time it was placed, then it should be usable from a hemodynamic (plumbing) standpoint. For this reason, I am now placing the following sentence in the impression of each and every study I read for line placement:

Function of the line cannot be evaluated radiographically. This must be determined by the presence or absence of blood flow at the time of insertion.

Now, the question becomes: is the clinician who placed the line responsible for looking at the post-procedure radiograph? I posted this question on AuntMinnie, and while there was some debate, the majority felt that yes, the clinician IS responsible. He/she placed the line, and will collect the fees for doing so. Line placement has known possible complications, and the clinicians are perfectly able to see these on the radiograph. Are we selling our birthright if we ask them to look themselves? I don't think so. Dr. "Sofa King" posted this on the AuntMinnie thread:

Part of the procedure for line placement in confirmation of positioning and excluding the presence of a pneumothorax. If you have not done this the procedure is not over. If you cannot do this you should not be performing the procedure. If you cant see the cathether traversing up the neck, you shouldn't be performing the procedure.

The ONLY purpose of these rediculous follow-up xrays for placement of anything in a patient is to spread or turn over liability. Don't kid yourself that it is for anything else.

That said, we are not asking them to interpret an xray. Like a stethescope and ultrasound (both of which most of these guys have in their offices) the xray is just another tool of the procedure. Don't think that the idea that you won't let these guys read things in the hospital will stop them from taking anything from you when they want. They have xrays in their office and they can easily take a one week course in anything and get credentialled.

Couldn't have said it better myself. We'll see how much trouble my little canned statement causes. For me, that is.

Teens’ Speech Patterns Often Fail to, Like, Demonstrate Intelligence

The "LIKE" phenomenon is taking over the nation. Kids today, mine included, cannot utter a sentence that doesn't include the word "LIKE". Fortunately, my kids respond to yelling, screaming, threats, and ultimately beatings, and their abuse of this four-letter word has abated somewhat. Sadly, "LIKE" spews forth as every other word from some of their friends, and that is NOT an exaggeration. I am at the point of not being able to understand these poor kids.

Somehow, I thought this was a new problem, but it seems that is not the case. Here is an article from the Columbus Dispatch dated 4/1/1998, written by William L. Bainbridge, who is Distinguished Research Professor at the University of Dayton and is President & Chief Executive Officer of SchoolMatch®, a Columbus based educational auditing, research, data firm:

One of our country's many talk show celebrities is CNN monarch Larry King. King has used his outstanding listening, questioning and communication skills to catapault himself into an exciting career as a premier television and radio interviewer.
In his spare time, the King of primetime question-and-answer shows has published several books focused on his communication secrets. In How to Talk to Anyone, Anytime, Anywhere, King advises his disciples not to rely on "nothing filler words." Words and phrases such as "you know," "as I said," "basically," "actually," "hopefully," and "whatever" are condemned by King as only slightly worse than "uh" and "um" in spoiling interpersonal communication.
Despite the best efforts of teachers and parents, the nothing filler word of the 1990's has been, and continues to be, the dreaded word LIKE. It must have started somewhere in a cheerleading camp and spread with rapid-fire speed through our schools with the help of the media beginning with the early 1980's song and movie, Valley Girl. The movie Clueless and its television adaptation currently being run ad nauseum on cable channels everywhere, unfortunately, presents an accurate picture of the misuse and overuse of this word.
Recently, our organization was conducting an "effectiveness audit" in an affluent suburban school district. The school system recorded incredibly high achievement in virtually all areas of the curriculum. During our team's site visit, we met with a group of community leaders including elected student leaders. The president of the senior class is an outstanding young lady with impeccable scholastic credentials. She has high scholarship examination scores and terrific grades. Her achievements and activities are most impressive.
After the session, several adults clustered in a private corner discussing this young person's "communication flaw," or what Larry King would call a "speaking tic." She seemed unable to speak more than five words without one of them being LIKE.
The session was videotaped. We reviewed the tape and, to no surprise, found sixty-four instances by actual count of this bright person cluttering her sentence with the word LIKE in less than four minutes: "You know LIKE I feel LIKE students LIKE have trouble LIKE selecting LIKE career awareness LIKE experiences." This student was given an opportunity to demonstrate her verbal skills before leaders of the community. In the minds of those in a position to help promote her aspirations, she undermined the serious concepts she was putting forward with a nothing word sentence splice. Moreover, her speech pattern seriously interfered with her attempts to discuss the issues and persuade the audience. What was she trying to accomplish? Had this tic been developed in the process of trying to be trendy with her peers? Some teenagers can turn this brainless language on and off at will. Others apparently have difficulty adjusting to the audience. Most are completely unaware of the extent to which listeners are irritated by this drivel.
Teens need to be encouraged to express themselves. But sentence fillers and splices, however, taken to an extreme, are not well-received in public presentations and interviews for employment, scholarships or college admissions.
If there is a parent or teacher of a teenager reading this who hasn't heard the LIKE phenomenon, consider yourself fortunate. For the rest of us, let's throw it out with the oral crutch "uh", "you know" and "like I said" of an older generation and try to promote better language skills and communication.

So, can we like stop this horrible like bad habit before we like kill somebody? Like DoctorDalai? Let's all like declare our homes like-free zones, so we can have some intelligent conversation, like we used to. You know?

Friday, May 05, 2006

California Legislature To Tom Cruise:

AuntMinnie.com reports today on a bill in the California Assembly designed to thwart private individuals from buying their own ultrasound scanners for home use:

The bill (A.B. 2360) was introduced by Lieu in March. An amended version of the bill, dated May 1, states that violation of the proposed law would carry a criminal misdemeanor charge. The bill was slated for its third reading on the Assembly floor on Thursday.
"If someone sees Tom Cruise buy one, they think this is the thing to do. This is a public safety measure. There's really no medical reason for an untrained person to use this machine," according to Lieu (
E!Online, May 4, 2006).

Personally, I'm not sure how many private folks out there are going to cough up $100,000-$300,000 for their own private sonography suite. I also have to wonder whether the California legislature has anything better to do.

Now, we all know that Tom is really into Scientology, which spurns much of conventional medicine. I am glad to see him embrace some of our technology. You may know that Scientology uses a device called an Electropsychometer, or E-meter for short, to perform Auditing. Here is an image of the L. Ron Hubbard Mark-VII Super Electropsychometer:

Very impressive. From the Scientology website, we learn that:

When the person holding the E-Meter electrodes thinks a thought, looks at a picture, reexperiences an incident or shifts some part of the reactive mind, he is moving and changing actual mental mass and energy. These changes in the mind influence the tiny flow of electrical energy generated by the E-Meter, causing the needle on its dial to move. The needle reactions on the E-Meter tell the auditor where the charge lies, and that it should be addressed through auditing.

Couldn't Tom and Katie have just looked in on little Suri with one of these instead?

A Blast From The Past...
Vital Images Comes A-Callin'

Mark, our PACS guru, phoned me this morning with some interesting news: Carrie from Vital Images was on the line, and wanted to ask about updating our software licenses. Mark was rather confused, a very rare state for him, because he didn't know we even had any of Vital's products. I clasped my hands together in a sinister manner and slobbered with glee....

You see, we do own three Vitreas, dating from the mid 1990's. All are Silicon Graphics computers, two running IRIX (SG's flavor of UNIX), and one running Windows NT. These represent an investment of something like $150,000 to $200,000 or so. I wasn't involved with their purchase. Actually, if memory serves, the NT was a trade-in or something. But I digress.

About three or four years ago, one of the computers blew a hard-drive. I tried to nurse it back to health, but to no avail. So I called Vital Images. TEN TIMES! And I emailed them ten more times. Nothing. I posted nasty things about them on AuntMinnie.com. Nothing. We chalked up our losses, and went on to bigger and better things, like GE AW's and Siemens Leonardos, and various installs of Voxar 3D, all of which have done the job nicely.

I returned Carrie's call, and as nicely as I could for someone out $200,000 on non-working equipment, explained the situation. She had only just joined the service force, and was not happy to hear of our plight. I suggested she elevate the complaint to the president of the company, although that would be mainly for their benefit. Given this incredible service faux pas, I would not even accept a freebie at this point. If Vital wishes to donate a Vitrea to a third-world country in my name to assuage their collective conscience, that would be fine. But do tell them not to expect stellar service if it breaks.

Carrie promised to figure out what had happened, and to keep such a thing from happening again. I wish she had been with Vital a few years ago....

Addendum: The Vital rep for our area did indeed contact me, and we had a very good conversation. I do wish this new generation had been around when our problems started. Anyone want to buy a first or second generation Vitrea?