Monday, December 25, 2006

Happy Chrismukkah!

My wife has become quite addicted to "The OC", and I have to admit I enjoy it as well. So, for her big gift this year, I was able to get hold of some screen-used props from the show itself. I'm hearing rumours that the fourth season of "The OC" will be the last; hopefully this isn't the case. (Although the show just hasn't been the same without Marissa!)

While it's a little late for Hanukkah greetings, it is Christmas Day, and I do want to wish everyone the happiest of holiday seasons. May your PACS systems run well, and your ER's be quiet. Ho Ho Ho!

Sunday, December 17, 2006

For Those New To The Field....

As a public service, here are some corporate misconceptions that need to be cleared up....

3mensio---is not a women's problem
Amicas---is not a Chinese manual calculator
Barco---has nothing to do with dogs
Bracco---is not the sound of retching
BRIT Systems---is not British
Cardinal Health---has nothing to do with the Vatican
Cedara---does not refer to pleasant-smelling trees
CHILI GmbH---has nothing to do with spicy food
Dell---is not where the farmer lives
Eclipsys---does not blot out the sun
Emageon---is not imaginary
Empiric---does not relate to Ceasar
Fluke Biomedical---does not deal with parasites
GE---is not an exclamation of delight
Intelerad---is not the opposite of stupid rad
Hologic---is not how streetwalkers reason
Kaiser Permanente---is not the king for life
Mayo Clinic---does not diagnose Hellman's
Novarad---does not deal with lox
PACSGEAR--is not a wheel with teeth inside your PACS
Picker---is not a little boy with a dirty finger
Proscan---is not a place for golf experts
RamSoft---is not a male problem
Siemens---has nothing to do with boats
Shimadzu---does not deserve "Gesundheit" in response
SoftMed Systems---see RamSoft
Stentor---is not one of those heart artery things
Stryker---does not require scabs
Sun Microsystems---does not make miniture stars
Swearingen Software---is not found in courtrooms
Thinking Systems---still requires humans
VIDAR Systems---does not make anything for Geordi LaForge

Saturday, December 09, 2006

More Agfa Visitors

When E.F. Hutton talks, people listen. When Dalai whines, people cover their ears. Actually, that isn't always the case. We were honored down here at our average hospital in our average town in the South to host a smaller Agfa entourage which included Bob C., Agfa's Senior Marketing Manager. (No, he does not sell old people.) I first met Bob at RSNA 2005, where he gave a masterful demo of Impax 6.0. You might recall my observation at the time that my visit to the booth was somewhat surreal. I had written about Impax 6.0 on my blog, they had all read it, and it was pretty clear the Agfa folks didn't really appreciate my literary talents. Oh well.
But fast forward to this week. Everything got off on a much better foot, and I think perhaps there might have been a smidgen of mutual respect going on. Of course, it helps that Impax 6.0 really has been showing its behind, and everyone realizes that I'm not totally full of it. I was able to spend about an hour with the Agfa folks, before my anxiety about the growing worklist made me bid them adieu. This was a very productive meeting, I think, at least for the long-term. Bob was able to see how Impax 6.0 functions (or doesn't) while in my hands, and I think he saw some things in ways he hadn't before. Take, for example, the concept of tool-toggling, which I harp on constantly. Bob had not considered that keeping a tool active until deactivated and then falling back on a default tool might not be intuitive. Agfa is the only company with this approach, and I for one don't like it. The idea was apparently to limit the "mouse milage", i.e., to keep one from having to move all over the screen to activate another tool, but in the end, I don't think it accomplishes this. As a corollary, even the window/level tool works differently than with any other product...left-click to activate, move the mouse to change window and level, and left-click to deactivate and go back to the scrolling tool. I'll take the way everyone else does it, thank you. Bob seemed surprised about that. We went on to discuss where the series bar should go (we agree it should be fixed at the top of the screen), and how to display old reports (I gave him my very simple idea of putting the date of the old report in big red numbers and letters at the top). We talked about a new little peculiarity Impax is manifesting, flickering upon viewing a newly-loaded CT, apparently due to slow caching, although it happens inside the enterprise as well as outside. Bob noted that there were several improvements that I missed at RSNA whilst frolicking amongst the 64-slice and beyond CT's. They will shortly have a spine-labelling program that in Bob's words is better than Amicas' (although from his description, I think it will be quite similar).
The meeting was much more cordial and informal than the blog-inspired stand-off of a year ago, and to be honest, it was probably more comfortable than the talks we had with the developers a few weeks back. In the former scenario, we had the distinct impression that we were calling someone's baby ugly. Well, I'm sorry, but for us, it is. Perhaps as head of marketing, and not the "parent" of the product, Bob can be a little more conciliatory toward our views. Case in point is hanging protocols. In Impax 5.2, it took a computer genius to apply them. In 6.0, it takes at least a PACS guru, although I probably could get one going in an hour or two if left uninterrupted (yeah, right). The developers were absolutely incredulous that I might want to make my own, but Bob expressed understanding as to why I might have that desire.
I think I sent the Agfa folks back to Canada on good terms, and I'll tell you, I am very impressed that they made the trip. This is the way to build a PACS, folks, although Agfa is about three years late in the process as far as I'm concerned. The keys are simple: listen, watch, and learn. I'll bet Agfa knows more about how real, live, average radiologists work now than they did before coming out here to the boonies. You simply cannot design a product based on a focus group of 5 or 10 or 20 rads. You need to see how a broad swath of them use a product, and go from there. Now, I violently disagree with the philosophy of giving everybody every bell and whistle they request. With that "please everyone at the expense of everyone else" attitude, we end up with the products we have now, bloat-ware with a thousand options that in the end are rarely used. Can you say "Feature Fatigue"? It is unwise in the extreme to add a dingus to please 1% of the buyers. As I have told Amicas a zillion times, keep it simple, or you'll be no better than those other guys. I think Bob might actually agree with me deep down, based on some of his comments, and he alluded to a "light" version of Impax 6.0 that I might have found more to my liking. At least he can see this issue from my point of view. But the important thing again is that he came to my place to see how I and my partners do things. This was incredibly important to us, and I hope to him. Every PACS manufacturer should consider this approach. Maybe I should charge admission.
I am about ready to lift my "Wait" designation on Impax 6.0. The workstation crashes have tapered down to only once or twice a day, much improved from every 10 minutes or so. From the hospital's PACS administrator comes the explanation:
A few weeks ago, Agfa had determined that over a period of time, server resources accumulated to the point that one of the servers would freeze up. Since then, they had put a process in place to release system resources, which has greatly decreased the frequency in which the client failed.Unfortunately, in order for us to determine the root cause of the problem, Microsoft has requested that we gather a "Crash Dump" log file off the server. In order for us to get this file, we need to disable the process written by Agfa and wait for the system to degredate. This may cause the clients to begin crashing with more frequency, however, I want to inform you that this is in efforts to determine the real nature of the issue.
So, maybe the problem will be solved for good. I do recall that there were similar problems in the beta install at Sparrow Hospital in Michigan, caused by some Microsoft or Windows problem that impacted Impax. Is history repeating itself? There are a lot of nay-sayers out there that aren't thrilled with any strong dependency on Microsoft, and this sort of thing does make you wonder. While I'm not that big a fan of the GE AW, it does run on Linux, and I have never seen it crash. Well, maybe once, but it is pretty darn stable. I think Brit Systems with their Linux PACS product may have it right after all.
Anyway, once the crashes in Impax 6 are fixed, I will change my warning from "Wait" to "Caveat Emptor". If you are considering this product, you or your rads are behooved to demo it to death. Get as much hands-on time as you want, and don't take "no" for an answer on that request. The only way you can tell if you will be able to live with Impax 6's peculiarities is to put it through its paces (or more accurately, have Impax put you through your paces). That is good advice for any PACS system, and indeed just about any high-level purchase. I'll let you know if this Microsoft issue turns out to be the real culprit.
And again, Bob, thanks for coming down. It means a great deal to us that you were willing to take the time to listen.

Friday, December 01, 2006

25,000 Hits
and some RSNA tidbits

Visitor number 25,000 comes from (XO Communications) in Hampshire, Illinois. Sadly, he or she only stayed on the site for a second, but still, a hit is a hit.

Four days at RSNA can go very quickly, although it's enough time to thoroughly wear you out. I had the honor (and I'm not being sarcastic) of rooming with Mike Cannavo, the One and Only PACSMan, since he couldn't find another room in Chicago. If you can imagine walking the Technical Exhibits with someone who spots every little advertising discrepancy and innuendo, well, that's what it's like strolling the GE Boulevard with Mike. Check out his (in)famous 2006 PACSMan Awards and keep in mind that I was along for the discovery of a few of the winners.

I actually tried to attend as many educational sessions as possible this RSNA, which didn't allow a lot of time on the show floor. I still managed to see and learn a few things... In no particular order:

  1. Cardiac CT is probably going to be as big for radiology as for cardiology; we just need to market it correctly and do it perfectly.

  2. To actually achieve that perfect cardiac CT takes a 64 slice CT (or beyond). Toshiba announced for the 7th time a 256 slice scanner, which may actually sell in a few years. GE is using some clever "step and shoot" techniques to lower the dose on its 64 slice unit, and GE promises to emphasize spatial resolution. Siemens offers the Somatom Definition which has two separate X-Ray sources. The Definition has the best temporal resolution in the business, but its price is about double that of the others (although no one knows how much Toshiba's opus will cost). I now have to convince the hospitals that the cost is justified. Wish me luck.

  3. I finally got to look briefly at McKesson's Horizon PACS. We never were allowed to consider McKesson because we had just dumped HBO as our HIS. I really didn't have enough time to do it justice, nor to do a proper write-up. Some of the big names from McKesson (many of them were from the original ALI team) gathered 'round the Dalai (who is already pretty round himself) for the demo. Again, I am humbled and honored by such attention! I have always heard good things about Horizon, and I found the stories to be well-founded. This is a very solid, usable program, which I would trade Impax 6 for in a minute. Horizon is a Smart-Client, but it is a Windows application, and does not utilize .NET. In my brief demo, I could see a lot of potential. Particular highlights include a nice streaming protocol that loads the images of a series based on which one your mouse is hovering over, and good hanging protocols. My one complaint is my usual whine: the system has a zillion configurations, and feature-fatigue could be imminent. How about keeping it simple?

  4. Rumour: A big Amicas client may bail and go with Fuji. Bad choice in my humble opinion.

  5. After sitting through umpteen educational sessions, I'm now worried about the last 100 cases I read before coming to RSNA.

  6. A meeting of radiology bloggers didn't go off quite as planned, but I did get to meet Steve Severance, formerly of the Baltimore VA, but now a consultant at We had a great talk about PACS, and having worked with the luminaries such as Eliot Siegel, his perspective is amazing.

  7. The first session I attended was about PACS workstation design, and I'll probably write a full post about that alone. Suffice it to say some of my ideas aren't that far off the wall.

  8. In the not-so-sexy but still interesing department, a Korean company that makes backlights for high-res monitors showed a prototype monitor that uses LED's for backlighting. This allows uniform lighting with easier calibration and much longer life. I hope to see a production version soon.

  9. GE's booth was larger than ever, easily covering several city blocks. Sadly, I didn't have time to see their "Future Theater" which supposedly showed what CT will be like in 10 years. No doubt GE will play a critical part.

  10. As if McCormick Place isn't large enough already, there is a new West Building under construction that will probably double the available floor space. Attendees will need to steal Agfa's Segways to get around.

  11. Amicas continues to progress nicely. A year ago, I had hoped to debut Version 6.0 (rather unfortunate title given the other Version 6.0 I deal with) at this RSNA. Well, it isn't ready yet, but the prototype gets better and better. I'm proud to say that it even incorporates a few of my suggestions, among a host of much better ideas. I truly think this system, written from scratch, will trump the other systems out there. It keeps the look and feel of the older product, while adding fantastic functionality, including some I can't talk about under NDA. I have two requests of Amicas on this topic: First, devote all possible resources to getting Version 6.0 out the door as soon as possible. Second, don't do an Impax and deploy it before it's ready. Trust your developers, and don't even think of running out of Red Bull! As for the near future, I got a chance to demo RadStream as integrated with LightBeam in prototype form. I was not a RadStream fan at first, since it seemed to mainly add an Amicas-like worklist to Centricity, which badly needs one. But, in its Amicas integration, it provides an incredible communcation system from tech to radiologist, and from radiologist to an "operator" who is in charge of getting reports out to referring docs. I just needed to see how it would work, and now that I have, I am a big fan. This is the most straight-forward approach out there, and it will work beautifully. Anyone want to be my operator? The communication package is rounded out by the VisionReach system that will allow automatic e-mailing, among other alerting, of properly equipped clinicians or their designates. I'd say Amicas is in for good times.

No doubt I've left something out, and I'd love to hear about your favorite booth or session. Next year in Chicago! (They might have the snow shoveled out by then!)

Oh, and by the way, I had to take call the day after I returned from RSNA. My Impax 6.0 station crashed about every 30 minutes throughout the evening. I wish I could report more progress from Agfa. Maybe next year.....

Prosty the Spokesgland©

Of all the amusing things at this year's RSNA, I think Prosty is certainly the most, well, unique. (Many thanks to Mike Cannavo, the One and Only PACSMan, for finding this little gem!) Now, prostate cancer is very bad business, something that will affect virtually every man that lives long enough to get it. The thrust of the "Manogram" movement is to develop a scan, akin to a mammogram, that will identify prostate cancer while still treatable. PET and ProstaScint are not quite up to the job as yet, and some new technology is desperately needed. Still, when you combine the Ren-and-Stimpy-esque figure with the most amusing cartoon, it becomes difficult to take ol' Prosty seriously.

In case you wanted the lyrics to the Prosty song, I have provided them for you below. Enjoy!

Prosty the Spokesgland

Is a prostate gland, we're told

Buried deep inside largely out of sight

He's ignored by young and old

Prosty the Spokesgland

How we hope that lump's benign

But it's hard to say

Cause the only way

To diagnose and treat is blind

There might just be some cancer

In that lump they found today

But we really can't be sure right now

Cause you can't trust the PSA

Prosty the Spokesgland

Spreads the word on what we need

No more pokes and prods

No more biopsies

How about some imaging?

Prosty the Spokesgland

It's time that we all gave a damn

Cause we know he needs New technologies

Like a hi-tech Man-ogram

Lumpety lump lumpLumpety lump lump

Look at Prosty grow

Lumpety lump lumpLumpety lump lump

No more bending over so

More RSNA news in my next post.....