Thursday, December 31, 2009

Romanian Spam, And Other Thoughts On 2009

I hate Spam with a passion, the electronic kind, that is; I don't think I've ever tasted the Hormel version. The spams I hate most are those from the same source that keep coming and coming and coming. In the past several months, I've been receiving literally hundreds of Spam e-mails from some degenerate in Romania, and according to SpamCop, it's all being sent from the Romanian ISP, I've alerted them dozens of times at the email listed on their contact page, but to no avail. So, I sent an email to the Romanian Ministry of Communications and Informational Society, asking for their help in shutting this jerk down. We'll see what comes of it.

2009 has been a year of changes, some good, some bad. On the other hand, some things didn't change at all. Here are just a few items that come to mind from the PACS world, not in any particular order:
  1. AMICAS buys Emageon, and is in turn bought by venture cap firm Thoma Bravo. AMICAS comes out with a higher stock price than has been seen in years (although the vultures disagree with the valuation for some reason). They also gain access to a vendor-neutral database (joining several other companies), a cardiac package, and a large number of customers they hope to keep happy. Emageon was a pretty good system, as evidenced by the loyalty demonstrated by some of its users. There may be a few more elements that AMICAS could utilize before sending the Emageon GUI into the Ethernet for the last time. AMICAS Version 6, affectionately known as simply AMICAS PACS, is deployed, although it took quite a while to get from prototype to production. We hope to get ours sometime in early to mid 2010.

  2. GE continues to slog away with the reimagination of Centricity. To my knowledge, and someone please correct me if I'm wrong, Centricity IW, the GUI purchased with the Dynamic Imaging acquisition, has yet to be completely and successfully deployed. We'll cross our fingers for 2010.

  3. Agfa IMPAX is once again the bane of my existence. I'll give credit to Agfa for fixing some of it's problems, but many remain. I'm expecting an upgrade in early 2010. Frankly, if I were Agfa, I would concentrate all possible resources on IMPAX 7, and get it out the door. Assuming it actually works properly at that point, which is a major leap of faith for me right now.

  4. Cloud computing/storage becomes the rage, with offerings from LifeImage and even DR Systems, amonst many others. To me, this is truly the future of PACS. I'm going to get around to writing a full article about the cloud concept sometime in 2010. (That's about the only resolution I'm making this year.)

  5. Enterprise PACS, with universal worklists blanketing multiple sites and multiple systems, appear from several vendors, notably Intelerad, Carestream (with the boldly-named SuperPACS™), and eRad, amongst others.

  6. Thin-client advanced imaging packages proliferate, with varying degrees of integration to PACS. Visage takes a unique approach, touting the ability of their system to serve as an overlay, if you will, to a legacy PACS.

  7. Siemens revamps their IT offerings with the new syngo.x platform. Look for syngo.via advanced imaging, and syngo.plaza PACS in the near future.

The major medical story overall is, of course, the nearly-complete passage of the health-care bill by Congress. This abomination will certainly change health-care . . . for the worse. Yes, more people will be insured, at tremendous cost, with the eventual erosion of what once was the best system in the world. Please don't bother citing statistics that "prove" otherwise. Those "facts" are gerrymandered and twisted to make us look far worse than we really are. Infant mortality, for example, is "worse" in the U.S. because we count every single live birth in the denominator. Most other nations don't. Our cancer survival is significantly better than elsewhere. You are twice as likely to live through a myocardial infarction here than in many other countries.

Those celebrating the "historic" passage of the bill may be deluded into thinking they have done some good. Sadly, the real reason behind this legislation is power. The Democrats have just snatched 1/6 of the economy for themselves, and they won't let it go until death do them part. My trite little phrase, "If the government controls your health-care, it controls your LIFE," is quite apropos. Once the government steps in and manages, if not provides, health-care, the majority of the public will become dependent upon the ruling party, and will vote them back in again and again. Feel free to disagree, but you won't convince me otherwise.

Our Attorney General, along with those of several other states, is investigating the legality and constitutionality of the gift given to Nebraska as a bribe to Senator Ben Nelson, and they are also looking into the propriety of forcing everyone in the country to buy insurance. We can only hope that the laws of this nation will be visited upon our out-of-control Democratic Congress with the same level of vengeance they have shown to us. And make no mistake, 2010 will be the year of revenge of the average U.S. citizen upon the power-mad Democrats who would have our nation emulate the socialism of their European idols.

Terrorism has reared its ugly shorts in the form of the Crotch-Bomber. We knew we were in line for more terrorist attacks, and I'm really surprised we haven't seen one until now. The Administration is deeply involved in the finger-pointing as to who didn't do what to prevent this near-tragedy. Sadly, until the Democrats acknowledge the fact that we are at war with the terrorists, we are in danger. It was with some trepidation that I put my kids on planes this week to visit friends. We aren't safe, and I don't trust our government to make much progress in this regard.

Climate-Gate should have altered the global climate warming change debate, but that was not quite the case. Emails, ummmm, liberated (supposedly by a hacker, but possibly by someone on the inside) from the Climate Research Unit at the University of East Anglia in England show that the data has been manipulated, altered, corrupted, and otherwise trashed to come to the anthropomorphic conclusion desired by these left-leaning "scientists". But the fact that there is now no "fact" in existence concerning mankind's responsibility for global warming (which isn't really even happening) doesn't bother those who are convinced of our guilt. Talking with these folks is a very surreal experience. "The data was faked," I say. "But we're killing the planet and we need to all change our ways!" the accolytes cry. "But there's no proof of mankind's involvement," I reply. "But we're killing the planet and we need to all change our ways!" the accolytes cry. What can you do? The only truth in all of this is that yet again, this issue becomes the excuse for a power-grab, a path to more and more government control and domination. And no, I don't think the government is acting in anyone's best interest.

You'll be amused to know that I intend to buy a hybrid vehicle when the time comes to replace something in my family fleet. I'm anticipating gas going up to European levels ($8/gallon) before too much longer, and once that happens, prices on hybrids will also skyrocket. While I don't approve of gratuitous pollution, I'm not convinced that my SUV and I are personally responsible for the death of the polar bears (which isn't really happening, either).

I haven't even begun to touch the specter of a nuclear Iran, the quagmire in Afghanistan, and many other critical issues.

Much is bleak on this New Year's Eve, but there is much promise as well. We can either look forward to the future and hope for change (not the hope and change delivered by Washington so far, thanks) or we can wallow in despair and anger over what is being done against us by our enemies, not to mention to us, supposedly for our own good. Best, of course, to choose life, hope, and optimism. 2010 will bring good things for the country and the world. We hope.

Maybe 2010 will deliver a working version of Centricity IW, and a more functional IMPAX 6.5. I can dream, can't I?

I'll be back next year, much to the chagrin of some of you, and perhaps the amusement of one or two of you.

And with that, I wish you all a most happy and healthy holiday! Don't drink and drive, by the way. Let me know if you need a cab, and I'll call one for you. Happy New Year, everyone!

Monday, December 28, 2009

Bravo, AMICAS!

Now that the press-release has hit the wires, I can reveal the nature of the "Big News" from the last teaser post:

BOSTON, Dec. 28 /PRNewswire-FirstCall/ -- AMICAS, Inc. (Nasdaq: AMCS), a leader in image and information management solutions, today announced that on December 24, 2009, it entered into a definitive merger agreement to be acquired by an affiliate of Thoma Bravo, LLC, in a transaction valued at approximately $217 million. The AMICAS Board of Directors unanimously approved the agreement and resolved to recommend that the shareholders of AMICAS adopt the agreement.

Under the terms of the agreement, AMICAS shareholders will receive $5.35 in cash for each share of AMICAS common stock they hold, representing a premium of approximately 24 percent over AMICAS' average closing share price during the 30 trading days ending December 24, 2009, and a 38 percent premium over AMICAS' average closing share price during the 90 trading days ending December 24, 2009. . .

"We look forward to continuing our mission to provide the best solutions for image and information management in healthcare," said Dr. Kahane. "We believe that working with Thoma Bravo will enable us to focus our resources on our business and our customers. With the additional capital and operational expertise available to AMICAS through Thoma Bravo, we will be able to grow as the needs of our customers evolve and will be enabled to better serve our market."

"Thoma Bravo is excited to partner with the AMICAS management team to continue growing the company into the leading provider of image IT solutions for the healthcare industry," said Orlando Bravo, a managing partner at Thoma Bravo.

"Thoma Bravo will further strengthen the industry leadership position of AMICAS through organic growth initiatives, acquisitions, and implementation of operational best practices," added Seth Boro, a principal at Thoma Bravo. "We look forward to helping AMICAS better serve the evolving needs of its healthcare industry customers."

This bodes well for AMICAS, while delivering a late Christmas present to their shareholders (which I am not). Based on my perusing of investment chat rooms and bulletin boards over the years, the market has absolutely no idea what PACS is or does, or which companies to trust. Being freed from the demands of shareholders should be very good for AMICAS. I guess time will tell.

When I heard the details of the merger/acquisition, I breathed a sigh of relief. The call to me and several other long-term AMICAS customers came on a Sunday evening during a holiday weekend. I had the sinking suspicion that AMICAS had been bought, and in my limited view, the only likely suitor left was Cerner. That would have spelled doom for AMICAS. Fortunately, I was wrong about that part. I just wish I had purchased some stock over the years, especially when it was below $2.00. But then, I would have lost credibility with the crowd that thinks I'm an AMICAS spokesman, which I'm not. And besides, I'm always skittish about putting my money where my mouth is. . .


My friend Mike Cannavo, the One and Only PACSMan, let me know about a couple of lawsuits pending on this merger/acquisition. A quick Google shows several somewhat predatory-smelling listings. Here is one example:

(Lawyers-R-Us) has commenced an investigation into possible breaches of fiduciary duty and other violations of state law by members of the Board of Directors of AMICAS, Inc. ("AMICAS") (NASDAQ: AMCS) in connection with their actions in causing AMICAS to enter into a definitive merger agreement with an affiliate of Thoma Bravo, LLC ("Thoma Bravo"). Under the terms of the agreement, AMICAS shareholders will receive $5.35 in cash for each share of AMICAS common stock they hold. AMICAS expects the transaction to close in the first quarter of 2010.

(Lawyers-R-Us') investigation concerns whether AMICAS' Board of Directors' acceptance and recommendation of the offer was fair and designed to secure the best possible price for all AMICAS shareholders.

If you are a shareholder of AMICAS and would like more information about your rights as a shareholder, please contact attorney (Mr. Lawyer) at 800-BITEME or by e-mail at

Lawyers-R-Us is a law firm with significant experience representing investors in merger-related shareholder class actions, shareholder derivative actions, and securities fraud class actions. For more information about the firm, please go to

Many of these gentlemen are stating that AMICAS should be selling for $6/share, even though the stock price hasn't been quite to that level in quite a long time. And people wonder why we don't have any respect for lawyers. . .

As an aside, I've been posting about AMICAS for years without properly using all-caps. I shall endeavor to do it right from now on. Sorry about that, guys.

Sunday, December 27, 2009

Big News

I'm sworn to secrecy, but there is big news coming tomorrow morning about a major PACS vendor. Watch the wires. You heard it here first!

Friday, December 25, 2009

Christmas Musings

Being Jewish, I don't do Christmas lights, but if I did, the display would look (and sound) something like this:

More information on this holiday extravaganza can be found at this link.

I'm on call for the day, working from 8AM through 11PM. Business is slow but steady, with a number of chest radiographs ordered for cough, various extremity studies for "pain", and a dozen or so exams for the aftermath of a fall. Overall, I think falls bring us more business than car wrecks, although the latter usually prompts a full-body CT. Of course, today's carnage includes head CT's on two 95-year-old's. Both showed atrophy. Imagine that.

I continue to be amazed at the minimal symptoms that bring someone into the ER, especially on a holiday like Christmas. Americans have been trained to seek care for the slightest twinge. We'll see how we like it when the lines are longer and the pampering is eliminated. That's where we're headed.

One of my friends was working the ER this morning, and we had a nice chat about IT's control over our lives. My friend is a very reasonable and easy-going guy, who orders far fewer CYA-type scans than some docs I know. This morning, however, he was not in a good mood. It seems his password quit working, and he couldn't get into the PACS system. Several calls to our "Help(less) Desk" yielded the message, "We are experienceing technical difficulties. Please leave a message." This did not go over well. I had to let him access the system with my login (don't even think of punishing me or him for that) while waiting for someone from the PACS team to get him back on. In the course of this snafu, he made a rather ominous statement, something we all need to think about. I'll paraphrase it and remove the expletives.

"IT needs to help us," he said. "Standing in the way of me getting to see the data and images on my patient will lead to someone getting hurt. And if that happens, I'm not going to take the rap for it."

I have to try to see both sides of this, but in the end, we have to err on the side of patient care. I understand that all the rules and regulations, and HIPAA and so on are there to protect the patient's privacy and that is critical. However, in an emergency situation, there has to be some compromise, some mechanism to go above and beyond the rules, for the good of the patient. If IT takes its rightful place as master of the computer/network end of PACS, then it has to be there with us to solve problems like this, even at 8AM on Christmas morning.

And now, if you will excuse me, I have to go look at the next dozen images of a 95-year-old who fell down while coughing. And as noted above, I am Jewish, not Christian, but I have great respect for the faith of my friends. After all, Jesus was just a nice Jewish boy who went into His Father's business. To Christians, the greeting of "Merry Christmas" conveys their joy and happiness of the birth of Jesus. It is a greeting borne of caring and not of malice. So, while it isn't politically correct, and I don't celebrate the holiday per se, I still want to wish everyone a very Merry Christmas and a Happy New Year!

Addendum: I just stumbled across this clip from the old TV series Northern Exposure. I hope you enjoy it as much as I did. (Many said at the time the show was running that I bore a strong resemblance to Rob Morrow, who played Fleischman. Of course that was one beard, and many pounds and gray hairs ago...)

Sunday, December 20, 2009

Dell, Windows 7, and Faulty Drivers

My wife LOVES Facebook, and she is, in particular, addicted to FarmVille, the game that glorifies shoveling manure and milking recalcitrant cows. To be fair, I play it too, but mainly because I can't let her beat me at a computer game! (And it's kind of relaxing in a mindless fashion.)

As CIO of the Dalai household, I get to decide who gets what computer. My wife's old Dell Dimension was starting to get a little long in the tooth, so off to the Dell Outlet site I went, and found a lovely Dell Studio Slim, with 6 (SIX!!!) G of RAM, a 600 Gig hard drive, and a 2.9 MHz Intel Core Duo processor. Not bad for the price I paid.

This morning was grand opening time for the new baby. I untangled all the wires and cables from the old installation, teased the old CPU out of the mess, rather like removing a dying heart in preparation for a transplant, and then gingerly plugged in the new, sleek Studio. Everything powered up nicely, and I walked through the preliminary set-up without difficulty. BUT. . . then came the attempt to connect to the internet. Epic Fail! To make a long story short, the RealTek (straight from Taiwan) network card wouldn't admit that it was connected at all, but it did claim to be otherwise functioning normally. I spent two hours on chat (on a different computer, obviously) with Dell, trying various possibilities, none of which seemed to budge anything. We tried uninstalling and reinstalling the NIC, and downloaded the latest software from the Dell site. Nada. (The RealTek site wouldn't even download the latest drivers, having links that just endless-looped back to the main download page.) I did discover an Ethernet service that wasn't on, and asked if that might do the trick. But at this point, the rep simply gave up. He said via chat,

I would have been glad to help you in this regard but I am sorry to inform you that we are not trained on Software issue because we are Hardware technicians. As I see that your system warranty only covers the Hard ware support, where in the current issue with your system is a Software issue and it is not covered under your system Hard ware. All the Software /Wireless /Virus /E-mail support /Data backup will be provided by the Dell DOC team and it is a Fee based support. They shall charge you a nominal fees only. (I would personally suggest you to go with DOC option). DOC will firstly determine the issue and than provide you the Fee details. If you feel the Fee as economical you can provide payment details and proceed with the resolution (or) you can decline it. Please let me know if you are interested, I can provide you the DOC Team phone number (or) Transfer chat to DOC support?
I was not impressed. This is a brand new, just out of the box (OK, it was refurbished, but they are supposed to be good as new, right?) machine, and I was not about to pay MORE for warranty support. Either it works today, or back in the box and back to Dell. My agent backpedalled a bit, especially after I mentioned that I was personally responsible for the purchase of hundreds of thousands of dollars worth of Dell equipment. After a pause, he suggested that I reinstall Windows 7, as that "might help".

Having nothing to lose but the added Dell trash-ware, I went ahead with the reinstall. And lo and behold, it worked! Green light on the Ethernet port, all systems go for internet and LAN connectivity!

Now, here's the interesting thing. I let Windows Update do its thing and install a newer driver for the RealTek NIC, and BAM...back to non-functionality. I rolled back the driver, and there we are, back online. At this point, I don't know if the driver is bad, the NIC is bad, Windows 7 is bad, or I've been bad and I'm being punished by the gods of Microsoft.

What lesson is there to be learned from all this? Perhaps most important is the power of the consumer. I was not about to pay extra for service on a brand new machine, and I made sure this was known. Maybe that made the difference and prompted the one suggestion that actually worked (mostly) or maybe that was just sheer dumb luck. But I was not about to keep a computer that didn't work, nor was I going to pay another $50 to make it work (and I'll bet the Dell DOC team wouldn't have found the problem anyway.) We should not accept expensive hardware and software that doesn't work, and doesn't do the job it was purchased to do.

What applies to a $500 refurbished computer applies to a $13 Million PACS system. Or at least it should. But somehow, the more we pay, the less likely we are to demand excellence. We don't want to admit that we made a mistake, and we swallow errors that we wouldn't tolerate in something we bought from Dell for $500. Or from Mercedes for $100,000. Does anyone see something ironic here?

For what it's worth, the Studio continues to run well, even after I turned it over to my wife. Her FarmVille farm has never looked better.

Tuesday, December 15, 2009

On The Twelfth Day Of PACS-mas, My Vendor Gave To Me...

A friend of mine is part of a large group in a large city, and they are none too happy with their Fuji Synapse PACS. As his (unaltered by Doctor Dalai) wish-list below nicely outlines, there are a number of features that are not found on their Fuji system (but are available from Amicas!) Without further ado...

1. I should be able to make custom window level settings so when I hit "7" I get MY bone settings.

2. I should be able to customize my right-click generated side bar. When I right click, there are probably 25 options and I only ever use 3 of them.

3. When I reserve a case from the list I should be able to see I've done so.

4. I should be able to pre-select cases on a list I do NOT want displayed if I start F8-ing through a list.

5. Synapse is very unstable. I've never worked with another program that spontaneously crashes at a rate near Synapse. It is unacceptable.

6. In the notes window there should be a single click button to add the word "dictated" without typing that also removes the case from the list and displays my next case.

7. We need a PACS that can support cine for ultrasound, especially vascular.

8. We need a PACS that has full Nucs and PET/CT capability to read on the fly as one reads all other cases.

9. I expect a customized worklist that populates every case I am responsible for covering and none that I am not, so I can access ALL of my cases from a single worklist (as Amicas does). I want a separate worklist also visible that shows any other cases I could read when my list is clean (as Amicas does).

10. I expect a smart worklist that allows me to move from one case to the next without ever returning to the list to look. A smart list needs to manage the order cases appear based on acuity and chronology (as Amicas does).

11. I want to perform MIP and 3D reformats on the fly, when needed, without having to request the study is sent to Terarecon. I expect to be able to SAVE those images (which Fuji can not do with its limited MPR function--Amicas can).

12. I expect images to pre-cache to my PC without me moving a finger. I want every case on my list to have every image loaded before I open it (as Amicas does).

13. I expect a single button click to send my case to OPS with notification to call ordering physician and transfer them to me (as Amicas does). I should never have to open multiple folders and drag a case.

14. I expect a separate single button click to send case to OPS for OPS to call the report (as Amicas does).

15. I expect a single click on my worklist to display all cases I've read that day so I can quickly go back to a case for a clinician (as Amicas does).

16. I want a completely customized hanging protocol that puts every series of my exam and the comparison exactly where I want them every time (as Amicas does).

17. I want to send a email or text link to the ordering doctor that takes them straight to my report and includes annotated images (as Amicas does).

18. When I open a report from Synapse in a new window, I should not have to resize that window EVERY time. It should remember the size I made it last time.

19. I want a way to see a case is cached on my PC before I open it (as Amicas does).

20. I should not have to tolerate sending suggestions like this for 2 years without any being addressed or getting concrete responses from my PACS vendor (as Fuji has).

21. I expect a PACS that mines all databases we access for relevant priors without the extra fee Fuji charges, I want it free like it is with Amicas.

22. I expect to be able to open extra comparison exams in new side windows so I don't have to give up my primary reading space on my layout for another old series (as Amicas does).

23. I want a side annotation that is visible but not distracting to indicate what studies are comparisons so I never have mis-arranged series and read the wrong date's exam as current (which I've done with Synapse). As you've guessed, Amicas has this feature.

24. A PACS system updating a list or exam in the back-ground should not disable our ability to continue scrolling through the exam we are reading, as it true for Synapse.

The interface with our exams is a critical component of our practice. We need to demand excellence. It is currently available.

Just not from Fuji, eh?

My friend went on to speculate that even beyond the above list, what we really need is " a bowling alley order button analog- push the button and help comes." This is probably one of the best ideas I have ever heard. Think about it... a help button that actually helps, either accessing the proper page of the manual based on the state of the PACS GUI at the moment, or alternatively patching one through to the vendor's (or hospital's) help desk, letting them see the problem at hand. This would be simple to implement, but incredibly powerful, much more user-friendly and downright useful than anything out there right now.

Once again, all the vendors have to do to make their customers happy is to listen to them! Simple? Apparently not for some of the larger companies.

On the First Day of PACS-mas, my vendor gave to me. . . a PACS that will work as guaranteed.

Thursday, December 10, 2009

The Dalai Can. . .

My Nuclear Medicine Techs have taken a page from my book of perverted songs, and wrote one about . . . me! Here it is with some minor changes to protect the innocent, and apologies to Willie Wonka, and Sammy Davis, Jr.:

Who can take an OctreoScan?
Actually read it, too?
Put in an impression
And add a suggestion or two. . .

The Dalai Man
Doctor Dalai Man can
Doctor Dalai Man can, cause he mixes it with knowledge and makes
The report sound good.

Who aggrevates scan patients,
With a multi-day delay?
Doesn't even matter if it's on a Saturday. . .

The Dalai Man. . .
Doctor Dalai Man can
Doctor Dalai Man can, cause he mixes it with knowledge and makes
The report sound good.

The Dalai Man makes
All that he dictates
Informative and insightful. . .
Talk about Technologist wishes,
He can even make knishes!

Who can run the Leo(nardo)
Better than the rest?
Set up a dummy button
That the other guys can press. . .

The Dalai Man
Doctor Dalai Man can
Doctor Dalai Man can, cause he mixes it with knowledge and makes
The report sound good.
And the report sounds good cause Doctor Dalai Man thinks it should....

Sunday, December 06, 2009

Up Against The Wall, iPhone Charger!

From the Department of Stuff You Need, But Just Didn't Know It, well actually, from FastMac, comes something really brilliant: the TruePower UCS Power Outlet With Built-in USB Ports! How many times have you needed to plug in your iPhone, iPod, or other USB-power-gobbling device, only to find the charger misplaced? For $10, you only have to worry about the cord being misplaced, as you can place USB power outlets throughout your home or business.

And, not that I'm all that green (except around the gills after a weekend of call), but this outlet does something most USB brick-chargers don't:
Please also note that the USB ports only draw power when something is physically connected to the port. We didn't want a vampire port that continually sucks and wastes power when not in use so this was one of the features on the top of our priority list during the design phase.
The outlet should ship in early 2010 after it receives final UL approval. You can preorder if you want to be the first on the block to get rid of your bricks. Hat tip to Engadget for this little gem.

Friday, December 04, 2009

FTC's New Blog Controls

As indicated by the badge to the left, I am a member of Wellsphere's Blogging community. This morning, I received a note from Wellsphere, which I assume went out to all their bloggers, concerning some new guidelines put out by the FTC:

“We are writing to let you know about revised Guidelines issued by the Federal Trade Commission (FTC) on October 5, 2009 relating to endorsement and testimonial advertising. These new Guidelines go into effect on December 1, and reflect the FTC’s interpretation with respect to federal law relating to advertising. These new Guidelines specifically apply to bloggers and could impose liability on bloggers for endorsements or testimonials.

The revised Guidelines state that:

· The Guidelines apply to Bloggers and online word-of-mouth marketers and require them to disclose any material connection to a company when reviewing the company’s products or services (failure to disclose any payment or receipt of free product from an advertiser or someone acting on their behalf could expose you to liability);

· Both advertisers and endorsers can be liable for false or unsubstantiated claims made in an endorsement (if you were given a product for free or were paid to write a review, then the claims you make about the product must be accurate and substantiated);

· Advertisements containing consumer endorsements, or testimonials, must disclose what results a reasonable consumer could expect from the product and can no longer rely on a disclaimer that “results may vary”;

The full text of the new guidelines can be found here, and some further explanation from the FTC is found here. The salient points are:
The revised Guides also add new examples to illustrate the long standing principle that “material connections” (sometimes payments or free products) between advertisers and endorsers – connections that consumers would not expect – must be disclosed. These examples address what constitutes an endorsement when the message is conveyed by bloggers or other “word-of-mouth” marketers. The revised Guides specify that while decisions will be reached on a case-by-case basis, the post of a blogger who receives cash or in-kind payment to review a product is considered an endorsement. Thus, bloggers who make an endorsement must disclose the material connections they share with the seller of the product or service. Likewise, if a company refers in an advertisement to the findings of a research organization that conducted research sponsored by the company, the advertisement must disclose the connection between the advertiser and the research organization. And a paid endorsement – like any other advertisement – is deceptive if it makes false or misleading claims.
I have mixed feelings about this, like most things in life these days. I do believe the public needs to be protected from false advertising, which seems to be the main thrust of this program. However, this becomes rather intrusive on the individual, the blogger in this case, and in theory at least might infringe upon one's First Amendment rights. For example, I might want to say something like, "I love the New Nabisco PACS!" (I could have said I like the Nabisco product the late George Carlin mentioned with those Seven Words, but this is a family blog...) Here I am, with a disclaimer in my profile telling you that what I publish is my opinion, and nothing more. Well, that isn't good enough. Americans apparently aren't considered savvy enough to question the sources of their information, and must have legal protection against a rogue blogger like myself who might have received a shipment of Nabisco cookies to give a positive review of their PACS (which of course doesn't exist). What if Nabisco had rewarded me with cookies after I blogged about their fictional product? What if I'm lying about it completely? Doesn't the reader of a blog have some small duty to ask these questions? Do I have the First Amendment right to post anything I please, even if it's false?

It would be nice if the FTC (and the FCC) would have a look into the motivations of the mainstream media outlets, all of them, even Fox, in the same spirit of protecting the public from misinformation, but I suppose that's asking too much. I guess they have to start small, with measly little blogs. On second thought, the news outlets are supposed to be doing that to the government, not the other way around. And only Fox comes close to even trying.

To comply with the ruling, I now have to come clean. I am currently paid nothing by Amicas, or any other vendor. I have been flown to Boston and to Tucson for meetings of the (unpaid) Amicas medical advisory board. I recently traveled to Australia at the expense of healthinc, a redistributor of Amicas down there, and received a boomerang as an honorarium for giving a talk to some of their customers. It was a very nice boomerang, by the way. Visits to Koala Park and boat rides around Sydney harbor were paid for by me and not healthinc.

I have been taken to Israel and Germany several years ago by Elscint, just as they were being purchased by GE. I've had a few other equipment junkets, but no cash changed hands.

The only payment I have accepted was an honorarium from Daxor for giving a speech at a regional meeting discussing their BVA-100 blood volume system, which I had been using for several years before being approached to give the talk. Frankly, I didn't do a great job on the talk, as I tried to cram a huge amount of information into a small amount of time, and Daxor hasn't asked me to speak since!

The material I publish, aside from quotes, of course, is mine alone. It is my opinion, and it is not paid for. I do have my price, but probably only GE could afford me.

And that's the way it is. Have fun with that, FTC.

Tuesday, December 01, 2009


Close on the heels of syngo.via (did you get my subtle references in the syngo.x post as to the name of the new 3d product) comes syngo.plaza:

Welcome to syngo.plaza, the new agile PACS solution for the clinical routine from Siemens Healthcare. As the first Picture Archiving and Communications System (PACS) from Siemens where 2D, 3D, and 4D reading come together in one place, syngo.plaza is poised to change the way multimodality images are read today. Siemens is unveiling this innovation at the 95th Scientific Assembly and Annual Meeting of the Radiological Society of North America (RSNA) from November 29 to December 3 at McCormick Place (Booth #825, East Building/Lakeside Center, Hall D) in Chicago.

“Customer-focused innovation runs in our veins here at Siemens, and syngo.plaza is a true example of that,” said Arthur Kaindl, CEO, Image and Knowledge Management, Siemens Healthcare. “For the first time, we are now offering fast and accurate multimodality reading on one single workplace, with one intuitive user interface. And we are helping to protect our customers´ investment, as already existing hardware components can be leveraged.”

Prepared Reading

Once an image is obtained, syngo.plaza automatically identifies the type based on the scanner that was used and then, in line with the case complexity, calls up the corresponding 2D, 3D, or 4D applications. Through no-click integration to syngo.via, Siemens new imaging software, users can access the appropriate syngo.via applications directly through syngo.plaza. Combined with a unified user-interface, this allows for a smooth transition between different applications and helps speed up the reading workflow.

With its wide application range, syngo.plaza even helps users master complex multi-modality cases through access to syngo.via and syngo Multimodality Workplace applications. And, with its Patient Jacket functionality, syngo.plaza makes it easy to view patient history at a glance – including prior exams, reports, and Digital Imaging and Communications in Medicine (DICOM) presentation states.

Personalized Workplace

In addition to its one-of-a-kind prepared reading capabilities, syngo.plaza also offers two viewing modes for users. The first is a pre-configured intuitive interface. The second is a customizable option that allows users to define and use the layouts they prefer. This role-based view helps streamline the reading workflow and helps eliminate time wasted adjusting to strictly one-size-fits-all PACS technologies. In addition, the time-saving SmartSelect tool enables users to access their most frequently used functions directly in the diagnostic screen without taking their eyes off the images. Plus, syngo.plaza’s innovative system architecture allows clinicians to access the software within their facility or remotely4.

Secured Investment

Finally, syngo.plaza helps to protect customers' investment by offering users the ability to leverage their existing hardware components, functionality, and storage configurations. The system supports the IT components that fit users’ needs and that offer an optimized price-performance ratio. In addition, users can easily adapt to changes in their own environment, enabling their PACS to grow in-line with their needs and budget – and with continuous technical innovations that keep them a step ahead. Furthermore, scalable storage allows syngo.plaza to adjust its shape to users’ requirements – offering multiple solutions ranging from dedicated to shared storage, from single to multiple archives, and from a single workplace to an enterprise PACS, all without compromising performance.

Sounds pretty good, although it still seems to act quite a bit like Amicas 6/Amicas PACS. My friend, Mike Cannavo, the One and Only PACSMan, has seen .plaza in person. He was about to accuse Siemens of rehashing the same old same old, but after viewing the new stuff in Chicago, he came away impressed. Siemens actually, finally, appears to have a working PACS and a good one at that. I'm intrigued by the "leveraging existing hardware" comment: does this mean that syngo.plaza can be used as an overlay to an existing PACS, such as Visage proposes with their PACS/advanced visualization product?

Let's see. . . We have syngo.via, and syngo.plaza. What's next? I know! How about syngo.worksproperlyanddoeswhatitpromises? That would be something quite new amongst the large PACS vendors. . .

Wednesday, November 25, 2009

Ziosoft Comments

Ziosoft has chimed in on the great FDA approval debate:

Hi Dr. Dalai,

In response to your posting on November 12, 2009, in order to be “FDA-cleared” for PRIMARY 2D diagnostic review in the US, I believe FDA mandates certain image display specifications such as loss-less image quality, minimum monitor resolution and DICOM monitor calibration. In this case, most PACS companies are in compliance if they position their systems as a PRIMARY 2D viewer whether it be local or remote.

However, if you are referring to FDA clearance for 3D diagnostic review systems, a 3D company only needs to show substantial “intended-use” equivalence of their system (and associated applications) to an existing predicate regardless if the system is used locally or remotely. Our Ziostation system has been FDA-cleared since 2007. FDA does not place any stipulations on display specifications since 3D is considered a SECONDARY diagnosis review application. In other words, dedicated 3D companies can use non-DICOM calibrated monitors, at any resolution. This is why any standard monitor can be used for 3D.

In Japan, our Ziostation system is used for both 3D and as a 2D viewer for primary diagnosis. Therefore, even though the Ziostation is positioned as primarily a 3D system in the US market, our system was architected to provide full loss-less image fidelity, using a true unified thin-client system. The functionality and image integrity are equivalent whether used locally or remotely.

I hope this provides some insight into this topic.

By the way, our zioTerm free 2D/3D application has been officially released (see attached press release). If you feel this would be of value to your readers, feel free to mention it in your blog.


Terry, Director of Marketing, Ziosoft, Inc.
Comments, GE? Comments, Tera?

Thursday, November 19, 2009

Wednesday, November 18, 2009

Siemens' Viable Alternative

Break out the caviar! Brought to you via, with only a minimal degree of joviality, here's a little preview of Siemens' enviable new offering at RSNA, based on the new syngo.x platform:

It's WAY too early to have a real name for this, but you don't need to drive over a viaduct to get here. It might even be visible on your VIAO. Hopefully, you won't need any Viagra to enjoy the experience.

I've had a brief close-up preview myself, as the second test installation (it's not yet on our production side) of the new system was just completed at our Agfa hospital. The integration with IMPAX seems to work well, which was no trivial feat of conviviality. What we have is a server providing a thin-client 3D application, launched from the IMPAX viewer. Right now, we have the basic tools, with VR, MPR, etc. However, I was shown previews of the more advanced functions that hint at a level of automation that could make this product the leviathan to beat in this space. The Siemens RSNA Preview page suggests an enterprise-wide syngo.x global, uniform application the size of Bolivia. In particular, this new standard is set to give us the next generation of Siemens PACS:

Can I have my images automatically opened in 2D, 3D and 4D?

The new PACS solution* combines 2D, 3D, and 4D reading – enabling fast reading in any dimension – together in one place. The system features case-specific reading, automatically knowing when to call up specific applications. It remembers users’ preferences, sorts images accordingly, and allows users to adapt reading tools and layouts to their needs. Due to its flexibility and minimal hardware requirements, existing hardware can be leveraged and storage capacity can be easily added.

* The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available.

Sounds a little like Amicas 6.0.

Anyway, there's more to come! Hopefully, I won't be accused of bloviating.

Tuesday, November 17, 2009

Visage Responds

I raised the question prompted by GE's claim about the approval or lack thereof first with some of the principals of Visage and Promedicus whilst at RANZCR. It was their opinion that their product was indeed kosher, if I might use that term. Malte W., the CTO of Visage, sent this response to my recent post:
Dear Dr. Dalai:

On behalf of Visage Imaging I would like to respond to the points you have raised in your posting of November 12, 2009.

The Visage PACS/CS system is cleared by the FDA for the purpose of diagnostic viewing. The ‘Intended Use’ as shown on the FDA web site includes reviewing of medical images, both locally as well as remotely and in distributed environments.

As your blog so effectively demonstrates we now live in a world where nothing is remote and "remote review" should not be a compromised special case. Therefore the Visage product line expands beyond traditional system boundaries by providing a single platform that combines traditional PACS functionality and advanced visualization in a truly integrated fashion. Visage allows for full fidelity diagnostic reading, both locally as well as over the network. It offers basic to advanced image access and image manipulation to your referrers, all on the same platform.

Visage Imaging's R&D team has continuously improved the technology to optimally exploit slow networks for diagnostic image viewing at the highest possible image fidelity. In the end, the outcome is what really matters for the actual user. That is, how fast is the system in all the relevant network scenarios, how easy is it to use, does it have all the required features? For primary interpretation image quality must be uncompromised. In other situations it may be desirable not to wait for a full fidelity image if a compressed image is availably more quickly. Visage supports both.

In the end users should judge by themselves which of the "smart" technologies meets their requirements best. Visage Imaging is looking forward to continuing the discussion at RSNA and invites everyone who is interested to take a look at the Visage solution. Please come to the Visage Imaging booth #8320 (Hall B) and judge for yourself what levels of versatility, quality, and performance the Visage platform provides.

Yours truly,

Malte W.,
Chief Technology Officer, Visage Imaging

I have yet to hear from the rest of the vendors in question. Thanks for your response, Malte. Sadly, I won't make it to RSNA, but I hope to learn more about Visage 7 soon!

Friday, November 13, 2009


Whilst trolling for information about who is approved for what and who isn't, I stumbled across something quite interesting. It seems that Siemens is about to revamp its backbone software with a new version called "syngo.x". From the FDA 510(k) summary:

syngo.x is a software solution intended to be used for viewing, manipulation, communication, and storage of medical images. It can be used as a stand-alone device or together with a variety of cleared and unmodified syngo.x based software options. syngo.x supports interpretation and evaluation of examinations within healthcare institutions, for example, in Radiology, Nuclear Medicine and Cardiology environments. The system is not intended for the displaying of digital mammography images for diagnosis in the U.S.

syngo.x is based on Windows. Due to special customer requirements and the clinical focus syngo.x can be configured in the same way as the syngo MultiModality Workplace with different combinations of syngo.x- or Windows -based software options and clinical applications which are intended to assist the physician in diagnosis and/or treatment planning. This includes commercially available post-processing software packages.

svngo.x Data Management
... ensures all authorized personnel fast and continuous access to radiological data. It's main functionality ranges from availability of images with regard to
data security, open interfaces, storage media and central system administration, to provide a flexible storage hierarchy.

The Workflow Management enables by integration of any HL7- / DICOMcompatible RIS (IHE Year 5) to the syngo product family a consistent workflow - from patient registration to requirement scheduling to a personal work list and supports therefore reporting, documentation or administrative tasks.

Technological Characteristics:
syngo.x is a "software. only" system, which will be delivered on CD-ROM /DVD to be installed on common IT hardware. This hardware has to fulfil the defined requirements. The Software will be installed by Siemens service engineers only.

The backend communication and storage solution is based on Windows 2008 operating system. The client machines are based on Windows XP. Any hardware platform, which complies to the specified minimum hardware and software requirements and with successful installation verification and validation activities can be supported. The herewith described syngo.x supports DICOM formatted images and

Sounds like a new edition of syngo is headed our way. We'll see it at RSNA, I assume....

Thursday, November 12, 2009

"The Only FDA Approved Remote Review System"

You might recall the "shootout" between Visage and TeraRecon we held here a few months ago. GE could not attend due to timing conflicts, but later held a separate demonstration of their AW Server system at our site. In brief, this is a thin-client version of the venerable AW software, which allows remote access to high-level processing capabilities. The system works well, especially for those who like the GE/AW approach to such things. It has a lot of power, but doesn't quite have the level of automation that was demonstrated by TeraRecon.

Our GE rep, of whom I'm far more of a fan than of the company itself, sent us these bullet points about the AW Server:

Designed with you…

  • Enhanced work flow tools for ultimate reading and collaboration
  • Easily track workflow status with custom work lists and filters
  • Switch between exams instantly to minimize interruptions
  • Easy access to all prior exams in the work list for quick comparisons

Beyond the walls…..

Diagnostic reads with Exclusive “Smart Compression” technology….Accessibility anywhere, anytime

  • Removes constraints on needing physical access to a workstation…Convert any PC to a high end, post processing workstation
  • Total thin Client solution
  • Only FDA approved Remote Review System
  • Unique “Smart Compression” Technology
  • One click to apply compression only during interaction
  • Compression “smartly” turns off when the mouse is released
  • Automatically display full fidelity static, high quality images for diagnosis!
  • Works over any network condition…from any location

Secure the future…

Seamless integration with the security and service features facilities need…Maximize investment

Of these claims, clearly the statement "Only FDA approved Remote Review System" catches the eye. I did a double-take on this, both when I read the e-mail, and when it was stated in the demonstration. This seems to be a rather bold statement on the surface, and I thought I should probably pursue it further. So, whilst at RANZCR, I asked the president of Promedicus, the company that owns Visage, if he was aware of this. He thought the statement was incorrect, and assumed that Visage, TeraRecon, and other similar products were all approved in the U.S. Curiouser and curiouser.

There was nothing left to do but ask GE directly, which I did via email. The answer came with an attached market clearance document from the FDA, although not quite the one that is found on the FDA website. The publicly available document is found HERE, and differs from the document GE sent me in its opening pages. The FDA's version has some different cover-sheets which we will discuss in a minute. The salient point from GE is found on the last page:

The device is not intended for diagnosis of mammography images. The device is not intended for diagnosis of lossy compressed images. For other images, trained physicians may use the images as a basis for diagnosis upon ensuring that monitor quality, ambient light conditions and image compression ratios are consistent with clinical application.

Italics are mine. The interpretation of this line is that one should only be diagnosing from full-fidelity images, and not lossy-compressed images. (Lossless compressed images are a no man's land, I guess.) GE's approach is something called "Smart Compression" as seen in their AW Server brochure below on page 4. (Sorry about the Scribd embedding, but I could not find the same brochure online.)

The important line reads:

Exclusive “Smart Compression” technology dynamically speeds you through the case – even at low bandwidths – so you can quickly view full fidelity, static images for instant diagnoses.
All this was reviewed in a conference call with several high-level folks in the AW division of GE Medical. This is the technology upon which they base the claim.

The approach is somewhat reminiscent of streaming technology as seen in Stentor and Dynamic Imaging PACS wherein the compressed images are around when you interact with the study, scroll, move around, whatever, but the full-fidelity image is displayed when you let up on the mouse. I assume GE's software decompresses lossless-compressed images on-the-fly to satisfy the claim of presenting full-fidelity images. How this applies to a 3D volume rendering or a MIP series or whatever, I haven't a clue.

The question now becomes, "What about the other guys?" What I'm going to do here is throw it open to any other vendor in this space that wants to respond with something I can post, and I will post it without editing or editorializing. I'm expecting responses from TeraRecon and Visage at the very least. Are you guys listening?

In the meantime, I did some additional digging over at the website. First, let's look at TeraRecon's 510(k) Premarket Notification, from December, 2005. Here are its indications for use:

The AquariusAPS server receives medical images from medical imaging acquisition devices adhering to the DICOM protocol for image transfer such as EBT, CT, MRI, and other volumetric or planar medical imaging modalities, and performs digital image processing to derive certain information or new images from these image sets. The information or new images thus derived is transmitted using the DICOM protocol to other devices supporting this standard protocol.

Lossy compressed mammographic images and digitized film screen images must not be reviewed for primary image interpretations. Mammographic images may only be interpreted using an FDA approved monitor that offers at least 5 MP resolution and meets other technical specifications reviewed and accepted by FDA." The intended use of the device is to provide time-saving pre-processing of images to remove the need for an image review system to perform these activities while a user is waiting for processing to complete, to optimize the use of the user's time.

The issue of using the thing for diagnosis really isn't addressed directly; one assumes that the FDA's permission to sell the device means we radiologists can actually use the device, I guess. And, they only discuss compression with respect to digital mammography.

When we look at the Visage 510(k) paperwork, things start to get a little murkier. Visage applied for approval for its PACS and CS (advanced visualization) software in one bundle.

Intended Use

Visage PACS/CS is a system for distributing, viewing, processing, and archiving medical images within and outside health care environments.

The Visage PACS/CS server receives image data in DICOM format via the hospital network. This provides universal connections to archives, modalities, and workstations.

Visage PACS/CS is to be used only by trained and instructed health care professionals. It can support physicians and/or their medical staff in providing their own diagnosis for medical cases. The final decision regarding diagnoses, however, resides with the doctors and/or their medical staff in their own area of responsibility.

Although the web and thin client technologies allow the software to be run on a variety of hardware platforms, for diagnostic purposes the user must make sure that the display hardware used for reading the images complies with state-of-the-art diagnostic requirements and currently valid laws.

Only DICOM for presentation images can be used on an FDA approved monitor for mammography for primary image diagnosis.

Only uncompressed or non-lossy compressed images must be used for primary image diagnosis in mammography.

It sounds to me like Visage has the same approval level. By the way, I've come to the realization that the indications here, as for the AW and TeraRecon, are written by the companies themselves, and approved by the FDA. That does help somewhat in the interpretation, doesn't it?

Which brings us back to the cover letter of the AW Server 510(k) application from the FDA. It includes the following:

AW Server is substantially equivalent to the devices listed below:

Model: Advantage Workstation 4.3
Manufacturer: General Electric Medical Systems
510 (k): K052995
Classification name: PACS per 21 CFR 892.2050
Regulatory Class: II
Product Code: LLZ

Model: AquariusNET Server
Manufacturer: TeraRecon, Inc.
510 (k): K012086
Classification name: PACS per 21 CFR 892.2050
System, Image Processing per CFR 892.2020
Regulatory Class: II
Product Code: 90-LLZ, 90-LMD

And that's what GE said about the AW Server! In this section of this letter, the Indications for Use are as follows:

AW Server is a medical software system that allows multiple users to remotely access AW applications from compatible computers on a network. The system allows networking, selection, processing and filming of multimodality DICOM images.

Both the client and server software are only for use with off the shelf hardware technology that meets defined minimum specifications.

The device is not intended for diagnosis of mammography images. The device is not intended for diagnosis of lossy compressed images. For other images, rained physicians ay use the images as a basis for diagnosis upon ensuring that monitor quality, ambient light conditions and image compression ratios are consistent with clinical application.

Remember, GE wrote these specs, and the government approved them. Reading this paragraph makes the question of what is allowed for diagnosis and what is not even less obvious.

I understand where GE is coming from with their claim, and I like the "Smart Compression" approach. Still, the claim to be the "only FDA approved remote review system" is very bold. If true, and if it stays true, I'll very strongly consider purchasing the AW Server, if and when I get the cash to do so.

Again, I invite the commentary of the other major players in this space. What say you?

Monday, November 09, 2009

PACS Loses One Of Its Own

I noted a significant spike in blog traffic this morning related to Sectra and sadly there was a tragic reason behind it. PACS has lost a true gentleman, Dr. John Goble, head of Sectra's North American operations. From the Sectra press release:
Shelton, CT – November 9, 2009 – Dr. John Goble, President of Sectra’s North American medical business was tragically killed in a helicopter accident in the vicinity of Adelanto Airport, CA, USA. Dr Goble, age 58, had led Sectra’s medical operations in the US since 1997.

”This is very sad news for all of us at Sectra. John Goble has been a strong and committed leader of our North American business for the past 12 years. John was a great person to work with, a close friend, as well as a very competent colleague, but most of all he was a loving husband, brother and son. Our thoughts and deepest sympathies go out to his family and friends in this moment”, says Dr Torbjörn Kronander, President of Sectra Medical Systems.

Sectra has appointed Tom Giordano, as acting President of Sectra North America. Tom Giordano, former Vice President, Marketing of Philips North America, has worked in executive positions at Philips Medical Systems since 1977. Since 2005 Tom Giordano has been a Sectra North America board member and management consultant and has a deep understanding of Sectra North America’s business and operations.

“In the midst of these very sad circumstances, we are grateful for having with us such an experienced leader and medical imaging professional as Tom Giordano. We will continue to serve our North American customers with the same commitment to excellence, under Tom’s leadership,” Torbjörn Kronander adds.
One of Dr. Goble's loves was flying a vintage helicopter, according to the LA Times:

A 1951 military helicopter that crashed and killed all three men aboard it Saturday was headed to an aircraft-and-classic car show honoring U.S. veterans at the Flabob Airport in Riverside, the event's director said.

The twin-rotor Piasecki PV-18 helicopter had been booked to appear as a non-flying display through Classic Rotors, a rare and vintage rotorcraft museum in Ramona, show director Jon Goldenbaum said Sunday.

The museum was closed Sunday night and a message left on it answering machine was not immediately returned.

Federal Aviation Administration officials said the vintage helicopter struck power lines shortly after taking off from Adelanto Airport about 8:30 a.m. Saturday.

I had met Dr. Goble only once, whilst visting the Sectra RSNA booth with Mike Cannavo. Dr. Goble impressed me as someone more of us in the business could emulate. Perhaps you recall how he handled Sectra being dumped as Philips' PACS product in favor of Stentor, as sent to AuntMinnie, and lifted for my blog:

Sectra has been in the US for nearly ten years, and we have a superb service and support team. In addition to Philips Medical Systems, we provide Level II support for our other partners, selected dealers and comprehensive support for our direct sales.

Our PACS products for the Orthopedics and Mammography markets are extremely well received by the US market. While Philips' acquisition of Stentor will undeniably impact our revenue in the short term, we intend to aggressively bid for service on our products and continue to protect the investment of customers who have purchased Sectra PACS... whether under the Philips label or directly from us.

Sectra will continue to innovate and bring industry leading products to market in the US. If you have questions about support for your system, extensions to your Sectra PACS or have a new opportunity, we'd be happy to talk with you.

John Goble, Ph.D., President, Sectra North America, Inc. Call us at 800.--------.

Many would have bemoaned the apparent betrayal, but Dr. Goble went on doing what he did best, taking care of his customers.

He will be missed.

Sunday, November 08, 2009


The U.S. House of Representatives bowed to pressure from Darth Pelosi and passed the monumental Affordable Health Care for America Act (H.R. 3932). Only one Republican defected, a freshman from Louisiana who somehow ended up representing a totally Democratic district. On the other side of the aisle, 39 Democrats, mostly the Blue Dog fiscal conservatives, voted against this lovely bill. The Democratic leadership quickly hailed the 220-215 razor-thin margin as a huge victory, delivering to Americans the health care reform most said they really didn't want. Of course, the Dems have taken the results of the 2008 election as a mandate to do pretty much whatever they pleased. But today's comments are significantly more annoying, with Miz Pelosi demonstrating near-post-coital-bliss over her secure place in history as the second coming of FDR.

This story ain't over, folks, as the Senate has yet to vote on their version, and that may prove even more amusing.

The misguided support of the AMA was cited by the Democrats as validation of their far-left position. Naturally they ignored the fact that less than 10% of American physicians belong to the AMA, and quite a few of the remaining fools (including me) bailed out of the AMA over this issue. Why can't we be as cohesive as the trial lawyers? Their members come out with a boost from the House health-care bill: any state that doesn't have damage caps already will be prohibited from getting them. Not only was tort reform not included in this gargantuan bill, it was actually repressed! Gee, thanks for looking into this thoroughly, AMA.

Even more amazing was the last-minute endorsement by the American Association of Retired Persons, AARP, of which I am soon to be a former member as well. You would think AARP would be up in arms about the pending Medicare reductions. But noooooooooo, they looked the other way. It seems that the AARP is just as nasty and greedy as Republicans are accused of being. From the Chicago Tribune, not exactly a Conservative rag:

A Washington Post front-page story on Oct. 27 questioned whether AARP has a conflict of interest in appearing to represent seniors while watching Congress cut Medicare.

"Democratic proposals to slash reimbursements for ... Medicare Advantage are widely expected to drive up demand for private Medigap policies like the ones offered by AARP, according to health-care experts, legislative aides and documents," the Post reported.

Medigap plans are a cash cow for AARP. And if people don't need them because they can enroll in Medicare Advantage plans, that's a revenue loss for AARP.

While the organization has some partnering arrangements with Medicare Advantage plans, they provide a fraction of the revenues to the organization that Medigap does.

Second, if Medicare's benefits are cut by $400 billion or more, seniors will have an ever greater need for Medigap coverage.

"There's an inherent conflict of interest," former AARP executive Marilyn Moon says of AARP's royalty arrangements. "They're ending up becoming very dependent on sources of income.

"Tens of thousands of seniors have resigned from AARP, many of them cutting up their membership cards to protest the organization's promotion of health reform.

The new chief executive officer of AARP, Barry Rand, who was a strong supporter of President Obama during last year's presidential campaign, says AARP is not protesting the Medicare cuts because reducing waste and fraud in Medicare will make the program stronger over the long term.

Medicare is in dire need of modernization to make it more efficient, but savings should go back in to making it more solvent. But instead of contributing any savings to the $38 trillion in long-term debt the program is facing, the bills before Congress would use Medicare funds to expand health insurance coverage to working Americans.

While expanding coverage also is a worthy goal, if AARP were representing its members well, it would argue that the money should come from other sources.It's no wonder seniors are upset.

Clearly, the interests of AARP and the 40 million seniors it purports to represent are not aligned in the health reform debate.

Gee, you mean there might be support of a bill that will ultimately hurt people because someone will make a sh*tload of money from it? I thought only slimy, greedy, nasty Republicans like Bush, Cheney, and Haliburton execs were capable of something like that. Imagine my surprise to find that an organization to which I belong behaved that way. My cut-up membership card will be in the mail to AARP tomorrow.

The title of this opus is "Cost Factors" and in the end, it is the most important part of the health-care debate that has NEVER been mentioned publicly.

The following information was brought to my attention on AuntMinnie by one of my more liberal friends who thought he was going to prove that insurance companies were going to finish the job of slashing physician incomes that the government had started. He quoted an article from Ezra Klein, one of the most liberal columnist/bloggers out there, who currently writes for the Washington Post. Mr. Klein interviewed Kaiser Permanente CEO George Halvorson, and in the course of the discussion, Mr. Halvorson handed Mr. Klein a stack of charts from the International Federation of Health Plans. These can be found here, and are repoduced below.

The message is pretty clear: health care charges in the US are sky-high relative to those cited from other nations. If that were the end of the story, it would indeed be the end of the story. But there is a lot more there than we realize at first blush.

We have to ask the childishly simply question, "WHY?" WHY are the costs so much higher here than elsewhere? Mr. Klein tries to ask the question, but then answers it with circular logic: it costs so much because it costs so much.

There is a simple explanation for why American health care costs so much more than health care in any other country: because we pay so much more for each unit of care. As Halvorson explained, and academics and consultancies have repeatedly confirmed, if you leave everything else the same -- the volume of procedures, the days we spend in the hospital, the number of surgeries we need -- but plug in the prices Canadians pay, our health-care spending falls by about 50 percent.

In other countries, governments set the rates that will be paid for different treatments and drugs, even when private insurers are doing the actual purchasing. In our country, the government doesn't set those rates for private insurers, which is why the prices paid by Medicare, as you'll see on some of these graphs, are much lower than those paid by private insurers. You'll also notice that the bit showing American prices is separated into blue and yellow: That shows the spread between the average price (the top of the blue) and the 90th percentile (the top of the yellow). Other countries don't have nearly that much variation, again because their pricing is standard.

He almost got the answer, but wearing goggles that allow you only to look to the Left tend to impair one's view.

Here's my interpretation, and I think it has great merit. You have to look at this in the opposite way. Our health care costs are not artificially high, we docs, and the hospitals, and the pharmaceutical companies, and so on, are not gouging the system. Rather, in the nations that are idolized, I mean held up as examples by the Left for us to follow, prices are artificially capped. Our prices are not doubled, theirs are halved, and there is a very, very significant philosophical and practical difference.

With governmental price controls, there is a limit on what can be accomplished. Yes, there is less profit, but there is less incentive as well. Look at Canada, for example:

So physicians in Canada make less money on each patient than physicians in the United States do, and the total impact of those payment differences makes up a major portion of the difference in care costs between the two countries.

For hospital care, the Canadian government doesn't set fees to control costs; instead, it directly controls each hospital's budget. The government of each province sets a specific annual budget for each local hospital, and the government expects each hospital in the province to operate within its assigned budget. Canadian provinces don't like to raise taxes to increase hospital budgets, so the local budgets are far lower than U.S. hospital revenue streams. Those hospital payment levels are likely to stay far lower until Canadian voters offer to pay more in taxes. "No new taxes" has the same political charm in Canada that it has in the United States, so the people who run Canadian hospitals are not expecting big budget increases soon.

Tight individual budgets mean that Canadian hospitals can't invest in medical equipment or new technology as easily as U.S. hospitals can. You can see the results in many spending areas.

For instance, there are more magnetic resonance imaging scanners in Minneapolis/St. Paul than there are in all of Canada.

Relatively long waiting times for some kinds of surgery in Canada tend to be a direct and logical consequence of tight local hospital budgets. When money is tight or runs out, care slows. One of the beauties and virtues of the Canadian system is the absolute equality of access for all citizens. So when care slows for anyone in an area, it slows for everyone in that area--unless you are a well-to-do Canadian who can afford to cross the border to buy your care more quickly in the United States. Canada does not pay for that "external" care.

Sounds eminently fair, doesn't it?

Less profit means less incentive to innovate, to develop, to invent, less incentive to find new drugs, or new cures. I'm still researching the numbers, but I think most would agree that the amount of such innovation coming out of the US dwarfs that from Europe, or Japan, or China. Moreover, much of what is done overseas is targeted toward the US market. As was mentioned on the Aunt Minnie thread, look at the European developers' booths at RSNA. They know which market means success or failure for them, and that market is right here in the United States.

Here is the bottom line: WE in America are funding the medical progress that aids the rest of the world. Were it not for the fact that we actually pay the price for innovation, it wouldn't happen, or at best it would be a mere shadow of what it is today. We do have some price controls, mainly on services provided to Medicare and Medicaid patients, and we see clearly how these impair service. Take examples of Zevalin and Bexxar, radioimmunotherapy agents for certain kinds of lymphoma. For now, they are used as a last-ditch effort to save those who failed other regimens, but both have the potential to be used as a first- or second-line therapy with great efficacy. The cost of the pharmaceutical itself is something like $30-40,000, of which Medicare pays $10,000-16,000 or so, depending upon where you live. To make up for the deficit, hospitals charge upwards of $100,000 to those who can pay, making these miracle drugs available for all. If the government artificially imposes price-fixing on these drugs for everyone, you can bet Zevalin and Bexxar will disappear from our armamentarium.

Extrapolate this world-wide. Once the last profitable market for medicine shuts down, so will progress. What has been the most amazing technical and scientific story of mankind, the rise of health-care beginning in the late 1800's, will come to a grinding halt, or at least a major slow-down. We funded it, and when we stop, everyone will lose.

Anyone with means to do so comes to the United States for critical medical care. They don't go to France, or to Germany, or to Japan, or to Switzerland, or to China. They come HERE. But that may soon cease. Because all of the sudden, the best money can buy isn't good enough for us. We now have to pay more so we can be mediocre. The irony of it all is that sooner or later, our friends in other nations will be incredibly angry at US for what we will be doing to them. By then, it will probably be too late to do anything about it.

As usual, be careful what you wish for, as in cost cutting. You might just get your wish.

Occam's Vrazor

I was a fan of the old science fiction series "V", which debuted on NBC rather ironically in 1984, almost exactly 25 years to the day before the advent of its ABC successor. Having finally seen the new version, courtesy of, I can only shake my head in wonder that this program was even allowed to air.

I have absolutely no question in my mind that this program, brought to you on the ABC television network, a member of the Main Stream Media, is a direct slap at the Obama administration and all of those out there deceived by it and pandering to it. The message couldn't be clearer if you spelled it out in red Crayola.

I certainly urge you to view the pilot episode and decide for yourself, but here are some of my observations:

  • In the opening scenes (remniscent of Independence Day) the alien ships arrive with accompanying seismic effects. A poignant result was the toppling of a giant crucifix in a Catholic church. Hint hint.
  • Anna, the aliens' Supreme Commander, is very attractive and slender, with some vague resemblance to You Know Who. See the image above.
  • The press fauns all over the aliens.
  • The Visitors promise great stuff for all, with only minimal cost to us.
  • There is a deliberate attempt to win over and indoctrinate youth.
  • The terms "Hope" and "Change" are liberally (pun intended) tossed about.
  • There are numerous references to worship and devotion of the Visitors, and fear over blindly accepting them and their "free" gifts.
  • The aliens promise "universal health care" (direct quote).
  • You won't like what lies beneath the surface of the Visitors.

There are of course numerous other references and digs to the Obama administration, and they are, at least to me, quite blatant. The fact that Hollywood produced and then aired this rather expensive show is awfully encouraging. The tide has perhaps turned, folks.

Let's hope Occam's Razor doesn't apply here.

Friday, October 30, 2009

My Australian Address: Dalai's Revised Laws of PACS

(This is the talk I gave to healthinc customers and friends Wednesday, October 21, 2009 in Brisbane, Queensland, Australia.)

A quick disclaimer: I'm not the REAL Dalai Lama, but he is coming to Sydney in December.

I’m guessing most of you have had a look at my blog, and maybe some of you have even peeked at my profile.

Hopefully, you won’t find me too disappointing in person! I’m just an average radiologist from an average small town in the Deep South of the US. Nothing special, I promise. So what am I, a nice Jewish boy from Nebraska doing here in Brisbane speaking to you as the Dalai Lama of PACS?

It's been an interesting journey. I’ve always loved anything to do with electronics or computers, as well as things medical. So it seemed logical to obtain an Electrical Engineering degree, and go on to medical school. At first, I wanted to be a Cardiologist, but I was able to resist the dark side, and I soon became enamoured with radiology. In those days, before CT was quite so wide spread, and when NMR was found only in chemistry labs, Nuclear Medicine was more computer-oriented than diagnostic radiology itself, and so a fellowship followed.

I’m now a private-practice radiologist in Columbia, South Carolina, a job I found by answering an ad posted in our reading room. (I had no idea where Columbia was when I called in, but it sounded like a nice place.)

In 1992, a few years into private practice, one of my senior partners introduced me to this thing called PACS, (although we really didn’t use the term so much in the early 90’s.) We slowly implemented a piece here, and a piece there, and by the mid 1990's our main hospital was one of the first to be totally (almost) filmless, and ultimately paperless. My partner eventually formed (or stole, I’m not sure) the idea of “Sit here, read there”. He was a visionary as far as such ideas go, although he always had some problems getting his home computer running smoothly. Sadly, he’s since gone on to a better place (Florida!), but I’ve been able to oversee the implementation of his idea. My group now covers five hospitals, two outpatient centers, and numerous doctors’ offices with modalities ranging from Computed Radiography to CT, PET/CT and MRI. With few exceptions, we can access any study from anywhere, the dream fulfilled.

I won’t exaggerate my role in this achieving this dream, although I did have some influence here and there. In large part, I’ve had to be the spokesman, and occasionally the champion for my group of radiologists, since many of my colleagues had little idea of how this PACS thing worked, or even how it should work, and by and large didn't care much as long as it did work. I began to post on, initially asking my contemporaries what to do about a system that failed constantly (but that my senior partner loved.) To hide from him, and from the little company involved (ScImage), I adopted a nickname I thought no one would connect to me. Totally out of the blue, I came up with “Dalai Lama”. It didn’t fool anyone, but an Internet presence was born. My immodest assumption that some of my AuntMinnie posts were worthy of a wider audience led to the creation of Dalai's PACS blog, and the rest is history. Obviously, I am posting my own personal opinions and observations and I just wanted everyone to take them for what they are worth. No divine knowledge or inspiration is implied. But, the sense that medical imaging products were not all they could be, and the willingness to make honest statements online about my observations, has made me what I am today, the premier radiologist PACS blogger. Actually, I’m still the ONLY radiologist PACS blogger, but that provides job security, I guess.

I cannot tell you how amazed I am to be speaking with you here today, half a world away from my own territory. But I have to believe that I’m experiencing the same trials and tribulations as every other radiologist. For some reason, I’m one of a very few of us speaking publicly about these observations, probably because the audience is pretty small, we perceive no one cares, most of us aren’t crass enough to lay things out as blatantly as I do, and many are hesitant to take on General Electric. But after a day slogging against a malfunctioning system, I think most of us do care, and want some changes.

I have had the joy of working with quite a number of systems beginning with our first, relatively primitive Agfa system, complete with UNIX based computers, back in 1993. Since then, well... The short list of my conquests includes Agfa, ScImage, Image Technology Laboratories, General Electric, Aspyra, and of course Amicas. And, let us not forget the innumerable CD-ROMs with rather poor excuses for viewing software included. I can make a positive comment about each and every one of these: they all do show the images. Sort of. Some don’t do much more than that, and in fact make it quite difficult to see the images, which is the whole point of the exercise! A very few are obviously written with the radiologist in mind, with input from a number of rads. Others are clearly authored by computer geeks who had little idea how to spell PACS, let alone how to handle X-rays and CT’s. The common thread with most of these is the utter lack of understanding of how I do things. Suffice it to say that most of these (not Amicas, fortunately, and some others out there such as Intelerad and a few more) haven't a clue about what we do and how we do it. Approaches range from an attempt to look like a spaceship control panel (I'm not exaggerating) to the concept of toggling tools on and off with no obvious rhyme or reason. One small company even sold us one of the earliest implementations of an online real-time MPR viewer, wrapped in one of the worst GUI's I have ever seen. It didn't occur to them that there was more to the software than the core viewer. Getting the images into the viewer was an exercise in agony. Most of the systems don't grasp the concept of an updated worklist, and most think that the more buttons there are, the better the deal. (Which is something that some of their IT-based customers also believe.) Clearly, no practicing radiologist actually touched these programs before their release.

Overall, it has always seemed to me that in a life and death business like ours, things could be done better.

In addition to the joys of the disparate, sometimes poorly written systems themselves, I’ve had to deal with our IT departments and their lack of understanding of our workflow, our needs, or often anything at all about what we do.

Over the years, certain trends and patterns in PACS and our relations with PACS vendors as well as Information Technology (or Information Services, or whatever we happen to call them) became clear. I’ve distilled these into the LAWS of PACS (autographed copies available for $10US in the back!). Here they are, without further ado. . . try to picture me as Moses coming down off Mount Sinai:

I. PACS is the radiology department.
This one is as obvious as it gets, but many still can't see the forest for the trees. Once PACS is in place, the film is gone, and in a very real sense, the mass of wires and computers is the entire department. Yes, there are still modalities, CR cassettes, barium, and so on, but for all intents and purposes, PACS is the department's face to the world.

II. PACS exists to improve patient care. Its users are the radiologists and radiologic technologists. The entire goal of the PACS team is to optimize PACS function for its users.
Again, this is so big and clear that many have trouble seeing it, or at least no one wants to admit it. Especially IT. There does seem to be some debate as to who should be considered the real users of PACS. Yes, in theory, everything and everyone in a hospital or clinic exists to improve patient care, from the guy who mops the floor to the neurosurgeon, to the CEO (yes, the CEO thinks he is above the surgeons, and we'll let him hold onto his fantasy). In essence, we all work for the patients, not the CIO, not the CEO (and certainly not the vendors).

I admit to some degree of bias, but I have to believe that PACS exists for me, the radiologist, to use for patient care. Quite often, IT doesn't quite get this very important reality. The IT version of this law might read, "We provide PACS because it is made up of computers, which we own throughout the enterprise. We know far better than you do how our computers work, and what software will be easiest for us to maintain. We would be much happier if you would refrain from actually touching the mouse or the keyboard." Fine, let them push the barium too!

III. PACS should be the shared responsibility of the radiology and IT departments.
Notice the word "should." PACS is one of those little projects that requires the help and expertise of a lot of folks. As in Dalai's Second Law, PACS is indeed at its core a collection of computers and wires, an IT project if there ever was one, right? But as per Dalai's First Law, PACS is the radiology department, governing everything from its workflow to its profit margin -- things understood best by radiology, and it is a critical component of PATIENT CARE!

Therefore, I make the bold statement that management of this very important system should be shared. A big discussion at SiiM in Charlotte this past June came to a similar conclusion. And it only makes sense to let the various departmental expertise apply to where it can do the most good, again for Patient Care.

Sadly, PACS, a rather high priced item, sometimes becomes a political hostage, yanked back and forth to the department that wields the greatest power and can draw the largest budget. Thus, territorial squabbling comes into play, and some who participate tend to lose their orientation, which should of course be directed toward...THE PATIENT!

IV. Once PACS, never back.
A little PACS downtime provides a wonderful reality check. It becomes very clear in the first 10 minutes or so that we cannot ever live without our system again. Film? What's that? Is there a good downtime plan? Is there any downtime plan?

V. Workflow is inversely proportional to the number of buttons on the PACS desktop.
I cannot, for love, money, or excessive ranting on my blog, get some of the big PACS companies to understand this. I was told by the head of a major PACS project from a major PACS company that its solution to providing a feature when you ask for A and I ask for B is to add a button that does both A and B.
Many modern systems have in this way become hyperconfigurable and suffer from the Lego-PACS syndrome -- that is, one can build the buttons on the interface in so many ways that the permutations would take a century to exhaust. I assume Lego is as popular here as it is back home, and it was indeed my favorite toy growing up. But the sad fact is, I don't want to be spending my time searching through a sea of buttons and menu items; I want to read my studies. There is a minimum feature set necessary to accomplish this simple goal, and beyond that, every extra function has the potential to slow me down. That’s not to say that I don’t like advanced functionality. I do love power! But there are ways to simplify and organize these controls so they are unobtrusive, but available.

VI. PACS should not get in your way.
A corollary of Dalai's Fifth Law: PACS exists to let me, the radiologist, look at my patients' images. Anything that gets between me and that image is a distraction, and gets in my way. Obviously, some of this will be necessary, but if I have to click excessively, or take 39 trips to the menu bar before I'm done with the exam, something is wrong. I love car analogies to illustrate this. The latest BMW’s have something called iDrive, which is a big mouse that controls 700 functions. Most people end up accessing about 20 of these. This is called “feature fatigue” and the multiplicity of stuff available distracts one from the road. Lexus vehicles on the other hand have simple, intuitive controls that make you feel more a part of the road. (Sadly, Lexus now has a new model with its own version of iDrive. Apparently my influence is limited.)

VII. The degree of understanding of radiologist workflow is inversely proportional to the size of the PACS company.
While not a hard and fast rule, it does seem that smaller companies can be more innovative, and responsive, at least to a point. With some of the "Big Iron" companies, unlike Burger King (which I understand is called Hungry Jacks around here) having things "my way" is simply not in the cards. The products of the larger companies seem to reflect the mentality of largess, and the phrase "bloatware" comes to mind. With this comes the anathema of the Lego PACS and obstructive designs I have bemoaned above. A large (spelled l-a-r-G-E) company who likes to claim that their imagination is always at work keeps buying out smaller companies, trying to become all things to all rads, or maybe they are just trying to find something that actually works. So far, their latest assimilation into the collective hasn’t worked very well.

VIII. An average PACS consultant will take six months to tell you what you already know.
There are some very good consultants out there, especially my very good friend Mike Cannavo, the One and Only PACSMan. Perhaps you have read his series of excellent articles on Aunt Minnie. If you really need someone, call Mike. He'll help you negotiate the tortuous road to acquiring PACS. But then, he is well above average.

In many cases, consultants are brought on board not so much for their expertise in PACS, but to provide someone to blame in case the PACS purchase doesn't please everyone involved. A great deal of information is available on the Internet, both from the vendors themselves and from happy (and unhappy) users posting on sites like After perusing the available information, going through various demos and site visits, and communicating with other users, I think one can amass a fair amount of knowledge about the various systems out there.

Where the above-average consultant shines is actual negotiation of the deal, with the understanding of the subtleties and nuances of contracts and such. Yes, they have their place, but if you hire a consultant with the thought of picking your PACS for you, I would respectfully submit that you are simply avoiding doing your homework. Remember, no one knows your business like you do.

IX. A true PACS guru is worth his/her weight in gold.
There is absolutely no way in the known universe to successfully implement PACS without a guru. What is a guru? Someone who knows the PACS in and out, knows the radiologists and technologists better than his or her own family, and can make the system work for the end users, as per Dalai's Second Law.

The vendors can be relied upon to varying degrees, at least for the initial installation, but ultimately, there must be someone there on the ground to keep everything running smoothly. As of a year or so ago, I would have said that there were about 100 PACS gurus in the country. By now, there are probably nearly a thousand or so, but they are still the most valuable folks in the hospital. Trust me on that.

I have been extremely fortunate to know several gurus over the years. My group's guru worked his way up to PACS from being chief trauma radiographer; therefore he understands Radiology workflow better than any IT wonk. This is a critical trait in a guru. The first guru I ever met was originally one of my Nuclear Medicine tech students. He had extensive computer and electronics training in his first career in the US Army, and so was well equipped to do the job. I'll never forget sitting with him in PACS committee meetings, run by IT. On some particular issue, IT was going on and on: "We can't do that, it won't work, we'll need to schedule a meeting in six months to decide if we should talk further about it." To which my old guru turned to me and whispered, "I've already done it and it works just fine!"

X. Remember that you are the PACS customer.
No offense to present company, but vendors have sneaky ways of disarming complaints: "You don't really need that function," "No one else does it that way," and "We're working on that, but we don't know when it will be available."

Don't let them get away with this bait-and-switch game. You wouldn't expect this sort of treatment at the Mercedes dealership, and most PACS are a lot more expensive than any car!

XI. All software errors, including those within a PACS, can be repaired if the vendor is sufficiently motivated to do so.
I've had some of the larger PACS companies tell me they just can't fix some bug, even one that crashes a system. What they really mean is, they won't fix the problem, or at least they feel the resources required would be more profitably deployed somewhere else, say on the next version of vaporware. As Windows users, we are all participating in the world's largest and longest beta test. At least Microsoft eventually fixes most of the things we discover. Why should we expect any less from our PACS vendors?

Urging our friends to see things our way isn't easy. Sometimes, one has to resort to bad publicity, as might be found on a certain radiologist's PACS blog....

Now, believe it or not, I don't jump for joy or cackle with glee when I post a bug report. Actually, I cringe, well, at least a little, knowing that I'm inviting trouble upon the company involved, as well as myself and my group. But when patient care is involved, you do what you have to do, and be prepared to take the consequences.

XII. If IT doesn’t like something, it will be termed a security risk.
I recently found a way to thwart IT, or so I thought, by using a macro program to automatically refresh a RIS window that would otherwise close every 30 minutes. Signing in to a Citrix window gets boring after the tenth time that day, you know. The macro worked, but IT removed it from all computers, saying that someone could create a macro that would bypass password entry. Sure they could. They could also use a wax pencil to inscribe their password on the monitor, as many of my colleagues have over the years. I’m not certain if we should ascribe this behaviour to paranoia, concern, laziness or simple meanness. Probably all four.

XIII. The PACS needs to be operable by the least technically savvy radiologist on staff.
This is inspired by one of my partners who is one of the best interventional radiologists I have ever met. Ironically, he has great difficulties handling anything run by computer. I often tell the story (to embarrass him) about the time he called me from a plane about to take off to ask how to turn up the volume on his laptop so his children could watch a DVD. While the PACS has to work for me, it has to work for my less-computer-savvy partner as well, or it might as well not work at all.

XIV. Drive before you buy.
I've been preaching this one for years now, and people still don't believe me. It is impossible to get the feel for a PACS graphical user interface (GUI) in a 10-minute demonstration, no matter how well it is presented. In fact, the better the presentation, the more chance that some smoke and mirrors are involved.

Ask, nay, demand, a demo of your own that you (not the salespeople) can pound on at will. Technically, this should not be a problem for any Web-based product, as there should be a demo server for just this purpose. The joys and pitfalls of various systems do not become apparent until you have actually tried to use them in a production environment.

XV. Speech recognition will be acceptable to me when the CEO, CFO, and CIO use it for their correspondence.
This topic probably deserves an entire article of its own, as it always inspires controversy. As I see it, speech recognition (it is not voice recognition, by the way) is a technology that has yet to be perfected. Comments on and elsewhere indicate that the level of satisfaction is pretty low. But hospital administrators still try to push it on us. Why? Because they pay transcriptionists, and they don't pay us.

Therefore, if they can shift even some of the transcriptionists' editing duties onto the radiologists, they save money and look good come budget time. If it takes us an extra hour a day to do our job and do all the editing expected from a human transcriptionist, well, that's OK, right? Wrong!

So, here's my counter offer: When the members of the C-suite (the CEO, CIO, CFO, etc.) find speech recognition adequate for their correspondence, I will deem it worthy of review for use in the reports I issue as my stock-in-trade, the reports that clinicians rely on to make life-and-death decisions about their patients. Fair enough?

XVI. PACS is not film.
In the early days of PACS, displays were designed to mimic a film view box. This seems sort of foolish to us today. The versatility of a soft-copy display is so much greater than that of a piece of film it just isn't funny. Can you window and level a piece of film? Can you cine through images on a filmed CT? Well, I suppose you could stack them up like a deck of playing cards and riffle through them, but come on! Take away film and your workflow improves 10-fold.

As Moses (or was it Pharoh?) said, "So let it be written, so let it be done!"

These lessons have been painfully learned. Ultimately, my experiences and observations have been punctuated by fights, I mean discussions, with our IT folks, and our vendors. On many issues, I have had to use my blog to garner attention to significant problems we have had with PACS systems, when there was no other way to get anyone to listen. Here is a great example plucked from my blog of how our IT department and a large vendor teamed up to make my life miserable with something called "G.I.D.I." As you will see, rather than make us giddy, it becomes more of an abbreviation, as in, "this G.D. thing is driving me crazy!"

"What is a GIDI?" Well, the official title of this software extravaganza is "Generic IMPAX DTMF Integration," and it was designed to help us communicate reports to the outside world. It was a good idea, with all the right intentions, but we all know what the road to Hell is paved with, don't we?

Here's the problem the GIDI was designed to solve: We have Agfa Impax PACS, and we also had an older Dictaphone analogue voice dictation system. As we dictate happily along, there must be a way to enter the patient into the system for the transcriptionist to know whose report she is typing. We could just read the patient ID, or the accession number, or something like that into the mike as the beginning of the dictation. But that wasn't good enough. The GIDI was supposed to solve the problem by automatically entering the touch-tones into the Dictaphone, via a SoundBlaster audio board that interfaces between the workstation and the analogue dictation line.

This should be a labor-saving device for all involved. Except for one little problem. It is a true pain in the backside to use. It was over engineered and under tested. In actual use, the tones are transmitted VERY SLOWLY. Yes, an extra 6 or 10 seconds per study is no big deal, unless you are reading 200 studies a day as we do some weekends. That would be 1200 seconds, or 20 minutes. Let's see...even an extra 10 minutes per day, working, say, 200 days per year, adds up to 2000 minutes or 33 hours. That would be just under four 9-hour working days per year. You get the idea. All that time wasted because of a program that is supposed to be helping me.

Even worse, the thing has a bad habit of hanging up the Dictaphone, crashing IMPAX, or decoupling itself with the dictation system, requiring restarting of the GIDI, redialing into Dictaphone, and sometimes rebooting the computer altogether. So, add another 10-20 minutes to the daily toil. The system only allows dictating one exam at a time, so we have to re-GIDI every study on a multiple trauma patient. (And I'm talking about a CT of the head, C-spine, T-Spine, L-spine, chest, abdomen, pelvis, and at least one extremity, as well as CR's of all of the above, so there could be 10-20 different clicks for one patient.)

Worst of all, occasionally, when the GIDI blows up, the study that was on the screen disappears, and if you weren't paying very close attention in those first few seconds, it is rather difficult to know who just left your screen. Thus, a number of studies are accidentally lost from the worklist, only to be rediscovered hours or days later.

This blog post caused a minor war between us, well, me, and IT. There were shrieks (literally) of anger, and requests to pull the plug on Dear Doctor Dalai. But I was right, and ultimately the GIDI was turned off.

This is the same IT team, by the way, that made a decision about PACS vendors with absolutely zero input from the radiologists.

It should surprise no one that Agfa delivered us a similar bout of foolishness quite recently involving our beloved IMPAX:

When I try to look at a study, say a CT, which has more data coming in from the modality, say a sagittal reformat, the client crashes. The crash occurs AFTER I have clicked the study into "Dictation Started" status, and the study in question subsequently disappears off the list. When the client comes back to life, I have to remember the name of the victim, or the study runs the risk of being lost to me, only to turn up later in the "you didn't read this on time!" pile. Dare I even hint at the possibility of an impact upon patient care?

Here's the problem as I understand it: We don't want people reading studies before all the data is in. Thus a study has a built-in delay that should keep it off the worklist until it's ready. But sometimes there is an even longer delay between the acquisition of the various parts of the study, and it appears on the list anyway. But if we access the study whilst more data is coming in, the system gets confused, since we shouldn't be reading it, and it crashes. Hence, my image of the monkey chasing the weasel. POP goes the Impax!

There ought to be a solution for this. If there is, please let us deploy it. If there isn't, please create one. Very quickly, please.
POP goes the Dalai!

As of this point, right now, today, Agfa’s response has been twofold: 1. We’re talking about it. 2. You should change your workflow to work around this error. Someone from Canada left me this comment on the blog post bemoaning this garbage:

I hope Agfa PACS is not implying that it is acceptable in any way to get this type of error message; you are offering a work around, not a solution. . . As an Impax user (and someone with a degree in Computer Science) I find it totally unacceptable that a live clinical product has this type of bug. Furthermore, Agfa makes little or no active effort to correct or prevent these types of bugs. Frankly, I have given up on reporting bugs.

The usual response from Agfa support is...after 1 week level 1 support says you are doing something wrong...after 1 month level 2 support says they will look into it, and have never seen this problem before...after several months level 3 support says 'Oh yes, that is a known issue, but it has not been given priority'. Is this the reputation any vendor would really want?

Sadly, we keep getting solutions designed without regard to the actual workflow of the actual human beings that actually use them. Again and again and again, we are delivered products that the engineers (keep in mind, I am an engineer by training as well) think we should like, but never asked us if we actually do. Maybe it all boils down to communication. Somehow there needs to be dialogue between the end-users of these things and the folks that create them. Don't go looking for something you can patent, guys, but try to come up with something that will truly help me do my job. And please listen to me when I tell you how I do my job, don't just show me newer and shinier gadgets that you think will enhance my workflow. Most of the time, they just get in my way. Like the GIDI. Which we got removed as quickly as we could. But the latest glitch tells me we still have a long, long way to go.

There is light at the end of the tunnel, as there are some companies that actually listen to us. I stumbled upon the Amicas booth at the SCAR (now SIIM) meeting in 2003 in Boston. There was an unoccupied workstation and I sat down and started pounding on it. I liked what I saw. Here was the Real-time worklist, looking much like it does today, which told me at a glance who was reading what, and what needed to be read. What a concept! The viewer was clean and functional. It worked, and it didn’t get in my way. That software, by the way, was LightBeam version 3.6 or 3.7. What you will be working with now is version 6, known simply as Amicas PACS, with Halo Viewer. (Where Halo came from, I don’t really know, but it sounds good. Perhaps there was an X-box player amongst the programmers!) I’m very proud to say that I had a hand in the development of Version 6. The parts you like are the ones I suggested. Those few parts you don't like I had nothing to do with! Seriously, though, Amicas decided to start from scratch, to completely rewrite the software, and I happened on the scene just as some of the ideas were beginning to gel. I’ve been up to Amicas HQ several times, and the Medical Advisory Committee has met several times over the past few years, trying to help create this next-generation product. As a final shake-down, I spent two solid days working with the guys in Boston, attempting to simulate my daily reading grind. That helped provide the final touches for Halo, or so I’m told. The final product was borne of Amica’s desire to listen to us, the radiologists, and help us do our job in the easiest manner possible. Of course, they listened to me and folks like me. However, as per Dalai’s Lucky Thirteenth Law, PACS has to work for the least-technically-savvy member of the group, and I tried to keep that in mind at all junctures.

My battles with IT wax and wane as well. Like Amicas, there are some IT folks that do understand my workflow and my needs. By and large, they, like my guru, rose up from the radiology ranks. They speak my language as well as that of the machines. They understand the ultimate goal, serving the patient, better than those who didn’t come from the health-care background.

The key here is communication, which is a two-way street. We have to make known our needs, and the manufacturers, the software writers, the vendors, and IT, all need to listen. And of course we need to hear and understand their restrictions and limitations as well. But if we say nothing, if we are content with suboptimal products, suboptimal service, and indifferent, condescending IT management, well then, we deserve what we get. But our patients deserve better than that, don’t they?

Healthcare in the US is at the cusp of major change, although as yet we have no idea how that will actually manifest. We do expect, sadly, that imaging revenue will be hit hard. We have in many ways been the victims of our own success. Imaging works, and works very well, to help our patients. We do such a good job of it that emergency medicine docs order CT scans of trauma patients before actually casting eyes on them. They think we can do a better job of diagnosis than they can, and probably they are correct! Thus we are incredibly busy, sometimes with more business than we can handle comfortably. For us, imaging has thus become a 24/7/365 proposition. I don’t know if you have to deal with this to the same degree as we do, but if a patient presents at 3AM with a headache that he’s had for the past week, he gets a head CT then and there. Americans, at least, have come to expect this level of attention.

As scanner technology improves, business increases, and hardware prices fall. Thus, it is now possible for not only radiologists, but clinical doctors as well to own their own machines. Some of the latter buy state-of-the-art battleships with all the bells and whistles some opt for the surplus East German versions powered by rats on a treadmill. Because our insurers don’t know the difference, studies from either one receive the same reimbursement. Thus, imaging self-referral by clinical doctors who own their own scanners has skyrocketed. Now, my clinical friends claim that this practice provides convenience for their patients, and I’m sure that’s true. But how do we explain the fact that those who have their own scanners order significantly more scans? Either they are overutilizing the technology, or their less-fortunate clinical brethren are underutilizing it. I’m not smart enough to tell you which is true. Our government may or may not ever get around to solving this. They actually think this is a turf battle, which needs no regulation on their part. What will happen to health care as a whole, I haven't a clue.

The only way to stay alive in the anticipated environment of change is to be as efficient as possible. A good PACS makes this happen; a bad PACS will hurt you.
Now, I understand that you have your own version of Medicare here, a mixture of public and private approaches. I would really like to learn more about it from your perspective. Apparently, you suffer with taxes being levied to support healthcare too- but luckily you don't have to deal with Messrs Obama and Biden. Last time I checked, you do have Kevin Rudd, and Nicola Roxon (Minister of Health and Aging), but at least you have the Queen.

The near-term looks grim to me, given the impending changes. Sales of equipment in the US are way down, as we don’t have a clue even yet what is coming at us. Still, I do envision some good things happening. There is a huge governmental drive in the US toward the Electronic Health Record. This is a good thing, although the government probably wants it more for tracking purposes than patient care. Most vendors, including Amicas, are developing vendor-neutral archives, which will simplify storage across the enterprise. There is also a huge push toward unified PACS, which gives one a single portal to a disparate enterprise, as well as universal identifiers to collect the data on your patient who was at Hospital A yesterday, Hospital B today, and will be seen at Clinic C next week. This is perhaps the most welcome invention of all, given the multitude of sites we cover, and the tendency of patients to visit them all at one point or another. In fact, the "portable patient" has been the bane of my existence for many many years, and I keep hoping to see this problem solved. On another front, advanced visualization will become a part of every PACS; you will find, by the way, that the on-board tool-set in Version 6 already has tremendous power for 3D processing.

But no matter how far we progress, Dalai’s Laws still apply. PACS exists for the good of the patients, and this we must never forget. We are all bound to find the system that suits us, that lets us do our job of caring for our patients in the best manner possible. I think we in this room have found one that’s pretty darn good.

This little journey through PACS is obviously far from over, and it has been quite interesting to say the least. As long as we keep in mind that the ultimate goal is the improvement of patient care, we will certainly all be traveling in the same direction.

I'm still more than a little bit stunned that anyone even looks at my blog, let alone my apparent world-wide readership. It's quite humbling to know that you have read my feeble attempts at prose, but it is very encouraging to realize that all of us in this field face and surmount similar challenges. We'll keep fighting the good fight on behalf of our patients, in spite of what some large companies might, well, imagine.

Your country is absolutely beautiful, and your people incredibly friendly. That being said, listen to this quote from the 1987 American Express Guidebook to Australia:

"Behind the wheel of a car, many Australians change from being normally very tolerant creatures into something far less attractive. In addition to fast and aggressive driving, they sometimes show a marked reluctance to obey traffic laws and lane discipline, which can be disconcerting for visitors accustomed to highway driving in Europe or the USA."
Obviously, the authors had never been in a cab in Boston or Washington, D.C. The book goes on:

"But it should be said that Australians are an extremely generous people. They possess a wry sense of humour and a laconic turn of phrase. They have a healthy disregard for authority and a great distaste for exaggeration, showing off, and other expressions applied to those who have an inflated sense of their importance. . . and there is nothing an Australian likes better than deflating such people."

It seems I've been an Australian all my life and I didn't even know it!

I would like to thank healthinc for giving me this incredible opportunity to speak with you tonight. I am particularly grateful to Natasha Noble, who spent hours on the phone with me at the very fringes of the day around here making countless arrangements for this all to be possible. This trip has given me the chance to visit with some old friends, Mark and Sonya, who live here in Brisbane, and whom I haven’t seen in many years. I hope you didn’t find this all too boring!

Most of all, I thank you for your time tonight and your readership of my blog. For what it's worth, I think you have made an excellent choice in vendors. That is my own, honest, humble opinion. So, as we say in the Deep South, Y’all Take Care! Thank you so much for coming tonight.