Tuesday, September 29, 2009

Crash and Burn

The saga of our IMPAX crashes continues. For the full background story, read THIS post and THIS post. Sadly, we have no resolution to this point.

Discussions with Agfa have yielded only the suggestion that we change our workflow, because it is the activation of the "dictation" button while images are incoming that leads to the crash. That is actually not an unreasonable suggestion, but it is only a small part of the solution. Having my client crash when I do a "no-no" is an even bigger "NO-NO" in the software world. An anonymous Canadian commenter on my last post said this:

I hope Agfa 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'.

And indeed this one turns out to be a known issue. It's time to give it priority, before it gets too cold up there in Waterloo.

Here are two quick and dirty coding fixes that would keep me from whining louder and losing sales for Agfa:
  1. Throw up a dialogue box when the error conditions occur saying something like, "There are new images being received for this study...please stand by."
  2. Grey-out the dictation button.

I prefer the first, personally.

Crashing the client is NOT an acceptable method of warning me about something. Fix this, please. Your customers are watching, and based on the comments I'm receiving, they aren't surprised by this. Is that a reputation you want to cultivate? I didn't think so.

Monday, September 21, 2009

Stage Right

Every so often, I run across a little program or tool that makes my life easier. Dr Martin Crowe, Consultant Radiologist at Queen Elizabeth Hospital, King’s Lynn,Norfolk in the UK has authored just such a program. StageCraft, found at http://www.tumourstager.com/, is a simple little application that helps the radiologist (or clinician) with TNM staging for a number of cancers. Below is the window for lung cancer:

With a few clicks, the TNM classification and staging are displayed. The app is packed with a lot of other helpful information such as the Fleischner Society guidelines for solitary pulmonary nodule (SPN) workup, and simple displays of the mediastinal nodal stations:

I have only one bit of advice for Dr. Crowe: Charge for this little gem! It's well worth it!

Sunday, September 20, 2009

Socialized PACS

I've commented in an earlier post about the Britain's difficult experiences with EMR. As part of their massive IT initiative, there has been an attempt to introduce PACS as well throughout the system. You can have a look at the NHS PACS site here, with numerous links to history and other information. From what I can gather, the project has been largely successful, although there have been some problems.

The "Stakeholders' Brochure" discusses the British PACS experience:

Prior to the advent of the National Programme for IT (NPfIT) it had taken 50 trusts some 14 years to implement PACS. But in the last three years, the national PACS programme – a key element within NPfIT – saw the pace accelerated massively and all hospital trusts now have experience of the technology.
The NHS National Programme for IT (NPfIT) is actually the umbrella under which national EMR and the various PACS are deployed, and the whole thing is itself under "a new agency called NHS Connecting for Health (CfH) was formed to deliver the programme. CfH absorbed both staff and workstreams from the abolished NHS Information Authority, the organisation it replaced."

This very ambitious program includes the following particulars:

*The NHS Care Records Service (NHS CRS)

*Choose and Book, an electronic booking service

*A system for the Electronic Transmission of Prescriptions (ETP)

*A new national broadband IT network for the NHS (N3) (see also external link to BT N3 website)

*Picture Archiving and Communications Systems (PACS) *IT supporting GPs including the Quality Management and Analysis System (QMAS) and a system for GP to GP record transfer.

*Contact â€" a central email and directory service for the NHS.

The Spine

The creation of a core data storage and messaging system, known as the Spine, is key to providing electronic NHS Care Records for every patient.The Spine will:

*Store personal characteristics of patients, such as demographic information

*Store summarised clinical information which may be important for the patient's future treatment and care

*Provide the security systems required to restrict access to the national and local systems

*Provide a secondary uses service, using anonymized data to provide business reports and statistics for research, planning and public health delivery

*Bind together all the local IT systems within the programme.

Clusters and Local Service Providers

The programme divides England into five areas known as "clusters": Southern, London, Eastern, North West and West Midlands, and North East. For each cluster, a different Local Service Provider (LSP) was contracted to be responsible for delivering services at a local level. This structure was intended to avoid the risk of committing to one supplier which might not then deliver; by having a number of different suppliers implementing similar systems in parallel, a degree of competition would be present which would not be if a single national contract had been tendered.

As of October 2005, four different industry consortia are LSPs:

*CSC Alliance - North West and West Midlands Cluster

*Accenture - North East and Eastern Clusters

*The Fujitsu Alliance - Southern Cluster

*Capital Care Alliance - London

National Application Service Providers

In addition to these LSPs the programme has appointed National Service Providers (NASPs) who are responsible for services that are common to all users e.g. Choose and Book and the national elements of the NHS Care Records Service that support the summary patient record and ensure patient confidentiality and information security. As of October 2005, the NASPs are:

*BT - NHS Care Records Service and N3

*Atos Origin and Cerner - Choose & Book

*Cable and Wireless - Contact

Obviously, this is an incredibly ambitious project, one that should be considered successful if it works at all, and indeed it does, as near as I can tell, anyway. But that's the good news.

A humongous project like this is going to have some cost issues, and apparently NPfIT does. From the Wiki:

Originally expected to cost £2.3 billion (bn) over three years, in June 2006 the total cost was estimated by the National Audit Office to be £12.4bn over 10 years, and the NAO also noted that "...it was not demonstrated that the financial value of the benefits exceeds the cost of the Programme"[14]. Similarly, the the British Computer Society (2006) concluded that "...the central costs incurred by NHS are such that, so far, the value for money from services deployed is poor"[15]. Officials involved in the programme have been quoted in the media estimating the final cost to be as high as £20bn, indicating a cost overrun of 440% to 770%[16].

In April 2007, the Public Accounts Committee of the House of Commons issued a damning 175-page report on the programme. The Committee chairman, Edward Leigh, claimed "This is the biggest IT project in the world and it is turning into the biggest disaster." The report concluded that, despite a probable expenditure of 20 billion pounds "at the present rate of progress it is unlikely that significant clinical benefits will be delivered by the end of the contract period."[2]

The costs of the venture should have been lessened by the contracts signed by the IT providers making them liable for huge sums of money if they withdrew from the project; however, when Accenture withdrew in September 2006, then Director-General for NPfIT Richard Granger charged them not £1bn, as the contract permitted, but just £63m[17]. Granger's first job was with Andersen Consulting[18], which later became Accenture.

Oooops.... Sounds rather like having certain members of a larGE company having much to do with CCHIT, but I digress.

The Southern Cluster had a bit of a problem. Initially,

GE Healthcare, a division of General Electric (NYSE:GE), today announced that it has signed a contract with Fujitsu Services Ltd., the designated Local Service Provider for the southern region of the National Health Service's (NHS's) National Programme for IT. Under the agreement, GE Healthcare will provide its Picture Archiving and Communication System (PACS) technology that will enable the conversion of hospitals and clinics to a new digitised system for storing, retrieving and displaying patients' medical images.

The UK government announced in May that the NHS in England will install nationwide digital imaging systems that allow medical images of a patient to be transmitted on demand around hospitals and to remote sites for expert medical scrutiny and diagnosis. The National Programme for IT is being implemented into five regional clusters, the southern cluster (covering the South East and South West) being the largest with approximately a third of the country's PACS.

GE Healthcare will supply PACS technology for the new digitised records system to its partner Fujitsu. PACS allows images such as x-rays and other medical scans to be digitized, stored and transmitted electronically, avoiding the need for cumbersome film development processes and delivery by post or by hand. Eventually, PACS, together with other components of the new IT system, will enable the electronic storage, display and retrieval of a patient's records at the touch of a button from anywhere in the country. (Business Wire, 11/22/04)

But something then went haywire:

Fujitsu may not have its contract renewed to provide Picture Archiving and Communications Systems (PACS) services to NHS trusts in the south of England.

The development comes two weeks after Fujitsu had its £1.1bn contract as local service provider (LSP) for the region terminated on 28 May, following its withdrawal from contract re-negotiations. Fujitsu had previously been expected to get the lucrative PACS deal renewed.

When the LSP contract was terminated, the linked PACS contract was also ended, leaving NHS trusts across the south with systems that were not covered by formal support contracts. (eHealthEurope, 6/16/2008)

What happened to Fujitsu? There was of course finger-pointing:

Fujitsu was working with medical imaging specialist GE Medical Systems on the project and was to provide support until 2013.

Negotiations had broken down due to what Fujitsu claimed were too-strict conditions on payment and deliverables, according to media reports that day. The Connecting for Health programme – which started in 2002 and was scheduled for completion 2010 – is already four years late, they said. (HospitalManagement.net 5/30/2008)

From eHealthEurope:

The development comes two weeks after Fujitsu had its £1.1bn contract as local service provider (LSP) for the region terminated on 28 May, following its withdrawal from contract re-negotiations. Fujitsu had previously been expected to get the lucrative PACS deal renewed.
When the LSP contract was terminated, the linked PACS contract was also ended, leaving NHS trusts across the south with systems that were not covered by formal support contracts.

E-Health Insider has been told that as a result, key clinical systems in the region – including PACS, Radiology Information Systems (RIS), child health, Map of Medicine and Cerner Millennium – are only covered by a “promise” of support from the ex-LSP. . .

This would have followed the pattern set in September 2006, when Accenture walked as LSP in the North and North East of England, but still retained its PACS contracts.
In a 28 May letter to NHS chief executives in the south about the ending of Fujitsu’s LSP contract, Gordon Hextall, head of NHS CfH said: “However, the PACS and RIS contracts are not expected to be affected by this outcome.”
The agency now appears to have reversed its position and to be proceeding on the assumption the terminated PACS contract will not be renewed.

Uhhh. . . Two of the cluster providers walked? This doesn't sound good. . . But Fujitsu apparently is continuing to support its RIS/PACS:

Fujitsu has delivered PACS in full and it is generally working well. Although there was a single contract covering both the Care Records Service and PACS and the termination of the contract therefore covers both items, the intention of both Fujitsu and the Department is that Fujitsu will continue to deliver PACS’ and RIS’ services in the South, subject to contract, at least in the short term prior to a general transition to an alternative supplier subject to the agreement of terms. Without prejudice to Fujitsu’s legal rights, Fujitsu continues to provide these services pending confirmation by the Department of commercial cover. (Parliament document, The National Programme for IT in the NHS: Progress since 2006)
For much more on the Fujitsu situation, have a look at pages 45 and on.

The reprecussions of the Fujitsu withdrawl are multitude, and Parliament wan't really pleased with how things had been going:

Recent progress in deploying the new care records systems has been very disappointing, with just six deployments in total during the first five months of 2008–09. The completion date of 2014–15, four years later than originally planned, was forecast before the termination of Fujitsu’s contract and must now be in doubt. The arrangements for the South have still not been resolved.

However, this aspect was indeed recently solved:

NHS Connecting for Health has confirmed that responsibility for Picture Archiving and Communication Systems (PACS) and Radiology Information Systems (RIS) in the south of England will be transferring from Fujitsu to the CSC Alliance (CSCA).

Fujitsu, following the termination of its contract in May 2008, has been continuing to support PACS and RIS in most of the trusts encompassed by three strategic health authorities (SHAs): South East Coast, South Central and the South West. It also supports a further three trusts outside of these areas.

The SHAs and NHS Connecting for Health have been working to put in place new arrangements to ensure continuity of service provision for PACS and RIS. A contract has now been signed with CSCA which will see it steadily assume responsibility for PACS and RIS in the trusts previously supported by Fujitsu. The contract period with CSCA is effective from 20th July 2009 through to June 2013.
Fujitsu will continue to support trusts until November 2009 and support service transition activities until the end of March 2010.

OK, problem solved, at least for now. But this betrays the problem with the philosophy. To have one monolithic vendor covering an area could work very well, or very poorly. And one more thing. Particular regions of Great Britain decided which vendors to utilize. Let me rephrase that. The bureaucrats of the NHS of the particular quasi-independent clusters decided which vendors to foist on the hospitals in their area. One more time. THE GOVERNMENT CHOSE THE PACS FOR THE DOCS. How does that sound? I've had the joy of an IT department dictating the decision for me, and I didn't like it one bit. But having the government choose, likely by lowest bidder, is absolutely asinine.

From all I can gather, the system does work, and the NHS took on a monumental job in trying to make it work for an entire nation, albeit a smaller nation than ours. Would we in America be willing to take on the sacrifices and limitations entailed by this approach? Well? Anyone?

Some Questions About The Health Care Plan

Last Thursday, House Republicans published ten "common sense" questions arising from President Obama's health care reform speech. (Hat tip to ADoc2Be who mentions this on her own blog.) Here are the statements from the speech and the questions thereof:

President Barack Obama: “Our collective failure to meet this challenge – year after year, decade after decade – has led us to the breaking point.”

Common Sense Question: If we are at the “breaking point,” then why doesn’t your government-run insurance plan start until 2013?

Dalai's Comment: Clearly, this is timed to start AFTER the 2012 election. How stupid does Mr. Obama think we are? Wait, don't answer that. Whilst I agree that something needs to be done, I am in utter disbelief that GM and Chrysler were felt to be greater "emergencies" than health care, so horrible that we had to borrow trillions of dollars against our descendants. Health care, a life-or-death proposition if there ever was one, has to be pre-funded and deficit-neutral, which means increasing taxes in some stealthy manner. Add the omission of tort-reform and we realize that this is nothing more than a power-grab, an attempt to place a huge chunk of our economy under governmental control, as well as a poorly-disguised scheme to redistribute wealth.

President Barack Obama: “There are now 30 million American citizens who cannot get coverage.”

Common Sense Question: On August 20, you said 46 million Americans were uninsured. What happened to 16 million Americans?

Dalai's Comment: "Cannot" get coverage or "will not" get coverage? There is a huge difference. The numbers are too nebulous to be the full basis for anything. I agree completely that something has to be done about this, having a child that will be uninsurable because of a chronic illness once he leaves my policy. But we do not have to destroy what we have to achieve that goal.

President Barack Obama: “And every day, 14,000 Americans lose their coverage.”

Common Sense Question: Does that mean 15 million Americans will lose their health care before your government plan starts in 2013?

President Barack Obama: “We spend one and a half times more per person on health care than any other country, but we aren’t any healthier for it.”

Common Sense Question: Then why do people travel from around the world to receive health care in the United States?

Dalai's Comment: As noted by my fellow blogger, ADoc2Be, we are not as healthy as we should be due to a significant number of us (including me) making bad choices. We overeat (that's my vice) we smoke, we drink to excess. And then we want to make that someone else's fault. We the physicians can and do try to limit these behaviours in our patients, but to little avail.

Those with means around the world in vast majority come here for high-level care, not to Britain, France, Japan, Germany, Switzerland, or a host of other nations with "progressive" medical care. Sorry, but that's the fact, Jack.

President Barack Obama: “Put simply, our health care problem is our deficit problem. Nothing else even comes close.”

Common Sense Question: Didn’t the non-partisan Congressional Budget Office say that the health care plan you have endorsed will add $239 billion to our annual deficits over the next ten years?

President Barack Obama: “Reducing the waste and inefficiency in Medicare and Medicaid will pay for most of this plan.”

Common Sense Question: If we can pay for “most” of health care reform by controlling waste and inefficiency, then why does a $900 billion health care plan include $820 billion in tax increases?

President Barack Obama: “…no federal dollars will be used to fund abortion.”

Common Sense Question: Do you object to House Democrats defeating an amendment in the House Energy and Commerce Committee markup that would have explicitly prohibited federal funding of abortion under a government-run health care plan?

President Barack Obama: “I will not sign a plan that adds one dime to our deficits – either now or in the future.”

Common Sense Question: Do you oppose the House Democrat health care plan, H.R. 3200, which the non-partisan Congressional Budget Office said will add $239 billion to our annual deficits over the next ten years and “would probably generate substantial increases in federal budget deficits” thereafter? If so, which Democrat plan are you going to support?

Dalai's Comment: See above. The finances don't make any sense at all.

President Barack Obama: “Reducing the waste and inefficiency in Medicare and Medicaid will pay for most of this plan…the plan I’m proposing will cost around $900 billion over the next 10 years…”

Common Sense Question: If there is so much “waste and inefficiency” in Medicare and Medicaid – two government-run health care plans – then won’t further government involvement in health care lead to further “waste and inefficiency”?

Dalai's Comment: And why can't we eliminate the "waste and inefficiency" RIGHT NOW, instead of waiting until 2013? And just HOW are we going to eliminate waste? Uh, maybe we should rephrase that...

President Barack Obama: “And I will continue to seek common ground in the weeks ahead. If you come to me with a serious set of proposals, I will be there to listen.”

Common Sense Question: Will you agree to meet with House Republican leaders to discuss health care reform, as they requested almost four months ago?

Dalai's Comment: Has Bart sent in his plan yet?

And here are some additional questions, food for thought, mainly. . .

Just what is our goal here? Do we wish to insure everyone? What is the basis for this desire? Are we saying morally that all life is important, and everyone needs to have access to care, and should that care be equal for all? If so, we must insure everyone possible. And I mean EVERYONE. Illegals, citizens of other nations, etc. If the moral imperative exists to provide health care, then we must do so for all. GLOBALLY. Mr. Obama's plan, and the mentality that we must provide (equally is implied) for all of our citizens just as the Socialist nations of the world seem to be doing is apparently based on flawed, jingoistic, nationalistic ideals, yes? It says that we have an obligation to help ONLY our fellow citizens, and how could that be true? A life is a life is a life, right? IF this is our goal, then we cannot allow distinction between a American's life, and an illegal-alien's life. Or the life of someone in Africa? Or India? Or China? And, if all life needs to be preserved, how do we justify allowing (or encouraging) abortion?

I'm just asking philosophical questions. Just something to think about. Here's some more to consider.

We will need quite a few more physicians to accomplish the goal of caring for EVERYONE, even if we incorrectly and unfairly limit this only to every US citizen. How will they train? Those of us who went through medical school know that the patients who present to a training institution (say, a county hospital with a high indigent population) are treated by medical students and residents, albeit under the supervision of an experienced physician. IF everyone deserves equal care, is this FAIR? Would you submit to having a junior medical student suture a laceration on your daughter's face? Why should an indigent have to suffer this humiliation? That's not FAIR, is it?

And another thought. My daughter the pre-med has given me the following analogy, gleaned from her Ethics class: You are walking down a country road, and you see a baby floating face-down in the middle of a nearby pond. Could you just continue to walk by and live with yourself later? Of course not. In this tale, the uninsured are represented by the baby, and we cannot live with ourselves without helping them, and the assumption is made that we aren't helping them. The analogy is heart-rending, but not completely accurate. First, we DO help. My group writes off literally millions of dollars in care for "self-pay" patients. We all know that "self-pay" means "no-pay" but we care for them anyway. Between that and the 50% I presently pay in taxes, I'm doing a HELL OF A LOT more for the poor than just about anyone who wants to criticize me. How much more should I do? Secondly, we can assume that the baby didn't want to end up face down in the pond. But many of our most ill citizens got that way via the vices I outlined above. They may not have explicitly chosen to acquire lung cancer when they lit up a cigarette, but they knew the consequences and rolled the dice. Do we have the obligation to pay for their care? Does an alcoholic dying of cirrhosis deserve a liver-transplant at our expense? Is it FAIR, is it RIGHT?

Back to an earlier point. If this is such an emergency, if insuring EVERYONE is the FAIR and RIGHT thing to do, then we should do so with all possible haste, and damn the cost. We should print money to cover this overwhelming necessity, well, no, let's just declare the health care is FREE, that anything and everything everyone needs is to be delivered gratis. Doctors and other health care workers, and especially pharmaceutical companies won't be paid, because filthy profit should have no say in health care, should it? No, let's do this right, folks.

While we're at it, it isn't FAIR that there are people in this country, and in the rest of the world, for that matter, who don't have enough to eat. Starting now, all food needs to be given away free as well, since people may die or become ill without adequate nutrition. OK, let's start slow. We'll have socialized nationalized food-care, and ultimately take this global. Healthy meals for all! Oh, by the way, we get to tell you what you can eat and what you can't. It isn't FAIR for Dr. Dalai to eat steak (production of which has a huge carbon footprint, and is a very inefficient way to consume food resources), while an impoverished child in North Korea has to eat pine needles.

I could go on, but I won't. Some of my readers have probably blown Circle-of-Willis aneurysms by now, and they will be overtaxing their local health-care delivery systems.

As I did before the last election, I am simply asking you to think about the implications of what you are demanding. I will very stubbornly continue to think that the current "emergency" push for health care revision is nothing more than a sham that has conned a lot of kind-hearted folks (mainly liberals) into BELIEVING. I do realize that our health-care system needs reform, and I doubt that anyone would seriously argue otherwise. But think long and hard about the change you wish to bring about, and why you want it. Think.

Wednesday, September 16, 2009

Eighty-Five Percent. . .

Republican Congressman Mike Rogers' opening statement on the health-care bill debate from July, 2009. I don't think I have ever heard the argument against governmental-control more powerfully made. Listen and believe.

Monday, September 14, 2009

Bart's Healthcare Plan

My friend Bart is a Radiation Oncologist, as well as a character of the first order. He is a very sharp guy, and when he puts his mind to a problem, he generally solves it. Bart has now turned his attention to the insurance and healthcare debate. The original text from Bart's healthcare plan is presented below, and he discussed it (rather briefly) with Ed Schultz on MSNBC. Mr. Obama, you wanted alternatives to your plan for Governmental Medicine; here's a good one:


1. This plan calls for every family in America to be covered with catastrophic health insurance paid for by the Federal Government. This policy would cover each family from $200,000 to $1.5 million. Statistics suggest it would only be accessed by less than 1.3% of the population. The purchase price of this plan is $60/month/family. Assuming there are 90 million households in America, the price of this would be approximately $5.5 billion.

2. The short-fall incurred by families and individuals from $0 through $200,000 would be covered by a separate policy. This policy would be furnished by businesses, individuals, or in the case of Medicare, the disabled and other retirees, the federal government. The deductible and the terms of the policy would be put out to bid with every insurance company having the ability to bid on the contracts. This bidding process would involve being able to go across state lines and could include large volume discounts. If a company is satisfied with their present agent, they could choose to continue with their own coverage. An example that I use is a $2000 deductible with a maximum exposure to the insurance company of $200,000. Assuming a company has 5,000 employees this policy could be purchased from my local BCBS for $250/month. The savings are realized to the insurance company because their maximum exposure is only $200,000/ policy.


1. The total cost of the catastrophic plan covering every household in America would be approximately $5.5 - $6 billion. The insurance companies would be able to offer vastly discounted rates due to the size of the pool being insured. The insurance companies would profit from this because statistics show that no more than 1.5% of the population would ever use this amount of insurance in a given year.

2. Open competition between the various insurance companies would come into play with the individual policies. They would have to include pre-existing conditions, portability, and could be shopped across state lines. Individuals who could not afford the cost of this policy would be subsidized through the federal government or through tax credits for businesses. Obviously, the provisions and restrictions on these policies would have to be negotiated with the help of the government.

3. If the government was required to pay for 1/3 of the population or 100million people at $250/month ($3,000/year) this would be $300 billion.

NOTE: The cost of Medicare alone in 2007 was $440 billion.


1. Every man, woman and child in America would be covered.

2. The cost of this program would be less than Medicare alone thus eliminating the need for higher taxes or surcharges on businesses and individuals.

3. Insurance coverage remains in private hands and is not controlled by the Federal Government. HR3200 called for the formation of 53 new federal agencies. This would no longer be necessary.

4. Additional savings could be obtained from dismantling some of the bureaucracy now associated with the administration of Medicare.

5. This entire bill could be written in a 10 page document that even the busiest member of Congress would have time to read.


1. The reimbursement of fees to both physicians and hospitals would have to be negotiated with the input from multiple parties. This would include, but not exclude, representatives from physicians, hospitals, insurance agencies, and state and federal governments.

2. It should be noted that the present bill (HR3200) calls for Medicare + 10%. This is totally unacceptable as no hospital or medical practice could remain open with this low level of reimbursement. This would only represent approximately 33% reimbursement of the total charges. Today Medicare's reimbursement rate of approximately 30% of the total charges would only climb to 33% if this was instituted. It takes approximately 45% of total charges for hospitals to remain profitable. An example of this is in a $100 charge for a drug, Medicare allowable is $80 when the actual cost of the drug to the practioner is $90. Without supplemental insurance the physician loses money while trying to help his patient.

3. The reimbursement rate must be sufficiently high to ensure previous obligations made by medical practices and hospitals for equipment, land, andemployees can still be met. It should also be high enough to allow for the purchase of new or replacement equipment.

4. Medicine must continue to attract the best and the brightest we have to offer. This has to be done by making the practice of medicine financially feasible. The government must subsidize the individual to help defray the cost of a medical education. It should be noted in European countries the cost of Medical School is free.

5. Finally, the issue of TORT REFORM must be addressed. I would propose that each case be reviewed by 3 independent physicians. These physicians would then recommend their opinions independently to a Board composed of physicians and lawyers. This Board would then decide (based on the three physicians recommendations):
(a) no case
(b) blatant malpractice
(c) or negotiation.

Caps on the total award would also have to be considered. This would save on insurance premiums for physicians and hospitals as well as help eliminate unnecessary tests performed due to the practice of defensive medicine.

Sunday, September 13, 2009

Please Don't Just Talk About Fixing This. . .

I complained about an IMPAX crashing problem in a prior post. You know, the one that gives this error:

So far, word back from Agfa is that the powers-that-be are "talking" about it.

I've already experienced the crash twice this morning.

Perhaps the "talk" will lead to a "fix" soon. I'm getting a little tired of this particular error, and we all know what happens when I get tired of something. . .

Did I happen to mention in the original post that this error makes the ENTIRE STUDY DISAPPEAR FROM THE LIST FOR SEVERAL MINUTES!??? Can we all say, "PATIENT CARE ISSUE"???

By the way, I have a feeling we are not the only site dealing with this problem. If you are currently using IMPAX 6.3.1 SU12, and you are experiencing crashes as described in the original post, please let me know by commenting below.

My patience has run out. I need this fixed by the end of the week. Thanks.

An Open Letter To The Board of Imaging Advantage

Ladies and Gentlemen:

I assume you have been following the back-and-forth discussions of your company on the numerous AuntMinnie.com threads. I regret to tell you that Imaging Advantage has not been held in particularly high regard by the radiology community based on those discussions.

We in private practice are not particularly enamoured with what we are seeing. Based on reports on the ground in Toledo, your staffing model does not seem to be working well at all. Apparently, in your earlier endeavours, you were able to keep the existing radiologists in their positions which at least allowed for a semblance of proper coverage. When CRC refused your offers, the plan seemed to deteriorate rapidly.

Your CEO, Mr. Hashim, claimed to have sent a letter to the ACR, and the text was linked to an AuntMinnie thread. I have to wonder if the letter actually was sent, as the ACR did not have any public response. In this letter, Mr. Hashim made several serious allegations against CRC, certainly well beyond what needed to be published in an open forum. Mr. Hashim's letter concluded:

We bring our tools and resources to support local doctors and community hospitals. This may include new technology, optimization of processes and protocols, subspecialty teleradiology services, quality control over-reads, and our unique fractional staffing model. The latter helps radiologists and groups keep their hospital contracts, while significantly enhancing the resources available to the hospitals and patients. Excellence in patient care can be furthered by this symbiotic relationship.
I can't see much of that actually occurring in Toledo.

Your cause has been "championed" on the AuntMinnie threads by a fellow calling himself "dmarkupMD" and then "HEGEMONRAD". To put it bluntly, this is not the sort of publicity you need right now. Under both names, as well as a half-dozen others which are clearly representing the same person, your "new paradigm" has been touted as something well beyond what it truly is. Those who disagree have been insulted and even threatened. The poster displays ideas and attitudes not fit for a representative of a professional organization.

I am respectfully requesting you to publicly disavow any knowledge of or connection with this guy. He is damaging your reputation well beyond any possible repair. If he works for you, I would recommend terminating him immediately, as he has done a great deal of harm to Imaging Advantage.

If Imaging Advantage wishes to discuss their operation with the community of radiologists on AuntMinnie, please do so in an open and above-board manner. I and many others have expressed our opinion of what you are doing and how you are doing it. If you want to portray a different image of your company, we would welcome a civil discussion. What has been attempted through the "dmarkupMD/HEGEMONRAD" character has been anything but civil, or productive for that matter.

Thank you for your attention.


Doctor Dalai,
Private Practice Radiologist

Friday, September 11, 2009


As a Nuclear Radiologist, I consider nuking is a good thing.

I think GE finally decided to listen to me. I have whined in the past about their Hawkeye's lack of diagnostic CT capability, in spite of all their efforts to convince me that it didn't matter. GE appears to now believe me, at least in the realm of cardiac SPECT/CT.

GE announced the Discovery NM/CT 570c last March, at the ACC meeting. The machine is geared toward cardiology, but it contains some significant advances that will apply to other realms.

First, GE finally saw the light, and attached a 64-slice Lightspeed VCT to the Discovery. This is a miracle in and of itself, and allows for high-end cardiac CT applicatons such as Calcium Scoring and CTA as well as CT-based attenuation correction. And did I mention that this will yield diagnostic CT images??

The potentially-revolutionary part of the 570c involves something called "Alcyone" technology. From Medicalphysicsweb.org,
Alcyone technology brings together a breakthrough design based on combining CZT detectors, focused pin-hole collimation, stationary data acquisition and 3D reconstruction, to improve workflow, dose management, and overall image quality. Unlike conventional nuclear imaging, all views are acquired simultaneously during a fully stationary SPECT acquisition, eliminating equipment movement during the scan and reducing the risk of motion artifacts. CZT detectors directly convert gamma rays into digital signals, eliminating the need for photomultiplier tubes, but maintaining high stopping power to deliver improved energy, spatial and temporal resolution.
It's sort of ironic that Philips took the alternative approach of solid-state CT detectors for their Brightview XCT scanner.

Notice that the GE Discovery has the CZT detectors mounted at 90 degrees from each other, optimal for cardiac work, but not for other applications.

My sources tell me that this will be remedied within the next month or so, when GE will introduce a general nuclear medicine (or maybe oncology?) version of the Discovery. Maybe they'll call it the 570d (for Dalai, of course) or more likely simply the 570. This will be worthy of a look, as a direct competitor to my longtime favorite, the Siemens Symbia.

The Discovery NM/CT 570c is presently installed only at the Rambam Medical Center in Haifa, Israel and at the University Hospital in Zurich, Switzerland. I would be honored to have a look at either facility. I do wonder where the first non-cardiac version will be placed. . .

Friday, September 04, 2009

Toledo, Take Two

The Imaging Advantage mess continues in Toledo, and the nasty back-and-forth on Aunt Minnie progresses non-stop on multiple threads, including THIS one as well as THIS one. The frenzy has not quite reached the low that punctuated the original thread, with an apparent IA insider calling himself dmarkupMD suggesting that I go visit the Gulags of Russia and experience, well, prisoner comeraderie, for lack of a more genteel term. Dear Dr. Markup was subsequently banned from Aunt Minnie, and the incredible hulk of a thread was closed.

A new IA supporter (a term loosely related to "athletic supporter") named HEGEMONRAD has appeared, again defending the "new paradigm" of the IA model, and claiming no responsibility for the displacement of the old group, CRC. As with the old thread, several other personas have appeared, all clearly authored by the same rogue, someone whose speech and spelling patterns suggest a non-native-English-speaker. The theme is always the same, although the last few posts have approached libel, suggesting that CRC paid techs and others to post negative material about IA. And, for the past several days, HEGEMONRAD has played a cat and mouse game with the "Anti-IA Camp," actually suggesting a meeting in Toledo with the "permanent" radiologists to clear the air. However, when a number of people responded positively to the RSVP, HEGEMONRAD demurred, throwing up restrictions, roadblocks, and other stalling tactics, making it rather clear that no meeting is intended.

In the meantime, other posters, including old CRC members and others identifying themselves as be within the MHP hospital system, have painted a very ugly picture of what is happening at Mercy, and this is also mentioned by those with connections on the ground there in Toledo. I won't quote directly, but suffice it to say that at the very least, patients are being inconvenienced.

HEGEMONRAD, dmarkupMD, and the host of other characters supporting IA don't really respond to any of this beyond creating personal attacks, aimed mostly at Spartandoc, the head of CRC. Which leads me to consider the following possibilities as to who HEDGEHOG, I mean HEGEMONRAD really is:

  1. He is simply a troll, typing with one hand and doing nothing more than causing trouble. Possible. However, he seems to have too much inside knowledge, and too much vitriol to be playing with us, and he has been at it for far longer than you would expect from a teen-aged deliquent.
  2. He is a member of another group in Toledo, and carries a grudge against CRC. I have discussed this possibility with CRC members, and there seems to be no one in the rather small Toledo radiologic community who would fit that description.
  3. He is a member of the MHP administration, and is trying to cover up a really, really bad decision, to dump CRC and go with IA. Possible.
  4. He is a member of the management team for IA, possibly even Naseer Hashim himself.

Mr. Hashim, the CEO of Imaging Advantage, has a fascinating past. His bio on the Imaging Advantage website notes these accomplishments among others:

In 2002, Mr. Hashim founded Legal Advantage Services, Inc., a legal outsourcing company, which grew to over 1000 clients representative of the top intellectual property law firms in the world.

Prior to this, Mr. Hashim served as legal and strategic head for Pleiades Group Limited, where he designed complex business and political alliances between the Russian Ministry of Atomic Energy (MINATOM), the United States Department of Energy (DOE), Lockheed Martin, Westinghouse, Raytheon, the AFL CIO and arranged a $2 Billion debt facility with Banque Paribas. All part of a $16 billion global transaction involving the blending down of nuclear weapons into peaceful fuel.

Good stuff. For some reason, Mr. Hashim's career as a screenwriter wasn't included, but the online version of Life Magazine, a publically-available website, has captured this part of his fame:

The caption reads:

NEW YORK - NOVEMBER 2: (U.S. TABLOIDS AND HOLLYWOOD REPORTER OUT) (L-R) Publicist Payal Chaudhri, Producer Naresh Sahni, screenwriter Naseer Hashim and agent Elaine Rogers attend the Georgette Mosbacher's and Harvey Weinstein's bipartisan election night party at The Palm Restaurant November 2, 2004 in New York City.

In this photo: Payal Chaudhri, Naresh Sahni, Naseer Hashim, Elaine Rogers

Photo: Evan Agostini/Getty Images, Nov 02, 2004

Let's think about what screenwriters do. They write or adapt stories for the big screen, creating and animating characters. . . Sound familiar? Now, I may be adding two and two and getting five, but hypotheticallly speaking, it seems like a screenwriter, with a lot to gain from doing so, might just be interested in bombarding a web forum with many different personas, trying to change peoples' minds about something near and dear to him. Makes you wonder, doesn't it?

Frankly, I am sick of HEDGEHOG and all his personas, whether he is truly Mr. Hashim or a sick teenager posting from his mother's basement. I would have thought Aunt Minnie would get rid of him, but I'm assuming that they won't in the interest of fairness. So be it. But I would suggest that NO ONE respond to this fellow anymore, except perhaps through an attorney when he commits slander.

I can't personally get to Toledo for the Big Meeting, and I'll wager it won't actually happen anyway. But something does need to be done here, with the rumours of suboptimal patient care lurking in the background. I would urge those with direct, first hand information to send it to the Toledo Blade, The Wall Street Journal, and even to 60 Minutes, Dateline, and 20/20, and certainly to the Ohio Medical Board. If the allegations are false, I'll be glad to report that too, right here with crow enough to go around. The patients HAVE to come first in any health-care situation. I don't have first hand knowledge of what's happening on the ground, as I am not in Toledo, but word from aquaintances as well as the postings on Aunt Minnie doesn't make me very sanguine about the situation.

Medicine is not a business like any other, and attempts to insinuate middlemen between doctor and patient for the express purpose of siphoning revenue will certainly NOT help the patients. That is as unacceptable as it gets. Frankly, I think it's time for IA and MHP to post a comment on their websites about all this. I would truly like to know that their main interest is indeed the patients.

Tuesday, September 01, 2009

Shall We Repeat The British EMR Mistakes, Too?

In March, I wrote about GE's offer to help us get our share of the EMR/EHR stimulus pie. Obviously, there is a lot of money to be made, and a lot to be distributed. There were rewards for early adoption, and penalties for slackers.

As with the potential governmental health care system, this has been done elsewhere, in Britain to be exact, and it didn't work very well.

Greg Freiherr, writing as Scan Man in Diagnostic Imaging notes:

Ironically, as the Feds wiggle this cornerstone of a national HIT system into place, the one in Britain is crumbling. Seven years after U.K. prime minister Tony Blair announced that English doctors within a decade would be able to share records, conservative politicians there are talking about pulling the plug on what they see as a terminally ill system, one that has not met its goals and shows no sign of being able to do so.

And it isn't just Scan Man who is indicting the British program. From the San Francisco Examiner 3/2/09:

. . .(A)sk health care providers in Britain’s National Health Service, who have been trying to get their HIT system to work properly for the past five years. The cost of NHS’ HIT has escalated to six times the original estimate — the U.S. equivalent of $18.4 billion — to serve just 30,000 physicians in 300 state-run hospitals, a fraction of the health care providers in the United States.

In January, Public Accounts Chairman Edward Leigh reported to fellow members of Parliament that essential systems are late or, when deployed, do not meet expectations of clinical staff. HIT is such a mess that Leigh recommended funding alternative systems if matters don’t improve within the next six months. But even if HIT is eventually junked, British taxpayers will still have to pay for it.

Freiherr goes on:

Parallels between this snake-bit program and our own are a little disconcerting. Like the one in the U.K., the U.S. initiative to digitize patient records is coming from the top down rather than the bottom up and it has tight deadlines. The White House-driven initiative will begin implementation already next year, wagging a carrot in the form of front-loaded reimbursement initiatives. After five years, the carrot turns to stick, as penalties come into effect for providers who haven't jumped on board.

Dr. Howard Brody, a medical ethicist who was quite in favor of EMR's, has the following rather pessimistic observations:

Shift your attention to Britain, where doctors' practices and the government have been way ahead of the United States in implementing EMR (virtually all British general practitioners have EMR in their offices). To finalize the shift away from paper records, the British National Health Service had planned a massive campaign (costing 12 billion pounds) to integrate all patient information in a single, grand national system.

Despite high hopes, it has not happened -- and it may never happen, now that the economic crisis has dried up funding. At some sites, as soon as they tried to go live with the new EMR, the computers crashed, and systems people could not fix the problems.

Some American critics think they know why the huge investment in the U.K. was a flop. No one in charge seemed to really know anything about the field of health information. The leader of the enterprise was a computer expert brought in from Cadbury-Schweppes, the candy and soft-drink company.

More worrisome to these critics is that the most vocal gurus leading the charge for the EMR in the U.S. seem blissfully unaware of these huge problems in Britain. They seem poised to repeat all the same mistakes.

My take on the American setting is EMR is wonderful when done well. "Well" means the software is designed by people who understand the needs of the end users (patients, doctors and nurses), and the implementation process is highly user-friendly, with tech support readily available at all times.

The worst disasters occur when a poorly designed EMR is crammed down people's throats by leadership without real buy-in from those in the trenches. What happens then, simply, is people who are supposed to use the system end up sabotaging it, and the millions spent to set it up go down the drain.

One hospital specialist in Boston wrote about his new multimillion-dollar EMR. It contains huge volumes of patient data, so huge you cannot find the important information among all the trivia. The physicians making rounds on the hospitalized patients have found the only way to keep sane is to scribble notes on 3x5 index cards as they go.

I'm getting more worried by the moment.

To be fair, Freiherr offers some hope for us viz-a-viz the British fiasco:

In some ways, the U.S. goals are loftier than those in Britain. The U.K. initiative had a much longer ramp-up: from 2002 to 2010. Also, it was to be spread over a smaller population: about 60 million versus 300 million. Where the U.S. plan has an advantage is in its goal. Rather than creating a centralized, national medical records system, the U.S. plan seeks to improve the efficiency of health care. Specific milestones will come from a still-evolving definition of "meaningful use," one that bureaucrats and providers are trying to scale up over the five-year period of adoption.

Also working to the advantage of the proposed U.S. initiative is a much more evolved IT infrastructure. When the U.K. program began, vendors had neither the technology nor the expertise to meet its ambitious goals. Things have changed since then. Best-of-breed IT systems continue to flourish, but they have become more comprehensive, spanning entire health care enterprises. The expertise to run these systems is beginning to develop as well. Earmarking grants for what will likely serve as HIT "centers of excellence" to serve as examples of how the technology can be successfully applied will add to this expertise. These centers may also serve as places where staff from other facilities can be trained before they jump into their own EMR systems.

But from the radiologic standpoint, there is a critical omission in our program:
Not yet addressed, however, is how the many currently operating HIT pieces, such as RIS and PACS, will be leveraged. To ignore them in the sculpting of a comprehensive EMR would be disastrous, as it would leave out critically important parts of the diagnostic process. And even if the decision to involve them in broad-based EMRs is made, there is no certainty that available interfaces will be up to the task.
Based on the British experience, and the limited implementations here in the States, EMR is probably not quite ready for a massive, immediate roll-out. This begs the question of why EMR has suddenly become a priority. From James Bovard, writing in the American Conservative (sorry about that, Sliberalins...):
But the feds have no technological silver bullet to distribute to docs across the land. David Kibbe, a top technology adviser to the American Academy of Family Physicians, warned Obama in an open letter late last year that existing medical software is often poorly designed and does a miserable job of exchanging information. Kibbe declared, “If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the Babel that already exists.”

So, why the rush? As usual, there are two words that define it all: Money and Control. There is a LOT of money to be made when the government forces everyone to do something like this, and a lot of money to be spent. GE's early imaginative involvement gives us a hint of this. Again, from the American Conservative:
Obama’s plan offers between $44,000 and $64,000 to doctors who computerize patient records and up to $11 million per hospital. “On the stick side of the equation,” the Wall Street Journal reported, “the measure includes Medicare payment penalties for physicians and hospitals that are not using electronic health records by 2014.”
As for control, just think what mining the data of a national EMR (or network thereof) could produce. The possibilities could make an insurance exec or a plaintiff lawyer salivate. How about finding out who smokes, whose cholesterol is too high, and so on? Privacy? HIPAA? We'll have to rely on that, won't we? We all trust our government with our most private information, don't we? You might as well. . . Perhaps I'll add a corollary to my inflammatory statement: If the Goverment has access to your health care data, it controls your life. Bovard continues:

The issue is not whether the personal health information the government commandeers will be abused. It is simply a question of when, where, and how.

Medical data does not simply track the number of times a person goes to the doctor seeking a cure for a runny nose or stubbed toe. Medical records can include details of long-ago abortions, impotence or sexually transmitted diseases, anti-depressants and mental breakdowns, AIDS or HIV status, or any number of diseases. No information is more integral to a person’s existence—or more deserving of discretion.

We now know that psychologists were brought to the prison at Guantánamo to exploit detainees’ weaknesses for interrogation purposes. Do the millions of Americans who have received psychological treatment want government agents to have access to their vulnerabilities? Suppose that when a policeman pulls you over for a speeding ticket he can quickly tap into a database with your health records, including any therapy. Even before he walks up to your car window and demands your identification, he will know if you have a “problem with authority.”

And just so you know I'm playing fair:
But the biggest betrayal occurred with the Health Insurance Portability and Accountability Act of 1996, known as HIPAA, which left the Department of Health and Human Services to define medical privacy. When HHS finally proposed regulations in the last month of the Clinton presidency, it noted, “The electronic information revolution is transforming the recording of health information so that the disclosure of information may require only a push of a button. In a matter of seconds, a person’s most profoundly private information can be shared with hundreds, thousands, even millions of individuals and organizations at a time.” But the Bush administration blocked the proposed privacy regulations and instead issued rules that largely abolished a patient’s consent over the use of his own medical data. It rolled out a red carpet to industries hungry to exploit private health information.
Harvard law professor Richard Sobel observed, “HIPAA is often described as a privacy rule. It is not. In fact, HIPAA is a disclosure regulation, and it has effectively dismantled the longstanding moral and legal tradition of patient confidentiality.”
See? Even a Republican can set us up for abuse! This should scare us all the more.

Ultimately, I am actually for a national EMR/EHR, as it ties in with my thoughts on a widespread PACS database. But we have to do it slowly and correctly, with proper safeguards, lest we end up where the British are today:

Two major opposition political parties in the United Kingdom are in a debate over how to maintain electronic health records, according to a report in The Guardian.

The Conservative Tories would like to encourage patients to use services such as Google Health and Microsoft HealthVault.

Another party, the Liberal Democrats, support a $19 billion dollar government plan to build a national patient record database. The plan has been in the works since 2005.

With Google or Microsoft, "people can store their health records securely online; they can show them to whichever doctor they want," David Cameron, the current Tory leader said at a recent conference. "They're in control, not the state."

However, Barry Murphy, head of technology at PricewaterhouseCoopers told ComputerWorld UK that although using Google or Microsoft could save money, it could also lead to complications.

"It would...need to be accompanied by an explicit and implicit trust that the data would not be misused, abused or lost," he said.

The UK's National Health Service has been planning an electronic database for patient records since 1998, according to a study sponsored by the Robert Wood Foundation. The database is expected to see completion in 2014, four years behind schedule.

Yee Gads, folks! If you can't trust Google, you certainly can't trust the government! I'm not so sure about Microsoft, though. . .