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.

Monday, October 26, 2009

Some Australian Afterthoughts

I'm back here in the Deep South, which is a great deal further north than I was yesterday. As it turns out, my home town sits at Latitude 34.0 degrees North, and Sydney is 34.0 degrees South. Quite a coincidence, eh? Being in the Southern Hemisphere felt no different than being any other place, I have to admit. From a scientific standpoint, everyone wanted to know which way the water swirls down the drain down there. Here is a video of the experiment, performed in my hotel in Sydney:

Now, which way does it go up here in the Northern Hemisphere?

I had some great times with my friends from Brisbane, who joined me back down in Sydney for the last 36 hours of my trip. We took a ferry to Manly Beach, rode to the top of the 300 meter Sydney Tower, and ate dinner in Sydney's small but hopping Chinatown. Have a peek at the Peking Duck (which we didn't order after this preview in the window!):

OK, sorry, but the kitchen was about 4 feet from our table, and this was the dinner show!

The 14 hour flight back to LAX was mostly boring, although there was one minor event. I had just fallen asleep in my cocoon when over the intercom comes: "We have a medical emergency. Would any physicians on board please ring the call button to identify yourselves?" Not again! There was a gastroenterologist in the seat across from me who was just stirring awake at the commotion. "C'mon," I said to him, "these things are a lot more fun with company, especially for a radiologist." We trotted back to steerage, where fortunately there were two other doctors tending to the situation. It seems that a little boy who was lactose intolerant got hold of a piece of cheese and ate it. Mom was hysterical, but the kid was fine. We shrugged and went back to our cocoons for the rest of the flight.

I got through Customs quite rapidly, but not fast enough to make my next flight, forcing a reschedule. This turned out to be fortunate, as I was bumped to Business on the subsequent leg of the trip. As luck would have it, I was seated next to a pleasant fellow who looked incredibly familiar. We chatted for a while, and then he settled in and pulled out a script to read. It turns out that my neighbor was a well-known actor. I didn't ask for his autograph, nor did I take his photo, and I won't even name him, so as to respect his privacy. He treated me like a regular guy, and I'll return the favor. I can tell you he had a TV series in the '80's and has had numerous TV and movie rolls since. That being said, he was as cordial and friendly as anyone I have ever met, with no airs or condescension about him. He didn't know me from Adam's housecat, but he spoke with me as if I were a friend from way back, at one point even calling me a "young doctor". That took great acting skill!

I'm still mulling over what I saw and heard about the Australian health care system. Frankly, it is probably the one foreign operation that has any chance at all of working here. At its most basic, it consists of a governmental safety-net for all, augmented by private insurance, which most who can afford it end up buying. Without the private part (pun intended), you go to the end of the line for anything non-emergent, but with it, you can schedule your elective cholecystectomy next Tuesday if you wish. The system is far from perfect, and complaints certainly exist. A very sad case was getting attention while I was over there:

Henry Salter, aged 11 months, was found with just minor injuries in the wreckage of a car, which had left Narromine Road, Tullamore just before 4pm AEDT on Friday. Police said the car was travelling west on Narromine Road when it left the roadway, crashed into a concrete drain and landed on its roof. Henry's parents Anita, 38, and Andrew, 30, died at the scene of the accident. Andrew Salter's father David Salter said the family would care for Henry. "We'll do everything that we can to make sure that Henry knows his mum and his dad," Mr Salter told the Seven Network.

Fairfax reported the couple were on the way to their Condobolin home from Dubbo Base Hospital, where Henry was receiving treatment for breathing troubles. "Twenty years ago this medical issue would have been treated in Condobolin," Mr Salter said. "It's cost-cutting. What is the dollar value of two people?"

The drive was 2 1/2 hours each way, and Henry's grandfather blamed the fatigue of this unnecessary journey for the accident. Heartrendering, but perhaps not so much of an indictment on the system.

Whilst Australians are fiercely independent, they are quite content with their government providing the safety net. Some visibly bristled when I voiced my conservative opinion, "If the government controls your healthcare, it controls your life." Would it be the same here? I guess we're about to find out.

But now, I must rest a bit, and try to overcome the worst jetlag I have had in a while, so I can function to some extent at work tomorrow.

Many thanks to healthinc and all my friends Down Under, old and new, for a fantastic experience. I hope to return someday and see much more of your incredible continent.

A Flying Obsession

We all have our hobbies, and sometimes they can become all-consuming. Take the example from today's Wall Street Journal of Mr. Anthony Toth, who has topped most of us with this little project in his garage:

Mr. Toth has built a precise replica of a first-class cabin from a Pan Am World Airways 747 in the garage of his two-bedroom condo in Redondo Beach, Calif. The setup includes almost everything fliers in the late 1970s and 1980s would have found onboard: pairs of red-and-blue reclining seats, original overhead luggage bins and a curved, red-carpeted staircase.

His earth-bound plane has just about every last detail from an airliner of that era, including the coffee maker (which looks very suspiciously like the Cuisinart I just bought a few months ago).

I first flew on a 747, coincidentally from Pan Am as well, when I was 11 or so, and even today, I have a great fascination for the venerable Jumbo Jet. Having just done one of the longest hauls available (Sydney-LAX; there are other even longer flights, but 14-15 hours is pretty impressive) I can say that service, while excellent on Delta, probably isn't quite what it was in the golden age of travel.

I am certainly impressed with Mr. Toth's achievement in recreating the First Class cabin. What I found rather disappointing were some of the comments on the piece; many folks dissed Mr. Toth for spending his time and money on something that obviously gives him great gratification. What ever happened to live and let live, or minding one's own business? I guess these traits have gone by the wayside in our extreme drive to HELP everyone and redistribute the wealth of those who don't use it in the manner the rest of the country thinks best.

To the naysayers, I can only say get your own life, and leave this guy alone. Sharing the love of flying with Mr. Toth, I can only say this model is a fantastic achievement. You're flying better than ever!

Thursday, October 22, 2009

Dalai Speaks! Audience Stays Awake!

I gave my little talk sponsored by healthinc on Wednesday night, to a very gracious and polite audience. As near as I could tell, only my fellow American dozed off for any significant time, but I'll attribute that to jet lag and not boredom. My talk consisted of the highlights of my experiences as the premier (only) radiologist PACS blogger, and my battles with IT and various PACS vendors. The radiologists in the crowd at least were very appreciative of the comments, and I suspect that the trials and tribulations we suffer in the US are similar to those of rads everywhere. There were several folks in the audience who used to to work for or with Agfa, GE, or both. Most appeared to agree with some of my more disparaging comments, and I'm told that one GE supporter simply sunk deeper and deeper into his seat as I continued to drone on. All in all, a very satisfying experience, and I hope everyone enjoyed it at least half as much as I did.

Yesterday, I spent some time in the healthinc booth, although radiologist traffic was rather minimal. Thus I got to wander the exhibit all, and attend a few quite excellent talks. I'm not sure how to transfer CME from the Australian version, so I'll simply have to be happy with having learned something. There are about 1,800 radiologists in all of Australia, and perhaps 2-300 attend the RANZCR/CSM meeting all told. There were only three simultaneous lecture tracks (not 50 as we see at RSNA), and the exhibit floor was more the size one sees at an SNM in North America, say about a tenth the size of that at RSNA. That allows this meeting to have something you'll never see at RSNA: free lunch amongst the exhibits!

I spoke with several folks on the exhibit floor, some friends of friends of friends, some as prearranged appointments, some whose booths I just wandered in to see. The friendliness of the folks here is unparalleled, and the way they took time to speak with this Yank was much appreciated.

I spent some time at the Visage booth, looking over their new offering that will arrive at RSNA time. Visage is owned by an Australian company, Promedicus, creators of another Australian RIS. In a nutshell, version 3.2 is designed to serve as a more generic viewer, adding the ability to look at CR's and CT's and everything else to the advanced visualization capabilities. One of the Promedicus execs told me that the aim is to "behead" a PACS, overlaying their viewer on top of a dysfunctional program to be used in its stead. (I could name a few dysfunctional PACS, by the way.) This would work better with RIS-driven workflow, which seems to be more popular here. Frankly, I think the idea has merit. Of course, I should probably see if we could rig Amicas PACS to do the same thing. . . Grafting a new interface over an old PACS might give us the best of all worlds.

Speaking of PACS that no one likes. . . I've spoken to a number of Agfa and GE users here. The consensus is that their PACS sucks. Sorry, there is no more genteel way to put it, guys. I should think the fact that there is international dislike of a product ought to mean something, but that's just me, I guess.

In the rumour department, it was floating about the floor that a large vendor has something in the IT realm coming out at RSNA that will leapfrog the competition. I could find no specifics, but the story seemed real enough that I just might have to go to RSNA after all and find out the truth.

I do have to tell you about a sphincter-tightening moment. I was introduced to a very eloquent and friendly fellow at the meeting, someone who worked with someone who had attended my talk. When he realized who I was, he looked at me and said, "I got in some very deep shit because of your blog!" It seems that he had used one of my various diatribes against complicated, semi-working systems as evidence that radiologists don't like such things. However, someone else in the same operation who did want to purchase some sort of complicated, semi-working program dug through my blog and found some nasty post (I'm guessing this one), which he apparently used in an attempt to discredit me, my blog, and my position on the topic, as well as the reputation of my new friend. Fortunately, his approach didn't work, and the truth as I published it prevailed. My friend lived on in his position to fight another day. While I'm certainly embarassed about the turn of events, the ending was a happy one (for most involved, anyway) and all's well that ends well. I have to emphasize that this blog is a personal publication, made up of things that amuse me. I do confess to having a childish sense of humour at times, but that, and the ability to post this stuff, is what keeps me from needing psychotropic medication.

On a happy note, there is a wonderful place here in Brisbane called the Lone Pine Koala Sanctuary (found online at This place is home to 130 koala bears (actually they are marsupials, not bears) as well as dozens of kangaroos, and other indigenous wildlife. For a small fee, I got to hold little Barnacle here:

He's cute, but those claws could do some damage!

Back to Sydney this afternoon and home on Sunday! Cheers!

Monday, October 19, 2009

Dalai's Down Under!

I made it to Sydney without much trouble at all, but that 15 hour flight from LA did seem to go on and on and on. Business class on Delta was very nice, with each seat forming a little cubby or cocoon. The seat itself could recline to horizontal, and I actually did manage to sleep much of the way. I did try to stay awake long enough to crash about 10PM Australian time, so I'm really not doing bad at all at the moment.

Delta did indeed get me there, in comfort and style, although I do have to warn those of you who might follow about what could have been an "epic fail" on their part. There is this little thing called the "Electronic Travel Authority" (ETA) required for travel to Australia. I'm not sure what it accomplishes other than separating the traveller from $20 AU, but that's beside the point. You can't get a boarding pass without one, and I had no idea of its existence. There was no flagging at the time the ticket was purchased, nor when I tried to check in online, or even at the airport kiosk. Fortunately, the Delta agent told me I could do this via internet, and by that point, I already had my iPhone out and connecting to Australia. The ETA was purchased in 5 minutes, and I was on my way. What did we do before iPhones? It would have been nice if Delta had told me about this somewhere earlier in the process, which would have saved me a bit of anxiety.

Sydney is a spectacularly beautiful city, built around the harbour that started it all. The city itself is amazingly clean. The people are friendly as can be, and very accomodating. They do drive on the wrong side of the street. I'm not even sure which side of the sidewalk to walk on, so as not to reveal myself as a Yank.

Here I am on the obligatory harbour cruise:

The Sydney Opera House, actually a collection of three separate theaters, is probably the most recognizable structure in the world today.

Each half-shell, if you will, is a section of a sphere, rather like creatively slicing an orange:

The Harbour Bridge used to be Sydney's landmark, also known as the Coathanger. For $200, one can climb up to the top, where the flags are in the photo. I passed on this wonderful opportunity.

Today, I have some meetings with Healthinc clients and personnel. Tomorrow I head off to Brisbane for RANZCR.

By the way, it seems that the "other" Dalai will be headed down here shortly. . .

I wish I could be here to see His Holiness, but maybe another time.

I did meet with a few Australian radiologists here in Sydney, and they were quite gracious and friendly. Both owned imaging centers that would rival anything back home, with CT, MR, US, NM, Mammo, DEXA, and so on. One even had a SPECT/CT!

Rads here work very hard, reading significantly more studies than our very busy group back home. This may be due in part to having less vacation, but still the daily grind is impressive. They too have the joys of Cardiologists, although the turf issues are a bit less intense. There has, for example, been a much higher level of cooperation for things like CCTA's between the two.

PACS is becoming widespread, but there are some problems with its adoption. Bandwidth out to the clinicians is a severe problem, for example, and a 4 MB up-and-downlink costs something like $12,000 AU/year, although this was probably for a commercial-grade line. I get on my home system 6-10 MB down (but only 1MB up) for $89/month, not $1000! (I'm since informed that home-grade DSL should be rather similarly priced.

In many ways, the infrastructure here is about 6-7 years behind the US. Clinicians are only starting to buy the more advanced scanners (beyond CR and US), and this like we once were as well. In more urban areas, there is almost a glut of radiology services, and in fact one of the outpatient centers we visited today was right next door to another one! But, like Florida, give that a few years and things will likely shake out.

More to come! Tomorrow, Brisbane and RANZCR!

Wednesday, October 14, 2009

Thwarting IT Thwarting Dalai

I haven't written much about our Cerner Millenium/RadNet setup, mainly because I just don't know where to start. If the goal of the Empiric/Fuji RIS that we own for our own purposes was to make the rads' lives easier, the goal of RadNet seems to be quite the opposite. Here is a case in point, and a solution.

Simply logging in to the Cerner product is amusing. We go through a Citrix gateway, and the process takes about one minute. (From home, we need to use a remote Citrix Desktop which takes even longer to access.) OK, a minute isn't that bad. BUT... the thing automatically signs off after 30 minutes of inactivity, so we often end up logging on ten or twenty times per day. Not good. "Can we increase the delay?" we asked. "NO!" answered IT. Why? Because there is no segregation between radiologists, technologists, and other users. If they set the delay to one hour for us, this would be system wide, which apparently is unacceptable. Impasse.

But wait! Remember I said the delay was after a period of inactivity. Therein lies the solution.

There are any number of macro programs out there for Windows. My favorite (because it's free) is AutoHotKey, found at This little package lets you write fairly complex macro programs, which can move the mouse around, click here and there, and do lots of things I haven't even bothered to explore as yet.

For the current problem, I figured I would only need to have the macro push the refresh button on the sign-out window. Pretty simple. I activated the macro recorder, clicked the button in question, and then stopped recording. I was left with this script:

WinWait, PACS Appbar P1646 - Citrix XenApp Plugins for Hosted Apps, IfWinNotActive, PACS Appbar P1646 - Citrix XenApp Plugins for Hosted Apps, , WinActivate, PACS Appbar P1646 - Citrix XenApp Plugins for Hosted Apps, WinWaitActive, PACS Appbar P1646 - Citrix XenApp Plugins for Hosted Apps, MouseClick, left, 456, 77

Sleep, 100

This pushes the button once. A few extra characters gets us this:


WinWait, PACS Appbar P1646 - Citrix XenApp Plugins for Hosted Apps, IfWinNotActive, PACS Appbar P1646 - Citrix XenApp Plugins for Hosted Apps, , WinActivate, PACS Appbar P1646 - Citrix XenApp Plugins for Hosted Apps, WinWaitActive, PACS Appbar P1646 - Citrix XenApp Plugins for Hosted Apps, MouseClick, left, 456, 77

Sleep, 700000


which now brings the window to the front and pushes the button every 700,000 milliseconds, or roughly every 12 minutes. Obviously, this is adjustable to one's preference. But since our turn-around times are monitored by the powers-that-be, I leave my settings as they are, and my TAT has come down dramatically (and it wasn't high to begin with!)

Where there's a will, and with IT, where there's a WON'T, there's a way.


After careful consideration and extensive testing, IT determined that AutoHotKey was a dangerous program. Someone adequately motivated could use it to create a log-in script that could bypass the need to know one's password, and we can't have that. No matter that someone similarly motivated could (and many of my partners have over the years) simply use a wax pencil to inscribe their password on the monitor bezel (or sometimes the screen itself). Fortunately, the macro text itself, as you see above, will work as a stand-alone batch file, so we once again reach an uneasy peace, and Dalai's solution lives on.

Tuesday, October 13, 2009

New GE SPECT/CT Is Rumour No Longer!

Imaging Technology News reports the debut of the new GE Discovery NM/CT 670, the SPECT/CT camera I disclosed to the world last month. This thing is so new it isn't even on the GE website yet. So, I'm left with only the tiny picture from the article:

This still shows us the opposable head SPECT, quite reminiscent of the Varicam and the Hawkeye, (disclosing the Elscint heritage) and a standard GE-looking CT. From the IT article:

GE Healthcare's Discovery NM/CT 670, a hybrid imaging platform designed to improve workflow, dose management, and overall image quality.

The system combines GE Healthcare’s BrightSpeed Elite 16-slice CT, a newly designed SPECT gantry for greater positional flexibility, and the latest advancements in Nuclear Medicine detectors.

The Discovery NM/CT 670 platform incorporates flexible and proven workflow technology advancements from 10 years of Infinia Hawkeye innovations and installations with a modular gantry, designed to embrace tomorrow’s technology today. The BrightSpeed Elite, providing multi-slice CT performance, completes the academic system.

I'll wait to see some specs to allow a full comparison to the Siemens Symbia. Likely the 670 represents serious competition from GE in the SPECT/CT realm. Finally. See, GE? All you have to do is listen to me and you'll have a winner!

Addendum: GE's website now apparently has a listing for the 670, but I get a Server Error when I try it. Maybe you'll have better luck!

In a press release from the 2009 European Association of Nuclear Medicine meeting in Barcelona, GE had this to say:

Maintaining its legacy of innovation, GE Healthcare will announce the launch of the Discovery NM/CT 670, a
hybrid imaging platform, combining the state of the art BrightSpeed Elite 16 slice CT and an advanced SPECT system to improve workflow, dose management, and overall image quality.

“We understand that a clinician does not want to compromise,” said Nathan Hermony, general manager of GE Healthcare’s Nuclear Medicine business. “We are providing the latest in SPECT and CT technology so clinicians can explore new dimensions of disease and provide the best possible treatment and monitoring of the patient. . .”

The Discovery NM/CT 670 is 510(k) pending at FDA. It is not available for sale in the United States.

I might have worded this a little differently, seeing as it is the radiologist, and not the clinician, who will choose the SPECT/CT instrument. And I'm not sure what it means to the GE "legacy of innovation" that they have finally introduced a similar machine to the Symbia, which has been around since 2004.

Dalai Goes Down (Under!)

See you at RANZCR!

Saturday, October 10, 2009

The Roadmap to Reform

I have a number of very intelligent friends and colleagues, each of whom are better writers than I am. Sadly (mainly for my readers) I am the one who has the foolishness to expose my talents to the public.

Here is another take on insurance reform, provided not by my friend Bart, but by a different colleague, which also makes perfect sense. I am publishing this even though my friend believes in the "private/public consortium" which I do not, the rest of this vision is clear and essentially uncontestable. In the interest of balanced reporting, I present his plan in its entirety.

Without further ado....

Medicine is sick.

I have talked to hundreds of doctors, scores of hospitals, and many outpatient ambulatory medical center and hospital administrators. They all agree. Medicine is sick. They all agree, something must be done about the way medicine is practiced in America. They all agree that the state of our healthcare PAYMENT system is flawed. I have never encountered anyone who is intimately associated with any aspect of healthcare payment and/or delivery in this country who will say "I like things just they way they are. We have a perfect system." There seems to be universal agreement that healthcare reform is necessary. There seems to be universal agreement that the status quo is unacceptable. WHY THEN ARE WE GRIDLOCKED? Why are Americans so upset with our lawmakers? Why is there a schism between liberals and conservatives? Why is there no agreement between doctors and lawyers? Do doctors serve patients, or themselves? Are doctors capitalists, or socialists? What is the future of healthcare?

I have my own version of reality to present to you. I can think of only one other conflict that seems anywhere close to as epic and complex as this, the Israeli / Palestinian conflict. Just as there is an agreed upon Roadmap to Peace, I have devised a roadmap to health care reform. I would like to present it for your consideration.

The Roadmap is linear. Each step builds upon the one before it. One can not bypass the order with success. I will also suggest that our current failure in reform is because conservatives want to begin with step number 1, and Liberals would like to begin with step number 10. Conservatives do not want to see step 10 come to fruition, liberals see steps 1-4 as benefiting corporations and not patients. Meeting, and beginning, in the middle will not work. Compromise will fail. We must all see the road map, with its relative merits, inevitability, and progress sequentially, together.

I will attempt to elaborate on each point in series. But the roadmap is as follows:
  1. High deductible, low cost, catastrophic coverage insurance available on the open free market (not government provided, but perhaps government supported).
  2. Removal of exclusionary criteria from normal insurance qualifications such as pre-existing conditions and lifetime benefit maximums.
  3. Price transparency in the medical charge structure. The price of services should be based upon the demonstrated resource based relative value scale, and the price is consistent and transparent, regardless of payer.
  4. Open market for insurance across state lines, and across employers. Open markets are effective markets. Limited, restricted, or bottlenecked markets lead to price inflation.
  5. Insurance portability. Your purchased free market insurance stays with you, not your employer. Employers may offer attractive insurance incentives and health care savings account allotments in order to attract and retain employees, but your insurance belongs to you, not your employer. Employers should not be obligated to provide insurance any more than they should be obligated to provide you with transportation or groceries.
  6. Tort reform will limit the practice of defensive medicine and curb the lotto mentality held by many patients, and many lawyers.
  7. Utilization oversight. Doctors would, and should be compared with national benchmarks as to appropriate utilization and outcomes, and outliers should be examined. This may or may not be done using the payment structure.
  8. Wellness reforms. With responsible insurance companies, payors, and responsible doctors, the patient will be asked to take increasing responsibility for themselves. Healthy lifestyles can be subsidized via discounts and unhealthy lifestyles will be taxed via higher premiums.
  9. End of life care. Responsible consultation and oversight is necessary in this area, but only after the patient has become engaged in his/her plight.
  10. Universal coverage options which include both a two tiered public/private consortium, and establishment of a minimum humane level of care agreed upon by committee, paid for by all, and availabe to anyone.

I look forward to its elaboration. I am just barely idealistic, and nieve enough to think this is actually possible. I believe that heathcare DELIVERY in America is some of the best in the world. However, its PAYMENT system is among the most shameful. Our current growth rate is unsustainable. The bubble will burst….eventually.

Friday, October 02, 2009

Toledo: A Test Case for the Radiology Community

Dalai's note: The following missive was published in the newsletter of the Ohio State Radiological Society, and copied on AuntMinnie. It was subsequently removed due to "copyright infringement," but I managed to snag it before it disappeared. If the OSRS wants me to take it down, I will, but I think the message is very, very important for all of us.

Recently, a radiology group in Toledo, Ohio, was displaced by non-radiologist-led company. What occurred has significant implications, not just for the Toledo, Ohio, community, but also radiology in general. Its outcome will likely shape how, where, and for whom radiologists work in the future.

The Consulting Radiologists Corporation (CRC), a group of 19 radiologists, had provided radiology services to three hospitals of Mercy Health Partners (MHP) in the Toledo area for over 60 years. MHP, a part of Cincinnati-based Catholic Health Partners, covers seven hospitals in Northwest Ohio. MHP decided to terminate radiology services from CRC with 19 days notice on May 19, 2009. MHP entered into an exclusive contract with non-radiologist-led, California-based Imaging Advantage (IA) to provide radiology management and interpretation services to all three hospitals. This decision to change providers completely bypassed medical staff and the medical executive committees at all three hospitals. IA pushed their product to MHP using the names of Massachusetts General Hospital (MGH) radiologists and MGH resources like their 3D lab, implying that MGH would be acutely involved in the activities at the MHP facilities. High-ranking MGH faculty members were initially listed on the IA website as “company leadership,” but their listing was suddenly removed following publicity of the connection.

About nine months prior to the radiologists’ removal, MHP administrators told CRC that an outside, “independent” consultant would evaluate the radiology departments to improve services at the their facilities, and report back to CRC and the administration with their findings. CRC believed that hospital administration was acting in good faith to address some issues within the departments, and was candid with their assessment. CRC never received any report from the consultants’ findings.

The consulting firm in question, RCG HealthCare Consulting, is neither “independent” nor unbiased. Many of the board members of RCG were also listed as “company leadership” on the IA website. Several have co-appointments at MGH. There is a clear RCG-IA-MGH axis, whereby presumably RCG would evaluate the radiology department seemingly acting as an “independent” agent, while covertly pushing IA’s services, and using the MGH name to exert influence on hospital administrators. Also, there are people within the ACR leadership who serve on RCG and IA boards. ACR leaders are in their bounds to work with IA and RCG. Ethically and morally speaking, however, ACR leadership should not be in the business of displacing local radiology groups or decreasing the independence of radiology practices.

CRC has been providing radiology services in the three hospitals for many decades with a gentleman’s agreement. In spite of that, CRC had been providing services through many challenges, such as hospital administration turnover, ups and downs of the hospital business, local hospital competition, and changes due to the overall economic climate in the region. The group had always provided services to MHP through good and bad times.

During the short transition, CRC members were offered 3 to 4 weeks of locum work with the verbal understanding to work “longer term” (though not necessarily permanently) as an employee of IA. All CRC members independently decided against this offer due to its ambiguity (no written, official contract was ever offered by IA) and to maintain independence to practice medicine through a radiologist-led group. The group decided to go forward and maintained the existence of the CRC by providing services to another non-MHP hospital, group-owned imaging center, and the Northwest Ohio community at large.

Immediately after the announcement of the termination of services on May 19, 2009, the hospital administration and IA began a smear campaign against CRC and its reputation of high-quality services by various means to justify their action. This included an open letter to Dr. Carol Rumack, President of the ACR, by the CEO of IA, Mr. M. Naseer-Uddin Hashim, as well as verbal communication, meetings, and emails with hospital clinicians, staff, and employees. CRC submitted to the ACR a response to Mr. Hashim’s open letter, refuting the allegations contained therein. In writing, CRC asked the MHP administration and Mr. Hashim to provide evidence for the allegations made in the open letter and an MHP bulletin. To this date, there has been no response to the letter from either IA or the MHP administration.

The post-CRC situation at the MHP facilities are dismal. I have heard from many sources indicating markedly decreased quality of patient care, a very unfortunate event. IA is still relying on temporary, locum radiologists and utilizing help from Idaho-based NightHawk Radiology Services for both day and night work. To my knowledge, IA does not have a permanent radiologist on the ground in Toledo at this time. Many procedures, including IR, are delayed or cancelled, due to the lack of available, qualified radiologists. I am deeply concerned about the decreased quality of and delayed patient care in the community.

Another entity affected by the change in radiology providers has been a radiology residency program. MHP hospitals served as clinical training sites for a residency program under the auspices of the University of Toledo College of Medicine. CRC physicians were accredited clinical faculty at the MHP hospitals. With the abrupt departure of CRC from these hospitals, the future of the residency program was called into question. Mr. Hashim maintained that the residents could still train at the facilities after IA began their radiology services. The Program Director, who is not a CRC member, stated that the replacement of local clinical faculty members with rotating locum radiologists as clinical instructors would violate radiology residency committee (RRC) and Accreditation Council on Graduate Medical Education (ACGME) guidelines. It should be noted that the Program Director was never contacted regarding the eminent removal of CRC from the MHP hospitals prior to their removal. IA maintained in their open letter that CRC was responsible for the removal of the residents, which is clearly not the case. Despite this recent turmoil, the residency program is stronger, with the support and cooperation of non-MHP hospitals in the Toledo area. CRC is still aligned with the University of Toledo radiology residency program, serving as clinical faculty members and committed to the education of future radiologists. The future of medicine in Northwest Ohio is at stake, given that many program graduates stay to practice in the region. Cessation of the program would have made it more difficult to recruit physicians to the Toledo area.

On June 8, 2009, when IA took over radiology services at the MHP hospitals, Dr. Paul Berger, the founder and, until November 2008, CEO of NightHawk Radiology Services, abruptly resigned from the board of directors at the company. Whether NightHawk’s involvement with IA is related to his resignation is a matter of debate, however, in his resignation letter, Dr. Berger stated that “the Company has embarked on business and strategic initiatives which in good conscience I cannot support and do not wish to be a part of going forward.” Since November 2008, the CEO of publicly traded NightHawk has been a non-radiologist. NightHawk’s involvement with IA has caused a backlash against the company from the radiology community. Radiology groups have either cancelled contracts or are strongly debating doing so.

In addition, a recent analyst stated NightHawk’s future strategy should include disintermediation, that is, negotiate with the hospitals directly, thereby bypassing the intermediary, the radiology group. This statement, and the recent events with IA, forced the non-radiologist CEO of NightHawk to issue a letter to its customers, stating unequivocally that the company will not pursue that strategy. I can only presume that the backlash was strong enough to force a CEO to make such a statement.

Even though the current CEO denies pursuing such a strategy, it is only a matter of time before NightHawk deals directly with hospitals, bypassing radiologists altogether. As with any other publicly traded company, the growth of the bottom line is fundamental to growth of the stock, and therefore the profits of large Wall Street investment firms and individuals. Once the company believes they have saturated the market through working with radiologists, the only way to increase profits is to displace groups that did not sign with them. Clearly, one way of pursuing such ends is by offering hospitals an alternative to their current situation. This should be worrisome to private radiology groups.

With the abrupt termination of CRC’s services at the hospitals, many radiologists might be wondering how to prevent such a takeover by outside entities. The ACR code of ethics requires radiologists to notify the local radiology group prior to entering into talks with the hospital administration. IA did not do that, but then again, IA is not a radiology group; it is an MBA- and JD-led enterprise that employs radiologists.

The long-term health of radiologists and their autonomy regarding their practices are at stake here. This is only a trial run, and could be a harbinger of realignment in radiology. Given this and the recent debate over healthcare expenditure nationally, it is important for radiologists to realize that without proactive steps, it is almost inevitable that the field will be commoditized.

First and foremost, the ACR and its affiliated state societies need to be stronger in the protection of radiologists right to self-autonomy. As we know, the ACR is actively involved fighting self-referral, imaging overutilization, in-office imaging services, and protecting reimbursement and patient safety and quality. In addition, the ACR should be active in informing members regarding the perils of non-radiologist-led companies such as IA and NightHawk. The more members are aware of such companies, the more likely members would refrain from using or providing their services to these enterprises. It is in the best interest for radiology as a specialty, and therefore, each individual radiologist.

Second, and I cannot state this enough, radiologists need to provide 24/7 service to their hospitals through different means, such as internal call coverage or developing shared night coverage between local groups. Over the past several years, there has been an increasing reliance on services such as NightHawk to provide weekend and overnight coverage for radiologists. I hope radiology groups realize that by providing their own services, hospital administrators and patients will realize the importance of radiologists as valuable consulting physicians in their hospital.

Third, radiologists need to be more involved in the medical community in their own setting. Radiologists should be more active in the medical staff activities, involve themselves in hospital committees, and have more communication with other clinicians for patient care. All radiologists must also be active in the political process to protect the specialty from outside forces.

Time will tell regarding the long-term result of the IA situation in Toledo, and its business model at large. The situation was chronicled in a recent Radiology Business Journal issue as well as in local media outlets. In addition, the situation has been hotly debated online, in the general radiology forums at Aunt Minnie and Dr. Dalai’s PACS blog.

Thursday, October 01, 2009

A Day In The Life Of A PACS Administrator

Absolutely hilarious, and totally true. Especially the part about the radiologist. At least that what my PACS administrator tells me!

Why Don't I Trash Amicas?

Anonymous (who cleverly surfed to my site under InPrivate or some other blocking system) has this to say about my latest Agfa bash:
Oh my.. while I appreciate, and actually anticipate, your posts, is anyone else getting sick and tired about hearing of the pitfalls of every vendor EXCEPT Amicas? Come on!! First of all, I agree with you as I am not a fan at all of GE, Agfa, Siemens, and many others. In addition, I am also an Amicas user!! However, my system crashes and my system has issues, just as does every system out there. I think, and this is just my honest opinion, that readers would better appreciate unbiased views as continuing to knock the others and failing to mention your own products shortcomings is a little silly. However, this is your Blog!!! (And I still love it.....)
I really do appreciate any readership I get, and I thank Anonymous for his (her?) comments.

I have, over the years, dealt with the issue of me and Amicas. No, they don't pay me, and yes, I am a loyal user. I go out of my way to point out on most occasions that I do not believe the Amicas product is perfect. And it isn't. There isn't a "perfect" system out there. I favor LightBeam (and soon Halo) because it lets me work in the manner I prefer, with minimal obstruction.

We have had problems, and service has on rare occasions been imperfect. However, the problems do get fixed, and therein lies the difference. By and large, Amicas listens.

I rant about the other vendors because there are times when this is the only way to get their attention. The recent situation with Agfa is quite telling in this regard. The glitch causing the client to crash is a known problem, and we have been trying to get it fixed for months. The client crash is bad enough, but the examination that was on-screen at the time of the crash DISAPPEARS for several minutes. It cannot be found on the worklist or by searching. Several exams have gone unread because of this, and that impedes patient care. Early on in this process, Agfa's lower tier response was simply, "We're talking about it. Change your workflow in the meantime." That is NOT acceptable, and when I'm backed up to the wall on something like this, I use the one tool I have at my disposal, and that is what you see here. I have since heard from higher levels, and I hope there will be more progress.

To date, I have not had to go through this with Amicas. Yes, we have had problems (the damn thing runs on Windows, after all!) but they have been solved. Occasionally it takes several tries. But Amicas has the good sense not to ignore problems and not to make it seem as if it's asking too much to fix them. IF they do, I will post about it, but frankly, I'm not expecting that to happen.

The biG Entities out there have systems designed by engineers for some vague prototypical customer, and clearly, some of their solutions suck. I said this directly to one of the senior GE folks to whom I was introduced at the DI booth at RSNA a few years back. The old Centricity Web, for example, is absolutely unusable. The poor GE exec looked like I had just killed his dog. Extrapolating a bit, I take this response, and a lot of what I see and hear, to mean that the folks designing this stuff have absolutely no clue whatsoever how we, the radiologists, use their very expensive products. This filters down to service as well. The suggestion of a workflow change in the current troubles is not a bad idea, in that there are ways to keep the rads from getting their grubby cursors on unfinished exams. BUT, using that approach as a fix for a client-crashing error doesn't cut it, and it shows some level of disconnect between vendor and customer.

You might think I sit in the corner with my laptop, cackling with glee every time I write something nasty. Nothing could be further from the truth. Frankly, I hate bashing. I'm scared of the trouble I could cause the company involved, as well as my group, my hospital, and myself. But sometimes, ya gotta do what ya gotta do, know what I mean?

Nordstrom's among only a few remaining retailers follows the old dictum of "The customer is always right." I don't think I'm always right, but I know how my end of the business works, and I know when something isn't working. An issue that sinks to the level of appearing here simply hasn't been adequately addressed. Really, all I need is for the vendors to listen and respond to their customers, me in particular. I hope that isn't asking too much.

Please do keep on reading, Anonymous! Perhaps you could send me a list of your problems, and we'll compare notes.

In the meantime, maybe I'll find something else to trash!