Friday, December 31, 2010

My Piece Of The Pile

While Nuclear Medicine probably began with the Curies, Frédéric Joliot-Curie and Irène Joliot-Curie, as well as Marie Curie (mother of Irene), the true Nuclear Era began in Chicago on December 2, 1942. From the Wiki:

Chicago Pile-1 (CP-1) was the world's first artificial nuclear reactor. CP-1 was built on a rackets court, under the abandoned west stands of the original Alonzo Stagg Field stadium, at the University of Chicago. The first artificial, self-sustaining, nuclear chain reaction was initiated within CP-1, on December 2, 1942. The site was designated a National Historic Landmark in 1965 and was added to the newly created National Register of Historic Places a little over a year later. The site was named a Chicago Landmark in 1971. It is one of the four Chicago Registered Historic Places from the original October 15, 1966, National Register of Historic Places list.


The reactor was a pile of uranium and graphite blocks, assembled under the supervision of the renowned Italian physicist Enrico Fermi, in collaboration with Leo Szilard, discoverer of the chain reaction. It contained a critical mass of fissile material, together with control rods, and was built as a part of the Manhattan Project by the University of Chicago Metallurgical Laboratory. The shape of the pile was intended to be roughly spherical, but as work proceeded Fermi calculated that critical mass could be achieved without finishing the entire pile as planned.

A labor strike prevented construction of the pile at the Argonne National Laboratory, so Fermi and his associates Martin Whittaker and Walter Zinn set about building the pile (the term "nuclear reactor" was not used until 1952) in a rackets court under the abandoned west stands of the university's Stagg Field. The pile consisted of uranium pellets as a neutron-producing "core", separated from one another by graphite blocks to slow the neutrons. Fermi himself described the apparatus as "a crude pile of black bricks and wooden timbers." The controls consisted of cadmium-coated rods that absorbed neutrons. Withdrawing the rods would increase neutron activity in the pile, leading to a self-sustaining chain reaction. Re-inserting the rods would dampen the reaction.

First nuclear reaction

On December 2, 1942, CP-1 was ready for a demonstration. Before a group of dignitaries, a young scientist named George Weil worked the final control rod while Fermi carefully monitored the neutron activity. The pile reached the critical mass for self-sustaining reaction at 3:25 p.m. Fermi shut it down 28 minutes later.

Unlike most reactors that have been built since, this first one had no radiation shielding and no cooling system of any kind. Fermi had convinced Arthur Compton that his calculations were reliable enough to rule out a runaway chain reaction or an explosion, but, as the official historians of the Atomic Energy Commission later noted, the "gamble" remained in conducting "a possibly catastrophic experiment in one of the most densely populated areas of the nation!"

Operation of CP-1 was terminated in February 1943. The reactor was then dismantled and moved to Red Gate Woods, the former site of Argonne National Laboratory, where it was reconstructed using the original materials, plus an enlarged radiation shield, and renamed Chicago Pile-2 (CP-2). CP-2 began operation in March 1943 and was later buried at the same site, now known as the Site A/Plot M Disposal Site.

Significance and commemoration

The site of the first man-made self-sustaining nuclear fission reaction received designation as a National Historic Landmark on February 18, 1965. On October 15, 1966, which is the day that the National Historic Preservation Act of 1966 was enacted creating the National Register of Historic Places, it was added to that as well. The site was named a Chicago Landmark on October 27, 1971. A small graphite block from the pile is on display at the Museum of Science and Industry in Chicago, another can be seen at the Bradbury Science Museum in Los Alamos, NM. The old Stagg Field plot of land is currently home to the Regenstein Library at the University of Chicago. A Henry Moore sculpture, Nuclear Energy, in a small quadrangle commemorates the nuclear experiment.
As it turns out, several tiny slivers of the graphite, encased in lucite, were also given to friends of the University of Chicago (I assume that translates to big donors and such), and several have found their way to eBay.  A fellow Nuclear Aficionado found one a few years back:
This 25th Anniversary memento popped up on eBay not long ago and I paid dearly for it. However, there’s not much of this stuff left; all but a couple bars of this famously pure graphite went on to be incorporated in CP-2 and thereafter entombed in concrete under a nondescript field in Illinois. The eBay seller would only say “I do know that my grandfather worked on the building of the atomic bomb but other than that I don’t know much else.” I have a feeling that the human story could be interesting, but on account of the seller’s reluctance to share so much as her grandfather’s name and other “personal information,” there’s nothing more to say right now.

The momento is pictured above.

I had almost won one of these several years ago, but I was outbid at the last minute (darn snipers!) and I've been watching for one ever since. By some miracle, two of them came up for bid a few weeks ago, and I bid successfully on one identical to that pictured above.  The second actually sold for double the amount I paid, which I guess makes mine worth more as well.  It was slightly different, perhaps encased in lucite at a different point in time.

I'll never do anything historical, but at least I can own a piece of history.  What better way to start a new year than to hold a connection to the past in the palm of my hand?  No, it's not radioactive, and it doesn't glow in the dark.

Happy New Year, everyone!

Wednesday, December 29, 2010

The Doctor Dalai Facebook Page!

I owe an apology of sorts to my Facebook friends.  You see, Mrs. Dalai tried to get me hooked on Farmville a year ago, but I just don't seem to have the agricultural instinct.  She has definitely caught the bug, however, and runs my farm, her farm, and a farm for both dogs.  Thus, my Facebook feed is full of dozens and hundreds of inane entries of Farm-vile related crap, and I'm sure I've been defriended by more than one disgusted reader.

It finally occurred to me today to do something productive to solve this dilemma, and so I created the Doctor Dalai Page on Facebook.  It's not much more than a feed from this blog at the moment, but it does give me another outlet for commentary and other foolishness.

So, click "Like" below and become a fan!

Tuesday, December 28, 2010

New Years' Notes

The most wonderful part of being the Dalai Lama of PACS is, of course, the amazing people I have met.  PACS is a business for the best and brightest, and somehow they tolerate me, too. 

I received this note the other day, and I pass it on with all due humility:


I am enjoying a rare couple of days of business-free family time, visiting my sister and my mother. One of my sons is also visiting.

In just a couple of days, I have probably gone through my online routine several times. First, check the Dalai’s blog. Then, check the AuntMinnie forums. And so on.

It occurred to me that I should write and thank you for your contributions, blog-wise. Over the years, you have delighted me, confounded me, vexed me, irritated me, gotten me so mad that I have cursed you. You serve up a pretty wide range of tastes, none of them bland.

I am politically pretty far to the left, and I have these same reactions when I read the editorial pages of The Wall Street Journal. And guess what? I buy the Journal every time I have the time to read it, mostly when I fly.

So, to one of my favorite bloggers: Thank you, Dr. Dalai, for your contributions, and for the continuing delight (and other reactions) that you give me.

My best regards to you and Mrs. Dalai, and may 2011 shower abundant blessings on the Dalai clan.

All the best...
As I have said countless times, I never cease to be amazed that anyone even reads the drivel I post.  I'm left speechless.  If I've brightened the day of at least one reader, or at least made him or her think about something, then it's all worthwhile. 

Not to be lost in the melancholy of the moment, allow me to return to my more ascerbic self.

Email also brought me this unsolicited advertisement for a little PACS company that I won't name:

Hello Dr. Dalai,

Sorry you missed us at RSNA. If you really want something new and different please read. We can out perform Life Image in every way. We are looking for luminary accounts let me know if you have an interest.

It has been brought to my attention that a new and different way to see images from anywhere on any computer is needed. Even though most PACS vendors provide a physician portal the truth is most physicians will not use it for a variety of reasons. Hospitals also have a problem dealing with CD’s. It is time consuming to make them and they sometimes cannot be read even if a viewer is available. If this sounds familiar please review the alternative solution from XX. I would like to discuss how we can help resolve these problems so please respond to this email and let’s talk.

Do You Need An Alternative to Sending out CD/DVDs

Do You Need a Simple Easy Way For Your Referring Doctors To See Their Images And Reports

Do You Need A PACS But Don’t Have The Capital Funds or Personnel To Support It.

Now There Is A Way You Only Pay A One Time Use Fee Per Study.

No On Site Hardware or Software Needed, Just An Internet Connection.

Please Read Below:

PACS, RIS and Image Sharing Across Communities

The XX supports the same image interpretation and reporting as a state-of-the-art web-based PACS. In addition, it enables image communications over the Internet for on-the-fly referring physician reporting, remote consultations, trauma transfers and more—without any dedicated software or hardware requirements for remote users. As a result, it is a highly effective image communication hub for Regional Health Information Organizations (RHIOs) or entire unaffiliated medical communities, providing an important step towards universal access to healthcare information. With appropriate permissions, multiple users in disparate locations simultaneously may schedule a patient visit, check exam status, access any study, interpret an image and obtain a report.

Lightning Fast 3D/4D Remote Processing

At the same time, XX’s lightning fast 3D/4D processing overcomes the challenge of formatting and delivering interactive high volume 3D/4D reconstructed images over the Internet on-demand. XX, for example, displays the latest 4D 320-slice CT scan output comprising 6700 images (3.35GB data) in seconds, by contrast to hours using conventional PACS and 3D processing solutions. Sites with an existing PACS can seamlessly integrate this functionality into their systems, and any site can take advantage of new revenue channels for advanced visualization without incurring a capital expense.

Taking Advantage of Computer Game Technology

At the heart of XX’s unique capabilities are Graphics Processing Units (GPUs), the same technology that powers today’s advanced video gaming cards. These GPUs are made up of hundreds of small processors that handle information simultaneously, in contrast to the single central processing unit (CPU) of a typical PACS server.

“XX’s artificial intelligence algorithms running on GPU technology make XX servers thinking machines. They are capable of producing XX™ and adapted to handle the ever-increasing volumes of medical data—100 times more powerful than current PACS servers,” notes XX, president and founder of XX.

One-time Fee-Per Study

With XX, any site, whatever its size and budget, can enjoy the most advanced digital imaging workflow without system set up costs and only a reasonable one-time per-study fee. “Hardware and software capital expenses, IT staffing and physical workspace no longer are barriers to the most advanced digital imaging applications and integrated PACS/RIS workflow,” explained XX.

He notes that getting started is easy, whether XX is implemented as a first-time conversion to a digital imaging environment, a cost-effective replacement for an existing PACS, or an added advanced visualization processing engine.

The XX supports authenticated access, encrypted communication, data and access redundancy and unlimited storage for the highest level of data safety and security. XX cloud-based advanced clinical viewing software has been cleared as a diagnostic device by the FDA,
Sounds intriguing to a degree, although the talk of being "100 times more powerful than current PACS servers" seems a little over the top.  How do you measure the power of a PACS server?  Processor speed?  RAM?  Probably the most important factor is the communications network, which has little to do with the PACS server itself. 
Unfortunately, XX went on to post similar information as a comment on my recent lifeIMAGE article.  That's a no-no.

There are a lot of PACS systems out there.  Many die off from lack of funding, some scrape by in competition with the big players, sometimes buoyed by customers who can (or will) only pay for a bargain-basement product.  Doubtless there are some good ideas out there, and XX's line suggests that he might actually have some innovations buried in the hype.  But caveat vendor:  too much hype spoils your message, at least if you are approaching someone like me who actually has some inkling of what you are talking about.  I've found that the more smoke and mirrors involved in a showing or marketing a product, the more likely it is that said product isn't all that.

Words to the wise.  And by the way, don't spam.

Saturday, December 11, 2010

A Note To The Mecca

Being an infidel, I can only visit Mecca through pictures, and it is a beautiful place indeed.  Fortunate are those able to make the haj to this Holy City.

Similarly, as a simple private practice radiologist out here in the boonies, I will never work in one of the medical Meccas.  You know the places I'm talking about, those incredible Bastions of Academic Medicine, the Shining Ivory Towers of Knowledge, the Shrines to Higher Learning, the Embodiments of Perfection, the Last Hope and the Last Chance.  May my friends and family (and I) never require your services.

Let me address the Mecca (it doesn't really matter which one) directly. 

Dear Mecca, I have more respect for you than you will ever know.  But it seems that the feeling is not mutual.  I received a letter from one of your patients today, a gentleman who was very distressed with me based on things he heard from The Mecca.  And I don't blame him.  Mecca, you told my patient that I and several of my partners had missed or misinterpreted a number of findings on his radiographs.  He was very angry, having been told by The Mecca that his disease could have been arrested earlier, but for our error.  Which of course would never have happened at The Mecca. 

Well, Mecca, I have had the chance to review the images in question.  Something is wrong.  There was no miss, no failure.  The lesion the gentleman stated clearly that you pointed out to him in a particular spot is nowhere to be found on his images.  Mecca, we have a problem. 

Ill patients, especially those who desperately seek help from The Mecca, are almost by definition scared and anxious.  I'll certainly grant the possibility that the gentleman in question didn't hear or didn't understand what he heard from The Mecca, but frankly, some of the specifics are so, well, specific, that I really have trouble accepting that explanation. I have to take my patient at his word, and assume you did tell him these things.  Was this to make you feel good about yourself at the expense of some nameless, faceless doc out in the boonies?  I can't imagine that you would sink so low.  Unless, of course, you are attempting to justify the metastasis of Mecca Medicine throughout the land, one patient at a time.  We've heard the claims from The Meccas over the years that simple radiologists like me aren't up to the job.  Are you trying to spread the Gospel of The Mecca via the patients who seek your help?  Is that what I'm up against?

I confess to you, Dear Mecca, that I'm human, and I make mistakes in this business, as does every other radiologist who has ever read more than one examination.  I'm sure there are some mistakes made even at The Mecca.  In this particular gentleman's case, we did not make a mistake, and you haven't done him any good by implying that I did.  Please, I beg of you, measure your words carefully when you talk with your patients.  They hang on everything you say, as if it meant life itself.  Which to them, it does.

And to the gentleman himself, whom is no doubt Internet-savvy and may be perusing this message as we speak, I have this to say:  The goal of everyone in this business, whether they are at The Mecca or in the boonies, is to keep you healthy.  You, the patient, are the most important person we deal with.  We all try our best.  Sometimes that isn't enough, and we will always keep trying to do better.  I do hope you received the finest of care from The Mecca, and while I disagree with their interpretation of your images, I still have respect for them, for your sake more than mine.  I wish you a full recovery, and happiness and good health for many years to come. 

Salaam alaikum.

RSNA 2010: Something Old, Something New,
Something Borrowed, Something....Green

For my final installment on RSNA 2010, I'm going to tie up a number of product observations into one rather large knot.  Hopefully it will all make sense in the end.

The software I'm going to discuss is in part stuff I've reviewed before, hence, something old.  There are some differences and enhancements here and there (something new) and some features that seem to cross vendor lines, although I'm sure they aren't really something borrowed.  And something green, well... that would of course refer to the larGE vendor that likes that color, which coincidentally is also my favorite.

After dabbling with the Discovery 670 SPECT/CT and the Xeleris station, I wandered over to the PACS-ville neighborhood of GE City at McCormick.  I met with some old friends, and made some new acquaintances.  I have to tell you, I really like the people at GE, especially those I have known from their previous lives.  These are good folks, and they are dedicated to releasing a decent product.  Which they will eventually. 

GE is still showing, and perhaps finally shipping, seven years after introduction, an integration of the Advantage Workstation to Centricity PACS.  AW Server, like pizza, is sold by the slice, with server configurations able to handle 8, 16, or 30 thousand concurrent sections.  Beyond this, one has to add more servers which are load-balanced.  Manipulation is then performed right in your Centricity 3.3 (or was that 3.2?) PACS window.  Very nice. 

Centricity 4, the latest version of the RA 1000 client, was on display, and it has some substantial improvements.  First, it is skinned in dark grey, much easier on the eye in a dark room than its predecessors.  It has the "SNAP!" tool (no, this is not a substitute for saying a dirty word) which basically is a tiny viewport pallette that appears upon double-clicking, and allows for image manipulation.  It is supposed to eliminate some back-and-forth to the toolbar, and I think it would be helpful after being used enough to become intuitive.  This component appears to be a direct port from the Dynamic Imaging Integradweb.  There is native MPR, and 3D images can be built into a hanging protocol.  But when I asked how many measurements could be displayed on an image, I was saddened to see that this number remains at four, and only four.  Why would we want to see more than that, after all?  Sadly, there are some nasty diseases that manifest themselves with more than two findings on any one image, and bidimensional measurements of more than two lesions require more than four measurements.  That's why.

It's nice to see Centricity 4 approching the usability of AMICAS 3 from 7 years ago.  I'm sorry, guys, but if you were to look at other products, such as the very fine software you purchased a few years ago, you would see where you need to be. 

Speaking of IntegradWeb, it does appear to be fully functional at last, reincarnated as the Centricity PACS Web Diagnostic (Web DX 2.0).  I presume this will finally take its place as the Centricity web viewer.  At least, I hope it will, as the old Centricity Web Viewer is without question the absolute worst viewing software on the market, bar none.  Nothing personal, guys, but it is literally that bad.  Burn it.  Seriously.  I mentioned this to a GE exec years ago, which shocked him to no end.  Maybe no one else has let GE know just how horrid this program really is, which would be very surprising.  I still have to use the old Centricity Web, and it is as much an exercise in agony as one can find in this business.  Have I said enough?

If I were running GE PACS, I would personally ditch the RA 1000/Centricity front end altogether in favor of IW, but that's just my own humble opinion.  I'm sure there are some legacy reasons for keeping the old Centricity alive.  Perhaps because there are a zillion Centricity sites out there that need care and feeding.  Oh, well.  I don't run GE.  I don't even run my house:  the two dogs have full control.

Let's shift gears to some different software, that for PET/CT viewing.  One of the old DI crew has prepared some very nice software for this purpose, based on the IntegradWeb 3.7 platform, although it is not yet released for public consumption.  I had the chance to compare it to the two big names in this venue, Mirada and MIM Software (formerly MIMVista). 

All three programs have mostly similar features, which I would deem necessary and sufficient for PET/CT reading.  No, neither my Siemens Leonardo or the AW 4.3 have many of these features at the moment, although my soon-to-be installed Segami system will.  At least I think it will. 

When one reads a PET/CT, there are several machinations involved.  First, you have to match the PET to the (almost) simultaneously acquired CT.  This shouldn't be a problem since the patient is scanned on the same gantry, hopefully without moving.  But sometimes they do move their heads or something, and it's nice for the machine to automatically register the PET to the CT.  (Note that this same mechanism can be used to match a PET to an MRI, saving $5 million on a new Siemens mMR hybrid.)  If there is a prior exam, and there usually is, you have to go through the same conniptions to match the old anatomy to the new.  These programs can all do so by rigid manipulation.  In other words, we take the old study, and shift it, zoom it, rotate it, basically do anything but distort it, and match it to the new exam as best as we can. 

Now, the Mirada 7D program can go one further, and actually deform the old study, pulling a bit here and tucking a bit there, to provide a more exact match.  I was told that the MIMfusion 5.1 could do this too, although I didn't have time to see this happen.  The DI, I mean GE prototype does not deform as yet.  This version registers via bones, the next will use organ margins for the match-up. 

All three can track a lesion from the old to the new study.  GE has the physician identify the border of a lesion with the computer creating an ROI, which is propagated to the new study.  The lesions are labelled, and a table created which documenting the change in size and/or uptake of the lesions.  Mirada and MIMfusion work similarly.  Mirada allows definition of a region via maximum SUV with subsequent edge-detection.  RECIST and PERCIST measurements are easily generated along with the table of other information.  MIM uses scripts to automate the workflow yielding automatic contouring for the lesions (PET EDGE gradient detection), again with manual definition or threshold-detection possible. 

Both MIMfusion and Mirada XD3 have versions of clinician portals.  Mirada is working on a rather nice feature, called Case Meeting, which encapsulates everything you need for a tumor-board presentation. MIM, of course, is working on the iPad/iPhone app, which is the reason I bought my first iPhone a few years back.  Their new version does a very nice job of displaying a fused study.  MIM also has access to cloud storage.

MIM has completely redone their interface with a new flexible layout and new icons.  There are multiple options on both for hanging protocols. 

The GE opus isn't available yet, but both MIMfusion and Mirada XD3 can be yours today for something like half the price of a Tesla Roadster.

Frankly, I am very impressed with both companies, (Mirada was recently bought back from Siemens by its founders) and both pieces of software.  When I encounter this situation, I usually punt, and I'll do so again in this manner.  Here we have two companies competing against each other, offering similar paths to the same end.  The obvious solution is for these two fine operations to merge in some fashion.  Their individual strengths could thus be compounded into a true killer-app.  I'll take a free copy of each program for providing that suggestion.

In the meantime, I do have to close with a report from another great company, Calgary Scientific.  I was able to visit with their principals, who appreciated the warm weather offered by Chicago this time of year relative to what they had back home.  I don't have a lot more to tell you than I did back when I wrote my iPad article last summer, but I got some more hands-on time with their products.   FDA approval for ResolutionMD, the client-server viewer, is apparently imminent, so it can be used diagnostically.  But the real show-stopper is Calgary's ability to port ANY software to the iPad, iPhone, or pretty much any other device with the PureWeb platform.  This is phenomenal, and opens up a lot of possibilities. 

And there you have it, my experiences at RSNA in several divided doses.  Did I mention that it was bloody cold in Chicago?  There are ways to warm up, however, as Mike Cannavo, the One and Only PACSMan, documents nicely:

That's me in the black with Mike and the crew.

El Grande!  See you next year at RSNA!

Friday, December 03, 2010

RSNA 2010: Bill

Seeing a President of the United States in person is something you never forget.  I've managed to be very briefly in the viscinity of every President from Nixon on up through Bush I, and on Tuesday, I sat 12 rows up from the stage where Bill Clinton spoke at RSNA.  I suppose I'll have to wait until GWB and even Barack Obama come to town for a book-signing or something.

Bill was paid $100,000 for his speech, and it was certainly the biggest draw ever at RSNA.  Special tickets from RSNA were required, and these were sent out separately from the usual thick envelope we all receive at this time of year.  (I had to have several other vouchers reprinted, and which included by mistake a second ticket for Bill, which I gave to one of my daughter's medical school friends.  Don't hate me; the kid was a big Bill fan.)  Entry to the Arie Crown Theater at McCormick was to commence at 12:30 P.M. for the 1:30 P.M. speech.  By 12:15, the line wound completely around the theater and almost to an exit, and I would guess there were at least 1,000 people waiting.  But once the doors opened, there was smooth sailing, and I landed in a rather good seat.  Of course, photos were prohibited, so I took one, along with everyone else. 

President Clinton has a lot of charisma, and knows when to bite his lip just at the right time to sound and look sincere.  I have to say, though, that the talk was rambling, and Bill seemed to stagger from one point to the next, sometimes not quite making it there.  He took a number of gratuitous shots at the Republicans whilst on the way to wherever, chiding them for wanting to continue the Bush tax-cuts which would "cost" $700 billion.  (I don't think it costs the government anything NOT to take my money, but it would COST ME a lot!)

Ultimately, the talk was about the inequality of health care in the poor nations, specifically the dismal state of diagnosis and treatment of cancer in the Third World, and he is certainly accurate in his description.  Of the 8 million cancer deaths annually, 70% occur in nations that get only 5% of resources.  Powerful statistic.  But the talk became much more about blaming the rest of us.  We shouldn't be asking about government vs. private control, he said.  The REAL question is are we going into the future, or staying in the present?  Sadly, the implication is clear:  only the STATE (as run by Bill, Hillary, Nancy, Bawney, etc.) can take us into the future. 

The world is unequal, unstable, and unsustainable as it stands, according to Mr. Clinton.  With that I agree.  But I don't agree that it's my fault, nor that we have to dump our healthcare system and throw all possible resources to the Third World to change this.  In MY humble opinion, what Bill failed to mention is WHY the developing countries are in such dire straights, and why simply throwing money at them won't help. In large part, the problem is not as much one of resources as distribution. The Third World does not have an adequate infrastructure to deliver health care to most of its population, and that is due to the level of corruption often found there. We can ship over an entire cargo vessel full of needed supplies, food, medication, whatever, and weeks later, find much of it for sale on the black market, diverted from those who truly needed help. These nations must fundamentally change their ways before anything good can happen.

Of course, Mr. Clinton wouldn't want to address that, because folks in the rest of the world (except Israel) can do no wrong, and we can do no right, unless we follow in lock-step with the Liberal Agenda. Left-leaning folks over here rend their garments over the horrible discrepencies between rich and poor in America, but it's OK that some Sultan or former sargeant-turned-Colonel can live like a king (literally) while his people eat dirt to stay alive (literally). 

Yes, we have an obligation to help the rest of the world, but the rest of the world has an obligation to itself that it isn't fulfilling.  When Bill wants to talk about that, I'll be listening. 

Mr. Clinton certainly has put his efforts where his mouth is, and he was not hesitant to tell the audience about some of the great work he has done since leaving office.  And he has done a tremendous amount of good, far more than I'll ever accomplish.  That level of gravitas and power comes with the title of Former President.  However, I'm a little peeved about his taking $100,000 of our dues money to more or less chastize us as he did.  I'm a little peeved at the RSNA as well, for that matter.  Was there some message the leadership wants to impart to us, but needed Bill to voice?  Are they really our advocates, or looking to globalize radiology, and hoping to average out radiologist incomes to a annual level way below what Bill got for his hour of lip-biting? 

Hopefully Bill will put our money to good use and donate it to a Third World nation.  Let him feel our pain, too.

ADDENDUM:  Rumor has it that Bill received $150,000 for his ramblin' wreck, but that this was paid by some anonymous donor.  Nice.

Thursday, December 02, 2010

RSNA 2010: Two SPECT/CT's

The one piece of equipment I would really like to have is a SPECT/CT scanner.  For some reason, our hospital doesn't want to part with the $1 Million or so that one would cost, but I'm hoping that the claim of having an extra CT in the house will help my case.  We'll see.  Maybe I'll just buy the darn thing myself and park it in a trailer...

My criteria for the scanner remain fairly simple:  I need an excellent SPECT camera integrated to an excellent, DIAGNOSTIC quality CT.  That's it.  Until recently, only the Siemens Symbia T series fit the bill, but as I have reported earlier, GE finally listened to me and put a proper CT, the BrightSpeed 16, in the package, creating the Discovery NM/CT 670.  The 670 comes in only one main flavor, with the 16 slice CT, while the Symbia can be had with 2, 6, or 16 slice versions.  Beyond that, the hardware differences between the two are relatively minor.  The GE has semiautomatic collimator change, while the Siemens will do this all by itself.  There are various automatic protocols for scanning and QC, and even center of rotation correction.  Both have 70cm apertures and both can handle 500 pound bar-be-cue addicts as we tend to have back home.  The Symbia has been around for a few years, and it is mated to the older Emotion CT platform.  Although this is still being sold, the upgrade paths for Emotion are not as robust as those for the newer BrightSpeed, and some of the newer software toys are not going to be available.  CARE, one of the dose-reduction initiatives will go Emotional, if you will, but SAFIRE, the iterative-reconstruction software, won't.  I didn't get dose figures, but I'll have to assume we won't clear that 2.4 mSv threshold.  I could be wrong. 

GE touts the new version 3 of the Xceleris computer for acquisition, processing, and viewing, although the viewer is rather busy and doesn't do some stuff that the AW workstation does do such as edge/threshold detection of a lesion.  There is, however, rigid registration of an old to a new study, and red contour lines are superimposed to confirm the match.  It is possible to superimpose two molecular imaging studies (PET or SPECT) over one CT with a triple color map.  There is some new cardiac software, which allows CT acquisition for just the rest or a stress nuclear perfusion which will then apply it to the stress or rest images respectively.  "Cardiac Morphing" gives a more accurate "splash" display, which can show the various slices of a perfusion study corrected for time.  In other words, I can see all the slices as they would appear in end diastole or end systole, which gives a bit different view than the conventional summated slices. 

Siemens is still showing the eSoft software I've been using with my Biograph PET/CT.  There is now a remote client,, which (finally!) allows viewing on any computer.  I did not see anything about how syngo.via might be used for processing or viewing the Symbia images.

Images.  Here's where I'm going to get myself in trouble.  I've just gone through an ACR accreditation at one of our places, and one of the older cameras didn't do well with bone SPECT.  Thus, I wanted to see how each of these new toys would do in that space.  I have to say both produced rather similar images.  And they were not great.  Now, when you superimpose the blobs over the CT acquired contemporaneously, they don't look so bad.  But viewing a bone SPECT on each workstation from the sample data that is always present at a trade show was, well, disappointing.  The vertebral bodies were muddled, and not clearly demarcated.  Disc spaces were faintly seen, if at all.  One team tried to refilter the data, but to no avail. 

Since I don't have funding at the moment, I have the luxury of sitting back and watching for improvement.  To be scrupulously fair, I'll probably have to see both of these battleships out in the field, with live data rather than the canned-RSNA images.  Now that I've dissed both machines, I'll bet the next bone SPECT on display will be incredible.  I'm hoping to see clearly, without having to use much imagination, some sharper images.  But then we are talking about Unclear Medicine, aren't we? 

More to come from sunny, but extremely cold and windy Chicago.

Wednesday, December 01, 2010

RSNA 2010: Merge

You might think that the folks at Merge do nothing but play all day.  Their booth here at RSNA has an entire section devoted to a video arcade (see above), and a wall of candy bins.  The major attraction, however, was this fine Tesla electric roadster in Merge Orange. (Yes, that is a stock color for Tesla.) 

Merge actually owns the car, and will use it for advertising purposes.  I certainly got a jolt out of sitting in it, mainly because one has to free-fall into the seat which is about 1cm off the ground.  Getting out is a bit of a production for someone my age as well.  The Tesla's body is designed by Lotus, but mine isn't.

I finally had the opportunity to speak with Michael Ferro, Chairman and CEO of Merrick Ventures, which owns Merge.  I came away from this 5 minute face-to-face meeting exhausted.  This fellow has so much energy he could probably charge up the Tesla just by looking at it.  Once he realized who I was, though, he perked up even more, and (most embarrassingly) made a point to bow in my direction, claiming not to be "worthy" to speak to Doctor Dalai.  The guy knows how to deal with pretentious folks like me!  I just wish I'd had a camera to capture that moment.  And as if I weren't flattered enough by that point, he went on to say that "the only things I read in this space are your blog and, and your blog has a lot more influence!"  From your lips to God's ears, Mr. Ferro.

We spent a few more moments discussing the state of Merge and healthcare.  Michael's dedication to reshaping the landscape is clear, and he noted that he does not draw a salary from Merge.  The company took on a tremendous debt to buy AMICAS, and all possible funds are directed to paying that back, although much is still devoted to R&D.  Mr. Ferro is not so much interested in leveling the healthcare playing field, as in boosting the position of Merge customers on that field.  As a Merge customer, I'm OK with that.  The goal of making Merge a Billion Dollar company is still front and center, and I do think it will happen.

As the boss had to head home for a few moments to see his kid's ballgame (that's the kind of CEO I want to be when I grow up), I was handed off to Justin Dearborn, formerly CEO of Merge, and now President of Merge, as well as Jeff Surges, the new CEO of Merge, and former President of Sales at Allscripts.  I'm not sure if moving from CEO to President is a promotion or a demotion, but both titles sounds rather impressive.  I had met Mr. Dearborn earlier this year on my visit to Merge HQ.  He is as quiet and deliberate as Mr. Ferro is flamboyant. Mr. Surges also seems a bit more restrained than Mr. Ferro, but here everyone is on the same page, and that page is to bring Merge to the forefront of healthcare IT.  We discussed, among other things, how we radiologists could be helped though the maze of Meaningful Ruse, I mean Meaningful Use, and this is something Merge will leverage in its favor, as well as that of its needy customers (like me).  There is a significant amount of reward money to be had (on the order of $44,000 per doc) from the government for implementing a meaningfully usable EMR, and there are penalties for those who don't take the cash.  Only the government could come up with something like that, but I digress.

As a legacy AMICAS customer, the one thing I want even more than a $44,000 handout, or even a Tesla (well, OK, I'd take the Tesla instead, but..) is confirmation that the upgrade roadmap I was given earlier this year will stay in place.  The President and CEO assured me that it would, and I was able to see signs elsewhere in the booth that this is so.  More on this momentarily.

After the meeting with the execs, I had a chance to wander the booth and see what's new.

My first stop was to see my pride and joy, the Halo Viewer in AMICAS 6.0/MR4.  It should be clearly noted that MR4 is the first to be released under the Merge banner, and it shows significant incremental progress as compared to the older version (MR1) that I have on my test server.  To be fair, most of these were present in intervening service releases that came out, or were supposed to come out, before the Merge-r, but they are new to me.  There is 64-bit support for 3D functions, and the whole thing is now Windows 7 compatible.  I would be happier if it was Mac compatible, but I've learned not to ask for that one anymore from most any company, although Intelerad recently took the plunge into Mac-dom.  There are a number of other improvements, such as a nicer interface for the customization of the fast-right-click sequence, and a smoother implementation of the multi-step hanging protocols.  There is a History button that allows rapid access to the last 25 exams (or more if you set it that way).  An outside CD can be loaded in the viewer on the workstation without uploading to PACS.  The latter is possible, although this may need a PACSGear appliance.  The multidimensional RealTime Worklist is much as it was.  Keep in mind, you can have more than one open and visible at the same time.

There was a little hushed talk about what version 6.1 might or might not have, and not much was said because most details are still in flux.  That probably applies to version 7, the, ummmmmm, Merged PACS supposedly blending the best of AMICAS, Emageon, and Fusion/Matrix software.  Of course, no one knows just how that patois might look just yet, and I'm hoping for an invite to the new and improved Advisory Committee so I can offer my biased opinions.  It does appear that 6.1 will use the ECM, or Enterprise Content Management, the old Emageon VNA, as its back-end.  I expect Merge will be able to get this integration accomplished a bit faster than some of their counterparts managed with a similar move.  It helps that there are already 300 ECM's out there, integrated to various other products. 

Interoperability is the name of the game for the future, and Merge wants to be a big player in that arena.  I never understood why until today, when a former Click colleague of Mr. Ferro's told me a story to which many can relate.  It seems that around the time Michael sold off Click, for a very large sum, he began to experience headaches, and the local docs couldn't find the reason.  He carried his jacket of films from place to place, and in many instances, he was told that he had to have a repeat study.  There had to be a better way, and the purchase of Merge was the first step in the quest to find it.  

Ultimately, the idea is not dissimilar to my desire to fix the portable patient mess, and Merge attacks it in a different manner than lifeIMAGE.  By leveraging various items from their acquired toy chests, Merge has assembled iConnect, "The Next Big Thing In Interoperability".  (At least they don't claim it to be a big f'n deal, although it has potential to be just that.)  The concept is simple, really.  All we want to do is access any image on any device at any time.  Simple?  No, it's not, not at all.  But the iConnect portfolio offers one path toward the greater goal.  

  • iConnect Access is a web-based platform-agnostic viewer, using AJAX for display.  It works very nicely on the iPad with a limited tool-set, and even better on a PC or a Mac with additional tools.  It has 510K approval for diagnostic reads.
  • iConnect Share is a drag-and-drop solution for studies on CD.
  • iConnect VNA is the ECM from Emageon as noted above.
  • iConnect Exchange is a bundle of the above modules.
  • iConnect DR uses the various components to establish a disaster recovery plan.
  • iConnect Kiosk is the free-standing registration portal I mentioned earlier.  
  • iConnect PHR allows storage of images from the other 'ologies, Pathology, Ophthalmology, etc.
As an aside, another vendor asked me if the Merge Kiosk would accept a patient-entered CD.  At this point, the answer is no.  But I asked my friend Luc, director of that part of the project if that was something they might add.  He considered it for a moment, and thought it might not be a bad idea, but thought the logistics of trying to get a patient to deal with a balky disk would be too hard to overcome.  I tend to agree.

I'm becoming more and more comfortable living under Merge management.  I had my fears, as you all know, but I think they have been proven mostly baseless. This is a somewhat different healthcare journey than I had signed up to take, but it is worthy none the less.

And now, if you'll excuse me, it is time that iConnect with a friend from Perth for dinner here in frigid Chicago.

RSNA 2010: Carestream and Sectra

Being a Personality in the PACS field (I doubt this is a goal to which many folks aspire) has significant advantages, one of which is the opportunity to be friends with some great people.  As Doctor Dalai, I'm in mild demand to come have a look at this product or that.  So far this trip, I've demo'ed Sectra and Carestream, the former at the request of Mike Cannavo, the One and Only PACSMan, and the latter at the request of Garn, our once and former AMICAS salesman.  (Actually, I go way back with Garn's family...his father and sister sold my group its first Image Data PhotoPhone system back in 1989.)

Let's start with Carestream.  Personally, the first thing that comes to mind when I hear that name is some sort of urological appliance, but I guess I'm the only one who has that problem.  In case you didn't know, Carestream was once Kodak's health imaging division, since bought out by Onex, a big venture-cap firm.  The software is written by Algotec, an Israeli firm with which I also have history, as they wrote the viewing software for our old Elscint CT's.    

The latest and greatest version of Carestream's RIS/PACS 11.1, bears only slight resemblance to the Algotec product I remember from SCAR (now SiiM) 2003.  This is a .NET program, which is self-deployed via web browser, like most of what's out there these days.  

The Archive Explorer is Carestream's flavor of worklist, and it is folder-based, somewhat like the Synapse approach.  The worklist disappears when a study is brought up on the viewer.  While the worklist is adequate, it doesn't give the real-time color feedback as I have come to know and love with AMICAS.  

The viewer itself has some similarities to the newer versions of Microsoft Office, with tabs and tools much like Word or Excel.  The toolbar and right-click menu can be customized.  When the viewer is active, a "mini archive" appears on the left-most screen, which includes priors although multiple filters can be applied to this display.  The thumbnail images can be dragged to a miniature representation of the monitor set-up for display.  

Display protocols are automatically launched based on study attributes.  Advanced visualization can be included in the arrangement.  

Carestream has included one rather spectacular function, that of automatic registration of a study of any cross-sectional modality to one of the same or any other modality.  Thus, an old and a new CT could be registered to one another, facilitating comparison.  A PET and a CT, or a CT and an MRI could be similarly linked.  The algorithm doesn't deform the comparison, but it will convert it to an MPR which might allow for a little closer match.  This is something I've only seen in advanced visualization programs, and it would be very nice to have.  

The system can bring up multiple old comparisons, but there is no clear flag or signal to let you instantly realize which is the current exam and which is the old one, and that could be problematic.

There is a rather complete vessel segmentation program that will identify the major blood vessels all by itself, and this works for coronaries as well.

There is a native report generator which is templated based on the study, and there is speech recognition with AutoText (precanned reports).

Carestream has a solution for enterprise viewing called SuperPACS, which essentially places a layer on top of disparate systems at multiple sites.  An "agent" wraps around the local system and builds an index, and Carestream's unified/integrated reporting allows easier distribution of the dictation back to where it belongs.

The Cloud is big at Carestream.  The company owns ten data centers around the world, and is the largest supplier of cloud solutions.  

There is the now-obligatory iPad app with a zero-foot-print viewer.  It is patient based, and displays in HTML 5, since Flash won't work on the 'Pad.  

Sectra, made in Sweden, was once the supplier of Philips PACS.  Philips sadly dumped them for Stentor iSite, and Sectra had to go it alone in this country under its own name.  It recovered from the experience well, and to its great credit, never once (at least publicly) acted the part of jilted lover toward Philips.

Sectra started the demo with a view of its prototype Visualization Table, a huge screen embedded in glass or plastic, designed for, you guessed it, autopsies!  I tried to get Mike to lay his head down over the image of the spinning skull (the screen uses multi-touch type gestures to manipulate 3D images), but for some reason he declined.  

We then saw Sectra's obligatory iPad app, which was a little more robust than some, and was able to stream the image for instant display gratification.  We also saw the latest app for Windows Phone, which was actually rather more powerful, having a limited but still pretty good subset of the main worklist available at your fingertips.

And on to PACS.  There were several Mikes present in the booth, and the Mike that ran the demo did a great job.  It was only after he was done and I was sliding off my stool (no comments) that one of the other Mikes told him who I was.  He did recover well, but that brief flash of panic made me wonder just what my reputation has become out there in the big bad world of PACS.

Sectra has done something either very good or very bad, depending on your point of view, placing a fourth monitor on the right of the usual three for a RIS display.  Of course, you don't have to use it, and the workflow can be driven by either RIS or PACS.  

The left-most monitor usually contains the information window, which is mostly similar to the last incarnation of Sectra PACS I saw a few years ago.  Basically, it consists of customizable panels which include the list of worklists, the worklist itself, a patient history panel, and a document/order and report panel.  This is a very busy screen.  Worklists are highly customizable, and can search across an enterprise, even tapping other connected PACS.  A little eye icon appears on the worklist in front of patients that are being read by someone else.  The worklist does not use color other than that little green eye, and the background of the entire Information window is a little about darkening it a bit so as not to dazzle my green eyes?

Filters can be applied to worklists for searches, and there is a nice big banner that comes up to tell you that filters are in place.  This may not sound like a big deal, but when you have some entry in the far right field of a search window that you forgot about, and you can't get any search results, you realize that such a warning might be a darn good idea.  Here that, Centricity?

Sectra does clearly mark the studies as to current and prior.  

The cursor wraps around the screen, which helps limit mouse movement.  (Believe me, it works.)  

Hanging protocols have improved somewhat from the old version.  There is an unusual combination of text and dragging windows around to create a hanging protocol.  It is still a bit harder than AMICAS' version, but much better than Agfa's (which doesn't work at all).  Staged hanging protocols are available.

High-level visualization, including PET/CT fusion and comparison, is accomplished through outside programs, with Mirada 7D recommended for PET in particular.  

For those who are allowed to import CD's, there is a "temporary merge" function that will let you treat two patients as one.  Very powerful option, but I do advise extreme caution when using it!

There is an optional Image Central which can be used to import non-DICOM studies into the PACS, thus serving the 'ologies other than Radiology.

Sectra uses off-the-shelf graphics cards to drive the high-res color monitors on its workstations.  

So, here we have another tale of two systems, and this time both are worthy of praise.  Neither is perfect, but I would be content to use either one.  In my always humble opinion, both could use a few tweaks, and I've mentioned a few of them above, but both companies seem to be interested in satisfying their users, which they appear to have done.

I'm not really sure why neither has had great penetration into the US market.  These are worthy contenders, and perhaps with a bit more (OK, a LOT more) publicity, they could be right up there with some of the larGEr vendors.  

Stay tuned.  More to come.

Tuesday, November 30, 2010

RSNA 2010: lifeIMAGE

My first stop on the exhibit floor was a visit to many old friends at lifeIMAGE.  I have to resist the temptation to refer to LI as the New AMICAS, but you could forgive me if I did, for many new and recent AMICAS graduates have found their way over.  These are the people that made AMICAS what it was, and I have no doubt there will be a repeat performance, although with a slightly different destination. 

You may recall my piece about lifeIMAGE from August, 2009.  Since then, there has been significant progress.  Let me bring you up to speed.

lifeIMAGE has a simple goal:  "lifeIMAGE helps you break down the barriers and provide real-time access to trusted sites and individuals. Our solutions help you deliver results of recent exams or the entire imaging history to community physicians and patients alike."  This is the answer to the "portable patient" I have bemoaned on AuntMinnie and elsewhere, and quells the disaster I live through every day.  At our oncology clinic, for example, I have to compare at least 5 CD's of outside studies with the current exam on PACS most every day.  At the trauma center, not a day goes by without a trauma victim bringing in a CT on a CD; if it won't open, or if it got lost in the ambulance, the patient gets scanned again.  Can you say "radiation"? 

LI has about the best answer I have found for this very serious problem, short of wiring the entire country together:

Millions of patient CDs

Today, imaging information often arrives on CDs with patients visiting physician offices and clinics throughout a healthcare enterprise. With lifeIMAGE, users can instantly upload, view, and share the outside exams from any workstation. Busy specialists save valuable time with automated workflow for identity reconciliation and push to PACS features.

Secure transfer from referral sites

Ideally, imaging information should arrive before patients' appointments or transfers. The lifeIMAGE service enables physicians to receive the data from anywhere without requiring any software at the sending end. The service improves referral flow, creates opportunities for second opinion and distance consulting while saving time and avoiding duplicate and unnecessary scans.

Electronic delivery of results

Specialties such as Orthopedics, Cardiology, Neurology, and Oncology most frequently refer patients to facilities that deliver results with high quality of service. The lifeIMAGE cloud-based result distribution system sets a new bar for quality. With our service, results and notifications are delivered automatically or on demand and the referring physicians or patients can collect results from any facility in one place.
There are three basic components, which have evolved nicely since I last had a look:
1) For facilities that receive a high volume of outside exams (patient CDs) and/or perform a high volume of imaging exams with outgoing results, the ideal network gateway is LILA™ (lifeIMAGE Local Appliance).

2) For facilities that refer a reasonable number of patients to larger facilities and would like to electronically send patient imaging history to other sites, the ideal network gateway is LISA™ (lifeIMAGE Smart Agent).

3) For physicians, facilities, or patients who care to create a cloud-based account to receive and share a modest volume of imaging studies from anywhere and with anyone, a lifeIMAGE LINCS™ Account is the ideal means of communication.

LILA utilizes "Drop Boxes" to which a referring site can upload a study, assuming they are properly credentialled.  The exam appears of course in the "In Box", and can be nominated for upload to the local PACS, with the approval of the PACS admin in charge of such things.  There is a limited, but still VERY adequate viewer within the system (which is platform independent, appearing in your web browser.)  Non-DICOM images, document scans, etc, can be attached. 

LINCS, the lifeIMAGE Cloud, allows for real time sharing of annotations.  My PACS doesn't even do that. 

Future plans include LIVE, lifeIMAGE Virtual Enterprise, which will connect two LILA sites, and create a "trust" agreement for a particular user to see a particular patient's data.  That certainly goes a long way toward solving the portable patient problem, as long as we can get the various hospitals on board.

I was lucky enough to arrive not long after the announcement of a very important development for lifeIMAGE, integration to Microsoft's Health Vault.  A patient simply establishes an account, receives a security code and sets up a security challenge question.  Once uploaded via lifeIMAGE, his/her exams are available to whomever the patient designates:
With a patient’s permission, physicians using lifeIMAGE services will have the option to share medical image exams and associated reports directly with a HealthVault account. When an exam is shared, patients will be prompted to complete the transfer by logging into their HealthVault account to claim the exam or creating a new account, and then claiming the exam. lifeIMAGE’s HIPAA-compliant platform employs a series of security checks to ensure the privacy and security of all data.

“The HealthVault platform is designed for ease of integration with third-party applications that bring value to the health consumer. lifeIMAGE’s image sharing application helps HealthVault account holders stay in control of their care and have an easier time obtaining second opinions from other physicians anywhere,” said Hamid Tabatabaie, president and CEO of lifeIMAGE.
This is a big, ummm, deal, to paraphrase the Vice President. 
As my hometown is of only moderate population, with five hospitals and various other imaging centers, I'm hoping to become the prototypical community to adopt the lifeIMAGE solution.  The problem we face is huge.  All I have to do is convince the powers-that-be that the answer is at hand.  I truly believe it is.
More to come from frigid Chicago.  I still don't get why anyone lives here...

RSNA 2010: Siemens Press Conference

There are various badges around RSNA, Blue for Members (like me), Crimson/Brown for exhibitors, and Pink for Press, to name a few.  I thought it might be amusing to have Press credentials, but Mike Cannavo, the One and Only PACSMan, and the good folks at discouraged me from this ambition.  It seems the Members badge gets you in more places, so there really is no point downgrading.  Still, slumming might have been fun.  But no matter.

Someone on the Siemens publicity team thought I deserved to be considered a member of the press for a moment or two, and invited me to their press conference held this morning.  As it inclued breakfast, I hauled myself downtown for the 7:30AM event.  I sat at a table full of legitimate healthcare reporters.  To my left was a lady who turned out to be quite a professional writer, as I found sitting next to her on the bus back north.  She was once a producer for a BIG networrk and had interviewed five Presidents.  She endeared herself to me by relating how she had gone head to head with GE and won earlier in the day.  To my right was Robin Leach from Healthy Lifestyles of the Rich and Famous.  (Well, not reallly, but the gentleman did remind me of Mr. Leach.  We all had placards with our name and publication, and I proudly placed mine in front of my breakfast plate.  Robin looked at the card, looked at me, rolled his eyes, shook his head, and said, "A blogger, eh?"  I said, "Yes, Sir!" in my best South Carolina drawl, and let it go at that.

The presentation was quite well done, with Herman Requardt, President and CEO of Siemens Healthcare, leading the way.  The theme for RSNA, and Siemens in particular this year is "Personalized Medicine" which means "whom to treat how" or more likely "whom can we charge how much?"  The gist of the presentation is that more intelligent, tailored therapy is on the horizon.  We simply have to amass enough data (with Siemens scanners) and then process said data (with Siemens syngo.whatever) to find the best approach.  Despite my tongue-in-cheek attitude, this is truly exciting stuff, and I like the Siemens approach.  Siemens likes their approach as well, and the claim was made that the rest of the world does as well, with Dr. Bernd Montag, CEO of Imaging and Therapy Systems Division stating that Siemens is Number ONE in market share, installed base, and profitability in this space.  I don't doubt it.  Dr. Montag cited the new hybrid PET and MR scanner, the mMR, which will only set your hospital back $4-5 Million or so.  "We have the right culture," he said.  "Yes, there was an economic crisis, but we continued to invest in R&D, and this is the result."  He went on to elaborate on Siemens goals of improving patient safety through dose reduction measures and the use of imaging to facilitate minimally-invasive surgical procedures.  As an aside, he observed that there is a lot more animosity among radiologists whose imaging is stolen by non-radiologists than among surgeons whose invasive procdures are down-sized by radiology. 

With respect to dose-reduction, Dr. Montag took a shot at Siemens' larGEst competitor:  "WE use absolute dose numbers and don't try to fool people with this 30% reduction business."  Siemens' goal in this is to reduce the dose of ALL "typical" CT exams to less than 2.4 mSv.  And I'm sure they will do it.  And I'm sure we'll all have to buy new scanners to achieve this.

To be complete, I should mention an excellent short review of Siemens mammography technology, including the yet-to-be approved tomosynthesis, given by Norbert Gaus, PhD.

Good stuff.  Maybe I'll be invited to more of these events, although I can guess which companies won't want me there.  Oh well. 

More to come.

ADDENDUM:  I spoke briefly with our GE CT rep just a few moments ago.  He said GE is shooting for a reduction to 1 mSv for all routine CT exams, and will no longer quote percentages of dose reductions.  That message sure got delivered quickly!  I can't imagine what's next.  Perhaps Toshiba will come up with a way to scan by drawing radiation out of the body, for a net dose of -5mSv.  You never know...

Monday, November 29, 2010

A Tale of Two Systems

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to heaven, we were all going direct the other way - in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.  Charles Dickens, A Tale of Two Cities. 
I'm standing at one of dozens of laptops set up near the Technical Exhibit Hall B at McCormick Place, in sunny, frigid Chicago.  It's been an exhausting first day, and I have miles to go before I sleep.  Still, I want to commit to the ether my thoughts of the day.  I've visited a number of vendors, and I'll be discussing my observations with a series of separate posts.  Many have noticed the sparsity of my postings lately, and I.. can only apologize and try to make it up in one fell swoop.  I've just been to Florida for Thanksgiving with the extended family, and did a rapid turn-around to get here last night.  All things being equal, I'd rather be in Florida, but we all do what we must. 

Let me start the barrage with a post I've been composing for several days.  The Tale of Two Systems refers to the iterations of Agfa IMPAX I've dealt with recently.  We had, until a few weeks ago, version 6.3.x, and my friends in Western Australia had 6.4.x.  At least ours worked most of the time, which sadly wasn't the case in Perth and environs.  Definitely the worst of PACS, I mean times. 

Over the past few weeks, Agfa has been fine-tuning the next edition, version 6.5.  It has major improvements, but the greatest upgrade of all has been the way Agfa handled the upgrade.  Distilling it down to two words, THEY LISTENED.  This next step is far from perfect, and it still has a lot of the legacy garbage from the previous 6.x's (and 5.x's, and 4.x's, and 3.x's, and probably 2.x's).  Still there are a number of things that actually work very well, markedly better than what we had before.  I won't go into vast detail, but suffice it to say that linking thge series of a multiplanar study is nearly automatic, and not an exercise in agony as it was before.  We have spine labelling, albeit a somewhat more complex version than I would have liked.  (Yes, the complex parts can be turned off, and we are left with a nice simple version that could have been written in a day and not take 5 years to implement, but I digress.)  We have voice clip capability so we don't have to type long missives to the ER.  And there are other improvements.  There are still problems.  There is no usable hanging-protocol arrangement.  There is still the nasty old tool-toggling. And so on. 

So why am I so upbeat?  Because Agfa made an incredible effort to keep us radiologists in the loop.  We received a pre-sale (but still FDA cleared) version, which has been tweaked almost daily in response to our requests and observations.  There were Agfa personnel onsite for much of the time, and we rads were invited (invited!!!) to participate in conference calls to keep the developers informed.  (And I can tell you that Version 7.x is being assembled in the same manner with input from us and several other groups.)  This is what I'm talking about!

In our discussions, it became very apparent why progress has stalled up to this point.  We bantered about the proper way to block someone from taking away a study someone is reading.  Most every product locks out everyone after the first.  In other words, if I open up Mrs. Jones' CT, no one else can read it.  They can look at it, but they can't dictate it or annotate it, at least with most systems.  With IMPAX, however, unless I click the "Start Dictate" button, the next guy can jump in and snatch the study away.  Years ago, I spoke with some of the principals about this.  I was told that Agfa's academic customers wanted it this way, and so it would stay.  That is not what I would call listening to the customer, at least not the customer standing in front of you with a serious complaint.  I would like to think Agfa has turned over a new leaf in this regard.

Time will tell.

In the meantime, I'm going to do my best to have the "best of times" at RSNA.  More to come.  It's 6 PM, and they're kicking us out of the building

Sunday, November 21, 2010

Champerty and Maintenance

Image courtesy of

Have you heard about the latest hot investment?  No, it's not plastics, young graduate.  Lawsuits.  Yes, lawsuits.  But I'm not talking about prosecuting (or persecuting) litigation.  I'm talking about investing in other people's suits.   

Actually, it turns out there is nothing new about this practice, but like wide ties (or is it narrow ties this year?) some things do eventually come back in style.  What we are seeing is the resurgence of a very old feudal practice banned by British Common Law (upon which our legal system is based).  Let's take a look.

Jeffrey Segal, M.D., J.D, founder of Medical Justice, delivers the disturbing message.   
At one time, before many of us were born, plaintiffs had to bankroll their own lawsuits. There, they would pay the attorney for his time and counsel. The plaintiff bore the entire risk for the outcome. But, if he won, he kept the entire pile of money, minus his expenses paid to the attorney.

The next – and dominant – paradigm: contingency fees. There, the risk is transferred to the attorney. In exchange for accepting that risk, the attorney keeps a healthy portion of any settlement / judgment after expenses. That amount is generally 33 to 40%. Naturally, the plaintiff’s attorney must diligently assess the risk / benefit for each opportunity. If the attorney loses, the plaintiff does not go bankrupt.

Enter the modern age.

Third party financing of lawsuits, as reported in the NY Times on November 15th: 
Large banks, hedge funds and private investors hungry for new and lucrative opportunities are bankrolling other people’s lawsuits, pumping hundreds of millions of dollars into medical malpractice claims, divorce battles and class actions against corporations — all in the hope of sharing in the potential winnings…

Ardec Funding, a New York lender backed by a hedge fund, lent $45,000 in June to a Manhattan lawyer hired by the parents of a baby brain-damaged at birth. The lawyer hired two doctors, a physical therapist and an economist to testify at a July trial. The jury ordered the delivering doctor and hospital to pay the baby $510,000. Ardec is collecting interest at an annual rate of 24 percent, or $900 a month, until the award is paid. 
For decades, state laws prevented people from “betting” on other person’s lawsuits (scrabble word: “champerty”). The rationale: such interventions would stir up vexatious litigation. Recent changes in some state laws are propping open the floodgates.
The New York Times article fleshes out the practice a bit more, revealing some of the good and bad aspects:
Lawsuit lending is a child of the subprime revolution, the mainstream embrace of high-risk lending at high interest rates that began in the early 1990s.
(T)he founder of the LawFinance Group, practiced law for more than two decades before moving into finance in California in 1992. A lawyer friend called to ask if he would lend to a client who had won a sexual harassment lawsuit. The woman’s former employer had appealed, and she needed money for living expenses or she would be forced to take a smaller settlement. Mr. Zimmerman invested $30,000 in the case; the former employer almost immediately dropped the appeal and paid out the verdict. Mr. Zimmerman made $20,000. “I said: ‘That’s an interesting way to make money. Is there a way to turn that into a business?’ ” he recalled. The company he created has since invested more than $350 million in litigation.
. . . A review by The New York Times and the Center for Public Integrity shows that the inflow of money is giving more people a day in court and arming them with well-paid experts and elaborate evidence. It is helping to ensure that cases are decided by merit rather than resources, echoing and expanding a shift a century ago when lawyers started fronting money for clients’ lawsuits.

But the review shows that borrowed money also is fueling abuses, including cases initiated and controlled by investors. A Florida judge in December ordered an investment banker who orchestrated a shareholder lawsuit against Fresh Del Monte Produce to repay the company’s legal expenses, ruling that the case should not have reached trial.
Back in the good old days, when feudal lords ran the show in England, and life-expectancy was 35 for those few children who survived into adulthood, it was not uncommon for the nobility to dabble in such things.  From the Wiki:

The restrictions arose to combat abuses in medieval England. Unscrupulous nobles and royal officials would lend their names to bolster the credibility of doubtful and fraudulent claims in return for a share of the property recovered.[6] Gradually, judicial independence was established and by the early 19th century Jeremy Bentham wrote:[7]

A mischief, in those times it seems but too common, though a mischief not to be cured by such laws, was, that a man would buy a weak claim, in hopes that power might convert it into a strong one, and that the sword of a baron, stalking into court with a rabble of retainers at his heels, might strike terror into the eyes of a judge upon the bench. At present, what cares an English judge for the swords of a hundred barons? Neither fearing nor hoping, hating nor loving, the judge of our days is ready with equal phlegm to administer, upon all occasions, that system, whatever it be, of justice or injustice, which the law has put into his hands. 
Brings to mind the image of Denny Crane sauntering into the courtroom with an AK-47:

Well, you get the idea. 

The concepts of champerty and maintenance followed.  From
 “Maintenance” is assistance to a litigant in pursuing or defending a lawsuit provided by someone who does not have a bona fide interest in the case. “Champerty” is a form of maintenance in which a nonparty undertakes to further another’s interest in a suit in exchange for a part of the litigated matter if a favorable result ensues. 14 Ohio Jurisprudence 3d (1995), Champerty and Maintenance, Section 1. “The doctrines of champerty and maintenance were developed at common law to prevent officious intermeddlers from stirring up strife and contention by vexatious and speculative litigation which would disturb the peace of society, lead to corrupt practices, and prevent the remedial process of the law.” 14 Corpus Juris Secondum (1991), Champerty and Maintenance, Section 3.
Stated a different way,
"Champerty was a 'means by which powerful men aggrandized their estates and the background was unquestionably that of private war.'" Id. at 375 (quoting Max Radin, Maintenance by Champerty, 24 Cal.L.Rev. 48, 58-64 (1935)). In response to rampant champerty and maintenance in feudal society, the law came to sternly prohibit these practices....
Some US states still have laws prohibiting champerty and maintenance, but many do not.  My own beloved state of South Carolina is one of the latter, based on a decision in the case of Osprey, Inc. v. Cabana Ltd. Partnership:

The South Carolina Supreme Court held that champerty-an agreement to finance a party's litigation in return for a portion of the matter involved in the lawsuit in the event of a successful outcome--can no longer be used as a defense to void financing agreements between parties to a lawsuit and outside financiers...
An appellate court agreed with the trial court that South Carolina recognizes the doctrine of champerty. However, the court limited the doctrine based on the reasoning that times have changed since the medieval era when champerty was strongly disfavored...
Affirming, the state high court modified the appellate court's ruling and completely abolished champerty as a defense. Other well-developed principles of law can more effectively accomplish the goals of preventing financing of groundless lawsuits and the filing of frivolous suits than the outdated notion of champerty, the court noted. The court observed that lawyers are prohibited from prosecuting frivolous lawsuits and may face various sanctions for doing so. Also, the doctrines of unconscionability, duress, and good faith establish standards of fair dealing between opposing parties. In addition, the court continued, the legislature has made barratry-the promotion of groundless judicial proceedings-a misdemeanor.
The court cautioned that its abolishment of champerty as a defense does not mean that all such financing agreements are enforceable. When an agreement is challenged, a court must consider whether the fees charged by the financier are excessive or whether any recovery is vitiated because of impermissible overreaching by the financier, the court explained. To determine what is fair and reasonable, a court may examine, among other things, whether the bargaining positions of the parties were equal and whether the financier engaged in officious intermeddling. After analyzing these factors and any others that may be relevant, a court may enforce, modify, or set aside an agreement, the court concluded.
I guess "excessive fees" are in the eyes of the beholder.  I think 24 percent interest per year is a little high, personally.

The courts today have decided for the most part that champerty is OK due to the far more transparent nature of our legal system when compared to that of feudal times.  Oh well.  I guess I'll have to defer to the judges, mostly former lawyers, who are the only ones in position to decide how current lawyers practice.  In some ways, champerty is a rather paradoxical thing.  Trial lawyers, mostly on the Left for some reason, love the chance to have someone invest in their cases, allowing more grandiose "evidence" and "experts" to be brought to bear, all for the benefit of their client.  Of course, this feeds the horrendous Capitalist greed of the investors at 24% interest.  So everybody wins.  Except for the concept of justice.

The whole point of the ban on champerty was to prevent undue influence on any particular case, the thwarting of justice in the name of profit or other motive beyond the scope of the situation itself.  In the old days, the mere presence of the feudal lord and a few of his cronies sitting in the back sharpening their lances was enough to sway the court.  Thus, a little investment of time and money went a long way.  Today, of course, the investors are paying surrogates to accomplish the intimidation, providing the finest "expert testimony" money can buy (literally) in exchance for their 24% interest.  This isn't justice, and it isn't fair or even particularly nice.  In addition, the plaintiff becomes beholden to the investor, and could be forced into a trial that isn't even necessary, in order to pad a judgement that never should have been made in the first place.  Yup, justice is served, alright.  On a silver platter with ketchup. 

The argument about tort reform always provided by the Left in general, as well as trial lawyers in particular, is that damage caps would unfairly limit "justice" in the form of compensation, and might not allow full recovery of damages.  While that might be true in a few cases, it is probably more reasonable to assume that the problem lies more with the amount of compensation the attorney will receive.  Human nature, folks.  Gotta love it.  Champerty, too, is touted as path to justice for those who otherwise couldn't afford it.  Balderdash.  In my book, this is simply a way to add a layer of profit to an already rigged system.  And yes, I do mean rigged.  As I have bemoaned before, our tort system is totally out of whack, and clearly encourages abuses such as champerty, since the folks with the most cash backing them up can buy the best testimony.  Remember, if testimony can be paid for, then it can be bought.  Human nature strikes again. 

Now don't get me wrong, I like profit.  But only when achieved on a level playing field.  I despise those who made money offering bogus investments like the derivatives based on bad loans.  (By the way, many thanks to Barney Frank for bringing down the US economy with his rabid insistance on the offering of loans to his constituents who couldn't possibly pay them back, leading the banks to try to dispose of the loss in this manner.)  Similarly, champerty is profitable because it is profitable to game the legal system, and thus deserves nothing but scorn.  No one will convince me otherwise. 

Since the courts and legislatures are filled with lawyers, champerty is likely with us to stay.  The solution, however, is simple, and provides an end-around run to bollux the lawyer's plans.  Sadly, it involves sacrifice on the part of physicians, and most will never go along.  Still, my logic is sound, and I think you'll agree I have a point.

To repeat what I noted above, if testimony can be paid for, then it can be bought.  The incentive to please those paying the exhorbitant bill leads one to testify to whatever it is that side wants to hear.  Testimony from an "expert witness" can run as high as $10,000-$20,000 per case.  This is ridiculous.  What I have proposed in the past is a simple decoupling of testimony from payment.  Witnesses must be subpoenaed, and brought to the court to TELL THE TRUTH, with no bias, and no incentive to say one thing or another.  They must not be beholden to either side, but rather be truly impartial experts.  The truth can only be set free if no one can buy it.

Clearly this will never happen unless legislated into law, and the chance of that is about as likely as my getting an invitation to Osama Bin Laden's grandson's Bar Mitzvah.  I know several litigators, and when I tell them of my idea, they laugh.  It seems that the first question any doctor asks when approached for testimony and case review is "HOW MUCH???"  Gimme, gimme, gimme.  We are no better than the lawyers in that regard, are we?  It's OK to take money for testimony, but it sure isn't any fun when you yourself get sued based on the evidence of some hired gun.  As usual, we are our own worst enemies. 

Champerty and maintenance.  Just when you thought it was safe to talk to lawyers again. 

Oh, I almost forgot.  Happy Thanksgiving, everyone!  (Even lawyers...)