Tuesday, December 27, 2011

Help Dr. Dalai Quiz Advanced Visualization Vendors!

I'm hoping my loyal and wise readers can give me a hand. As you know, we are set to have a "shoot out" between several Advanced Visualization vendors next Wednesday. The list as it stands includes GE, Philips, TeraRecon, Siemens, and Vital Images, narrowed mostly by our initial look at CT scanners.

This is a big decision with lots of money involved, and we want to do it right. Therefore, I'm turning to my friends out there for advice. Here are the basic questions we are asking the vendors. PLEASE let me know if we've left something out...
  • Please provide a brief overview of your system. A drawing would be great.
  • What is your licensing scheme for both thin and thick clients? 
  • Are there two tiers of functionality? Please elaborate on which functions are included for each level. In particular, do you offer on thick and/or thin client:
    • Coronary/cardiac evaluation
    • Stent planning
    • Brain perfusion
    • PET/CT with automatic registration and propagation of lesion ROI’s from prior to new study
    • SPECT/CT processing
    • Fusion of any two modalities
    • Creation of report-quality AVI’s
    • Transparent/translucent bone rendering
    • Vessel seeding/growing
  • Is any special hardware required for the thick client?
  • How many servers are required for full functionality? Is there a user or a slice limit per server? Please outline or provide a table to illustrate.
  • Does the thin client require any additional software to be installed, i.e. Java, .NET, etc. If so, what version?
  • Will the thin client work on a MacOSX, iOS, Android? Does either thin or thick client function well in a Citrix environment, the latter utilized on desktop machine or mobile device with iOS or Android?
  • How does the user login to either product? Does the system have its own user database or can it authenticate to Active Directory? 
  • Has your product been fully integrated with IMPAX 6.5? Please describe the usual workflow we would experience when accessing a study on your system via IMPAX.
  • How will we handle routing of separate datasets to your system as opposed to PACS? (We will likely want to send full thin-slice images to your server but not to PACS itself.)
Have I forgotten anything? Oh, yes...Happy New Year, everyone!!!!


Here are the questions in final form as sent to the various vendors:

Advanced Visualization Demonstration Questions
  • Please provide a brief overview of your system. A drawing would be great. Handouts are appreciated.
  • How many servers are required for full functionality? Is there a user or a slice limit per server?
  • Please outline or provide a table to illustrate.
  • What is your licensing scheme for both thick and thin Clients?
  • Are there 2 Tiers of functionality, as in Thin and Thick Client? Please elaborate on the functionality available for each Tier.
  • Will both clients function well in a Citrix environment?
  • What is the client to server ratio for each type of Client?
  • Does the thick client require any special hardware?
  • How does the user login to either product?
  • Does the system have its own user database or can it authenticate to Active Directory?
  • What type of auditing functionality does it have?
  • Has your product been fully integrated with AGFA’s IMPAX 6.5? Please describe the usual workflow we would experience when accessing a study on your system via IMPAX. (Any images created on your system would be stored on IMPAX.)
  • How will we handle routing of separate datasets to your system as opposed to IMPAX? We will likely want to send full thin-slice images to your server but not to IMPAX.
Thin Client
  • How do you access the thin client?
  • Is it URL based?
  • Is it dependant on a specific browser or require any additional software to be installed, i.e. Java, .NET, etc? If so what version?
  • Will the thin client work on a MacOSX, iOS, or Android?
  • How many concurrent users can it support?
  • In situations with low bandwidth (outside the Hospitals) how does the thin client perform?
  • What happens if the connection between server and client times out?
Hopefully we haven't missed much.

My primary goal is to see how these various systems will perform in a pseudo-production environment. I do realize that some of the demonstrations will be hobbled by the restraints WE have placed on the vendors. We are asking them to use data from OUR scanners (which include both GE and Siemens), and we have NOT given the cases to them in advance. Some vendors noted that their automation depends on "learning" the scanners from their DICOM headers, and I almost caved on this issue, but ultimately decided to keep the playing field completely level, for better or worse.

Staging this sort of comparison is quite interesting, and the emotions and actions inspired can be amusing as well. One vendor wanted to place servers in our data center as a long-term demo. Another, as above, wanted the data in advance to train its automation on our particulars. Several requested connections to IMPAX for the demo. We said "no" to all of these, although I'm still wondering if we needlessly limited some of the vendors in our efforts to be "fair" to all. We'll see.

Doing my research at RSNA was fun as well. I had the chance to meet several of the CEO's of the companies involved, some after more or less showing up at their carpeted ranches unannounced. (I did not get to GE's mega-booth, which took some maneuvering to avoid, but I'm sure Jeff Immelt had better things to do than talk to me anyway.) All but one vendor seemed quite interested in making sure I saw what I needed to see; the outlier found an apps person who was clearly brilliant, knew the product inside and out, and barely spoke a word of English. Next time, I'll be courteous enough to make an appointment.

In the end, we probably won't go wrong with any of these fine products. I'm just hoping to find the marriage made in I.T. Heaven, although those are probably contradictory terms...

Monday, December 26, 2011

Duh...Importing Outside Studies Into PACS Avoids Repeats

See the recent Aunt Minnie article with a similar title. Basically, someone did some research and found that if a patient has an outside study on CD, AND it imports successfully, they are less likely to undergo additional imaging.

(Graph courtesy Sodickson, et. al., August 2011 Radiology, 260,408-413.)

Gee whiz, folks, is anyone surprised? We don't have to repeat studies performed an hour ago as long as we can actually see them? Knock me over with a feather.

This is such an obvious observation that I'm really surprised at Radiology for publishing it, although I guess one has to prove everything in this day and age. The AuntMinnie article cites a talk at RSNA by Michael Lu yielding similar observations about hepatocellular cancer patients.

My thought is, of course, to avoid even the CD, and have direct transmission of the prior exam into the system where the patient now resides. lifeIMAGE, for example, does this very well. In my humble opinion, there is no longer any need for the fragile and fickle CD-ROM's. The only impediment to switching away is politics, which will be overcome sooner or later. Why not get on the bandwagon now? This is such a no-brainer, it isn't even funny.

Hat tip to The Once and Former PACSMan.

Wednesday, December 21, 2011

Chicago Sun-Times To Be Sold...
To Consortium Including Merge/Merrick's Ferro

Yesterday's Chicago Sun-Times reports that the venerable paper is to be sold to a consortium of investors including Michael Ferro, of Merge Healthcare and Merrick Ventures fame:

The sale of Chicago's No. 2 newspaper is imminent, sources close to the situation said.

Sun-Times Media is expected to announce Wednesday that it has struck a deal to be bought by a group of local investors led by Michael Ferro, chief executive of Chicago-based Merrick Ventures, a technology holding company. The group also includes John Canning, chairman of Chicago-based private equity firm Madison Dearborn Partners.

The new group plans to name Timothy Knight, the former publisher and CEO of Newsday, which was once controlled by Chicago-based Tribune Co., as CEO of its holding company, sources said.

Existing Sun-Times investors who will remain stakeholders include Chicago Blackhawks owner Rocky Wirtz as well as Mesirow CEO Richard Price.

Talk about branching out! There are some nay-sayers out there, however, who obviously aren't aware of Mr. Ferro's financial accumen:

Many industry observers have scratched their heads over why the new group is plunging into the newspaper business at such a perilous time for the industry and the economy. The Sun-Times emerged from bankruptcy with little debt, and the paper has dramatically reduced costs under Halbreich by, among other things, slashing its workforce and outsourcing its printing operations to Tribune's Freedom Center.

But as is the case for almost every newspaper company, the Sun-Times' revenue has been under pressure for years as advertisers, like readers, gravitate toward the Internet. Tyree's group (In 2009, an investor group led by Mesirow's previous CEO, Jim Tyree, rescued the Sun-Times from bankruptcy for about $25 million. Tyree died earlier this year. The Tyree group paid $5 million in cash for the company and agreed to take on $20 million in liabilities) tried to reverse the trend by emphasizing a digital strategy aimed at making the most of relatively strong Web traffic. But it is too early to tell whether a recent initiative to boost revenue by charging for some online content will pay off.

One longtime industry executive speculated that the risk the new investors are taking may be mitigated by the acquisition price. That has yet to be disclosed but will likely reflect the fact that the Sun-Times remains a work in progress in an industry under siege, the executive said.
Rescuing the Sun-Times might be harder than rescuing Merge, given the fact that print newspapers are going the way of the buggy-whip and corded telephones. Merge was purchased for pennies (?dimes?) on the dollar, and rapidly turned toward success. Look for some unusual paradigm changes that will turn the Times around in a way none of us would expect. Like maybe an iPhone/iPad app that checks your pulse as you read the e-newspaper and adjusts content accordingly. Who knows?

I'd like to be the first to apply for special PACS correspondant for the Sun-Times. There might be better writers on staff, but none who can write from the heart like yours truly..

Sunday, December 18, 2011

Mar-Mar, Misses, and Madness

Not long before RSNA, we lost Marion, my mother-in-law, affectionately known as "Mar-Mar". Her health had been deteriorating for a while, and then she fell, compressed a couple of vertebrae, and spiraled down quite rapidly. Fortunately, she had left instructions to avoid all heroic measures, and she died peacefully with Mrs. Dalai and I and her long-term care nurse by her side. I hope to go in the same manner, although not for quite a while.

In the course of working up her fractures, it was discovered that she had a mass, which turned out to be malignant. I asked her physician to review her images with us prior to biopsy, and there was indeed a truly ugly lesion. The hospital used a PACS that shows thumbnails, and we could easily see a very tiny image from a study performed last year. And that thumbnail quite clearly showed the very same lesion, although somewhat smaller. Mar-Mar's cancer had been missed, and allowed to progress for at least 10 months.

In her particular case, this was a blessing.  Rather than prolong her dying with futile and probably painful therapy, the miss prolonged her living. She had 10 months of having lunch with the ladies, playing cards, and generally doing what she wanted to do. We have no regrets, and no anger toward those who made the error.

That last one is the most important item for today's discussion. Anger plays a huge part in the deterioration of our society, in general, and in the medical malpractice game in particular. Let me diverge a moment to tell you about something that happened to me a few days ago. Bear with me and the relationship will become clear.

I was at the neighborhood strip mall, having mailed a package at the Post Office branch. I started to pull out of the parking place with my lumbering, gas-guzzling SUV, when to my shock, I saw a beat-up little red sedan cruise right behind me. I slammed on my brakes, fortunately in time, and avoided the otherwise inevitable accident. I suppose it would have been my fault had I hit, but I had looked both ways, and I've got to assume the driver sped up as I started out of my parking spot. But that isn't the important detail. The driver, a girl in her 20's wearing a black chef's tunic, stopped about 20 feet from me, got out of her car, and started shaking her fist and yelling, while a young bearded male in the passenger seat sat and watched the show.  I waved gently, as if to say, "yeah, I know, but we're all OK." She kept it up, so I drove off the other way. She followed me for a mile or so, then got tired of it and went on her way.

What does this have to do with misses and malpractice? I've got enough friends who happen to be litigators to know that two things drive a malpractice suit: anger and greed/envy, and they go hand-in-hand. (And as an aside, the majority of cases appear to reach the attention of a lawyer because ANOTHER DOCTOR told the patient that something wasn't done as well as HE would have done it.) As with the young lady driving the beat-up car, an accident or even an incident that approaches such is enough to promote rage in some of us, perhaps even most of us. It doesn't matter that the act was unintentional. I did not set out yesterday to trash some kid's little red jalopy. I think it's also reasonable to say that no physician decides some morning to cause harm to his patient. A missed finding, like a parking-lot collision, is an accident. It is not meant to happen, and everyone would prefer that it doesn't. This is where greed and envy can augment the madness of rage. The young lady above, at some level, realized that my truck was likely worth 8-10 times what her beater might bring, and no doubt this got her all the more riled.  Why should that doofus have a nice car? Who gave him the right to almost plow into me? He must think he owns the road, having an expensive car like that. I'll show him! 

In the case of a miss or other adventure in medical errors, I think the same thing applies, although certainly with a little more justification. There is clearly a relationship between doctor and patient. If something goes wrong, the patient feels betrayed And the patient gets angry. Given the perception of docs as wealthy, the next step in the mental equation may become: he hurt me (or could have hurt me) and he's going to pay! He can afford it!

While a financial award could put a car back together again, it may not be able to fix what was broken by the medical error. Somewhere along the way, our society has decided that money can compensate for the damage, and maybe that is true. However, juries of our "peers" are wont to award huge sums as punitive measure to "punish" the "bad" doctor. And let us not forget the fact that the litigator might receive 30-50% of the proceeds.

This is wrong. The whole scenario is horrible, and accomplishes nothing but padding the pockets of the litigating AND the defending lawyers. It leads to millions and billions of dollars spent for "cover your ass" procedures and tests. And it's all predicated on the anger over an accident and the thought that there might be a gold-mine to be had having won the malpractice lottery. This must stop.

I want this to be Mar-Mar's legacy: we must forgive those who make honest mistakes. We need to remove  anger, greed and envy (and lawyers) from the equation, and somehow set up some entity, some body or board, that would determine actual damages and arrange for those to be made as whole as possible, but without multi-million dollar punitive, redistributive, awards . I know this is next to impossible, as there is way too much money to be made by trying "rich" doctors in front of a jury of their "peers" who would love nothing more than to sock it to them. But it is the right thing, and all but those who profit from the malpractice industry, not just the lawyers, but the plaintiff whores who sell their testimony, know that I'm spot on.  Mar-Mar would approve.

Saturday, December 10, 2011

How The Kvetch Stole Chanukah

Dalai's Note:  I was trying to think of a Christmas theme to pervert for next year's RSNA article. Dalai, Jr. suggested something about the Grinch (or GErinch) stealing RSNA, and in my creative fervor, the phrase, "all the Joos down in Joo-ville" came to mind. I Googled this, and found that someone had beaten me to the punch (line). I present the absolutely hilarious piece by David Goldstein below. (If the terminology is confusing, ask one of your Joo-ish friends. If you don't have any Joo-ish friends, don't bother reading!)

Every Joo
Down in Joo-ville
Liked Chanukah as such…

But the Kvetch,
Who lived just north of Joo-ville,
… not so much.

The Kvetch hated Chanukah, the whole Chanukah season.
Now don't ask me why. What? Should I know the reason?
It could be he wasn’t a mensch, that is all.
Or his petzel, perhaps, was two sizes too small.
Such meshug’as comes from one thing or another,
But like most Joo-ish boys, we should just blame his mother!

The reason, whatever,
His mom or his putz,
The Kvetch hated Chanukah. Oy, what a yutz!
For he knew every Joo down in Joo-ville tonight
Was busy preparing menorahs to light.

“And they’re giving out gelt!” he sighed as he said
“I need waxy chocolate like holes in my head!”
Then he nervously whined as his fingers tapped horas,
“I MUST stop the Joos from igniting menorahs!”

The Kvetch knew that soon…

… All the Joo girls and boys
Would say the baruch’ha, then unwrap their toys!
And then! Oh, the oys! Oh, the Oys! Oys! Oys! Oys!
If it’s not what they wanted, the OYS! OYS! OYS! OYS!

Then the Joos, young and old, would sit down for a nosh.
And they’d nosh! And they’d nosh!
And they’d NOSH! NOSH! NOSH! NOSH!
They would nosh on Joo-latkes, and Gefilte-Joo-Fish,
Which was surely the Kvetch’s least favorite dish!

They’d do something
Which made the Kvetch plotz!
Every Joo down in Joo-ville, Bar Mitzvahed or not,
Would sit down together, their proud ponim’s grinning.
Then dreidels in hand, all the Joos would start spinning!

They’d spin! And they’d spin!
And the more the Kvetch thought of this Joo-Dreidel-Spin,
The more the Kvetch thought, “I can’t let this begin!
“Oy, for fifty-three years I’ve put up with it now!
“Chanukah, Schmanukah! Stop it!
… But HOW?”

Then he got an idea!
And the moment he had,
He said
“I’m no Einstein, but this… not half bad!”

“I know just what to do!” Then he donned an old sheet,
And dug up some sandals to wear on his feet.
“I’m the Prophet Elijiah! They’ve set me a plate!”
(For the Kvetch couldn’t keep Joo-ish holidays straight.)
“The Joos ‘ll oblige ol’ Elijiah, no doubt!
“I will simply walk in. Then I’ll clean the place out!”

“All I need is a camel...”
He looked far and near,
But this wasn’t the desert, and camels are dear.
Did that stop the old Kvetch...?
That pischer? No, never:
“If I can’t find a camel,” the Kvetch said, “...whatever.”
So he called his dog, Max. Then he took an old sack
And he tied a hump onto the front of his back.

He climbed on this
dog-dromedaryish mammal.
You never have seen
Such a schmuck on a camel.

Then the Kvetch cried “Oy vey!”
As old Max started down
Toward the homes, while the Joos
Where still schmoozing in town.

All their driveways were empty. Just SUV tracks.
All the Joos were out last-minute-shopping at Saks,
As he rode to a not-so-small house on old Max.
“It’s a good thing I brought” the old Prophet Kvetch thought,
“All these bags with to stuff all the stuff the Joos bought.”

Then he looked at the chimney. It seemed quite a stretch
That a fat goy like Santa could fit, thought the Kvetch,
“Still, the goyim believe stranger things, that’s for sure.”
Then the Kvetch shrugged his shoulders, and walked through the door
Where the little Joo dreidels were all strewn about.
“These dreidels,” he grinned, “are the first to go out!”

And he schvitzed, as he shlepped, with an odor unpleasant,
Around the whole house, as he took every present!
Barbie dolls! Mountain bikes! Brios! And blocks!
Pokemon! GameBoys! And all of that shlock!
And he stuffed them in bags. Then his arms spread akimbo,
He shlepped all the bags, one by one, out the wimbo!

Then he shlepped to the kitchen. He took every dish.
He took the Joo-latkes. The Gefilte-Joo-Fish.
He cleaned out the Sub-Zero so nimbly and neat,
Careful to separate dairy from meat.
Then he shlepped the Joo-nosh right out the front door-a.
“And NOW!” kvelled the Kvetch, “I will shlep the menorah!”

And he grabbed the menorah, and started to shlep on,
When he heard a whine, like a cat being stepped on.
He spun ‘round with shpilkes, and coming his way,
It was Ruth Levy-Joo, who was two, if a day.

The Kvetch had been caught by this small shaina maidel,
Who’d been watching TV on her big RCA’dle.
“The Prophet Elijiah?” she quizzed the old fool,
“You visit on Pesach, they taught us in shul.”

And although the old Kvetch was surprised and confused,
It’s not hard to lie to a girl in her twos.
“Bubbeleh… sweatheart…” he started his tale,
“Your dad paid full price, when this all was on sale!
“And like any good merchant, I just want to please ya.
“I’ll ring it up right, then I’ll refund your VISA.”

Then he patted her tush. Put a Barney tape in.
And she spaced-out as fast as the spindle could spin.
And as Ruth Levy-Joo watched her mauve dinosaura,
HE went to the door and shlepped out the menorah!

Then the match for the shamas
Was last to be filched!
Then he shlepped himself out to continue his pillage.
On the walls he left nothing at all. Bubkes. Zilch.
And the one speck of food
That he left in the house
Was a matzoh ball even too dense for a mouse.

He did the same schtick
In the other Joos' houses.

Leaving knaidlach
Too dense
For the other Joos' mouses!

It was quarter to dusk…
All the Joos, still at Saks,
All the Joos, still a-shmooze
When he packed up old Max,
Packed him up with their presents! The gelt and the dreidels!
The chotchkes and latkes! The knish and the knaidels!

He hauled it all up to his condo in haste!
(A Grinch might have dumped it, but why go to waste?)
“Shtup you!” to the Joos, the Kvetch loudly cheered,
“They’re finding out Chanukah’s cancelled this year!
“They’re just coming home! I know just what they’ll say!
“They’ll ask their homeowners insurance to pay,
“Then the Joos down in Joo-ville will all cry OY VEY!”

“All those Oys,” kvelled the Kvetch,
“Now THIS I must hear!”
So he paused. And the Kvetch put his hand to his ear.
And he did hear a sound rising up from the shtetl.
It started to grow. Then the Kvetch grew unsettled…

Why the sound wasn’t sad,
It was more like the noise
Of a UPS trucker
Delivering toys!

He stared down at Joo-ville!
And then the Kvetch shook,
As truck after truck
Replaced all that he took!

Every Joo down in Joo-ville, the Golds and the Steins,
Re-ordered their presents by going online!

Chanukah HADN’T been cancelled!
…On UPS trucks… but it came just the same!

Then the Kvetch, staring down at the gifts where they sat,
Stood kvitching and kvetching: “For this, I did that?
“It came without traffic! It came without tax!
“It came without shopping at Bloomie’s or Saks!”
And he kvetched on and on, til he started to shvitz,
Then the Kvetch thought of something which might make him rich!
“Maybe stores,” thought the Kvetch, “don’t need mortar and bricks.
“Maybe toys can be bought with a few well-placed clicks!”

And what happened then…?
Well… in Joo-ville they say
That the Kvetch raised
Ten million in venture that day!
And the minute his web site was ready to go,
He raised ten billion more on his new IPO!
He sold back the toys to the homes they came from!
And he…

… he the Kvetch…!
Founded YA-JOO.COM!

©2000 by David Goldstein
All rights reserved
[An HA holiday tradition, with apologies to the late, great Dr. Seuss — but not to the greedy, litigious bastards at Dr. Seuss Enterprises, LLC. So there. Happy Christmukah.]

Water On Mars!
Government To Level Planetary Playing Field??

From Fox:
NASA Rover Finds Convincing Evidence of Water on Ancient Mars

A well-traveled NASA Mars rover has found some of the best evidence yet that water flowed on the Red Planet's surface long ago, researchers announced Wed., Dec. 7. The Opportunity rover, which landed on Mars nearly eight years ago, has discovered a thin, bright mineral vein along the rim of a huge crater called Endeavour. This mineral is almost certainly gypsum that was deposited by liquid water billions of years ago, researchers said.

"This is the single most powerful piece of evidence for liquid water at Mars that has been discovered by the Opportunity rover," Steve Squyres of Cornell University, Opportunity's principal investigator, told reporters here today during the 2011 winter meeting of the American Geophysical Union.

I can see the headlines now...
The Obama Administration announced plans for immediate interplanetary water redistribution yesterday. "The water-gap between rich and poor planets is unfair and unsustainable; it must be addressed immediately," according to an unnamed spokesman...

Sunday, December 04, 2011

You Might Just Be An Occupier If...

You just might be an "Occupier"

(from this week's Jewish Press, NY, Dec 2 issue)
By Steven Plaut (from stevenplaut.blogspot.com)

Many of us are scratching our heads, and in some cases other parts of our anatomy, trying to make sense of the "Occupy Wall Street" movement and its sundry clones around the US and now around the world.

Just what do these urchins really want? What do they think and believe?

Well, we thought we would recruit Jeff Foxworthy to try to assist us. Most of you probably are familiar with the great American comedian from the Deep South. He is best known for his comedy shticks based on the refrain, "Then you just might be a redneck." For example, if you have 24 pickup trucks and none of them work, then you just might be a redneck. That sort of thing.

Well, it occurs to us that Jeff Foxworthy could really clean up if he altered his shtick slightly to comment on those "who just might be Wall Street Occupiers."

Here we go:

1. If you dismiss anything you dislike as "neo-liberalism," then you just might be a Wall Street Occupier. Never be tricked into attempting to define that nonsense term.

2. If you refuse to recognize the fact that every idea of Marx's was debunked over 160 years ago, then you just might be a Wall Street Occupier.

3. If you wear Nike shoes, designer jeans, and carry your smart phone to the demonstrations against capitalism, then you just might be a Wall Street Occupier.

4. If you think that REAL communism could really work but it just has never been tried or tested, you just might be a Wall Street Occupier.

5. If you pretend that you have never heard that communism produces starvation and cannibalism, then you just might be a Wall Street Occupier.

6. If you pretend you think the United States controls an empire, even though you cannot think of any colonies it owns, then you just might be a Wall Street Occupier.

7. If you think other people must always be required to relinquish their material things so that you may pursue social justice and feel idealistic and righteous, then you just might be a Wall Street Occupier.

8. If you consider your own property to be sacred, while other people's property should be used for social engineering and doing good, then you just might be a Wall Street Occupier.

9. If you think it is the main purpose of universities to indoctrinate students in leftwing ideology, then you just might be a Wall Street Occupier.

10. If you think shooting terrorists constitutes "war crimes," then you just might be a Wall Street Occupier.

11. If you favor academic departments in which only enlightened leftist opinion may be expressed and where there is no room for non-leftist dissenting opinion to be heard, then you just might be a Wall Street Occupier.

12. If you believe that the only legitimate way for Israel to defend its citizens against terrorism is to capitulate to the demands of the terrorists, then you just might be a Wall Street Occupier.

13. If you believe that eating meat is murder, while partial birth abortion is not, then you just might be a Wall Street Occupier.

14. If you use the term Islamophobia often, but never use the term Islamofascism, then you just might be a Wall Street Occupier.

15. If you believe that everything wrong with the world is because of the United States, and that anything left over that is wrong with the world is the fault of the Jews, then you just might be a Wall Street Occupier.

16. If you think there is nothing useful to be learned from the fact that Cuba used to be the richest country in Latin America and today is the poorest country in Latin America, then you just might be a Wall Street Occupier.

17. If you are not aware of the fact that Cubans steal boats to sneak into the US but no low-income Americans steal boats to sneak into Cuba, then you just might be a Wall Street Occupier.

18. If you think there is nothing we can learn from comparing the histories of East Germany with West Germany before the unification, or North Korean with South Korea, then you just might be a Wall Street Occupier.

19. If you think that all arguments may be settled by telling a non-leftist that he reminds you of Rush Limbaugh or Glenn Beck, then you just might be a Wall Street Occupier.

20. If you claim that the fact that are proportionately more blacks in prison than whites proves that the courts and police are racist, but the fact that there are many more males in prison than females is because males commit more crimes, then you just might be a Wall Street Occupier.

21. If you support proposals that make real problems of the world worse, just as long as advocating them makes you feel caring and righteous, then you just might be a Wall Street Occupier..

22. If you think Israel is an apartheid regime, then you just might be a Wall Street Occupier.

23. If you prefer that poor people in the Third World starve rather than that they should embrace capitalism and live like you do, then you just might be a Wall Street Occupier.

24. If you believe that acts of violence against Jews or Americans are never terrorism but rather resistance, then you just might be a Wall Street Occupier.

25. If you think the US itself caused the 9-11 attacks on itself because of American insensitivity and racism, then you just might be a Wall Street Occupier.

26. If you believe that terrorism is caused by poverty, then you just might be a Wall Street Occupier.

27. If you believe that SUVs threaten life on earth, and - more generally - that the planet is in imminent danger of destruction unless everyone does what you want them to do, then you just might be a Wall Street Occupier.

28. If you assert passionately that Marxists care about people, while Conservatives hate all people and small animals and are not as smart as leftists, then you just might be a Wall Street Occupier.

29. If you believe that, if one country is rich and another poor, it must be because the rich one stole wealth away from the poor one, then you just might be a Wall Street Occupier.

30. If you demand social justice but have no idea how to define what it means or explain how to achieve it, then you just might be a Wall
Street Occupier.

31. If you do not think you need to get a job first before you become a leader of the working class, then you just might be a Wall Street Occupier.
I couldn't have said it better myself!

Friday, December 02, 2011

Farewell To Chicago and RSNA 2011

Even though it's a bit chilly down here in the Deep South, it is still considerably warmer than Chicago, and it's good to be back home.

My major concentration this trip was on Advanced Visualization, in preparation for our Shoot Out coming in January. I looked closely at the four major vendors involved. I got to meet the CEO's of three of the companies, and had prolonged demos at the same three. One company has invited me to its headquarters, which I must decline while we are in the midst of the decision process. I'm sure I'll still be welcome even if we chose one of the "other guys"...

On other topics...I was really amazed at the number of people who recognized me and/or admitted to being regular readers of this blog. I know I disappointed several of you by not making it back to your booths, and for that I apologize profusely. Contact me earlier next year, and I'll try to do better.

Finally, you may have heard by now that my good friend Mike Cannavo, still the One and Only PACSMan, has gone corporate. He now works for one of the large PACS companies (no, not that larGE company) and has had to hang up his pen. Mike wrote the annual RSNA wrap-up column for AuntMinnie.com for many years.  Now that he has retired, so to speak, I have been offered the chance to take over this prestigious piece. Rather than try to duplicate Mike's inimitable approach, I decided to go quite far afield with a piece of fiction and parody. So, without further ado, please enjoy my first (and possibly last) AuntMinnie RSNA column:

An RSNA 'Christmas Carol'

December 1, 2011 -- For years, the PACSman Awards were an annual tradition inAuntMinnie.com's coverage of the RSNA conference. With the PACSman hanging up his typewriter last year, the baton has now passed to the Dalai Lama of PACS, radiologist and blogger Dr. Sam Friedman, who shares his unique RSNA experience.

CHICAGO - The PACSman was gone, and radiology wasn't looking too good either, no doubt about it. The somber, funereal atmosphere in McCormick Place at the RSNA conference was pervasive, even palpable.

Radiologists wandered the halls, heads bowed, hoping to learn something that might make them a better hospitalist, or pathologist, or whatever the Affordable Care Act might actually support. But there were still some bright spots here and there. A new scanner, a novel technique. A shred of hope for some disruptive technology.

I entered the Technical Exhibit Hall, hoping more for some free candy to quiet my rumbling stomach than any particular revelation. I was immediately swarmed by salesmen in ill-fitting Men's Wearhouse suits.

"A happy RSNA to you, Dalai, would you be so kind as to have a look at our wares?"

"Bah, humbug!" I replied, looking for something to scrounge, or even some swag to take back to my family -- a key chain, a little flashlight, anything to justify my trip to this drab, cold place.

"But Dalai, this is the most incredible of all radiology meetings!" they said. "Surely you have found something amazing here!"
I shook my head and kept walking. There was nothing wonderful here. Why did I choose imaging anyway? Because I loved the field? Ah, the foolishness of youth.

Finding no solace, I turned on my heel and returned along the Grand Concourse to the North Building. In a small basement classroom, I found the session I was seeking, an uplifting little talk titled "Tales of Alleged Radiology Fraud and Abuse."

I settled into the chair and pulled out my iPhone, hoping to find a pleasant email from home. Instead, there were three angry emails from my PACS administrators, all expressing escalating desire to serve up my partners as Christmas dinner for the local wildlife.

As the speaker droned on about the loopholes in Stark II, I found myself becoming drowsy, and to my embarrassment, my head nodded, my chin hit my chest, and I shuddered, startled back awake once again ...

But ... something was wrong, very wrong. I looked about. The harsh lines of the plain McCormick Place classroom were gone. Rather, as I looked around, the room was plush and even gilded. The chairs were comfortable. A man with a bushy mustache at the podium was wearing a suit with narrow lapels and an even narrower tie, and he was speaking about the "revolutionary EMI Mark I." There was a heavily pixelated image on the screen that seemed to be a brain, but it was not very well defined. I blinked. On the podium, emblazoned in gold, was the inscription "the Palmer House Hotel."

Wait! The Palmer House? EMI Mark I? How was this possible? The Mark I was introduced at the RSNA annual meeting in ... 1972! Could it be?

"You bet your ass, goombah!"

I turned to the source of the booming voice next to me.

"PACSman!" I cried out in surprise. "How did you get here? How did I get here?"

It was then I noticed that while he was there beside me, he wasn't quite all there; I could see through him to the gentleman seated two chairs away. He was bound in Cat-5e cable, with broken hard drives lashed to his feet. Strangely, no heads turned in annoyance over our conversation.
"Dalai, buddy, you ate some bad shrimp last night," the PACSman continued. "I told you not to go to any parties put on by the big companies, but does anyone ever listen to me? Oh well, it's nothing but a thing anyway."

"But PACSman, I thought you were gone!" I exclaimed. "Why are we at an RSNA from 40 years ago?"

"One thing at a time, bubbie," he said. "Yes, I've departed your world for one I think will be better. Live and learn, or maybe die and learn, heh? As for the why, look up, friend. You've been brought here to RSNA Past so you can remember the joy and love you once had for medical imaging. Can't you feel the electricity in the air? This was the day when CT became king! Cross-sectional imaging, baby! It all started here!"

Indeed, I could feel the excitement creeping up on me. It was none other than Dr. Sir Godfrey Hounsfield himself speaking to the enraptured crowd at the Palmer House ballroom. What I wouldn't give to have been there -- I mean here -- I mean, whatever.

I listened for a few more moments, but again, my head started to nod, and once more I awoke with a start. I was back in the modern McCormick Place, but instead of re-emerging in the small classroom, I was seated in the cavernous Arie Crown Theater, front row and center. And the gaseous apparition of my friend the PACSman was seated next to me. Clearly, my strange journey wasn't over.

"Hey, Dalai! Pay attention," he admonished. "The president of the American Medical Association is schooling you guys about how much trouble you're in. Something about triple jeopardy and not getting paid. Sounds like a triple whammy to me."

And he was right about that. I couldn't take any more of this. I got up and walked out, magically disturbing no one, the PACSman trailing behind, broken hard drives clanking at his feet.

We wound our way over the bridge to the Grand Concourse, then wandered aimlessly to the Technical Exhibit Hall in the South Building. Before long, we encountered a booth that easily covered the area of a football field. There were hundreds of black-suited, brown-badged gents milling about, looking for anyone wearing the coveted blue-rimmed name tag. I had one on, of course, but I was now accustomed to my invisible status, and I expected to remain unaccosted. The shiny new scanners, lights blinking, spun their tubes in futile pursuit of customers.

"PACSman, what are we to see here?" I asked.

"Isn't it obvious?" he asked. "Here's the deal. No one knows where healthcare is going, so we're all going to start enjoying Thanksgiving again for the first time in 75 years. Instead of freezing our asses off, we'll do an interactive virtual conference with scheduled demos and everything. No muss, no fuss, and no 'free' meals. As a bonus, system prices will drop 30% because vendors won't have to pay for RSNA. It's sheer brilliance, I tell ya!"

I sat down on a PET/CT gantry and bowed my head. The room spun, and when I looked up again, we were seated on a bench beside Lake Michigan. It was a blustery day, with winds one only sees in Chicago in the winter. Strangely, I felt no chill, as I watched leaves blowing through the PACSman's shadowy figure.

I looked behind me and gasped. The once-stately Lakeside Center was in ruins, shattered black pillars and glass everywhere.

"PACSman! What happened here?"

"Oy, Dalai, you need to lay off the Kung Pao, OK? Welcome to RSNA 2045," he said. "Or, well, it would have been if there still was an RSNA. Which there isn't."

"But why?"

"What did you expect?" he said. "Between the UnAffordable Care Act, the doctors' 'fix' that fixed you guys good, and all of your good friends, the clinicians, you radiologists didn't stand a chance."

"But who reads imaging studies now?" I asked.

"Geez, Dalai, why do you even care? OK, OK," he said. "You've come this far. Look, imaging reached the point where it didn't pay squat, right? So no one wanted to do it anymore. Even physicians' assistants and nurse practitioners wouldn't touch it. Imaging got so cheap that people got their scans at Walmart and everybody's data were stored in the cloud or on some vulture -- I mean, vendor-neutral -- archive. Got that? So many images were crammed into all these interconnecting networks that ... badda bing, badda boom, they grew self-aware. So, the damn computers are doing the diagnosing themselves. Whaddya think of that? End of the line for radiology."

"No, PACSman!" I exclaimed. "It cannot be! This is an honorable profession, and it cannot end this way!"

I sat back down on the bench, staring at the frigid breakers on Lake Michigan, the wind whipping through my spectral presence by the ruins. I slowly drifted off to the crashing of the waves.

"Dammit, Dalai, watch what you're doing!"

I looked up quickly. The PACSman was standing next to me, very much alive and quite solid, nursing his foot, which I had apparently stepped upon in my delirium. We were in the Technical Exhibit Hall once more. Again, something was different. The booths were lit more brightly than ever before, the scanners positively glowed, and the salesmen were all grinning and patting each other on the back. The customers with blue badges were smiling too, several making excited cellphone calls, clearly happy with a deal they had just made.

"What ... what's going on?" I mumbled, totally disoriented by this, the final shift back to reality. But it was a different, better reality than the one I had left but a moment ago.

"Gawd, Dalai, you really need a cup of coffee or something," PACSman said. "They just announced record sales for this RSNA. All the big boys have sold more scanners in the past three days than they had in the past five years! It's a damn miracle!"

"Yes, PACSman, yes!" I exclaimed. "It had to happen! So many of us love radiology. What a relief! How were we rescued?"

"Probably something to do with that first Tuesday in November, goombah," he said. "Hey, I'd like to stand around and shoot the breeze, but I have to get back to my new home away from home. I'm in a good place now ... good company, good people, good product, and all that jazz."

As he walked away, he turned, smiled at me, and said, "Hey Dalai, guess who gets the Flashdance Award?"

I laughed, thankful that some things never change ...

I ambled my way to the glass portal of the Grand Concourse. The sun was shining brightly, and the traffic cops had shed their slickers in the warm afternoon.

I went outside and walked down by the Hyatt for a ways, then looked back at the sparkling edifice of McCormick Place. I couldn't help but notice the huge banner: "Welcome to RSNA, 2012."

In addition to regular posts in the AuntMinnie.com PACS Digital Community Forums, Dr. Friedman also maintains a blog at www.doctordalai.com. His observations and opinions are entirely his own.

I guess I should probably keep my day job....

Wednesday, November 30, 2011

Vital: Denoising Is NOT Dose Reduction

After my visit to Kang and HealthFortis, which, by the way is associated with lifeIMAGE, I had the chance to wander over to Vital Images, and discuss our upcoming Shoot Out for Advanced Imaging. I must have been in the company of the right people (hear that, John?) as before I knew it, I was introduced to the CEO and to the EVP of Sales. After the pleasantries, I had the chance to really look hard at some of the things I needed to see, and had a really informative chat with our intrepid (and beleaguered, mostly by me) salesman and technical folks. I left knowing much more that I started with, but I'm going to leave the feature-list for the report of the Shoot Out itself.

One thing I do want to publish right now, though, is some information about denoising. Vital has a really nice denoising subroutine, which will take a noisy scan and smooth it out. Vital made it clear to me, however, and said that absolutely I have their permission to broadcast to the world, that this is NOT dose-reduction software. All it does is make an image that is degraded for whatever reason (NOT to include deliberately degraded) look prettier. No guarantees on whether data is lost, although almost certainly there won't be much lost at all, but users are urged to toggle back and forth between the pretty and the not-so-pretty pictures.

Where the idea of using denoising for dose-reduction came from, I'm not sure. I don't believe Vital ever promised this at all. I think in retrospect we must have found it perusing information from Clarity which DOES promise that one can lower the parameters to levels that produce crappy dose-reduced scans and then "rescue" them with their box, which performs digital filtering on the images:
Clarity is server-based and seamlessly integrates into your existing DICOM network. During installation of the Clarity solution, dose-optimized protocols are established on the CT scanner(s) to deliver desired image quality at reduced dose levels. Low dose images are transferred from the CT scanner to a Clarity server that resides on your DICOM network. Based on desired results that have been pre-determined by your Radiology staff, Clarity algorithms enhance image quality and automatically route the final images to their intended destinations.
I'm not buying it. In either sense of the term.

Much obliged to the good folks at Vital.

CPOE So Easy A Caveman Surgeon Could Use It!

Whilst cavorting with old friends at lifeIMAGE (see the previous post), I had the chance to connect with another old friend, Kang, formerly one of the technical gurus of AMICAS, now CEO of his own little company, HealthFortis. (He's working with another AMICAS alum, Dmitry, whom I sadly didn't get to see this trip.)

Kang, having created some wonderful stuff AMICAS over the years, needed a new challenge, and he picked a big one: CPOE, aka Computerized Physician Order Entry. (Some say "Provider" instead of Physician, which clearly tells us physicians that we are no longer held in particularly high regard, but whatever.) CPOE is clearly a tough nut to crack, as one must create software that physicians (even surgeons and, yes, even orthopedic surgeons) will have to use to order stuff for their patients. Keep in mind, these are guys (and gals) who are used to scribbling something illegible on a piece of paper over the course of three seconds, and then faxing or maybe throwing it (literally) at someone with the full expectation that their intentions will be telegraphed magically. Of course, sometimes they will lower themselves to simply barking said orders at someone, in person or by phone, with the same somewhat unrealistic expectations of completion.

Now that EMR's and such have taken over, computerizing this process in the form of CPOE is felt desirable, and even necessary. But no one asked the physicians about this, and therein lies the path to big trouble.

Our largest hospital system instituted Cerner Millenium CPOE over the past few years, and the physicians to a man (and woman) seem to hate it with a passion. I'm on the CPOE committee for one of our other hospital systems, and we are struggling with the joys of trying to crowbar a entry process into the ancient legacy MediTech Magic program, you know, the one that ports a 1980's green Data General window to Windows. I'd rather be the bagel delivery-boy for the Gaza district.

Kang nicely outlines what is wrong with pretty much every CPOE product out there: it tries to make docs do things differently, and, trust me, docs do not want to do things differently. Why are we forcing them to take 5-20 minutes and 59 mouse-clicks to accomplish what they once did with a piece of paper and a pencil in 3 seconds? The intelligent approach is to first make it easy for the physician to use CPOE, and then leverage all the nice things that an electronic approach can deliver. This, of course, includes "Decision Support at the Point of Decision." Brilliant!

HealthFortis takes a very simple approach. There are just a few points of entry, but they spawn everything appropriate to taking the order, and all of the entry boxes allow for free-text, much like Google, with a list of possible entries building and then narrowing as you type. To find your patient, you might simply type Do Da, which would bring up Doctor Dalai, among other less interesting people. Select the patient and then a simple window appears, wherein you enter the diagnosis and, if you wish at that point, the exam to be done. Here's where the magic starts.  Suppose you enter "AA".  The program gives a few possibilities, such as "AAA", which we then select. You are then given a list of possible exams, ranked by ACR recommendation codes from 9 (good choice) to 1 (you have to be kidding!). Clicking the exam you want spawns an order in HL-7 to be delivered back to your HIS/EMR.  If the condition/symptom isn't quite so specific, the program brings up more data and options to help you decide. Of course, you can still override this and forge on ahead with an arteriogram for little toe pain, but you will definately get a "1" for that choice, and you will be told just why that is inappropriate.

There is included some nice stuff like searches for recent orders of the same type (did you really want to repeat the CT for the 10th time this month?)

Right now, the system is in its infancy, having been online for only a few months, but it is growing, and I'll predict there will be rather wide-spread acceptance. The order-sets for the moment include more radiology exams than anything else, at least as I understand it. Kang did outline a heuristic learning function, which will help grow the database; as more and more entry-pairs are collected, the system will learn which are being used most frequently, and make them more easily available.

This is one of those offerings that is elegant in its simplicity and usability. I'm not sure it will be ready for full hospital use in time to derail MediTech, but it possibly could be deployed at least to physicians ordering stuff from outside the hospital. I'll take that for now.

Make it easy and they will come. Guaranteed.

Disruptive Technology

I'm sitting at one of the RSNA Bistro venues, having just spent $20 on a mediocre buffet meal which did at least consist of some mildly healthy alternatives. I've got a couple of things to tell you about, some from the meeting, of course, but one gleaned from FoxNews while perusing the net over lunch.

Let's start with the fun stuff. I think I've stumbled across the next revolution in photography, and truly this is a disruptive technology. I'm referring to the new Lytro camera, which uses "light field" imaging instead of regular old, well, light.  Here are the three models, the middle version having 16 GB of storage for 750 images, and the others coming in at 8GB for 350 images.

I'll refer you to Lytro's site for an explanation of what goes on in this little box.

Capture living pictures with the press of a single button. By instantly capturing complete light field data, the Lytro gives you capabilities you've never had in a regular camera...

Since you'll capture the color, intensity, and direction of all the light, you can experience the first major light field capability - focusing after the fact. Focus and re-focus, anywhere in the picture. You can refocus your pictures at anytime, after the fact.
And focusing after the fact, means no auto-focus motor. No auto-focus motor means no shutter delay. So, capture the moment you meant to capture not the one a shutter-delayed camera captured for you.
And here is what you can create. Click anywhere on the image to refocus, double-click to zoom.

This is the start of something big, I think, although it will probably take quite a while for this to migrate into mainstream photography. Of course, it took quite a while for digital to overtake film. You saw it here on DoctorDalai.com first.

On to things Radiologic.

I attended a seminar on the lifeIMAGE LINCS, the lifeImage Network Cloud Service, narrated by CEO Hamid Tabatabaie, former CEO of AMICAS if you didn't know. LINCS is now fully operational, and it is being used at multiple centers. Hamid showed us a live view of user stats, and the system is quite impressively active. For the full explanation, check the lifeIMAGE website. In brief, the system facilitates easy, HIPAA-compliant sharing of studies between institutions, with the idea of empowering physicians themselves to "be the network". Most every permutation is considered, as long as someone in the equation has a LINCS account. The study can be sent or received with a few clicks among LINCS members, and if a "foreign" study is to be imported to LINCS, appropriate electronic paperwork is presented. A study can then be nominated to be uploaded to PACS, pending approval by whichever human you designate.

Two partnerships offering viewer options and more were announced:

  • lifeIMAGE is demonstrating a technology intergration with Vital Images, an advanced visualization and analysis software company, which shows Vital’s FDA-cleared universal viewer launching from LINCS. The two companies are also exploring a collaboration to provide on-demand access through LINCS to advanced visualization tools and comprehensive clinical solutions for cardiovascular, neurovascular and oncology imaging.
  • lifeIMAGE also has partnered with ClearCanvas, a leading provider of innovative diagnostic imaging applications, including Picture Archival and Communication Systems (PACS) and workstations. ClearCanvas offers a free version of its diagnostic workstations in an open-source format, as well as an FDA-approved clinical version, that will connect the 15,000 members of the ClearCanvas community to lifeIMAGE.
In my own humble opinion, this places lifeIMAGE on the road to creating a Cloud-based PACS, although when I suggested this to Hamid he just smiled and shook his head. Maybe someday.

lifeIMAGE literally offers us a life-saving (and disruptive) technology, and that is NOT an exaggeration. At our trauma hospital, it is more likely than not that a patient will arrive with a CD from St. Elsewhere that has not even been reported, and probably not even reviewed. And sometimes, that CD won't even load. In the best possible circumstance, we the rads spend 10 minutes loading the CD and reviewing it with the house staff. In other cases, the patient is rescanned, the new scan interpreted, and then reviewed with the residents, adding 30-40 minutes to the process (and doubling the radiation dose if anyone cares about that.) Of course, in the worst possible scenario, the patient could well be dead 20 minutes after arrival in the ED if he is the victim of severe trauma. What would we give to have the images in hand and reviewed before the patient hits the door? A few dollars goes a long way, and that's what lifeIMAGE costs when distilled down to the basics.

Not to sound histrionic, but isn't the patient's life worth that? (And no, I don't get a kickback from Hamid.) This is damn good technology, and you should, you MUST look at it.

My second disruptive technology is one you can't buy, directly, that is. Fovia sells their 3D technology not to end-users like me, but rather to PACS and Advanced Visualization companies, including Merge (where I use a limited thick-client version on my PACS), as well as GE, and Vital, among several others. The full version of their engine operates as a thin-client with server-side processing, and it works very, very well. Fovia has taken a very logical approach. "Which would you bet on as the best investment," asked Ken, Fovia's CEO, "a system that uses proprietary graphics cards, one that uses off-the-shelf gaming video cards, or one that uses the CPU of your computer and leverages Moore's Law?" Ken's answer, of course, is number three.

Fovia has bucked the system, going against the prevailing paradigm of proprietary graphics cards (viz TeraRecon) or gaming cards (nVidia, etc.) and does the graphic processing with a server's CPUs. This may seem counterintuitive at first, but stop and peek inside your computer. Even the little MacBook Airs now have a dual-core processor, and what you can buy for $1K on the street (well, don't buy it on the street, but you get the idea) outstrips anything you could have purchased for $10K 5 years ago. Add multithreading to the mix, and you can see that leveraging your investment based on the assumption that CPU's will become more powerful makes considerably more sense than assuming any other factor will accelerate to the same degree. Fovia notes a 30-50 fold increase in the speed of their product over the last 5 years, based in part on the rapid growth of CPU processing power. Fovia's system is highly scalable and flexible...the more CPU's, the faster it runs. Given Intel's recent announcement of a 50-core chip, the speed of processing might be as close to instantaneous as possible.

You will agree that Fovia's High Definition Volume Rendering (HDVR) can produce some powerful images as you will see in this gallery page iframed from Fovia (if it doesn't load, go to this LINK):

Fovia's claim to fame is the use of a frequency domain-based algorithm, for the techies among us. This involves "deep supersampling," rendering each voxel 32,768 times.  Sounds pretty involved to me.

While you can't buy Fovia directly, you can buy some products which use its technology. As an aside, I discussed with the execs the possibility of Fovia creating its own GUI, its own wrapper for the incredible viewing software. The answer? "Others have suggested that..." I guess we'll have to wait and see. But for the moment, they do a darn good job in the background.


Dr. Robert Taylor, CEO of TeraRecon, sent me this comment on the dedicated-card vs. GPU vs. CPU debate:

I read your blog this AM and noticed the barb from Fovia about proprietary cards. To set the record straight, I just wanted to point out, TeraRecon also has a full SW option and we only use the VolumePro (VP) because it happens to be dramatically better than using software and scalable. We can now render over 70,000 slices in real time (the combination of many users working at once) from a single 2U server thanks to this technology. Today, and for the foreseeable future, that's impossible with SW (Fovia, GE, Philips) or GPU (Vital, Siemens).

When the sledgehammer (VP) is not required, we also have the nutcracker (SW), and this is why we have sold hundreds of laptop-based systems that work without a graphics board in sight. We also hope and expect that one day CPU technology will be able to do what is needed, and we're fine with that. It's the application that matters in the long run.

Tuesday, November 29, 2011

RSNA 2011: Siemens Hints At The Future

I mentioned something in the last post about attending the Siemens Media Breakfast, and I promised to elaborate.

As a quasi member of the press, perhaps we should say vanity press, I was once again invited to the annual media event. Being on my new eating program, I didn't take much advantage of the proffered breakfast, but I did listen intently to the talks given by Hermann Requardt, President and Chief Executive Officer of Siemens Healthcare, and Gregory Sorensen, MD, Chief Executive Officer, Siemens Healthcare North America.

There were the usual announcements and scanner refreshes/updates.  The Siemens Biograph mCT gets some new software to allow better quantitation and reproducibility. We are told that this is the best selling PET/CT on the market today.  Wish I had one. The Biograph mMR, the PET/MR scanner, has been installed at 10 sites with 20 pending orders. Wish I had one of those, too, but a $5M expenditure is not in my future. While it was said that the mMR has no competition, Philips apparently has one about to be approved, and GE did announce one in the works.

Two new CT scanners were announced, the Somatom Definition Edge, a single-source scanner utilizing the new Stellar Detector, with 0.3mm routine spatial resolution, and the "business class" Somatom Perspective, a 128-slice state-of-the-art machine with low dose imaging and a lower price point.

There will be two new Acuson units, the cheaper S1000 and the top of the line S3000, the latter having built in automatic fusion to other modalities.

There is a new association with Eli Lilly to distribute the latter's amyloid tracer via Siemens' PET NET network.

The syngo family is mobilized, in other words, it can be accessed remotely, via computer or iPad or whatever. Supposedly mobile apps will allow manipulation, although on the exhibit floor, there was a some hemming and hawing as to how much one can or cannot do on an iPad.

More important than the machinery are the rather candid observations offered by the Siemens execs.

Dr. Requardt opened with a statement that we all know is true: Healthcare spending at current levels is not sustainable. In developed countries, there is the desire to decrease costs, but in emerging countries  there is need to increase access to health care. Siemens sees a "sweet spot" wherein the two curves meet, and they plan to position themselves to take full advantage of this. Turning the conventional paradigms around, Siemens now views therapy as the driver of imaging, and using industrial terminology, healthcare becomes a "project" business, wherein innovation is the solution and not the problem. The disconnect between diagnosis and treatment lead to increased nonconformance costs, and a shift to emphasize therapy my better satisfy patients' needs and wants.

Dr. R rather humbly (or not) noted that Siemens had "misdirected" some investments because they didn't realize the healthcare sector was "not fast enough to respond to technology". Hate to say it, but this implies the sector wasn't smart enough to grasp some of what Siemens offered. Or perhaps what Siemens gave us here and there wasn't what we needed at the time. Particle therapy was cited as a case in point. Siemens developed/created/improved the technology, but it hasn't sold well. Apparently, this was NOT one of the "non-regret" moves Siemens wants to see in the future.

I've already alluded to the statement about PACS. "We will focus on core secgments," said Dr. Requardt. "RIS/PACS today is a commodity these days, with dramatic changes in network environments. Our future investments will reflect this." Is Siemens dropping out of the RIS/PACS market? It seems that with every vendor now offering a Vulture Vendor Neutral Archive (VNA), Siemens no longer wants to compete (much?) in this space.  Sad, given the fact that the new syngo.plaza might actually be their first workable interface.

Dr. Sorenson took over, describing the demographic "wave" of aging Baby-Boomers (hey, I'm one of them!!) 80% of healthcare costs are for older patients, and Medicare is decreasing spending. Imaging expenditures are being cut back in particular, with still some increases for primary care. Dr. Sorenson describes imaging reimbursement as a bubble: reimbursement was so high that it created its own demand. (To be fair, the equipment companies, including Siemens, need to stand up and acknowledge the role they played in dangling those reimbursements in front of clinicians as incentives to purchase their scanners.)

In what I find to be a rather ominous, but still realistic, approach, Siemens plans to address the increased scrutiny we docs are now experiencing, mainly from governmental sources. This drive masquerades as a drive toward minimizing "practice variability". IT tools will move us toward evidence-based, rational care. Reading deeply between the lines, our systems will tattle on us physicians if we stray from the government (or third-party payer norm, whatever that is. Big Brother will be watching us. Now, I don't blame Siemens for this, and being a good Capitalist, I will even applaud them for blazing a path to profit through this mess. But I'm still not happy about it at all. It's probably time to retire.

Siemens will spend 1.4 Billion Euro on R&D this year, and it certainly shows. That's actually just about the same number as their reported profit.

Finally, Siemens, the German company, now manufactures half of its CT's in China. "We make it wherever it's adequate to make it." The factories in China are 100% staffed by Chinese nationals, and the facilities are identical to their German counterparts. Far better to invest in China than to be the main investment, I would say.

I wonder what Siemens will bring us next year?

Monday, November 28, 2011

View From The Balcony..

I'm back at RSNA for what must be the 13th or 15th time since my first time way back in 1990.  Or was it 1989? Back then, the meeting spanned the entire Lakeside building, which was all there was of McCormick Place at the time.

Today, many of the BIG vendors have reoccupied Hall D of the Lakeside building, although I'm seeing a lot of empty space in the periphery of the North and South exhibit halls.

I'm sitting up on the Balcony Cafe in exhibit hall.  It's quieter up here, the wifi is strong, and there are numerous power outlets. My iPhone 4 is gobbling up battery power, thanks to iOS 5.0.1, and I've stolen Mrs. Dalai's Macbook Air to facilitate reporting from the floor.

The atmosphere here is pretty vibrant, and there seems to be a lot of interest at the booths, although I have no idea of how much money is actually changing hands.

I've been to several educational sessions already, and I've spent some time on the floor.  There isn't a LOT thats new, but there are a few interesting things here and there. I'll have a separate report on the Siemens Media Breakfast later, but their big news involves the introduction of two new CT scanners.  And, there was a remark made in passing almost concerning the act that RIS/PACS is now a commodity, and as such it may not justify quite the same level of investment it once did. That's unfortunate, as syngo.plaza might actually be Siemens' first functional PACS.

I've had a look at one of the two SPECT/CT candidates, and while its bone SPECT images haven't improved much, there are some other minor improvements.  I'll have a peak at the other one tomorrow or Wednesday.

A friend of mine who works at McKesson had me take a look at their latest PACS GUI. While it's busy and has maybe too much customization, I'm coming to appreciate what it can do; it's a very powerful interface, and if I needed to replace a PACS, it would be on my short-list of competitors. McK has finally decided to converge the various clients, so the view is more or less the same no matter if you access the PACS from home or office. So far, no iPad client, but there is something pretty revolutionary in the works, although apparently not yet enough of a work-in-progress per se that it can be seen by the likes of me.

Probably my greatest accomplishment today was to connect the folks of Blackford Analysis to a major PACS vendor. The rest is up to you, mates!

What has surprised me most of all is the number of folks who remember me from earlier interactions, and continue to read the blog. I continue to be humbled by the fact that anyone actually looks at this thing, but you all have my deepest gratitude for doing so.

Tonight, dinner with some old friends, and then meeting up with some other old friends. My daughter might even be able to break away for a moment and join us!

I'm tired already, and it's only Monday at RSNA...

Sunday, November 27, 2011

Your Village Called
Their Radiologists Went To RSNA

I'm on my now-annual trek to Chicago for RSNA. I go every year now that my daughter is in school up there in the frigid North.

(As an aside, I think I've come up with a wonderful idea viz-a-viz the horrendous weather in places like Chicago and Buffalo. We need to swap cities with Mexico. Chicago could trade places with, say, Cancun, and New York City and Mexico city could easily flip-flop. No? Well, darn..)

I've been bombarded with advertisements from a sampling of the zillions of vendors out there in the imaging space, and you might hear about some of these when I submit The Dalai's to Aunt Minnie. More on that later.

There is one marketing communication that is just so far off the wall, I have to let you know about it even while I'm still in the air.  I won't name the name, but the ad comes from one of the publishing houses specializing in things radiologic. Where they came up with this idea, I haven't a clue, but here's what you could see if you happen to be in the right place tomorrow at the right time:
RSNA Tribute Flash Mob – Monday November 28 at 9:45 AM
Haven't you all wanted to participate in a flash mob? Here is your chance! We have created an RSNA Tribute song (and dance) to be performed on Monday morning at 9:45am right before the exhibits open. If you have never heard of a flash mob, here's the story:

The music ("R-S-N-A" to the tune of "Y-M-C-A" – EVERYONE knows this song!) starts and just a couple of people start dancing and singing along…gradually more and more people join in and before you know it there are a whole bunch of folks rockin' out. So you are wondering what you have to do? Just click on the link below. We've posted the very basic dance steps (don't worry, they are quite simple) with music. You don't have to be a singer – the music has been professionally recorded and will be broadcast at full volume! We will have the expert support of some Chicago college dance students, so you won't be alone and you can just "follow the leader" as they dance! We plan to have a short rehearsal in Chicago. Our goal is to record this to relive the celebration, and laugh (a lot). We are quite sure that this will be a first for RSNA and we feel that it is the duty of all (the) family members to bring a bit of liveliness to this staid and somber meeting.
Here are the new lyrics, butchered sung on YouTube:

And for those far more coordinated than I, here are the dance instructions:

I'm probably going to be in an educational (OK, I'm trainable if not educable) session when this goes down, so I'll expect reports and links to videos of the actual event.

Frankly, I think I need to pervert rewrite YMCA myself...

Hey Doc, My Ass Hurts, Oy Vey!
I need me a CT TODAY!
Ummm...never mind...

Addendum...It actually went down!

Hat tip to Ken from Fovia.

Saturday, November 26, 2011

iPads From Our Futures Past

Apple loves to sue people and companies that even hint at coming close to imitating their stuff. The latest prolonged battle targets Samsung, whose Galaxy Tab is said to be a "slavish copy" of the iPad. In response to several legal defeats, Samsung is slightly modifying the Galaxy to prevent anyone from possibly confusing it with an iPad. Not that anyone would have.

If you are at all interested in the legal machinations, check out THIS article from Mashable.com.

Samsung, to their corporate credit, has come up with a novel defense that might just work in the courts. Samsung claims that the "look and feel" of an iPad has been around quite a while, as we see in this clip from Stanley Kubrick's SciFi masterpiece, "2001, A Space Odyssey":

And that's not all.  Consider Star Trek's various "Padd's":


And even from the Original Series!

Yup...there's nothing new under the various suns in the Star Trek universe.

Oh, by the way, there's a tablet out there that doesn't get much mention, but I think was truly the original, forming the basis of a lot of things we deal with today:

Top that, Apple!

Wednesday, November 23, 2011

Another Shoot-Out,
Or, A Requiem For Advanced Imaging

Shoot-Out at the OK Corral
The word has gotten out to some of our potential vendors, so I might as well go public. We're having another shoot-out, and it should be quite interesting.

Our larger hospital system seems to have found some funding for an advanced imaging product of some sort, and somehow your friend Doctor Dalai has become the point-man in the decision. Initially, we were going to go with a bundled solution, as we need a few CT scanners, not to mention my beloved SPECT/CT scanner. Sadly (for the vendor in question), some of the initial prices ("good only for the next 10 days!") were way out of line, and so we are unbundling the purchase. I am thus free to pursue the best-in-breed of Advanced Imaging and SPECT/CT.  Someone else gets to worry about CT.

There are only a few choices when it comes to SPECT/CT, and I've reviewed them before. But advanced imaging is another story.

To create the atmosphere for a fair and balanced decision with respect to advanced imaging software, we will arrange a "shoot out" between some of the major vendors and their products.  I say "some" because we don't have enough room or time to showcase every possibility, so we are limiting the scope to a few programs that seem to have potential to accomplish what we need to do. A side-by-side comparison seems much more efficacious than the series of 20-minute demos we've been enduring. Plus, some of the vendors have been, shall we say, a teeny bit aggressive about placing their product for a prolonged demo, to the point that we were to accommodate about a half-a-dozen servers and 5 IP addresses. That might be the next step, but we need to be absolutely certain that our needs will be met before we start opening up rack-space in the data center.

The format will be similar to the Stanford PET/CT competition I wrote about a while back, with the vendors processing data we provide on a real-time basis. We will give them a script to follow, so we can see the same things done on the different machines, and then of course there will be some time for the vendors to do their own thing.

The script is still in flux, but I have a number of things that we need to see, and a few that we would like to see. In no particular order, here's what's on the list so far:
  • One-button processing, or as near to this ideal as possible. Of course, there must be a way to go back and manually alter anything that needs altering.
  • To the greatest degree possible, the system must be operable/viewable from anywhere, and any platform (PACS station, laptop, iPhone, iPad, Android phone or tablet, and whatever else comes up in the near future.)
  • There must be complete and total integration with IMPAX 6.5 and beyond, our illustrious PACS.
  • Procedures will include (but certainly not be limited to):
    • Brain perfusion
    • PET/CT viewing
    • Full cardiac/coronary work-up
    • Virtual colonography
    • Bone subtraction/transparent/translucent rendering
    • AVI creation
Suggestions for other items are welcome, although vendors need to be circumspect on this.

In addition, we have been tempted by "dose reduction" or "denoising"software, which is included in some of the advanced packages. I've discussed the concept earlier, and frankly, I still don't like the idea of dropping the quality of a scan in hopes of rescuing it later. So, to me anyway, this will not be a critical component. If it comes with, fine, if it doesn't, also fine.

The tentative schedule for the shoot-out is set for early January. Ambulances will be at the ready for the fallen.

Tuesday, November 15, 2011

The Match Game

Once in a great while, something comes across my virtual e-mail desk that gets me excited, and when you reach my age, getting excited is rare and possibly dangerous. Nonetheless, when I saw what the folks from Blackford Analysis (http://www.blackfordanalysis.com) had to offer, I definitely got a thrill.

Blackford comes from outer space, almost literally. Their origins are in the astrophysics world, and their break-through technology is called MOPED:

Blackford Analysis’s core technology is MOPED, an algorithm developed in astrophysics to tackle analysis of immense datasets. The patented approach involves compressing the huge datasets while retaining all information needed to solve a problem – allowing speedups of many orders of magnitude over traditional techniques.

The technology comes from astronomical surveys, where instruments capture gigabytes of images per hour. This information is generally interpreted by comparison with models, essentially complex formulae driven by a set of parameters, which reproduce the observations.

Parameters might be the mass of a galaxy, or the distance it is from Earth, and there will be some combination of parameters that produces a modelled image that is very close to that actually seen through the telescope. Situations like this are called ‘parametric modelling problems’.

MOPED’s particular ability when solving such problems is that it speeds up the step that determines how well a given combination of parameters recreates the image.

After the initial compression, the time taken for each combination changes from being set by the number of pixels to being set by the number of parameters. If 10 parameters were to be determined by an image taken by a modern digital camera with 12 million pixels, the calculation would be more than one million times faster.

This means that problems that were too slow become possible, often solvable in real-time. As datasets become larger, and the cost of the hardware resources required to tackle them rocket, the case for MOPED is even more compelling: the powerful algorithm vastly reduces that hardware cost.
So what does this have to do with imaging?  It seems that we can apply the algorithm to matching volumes, such as two CT scans!
Developed by Blackford Analysis, the medical imaging technology makes it possible for radiologists to anatomically link small features such as lung nodules between studies for the first time within the PACS.

While the radiology imaging software will also align CT and MR from any part of the body, instant anatomical alignment in the chest is a major breakthrough, given respiratory movement and the requirement for a deformable registration.

Blackford Analysis’ technology greatly reduces the time it takes to compare current and prior studies, a drain of radiologist’s time as volumetric datasets increase in size and complexity and become ever more commonplace.

A key advantage of the software is that it designed for integration in the existing PACS environment so radiologists can use it without having to interrupt their natural review processes by moving to another workstation.

Crucially, the alignment is achieved without any alteration of the raw slice data so radiologists don't need to worry about the authenticity of what they are reviewing.
A video is worth at least 10,000 words:

Blackford is thinking outside the box.  In all of the other registration programs I've seen, an attempt is made to match the entire volume of the old study to the new. Because patients are not rigid (their bodies aren't, anyway) this doesn't work so well. Some software will attempt to distort the data-set to achieve a fit, which could conceivably distort the findings as well.  Blackford takes the novel and proper approach of an instantaneous point-to-point mapping, finding the exact spot on the old study that I'm seeing in the new exam.  Brilliant! That's really all we need in the end, isn't it? And it does appear to work quite well. And to have it actually integrated into the PACS viewer would be incredible.

I hope to meet with the folks from Blackwell at RSNA and see the thing live and in action.

PACS vendors: you WANT this in your product. You really do. Jump on it now.

Contact r

Friday, October 28, 2011

For The OWS Crowd...

It just isn't FAIR!!!!!

Hat tip to Dr. Sanity.

Dalai Gets Schooled By Merge

Nanak, my PACS guru, recently asked for permission to attend a MERGE PACS training session. The description looked so good, I wanted to attend as well:
Merge Healthcare, the leading developer of information technology to create a better electronic healthcare experience, invites you to attend a specialized training session. During training, our technical experts will walk you through a deep dive of the technology’s features and functionality so you gain the critical skills necessary to maximize your investment in Merge solutions.

Where: Daytona, Florida

Learning objectives:
  • Systems Overview - PACS Components
  • Server Maintenance
  • Definition of logs and what they mean
  • Advanced trouble shooting techniques
  • MWL Filtering (how it works)
  • Creating advance transfer rules
  • Managing Image volumes and watermarks
  • RTWL filtering
  • Management Tools
The two-day session was held at Merge Southern Headquarters in Daytona Beach, Florida:

As it turns out, this is also Merge's main support site, and so we got to see the "prairie-dog village" as Nanak calls it, where the support folks do their thing:

We had the opportunity to meet in person many of the folks who had been taking care of us and our system for the past few years. We also discovered the secret of their seemingly unlimited energy:

We also got the chance to have dinner with my friend Mike Cannavo, the PACS exec formerly known as the PACMan. (Mike now works for The Man at a big-name vendor.)

The course itself was frankly slightly above my level.  While I do have administrative privileges, I don't dabble too much in the back-end of our system (presently Version 5.0) or the hospital's (version 6.0.4), but I did find it quite valuable to learn more about what goes on there. There are some places I'm not going to tread, and even Nanak doesn't like to dive into the DB2 database, which can be dangerous indeed, but we now know more about how to do so if need be.

One major change between our 6.0.4 and the latest 6.2 is that the name AMICAS is slowly being relegated to the trash bins of history and my failing memory.  The new sign-on screen reads thus:

Perhaps I should moonlight as a PACS admin with my new education. Nah...radiology is probably easier. But I did learn a particularly valuable lesson: Nanak really knows his stuff.  Throughout the whole class, he was helping me understand what was going on, and it was pretty clear he has a huge grasp of this stuff. Remember Dalai's IXth law: 
A true PACS guru is worth his/her weight in gold.
In Nanak's case, that's a lot of gold. But still absolutely true.