Sunday, December 16, 2012

The Belated RSNA PACS Post IV: A LarGE Surprise...

The Merge booth bordered on the edge of GE-Town, which I believe was somewhat smaller this year as compared to RSNAs of the past. In fact, there was a LOT of unused territory on the exhibit floor, cordoned off with the standard blue curtains. I would guess there was at least 1/8 of the floor unused, which is unusual, but probably indicative of bad times to come.

Anyway, my friends at Merge told me that there was a big to-do at the GE booth before I got there, that Mr. Immelt himself had been present, that something Really BIG must be happening. Given the presence of Herr Gro├čen Kopf over at Siemens, I figured I'd missed Immelt, but I decided to wander over to GE-land anyway.

Turning my badge around so my name wouldn't show (yes, badges this year were printed on both sides, but I stuck my class tickets in the holder, covering the demographics on the back), I marched right in to the PACS area, noting nearby the big display about GE's new quiet MRI. Having been in a GE MRI (we own two), I can vouch for the need to silence them a bit, and apparently GE has made great strides in this regard. There was also an announcement for a hybrid PET/CT/MRI, which is really just a PET/CT and MRI image merger. Cheaper than bolting all three gantries together I suppose, although not as interesting.

To me, the biG Excitement came in the PACS booth. Here, we find the new GE Universal PACS viewer, and this represents a HUGE departure from the status quo. I didn't have time for a proper demo, but with a few minutes exposure, I was quite impressed. Suffice it to say, GE FINALLY gets it, or at least some of it, and offeres a unified, web-based PACS viewer that integrates the AW platform's visualization ans well as automation. Did I mention that it is web-based? And that it isn't Centricity IW, the late, great product from the late, great Dynamic Imaging?

In my brief demo, the following features were emphasized:

  1. This is a web-based ActiveX client.
  2. There is a zero-footprint version for clinicians, and mobile access, with considerable functionality
  3. Native MIP and MPR
  4. Timeline display
  5. Relevant Priors based on body-part
  6. Auto-open cine's 
  7. Multimodality fusion (which I think they said was drag-and-drop)
  8. Smart Reading protocols, which learn your preferences as you go.
GE literature adds:
  1. Intelligent productivity tools, including smart hanging protocols; 
  2. Advanced Visualization applications, including oncology; powered by AW
  3. Breast Imaging Workflow, including screening and diagnostic capabilities; 
  4. A common, streamlined, ergonomic user interface; and 
  5. Access anywhere the Internet is available — web based, zero footprint and web client access.
To flesh out my report, I'll direct you to the pertinent GE site. Here's an introductory video from that link:

Also, here's the full text (sorry) from GEs press release:
CHICAGO – NOVEMBER 26, 12 – With this week’s introduction of Universal Viewer, GE Healthcare aims to put clinical insight within reach to help radiologists and referring physicians deliver patient results efficiently. Universal Viewer brings together advanced visualization, intelligent productivity tools, and multimodality workflow for oncology and breast imaging all within one intuitive workspace that can be accessed anywhere, anytime. It works with Centricity* PACS, Centricity PACS-IW, and Centricity Clinical Archive.

A recent GE-sponsored study conducted by ACR Image Metrix, a subsidiary of the American College of Radiology, showed up to 2.5 hours in a radiologist’s day wasted because of workflow inefficiency. As healthcare rapidly evolves to a more patient-centric, collaborative, and outcomes-focused model, customers need to integrate information across different systems to help make patient diagnosis and treatment more efficient. Rather than creating complexity with multiple logins, tools that behave differently, and separate workstations, Universal Viewer has the potential to provide 5% productivity improvement. It has a unified user interface with a single look and feel that is easy to learn and able to adapt to radiologists’ preferences, automating exam setup. Referring physicians can access the viewer from anywhere and patients can get from the exam to their results in less time.

Centricity PACS and Centricity PACS-IW users will find a new dimension of clinical intelligence as they explore Universal Viewer. It enables seamless workflow with pre- and post-processing. Advanced clinical applications, powered by AW, are embedded to enable oncology quantification, auto bone removal, vessel analysis, and registration. In an industry “first,” Universal Viewer also includes integrated mammography tools for screening and diagnostics, with the ability to display images across a breadth of modalities, support CAD markers and IHE profiles, and connect with reporting systems.

“This is really fantastic,’” said Dr. James Whitfill, Chief Medical Informatics Officer of Southwest Diagnostic Imaging in Scottsdale, Ariz. “When we bring all of this together and provide what I think we’re all asking for, it’s really going to be an exciting step forward.”

For radiologists who want a next generation viewer that requires less manual setup to read exams, Universal Viewer has the potential to reduce mouse clicks by 70%[1]. It has a “smart reading protocols” feature developed in GE’s Global Research Center that essentially digitizes radiologists’ sequencing preferences on the fly as though it were hanging physical film across a lightbox. It introduces case-based reasoning techniques, including machine learning algorithms, image analytics, and text mining for automating exam setup.

“Adopting new applications means change for providers, but minimizing change by keeping workflows consistent can help to reduce the impact and lost productivity associated with the change. Machine learning features are a great way to digitize workflows without long, costly implementation projects and extensive application customization,” said Judy Hanover of IDC, a leading analyst firm, “Radiologists will appreciate being able to work in a digital environment without having to abandon their familiar customs.”

A zero footprint (ZFP) exam viewer intended to deliver non-diagnostic, review only capabilities provides clinicians with easy, enterprise-wide access to images and reports through connectivity with an EMR or GE Healthcare’s Centricity Clinical Archive. The ZFP has the added advantages of a zero installation with no download of any software to the user’s device. It also does not require administrative rights required to access.

Jan De Witte, President and Chief Executive Officer of GE Healthcare IT and Performance Solutions said, “This is an enormous step on a path to our future, a future of intensifying imaging investment and innovation. Customers have told us that systems have become too complex and interoperability needs improvement. This takes away time they could be reading exams and delivering patient results. We invite radiologists everywhere to join us and view our proposed solution, Universal Viewer. We invite them to tell us what they think and, most of all, to stand by to see the future of imaging IT delivered to their desktops.”
To emphasize..."Customers have told us that systems have become too complex and interoperability needs improvement." GEeee...WHAT HAVE I BEEN SAYING FOR THE PAST SEVEN YEARS ON THIS BLOG????? It's nice that GE finally chose to listen to their customers, at least those who actually use their product, and not those who told them Centricity web was something to be proud of.

To be fair, Siemens' plaza.via takes a similar approach, but for better or worse it uses the syngo platform. AMICAS/Merge and others have been doing this sort of thing for quite a while, too. It's just phenomenal that GE has finally taken this route.

I need more hands-on time with Universal to give you much more feedback. Hopefully, GE will see fit to upgrade our horrendous Centricity 3.x installation with the new software. Please? Pretty Please? Well, I can dream, can't I?

The Belated RSNA PACS Post III: Agfa

When I was in school, and then in residency, I used to define the best professors those who could tell me I was full of it and make me like it.

I don't think I would make a very good professor, but Agfa is a true class-act on this score. I've whined rather mercilessly about some of their approaches with which I don't agree, and I've mentioned some problems with certain installations in the Eastern/Southern Hemisphere periodically. Still, the people at Agfa have been incredibly friendly and amicable toward me, trying hard to at least listen to my rants and do what they can do within whatever restraints they operate under. 

I spent but a few moments at the Agfa booth, devoting much of the time to the latest version of Agility, or IMPAX 7 as I like to call it. I'm under NDA not to talk about it, but I CAN tell you that it will be much more powerful and intuitive than good ol' IMPAX 6. 

In the meantime, IMPAX 6.5.3, the latest release, will have improved background caching, and boasts various clinical app suites for advanced imaging, from basic MPR and 3D to PET/CT fusion.

The Agfa booth hosted a little company called Real Time Medical, which offered a workflow engine that would unite disparate PACS, RIS, speech recognition, etc., under one wrapper. From their website:

Real Time Medical develops vendor-neutral context-aware workflow management software solutions for diagnostic imaging organizations (DIOs).

In introducing diagnostic imaging to context-awareness in workflow management, we offer breakthrough methodologies to automate and optimize the way workloads and workflows are managed in DIOs, with an eye to drive more value out of their existing PACS/RIS investments and confidently prepare themselves for a rapidly changing future.

Our software products, under the umbrella platform DiaShare™, concentrate on the areas of workflow management and enterprise productivity (WORKFLOW) and quality assurance (QUALITY). Both are seamlessly vendor-neutral because of our elegant connectivity, integration and interoperability engine (OPEN)....

DiaShare™ WORKFLOW removes concerns regarding physical locations, traditional IT infrastructure and existing RIS/PACS infrastructure, and answers the question: how can your system’s workload be optimally managed according to contextual parameters you set, and can easily change as environmental conditions change.

The DiaShare platform does require the use of their particular worklist, but it's a good start. I'd like to see all this done in the background, i.e., I want to see the worklists of all my connected PACS show up within IMPAX, or Merge, or whatever, in a manner transparent to where I'm sitting. We're almost there, I think.

Apparently our funding for upgrading to the next version of Agfa is limited, so I may have to rely on outside reports to let you know how well it works. Agility has been deployed in beta in a few sites around the world, and I think one here in the States. I offered our services, but then thought better of it, given how stubborn our guys can be sometimes...

The Belated RSNA 2012 PACS Post II: Merge

Being a happy Merge customer, one of my most important visits on the exhibit floor is to their big orange booth. Sadly, the orange Tesla is no longer on exhibit, although I'm told it is still part of the Merge fleet, and might possibly be available to be taken for a spin by the best Merge customers. I'm not sure I qualify for that, and besides, I wouldn't even think of driving in Chicago in a $100,000 vehicle.

You may remember the pre-RSNA Merge teasers:

And indeed, there was a big orange box in the middle of the booth:

That's me with an unidentified member of Merge who was trying to conduct business on her cellphone but was forced to pose with me by certain photo-shy Merge folks. (You know who you are!!)

What's inside the box is "Clear", literally!  The box itself a dramatization/simulation of Merge-Clear, a new quick and easy ordering system allowing imaging centers to "stay in the loop" and hopefully increase their referrals. The clinician gets online, even using iPhone/iPad, (I think Android is supported as well) or whatever to post the order, and the appropriately registered patient can get online and schedule the exam at the place of his/her choice, (of course those imaging centers registered with have the chance to advertise WiFi or child-care, or free drinks, etc., and the lucky patient can even preregister or fill out paperwork on an iPad.) The ordering doc can then view the report on the iPhone whilst on the golf-course, illustrated by a very nice set of clubs at the far end of the box. Some very interesting metrics and data-mining can be found within Clear, such as ways to see how many patients your center is losing because you don't have child-care, and so on.

Merge has established a partnership with SureScripts to create a portal into most EMR's:
Merge Healthcare Incorporated (NASDAQ: MRGE), a leading provider of clinical systems and innovations that seek to transform healthcare, will connect its extensive imaging network with the Surescripts Network for Clinical Interoperability. This connectivity will allow hospitals and imaging centers to electronically deliver imaging reports to care provider organizations through EHRs on the Surescripts Network. In addition to electronically receiving the report through their EHR, ordering physicians will be able to access and view images securely from the Merge Honeycomb™ cloud-based solution. Sharing results and images is immediately valuable and will become increasingly critical as EHR vendors work to certify their systems and organizations look to attest to Meaningful Use (MU) Stage 2.

"With the majority of physician groups and hospitals now having an EHR in place, these organizations want to receive results electronically to increase efficiency and avoid errors, however connecting to hundreds of certified EHRs is expensive, custom work," said Jeff Surges, CEO of Merge Healthcare. “With Surescripts delivering connectivity solutions that improve the delivery of vital clinical care information between care providers/organizations, and Merge offering premium imaging content, we can help hospitals and imaging centers improve efficiency, reduce costs and most importantly, strengthen care collaboration among referring physicians by delivering radiology reports and image links directly into the physician’s EHR.”
As usual, it's all about who you know, eh? Merge itself knows a lot of folks, claiming to have managed 82 million of the 370 million annual ambulatory imaging procedures in the US. (This does not include ePhlegm, by the way.) That's quite a footprint in the ambulatory space.

In other news, Honeycomb, the cloud image repository, is up to 3.9 million images in its first five months of operation.

iConnect, the access and sharing system with Facebook style interface, is also now iconnected to SureScripts as well, providing image access to the EMR, and it includes server-side rendering, requiring another server, but able to handle default JPEG2000 or DICOM images, even on my beloved Retina displays. (It won't work with a virtual server as we have been assembling for our PACS upgrade.) If more power is required, iConnect can launch the Halo PACS viewer.

There were a few incremental changes to AMICAS Merge PACS 6.5, with more powerful credentialing, determining who can read what, and the creation of a temporary worklist via the search function. Ortho tools were added in 6.4 as were multiple teaching files.

Perhaps the most important comment I can make about Merge is that while it isn't AMICAS, its stewardship of the software has been exemplary, providing good service, and growing the product nicely, even in this age of cutbacks. I anticipate this to continue, sale or no sale (and NO ONE mentioned anything about a sale, by the way...)

The Belated, Limited RSNA 2012 PACS Post I: lifeIMAGE and HealthFortis

My sincerest apologies to my readers, some of whom have nicely pointed out that I've been lax in my Post-RSNA posts. In years past, I've been very diligent about posting my RSNA observations immediately, never letting even a day go by without putting something down on virtual paper for my loyal fans, all three of you. I guess this is what happens when I violate the rules set out by Dr. Bruce Hillman in a recent JACR editorial: "The key to a happy career is being low enough on the totem pole to escape notice. Even better is to be so far down the hierarchy as to be beneath contempt."

But like the kid with the dog-chewed homework, I've got several excuses.

First, when you go to RSNA with wife and family, your time must be devoted to...wife and family. Instead of hanging around McCormick with my laptop as the sun set on Chicago, pounding away at a pithy post, I was compelled to high-tail it back to the hotel to meet up with the boss. Yes, it's Mrs. Dalai's fault, but PLEASE don't tell her I said so!

Second, I've been battling a light case of the flu. No, I haven't taken the confirmatory test, but the pharmacist at Rite-Aide, whom I trust more than most physicians, tells me she's seen a lot of this among those of us who took the flu vaccine. Those who didn't have the shot are getting REALLY sick. But I'm doing better.

Third, in anticipation of changing tax laws, especially those concerning non-cash contributions and deductions, I've been going through the house and donating everything not nailed down. (The dogs have been hiding under the bed.) A collection of 300 Beanie Babies (remember those damnable things?) went to our local Children's Hospital. My collection of every transistorized version of Zenith Trans-Oceanic shortwave radios, 30 miniature transistor radios, and 7 Minox spy-cameras and dozens of accessories all went to our State Museum. And finally, and most painfully, my beloved collection of 19 huge classroom-sized slide rules and 70 more normal-sized and projection slide rules went to MIT. And let me tell you, sending a bunch of 8-foot long objects to Massachusetts is not an easy task.  Watch for the Dalai Memorial Slide-Rule exhibit at the MIT Museum sometime in the next year or so.

Finally, not so much in anticipation of any change in the law, but more in reaction to our neighbor's house being burglarized at high noon last week, I bought a gun and started to learn how to use it. For those who are interested in such things, it is a Heckler and Koch P7M8 with Robar NP3 coating.

This is an old model, no longer made by H&K, which was designed for the German police. It has no safety per se; to cock the weapon, one squeezes the handle. Without the squeeze, the gun cannot fire, PERIOD, making it one of the safest firearms out there. I went to the local firing range, and with a lesson (having not fired a gun in 30 years) I shot 50 rounds with fairly good accuracy:

I'm not a huge gun advocate, but I think it is self-evident that had someone at the Sandy Hook School in Connecticut been armed, 26 innocent children and their protectors would more likely be alive today. And that's all I'm going to say about that. (Don't even bother to comment.)

Right. Let's get on to business.

From my earliest, infantile postings, I've been bemoaning the problem of the "portable patient," the fellow whose imaging studies are spread about the land like a virus. My friends at lifeIMAGE, including CEO Hamid Tabatabaie many other wise folks from the old AMICAS days, continue to lead the charge in solving this particular bane of my existence. There has certainly been progress in digitizing even the smaller hospitals, but the free-standing PACS therein create what lifeIMAGE terms "information silos".  A new (well, evolutionary, anyway) service called Connections™eases the communication between these silos, the patients whose information they contain, and the medical personnel that staff them.
lifeIMAGE Connections employs simple and social workflow to connect people in real-time to send or receive imaging information. Physicians, patients and imaging service providers can connect to sources of imaging data on CDs, remote PACS networks, scanners or electronic health records. This will drive better, less expensive patient care by preventing unnecessary imaging exams, and will also foster a new level of collaboration on imaging that will escalate the value and scope of radiology in healthcare delivery.

Accountable Imaging™ is a commitment to bridge silos of medical imaging information to avoid unnecessary exams, delays in care and medical errors. lifeIMAGE Connections facilitates the seamless exchange of studies between institutions, physicians and patients anywhere, supporting radiology practices that pledge to be accountable.
For those whose path will force them into an Accountable Care Organization (ACO):
In the coming year, Connections will evolve to support new models of provider collaboration. To help hospitals involved in ACOs meet quality and cost containment goals, lifeIMAGE will provide imaging duplication detection through integration with clinical decision support and EMR applications. This will connect physicians who are part of at-risk models to relevant prior imaging, no matter where it is stored. lifeIMAGE is demonstrating its early integration with HealthFortis, a leading decision support system, at RSNA.
lifeIMAGE had at RSNA-time approximately 300,000,000 images under management. Not bad. Clearly, the market agrees that their solution works: customer list reads like a Who's Who of radiology:

Yes, there are other ways to skin the silos, so to speak, and many PACS companies tout them. But I firmly believe lifeIMAGE has solved this problem in the most vendor-neutral and HIPAA compliant manner possible. I have but one regret: I'm not yet a customer. But I'm working on it!

On a tangential issue, I got to hear as well about the continued evolution of HealthFortis, mentioned above and described in one my RSNA 2011 posts. Kang Wang, another of the software geniuses (and I do not use that term flippantly) has taken the approach to CPOE that would never occur to a megalithic company:  BE the piece of paper the surgeons and clinicians really want! Never slow down the docs, but add decision support to the format they already know. The interface is simple, intuitive, EMR integrated, cloud based, it actually works. Initial placements have demonstrated that compliance with the system increases rapidly with use, with fewer and fewer incorrect orders. While the average "decision support" software simply second-guesses the user, HealthFortis HELPS select the recommended procedure, following a search and display algorithm reminiscent of Google.  Appropriateness of radiological procedure selections are graded by the ACR Appropriateness Criteria, with 9 for the best and 1 for the worst choices given the particular setting.

Sitting on the periphery of the CPOE committee of one of our hospitals which is trying to rework 20-year-old MediTech software, and hearing the shrieks of pain and agony from the other which is trying to make Cerner user-friendly, I can tell you first hand that Kang's approach is light-years ahead of the old-fashioned ways.

lifeIMAGE and HealthFortis have, through simple interfaces and effective software, solved some of the most troublesome problems we face in the "Information Tsunami". I urge you to have a look for yourself.

Tuesday, December 04, 2012


I know RSNA was last week, and I've been bad about posting my observations. This is what happens when I you bring your wife to RSNA and your kid lives in the vicinity...instead of staying up late writing blog posts, you go out to dinner and generally have a good time in Chicago.  On top of this, I had a bunch of things to accomplish when I got home. Please stand by for some interesting PACS revelations from Merge, Agfa, lifeIMAGE, and (gasp) GE!