Friday RSNA Postcards

Thursday RSNA Postcards

Today's RSNA Postcards

More RSNA from Dr. Sardonicus

My friend, Dr. Sardonicus, sends these postcards from RSNA:

Small Food

My friend, Dr. Sardonicus, has graciously offered to send in periodic missives from RSNA. Here is his first Postcard from Chicago:

RE: RSNA

Image courtesy RadRounds.com

Just a quick note...I will NOT be attending RSNA this year. That vacation week went quite quickly in our annual selection extravaganza, otherwise known as "feeding time at the zoo". It seems that those who possess either Thanksgiving week, or the week after, which is traditionally when we all go enjoy the lovely weather in Chicago, do not have to be on call for Thanksgiving weekend.

I AM anticipating submitting my now-annual alternate-reality novella to AuntMinnie.com. Whether it will be published now that Mike Cannavo, the One and ONLY PACSMan has returned to his typewriter remains to be seen.

In the meantime, I'll ask for your help in informing the masses of the goings-on in Chicago. If you see something that you feel is worthy of attention, please write up a few paragraphs and send them to me at DoctorDalai(at)gmail.com. Let me know if you want your name attached, and of course if you are a vendor, of that product or another. (I'll have no slams of GE stuff by Siemens people or vice versa.)

Here's your chance to be a guest columnist on DoctorDalai.com, surely the life-goal of most of my readers.

Happy Thanksgiving, everyone!

JBoss Exploits Merge PACSAn Alert To Merge PACS Sites

Image courtesy monitis.com

I'll dispense with the usual apologies for not having recent blog entries. You don't want to know about all the crap going on in my life, both on the personal and professional level. Suffice it to say that one can lead a horse to water, but can't make him play water polo.

Let's cut to the chase. Those of you with Merge PACS might have a problem. Our enterprise has a spoke-server placed at a remote location, which unbeknownst to us, had been setup as open to the world, having ports 80 and 8080 (ask your PACS or IT people) unblocked. Oops number one.

Oops number two involves the fact that Merge PACS server software uses something called JBOSS in its machinations. So just what IS JBOSS, anyway?

From the Wiki:

WildFly,[3] formerly known as JavaBeans Open Source Software Application Server (JBoss AS, or simply JBoss) is an application server authored by JBoss, now developed by Red Hat. WildFly is written in Java and is executable on top of the Java Platform, Enterprise Edition (Java EE), which is available cross-platform.

WildFly is free and open-source software, subject to the requirements of the GNU Lesser General Public License (LGPL), version 2.1.

The renaming to WildFly was done to reduce confusion. The renaming only affects the JBoss Application Server project. The JBoss Community or the Red Hat JBoss product line (with JBoss Enterprise Application Platform) all retain their names.[4]

In other words, it's free software for running web applications, of which AMICAS Merge PACS is one.

Sadly, Merge, like a vast number of other companies, is a step or two behind the latest release of JBoss/WildFly, meaning that hackers of the older versions are free to do their thing. From the November 18 issue of PC World:

Attackers are actively exploiting a known vulnerability to compromise JBoss Java EE application servers that expose the HTTP Invoker service to the Internet in an insecure manner.

At the beginning of October security researcher Andrea Micalizzi released an exploit for a vulnerability he identified in products from multiple vendors including Hewlett-Packard, McAfee, Symantec and IBM that use 4.x and 5.x versions of JBoss. That vulnerability, tracked as CVE-2013-4810, allows unauthenticated attackers to install an arbitrary application on JBoss deployments that expose the EJBInvokerServlet or JMXInvokerServlet.

Micalizzi's exploit installs a Web shell application called pwn.jsp that can be used to execute shell commands on the operating system via HTTP requests. The commands are executed with the privileges of the OS user running JBoss, which in the case of some JBoss deployments can be a high privileged, administrative user.

Researchers from security firm Imperva have recently detected an increase in attacks against JBoss servers that used Micalizzi's exploit to install the original pwn.jsp shell, but also a more complex Web shell called JspSpy.

We were alerted to the problem by the remote site, which experienced the equivalent of a Denial of Service (DOS) attack because the damn rogue application we caught started sending out streams of gibberish (fortunately NOT patient data) fast enough to bring down the system. We were blamed for having the infection, and it did indeed nest there on our server, but the infection actually came through our hosts' network. That gap has now been sealed.

Here's the more detailed description from my PACS guys:

On Wednesday our PACS vendor Merge acknowledged a JBOSS vulnerability within the PACS application. The exploit was a worm that scoured the Internet for all un-patched JBOSS versions 4.x and 5.x that were accessible via TCP port 8080. Because TCP port 8080 was open on the firewall for the spoke PACS server the worm was able to find and infect the PACS server. The exploit only affected the PACS server because it runs JBOSS. After we examined what the worm was trying to accomplish, it was determined that the payload consisted of PERL scripts designed to take the server and network down. On Tuesday afternoon, we created a script that constantly killed the process that was overloading the network and that protected the network until Merge could create a patch.

Merge's software development team and IT Security recreated the affected server in a test environment and were able to reproduce the exploit. They created a patch and thoroughly tested it. As of 4pm Thursday, Merge patched the security hole within JBOSS and the site closed TCP 8080 and TCP 80 on the firewall securing the server against further attacks from this exploit.

Merge has assured us that no patient data was compromised or sent out as a result of this exploit.

My compliments to Merge for acting VERY quickly to contain this problem. We were about to be forced off-line as a shotgun fix to the situation. Which would have compromised patient care, but that's another story.

So...to all Merge PACS customers...please contact Merge to see if you need this patch. Most likely, you do. But don't everyone call them all at once, please.

Clinical SPECT/CT—Time for a New Standard of Care

I haven't been able to attend the SNMMI (Society of Nuclear Medicine and Molecular Imaging) meeting in quite a while. It is unfortunately scheduled on the first week of June, and even if I can score the week off, I'm usually off on vacation with the family.

This year's meeting was in Vancouver, my most favorite city on the planet, so I'm doubly deprived. It's in St. Louis next year, and I'm going to try my best to be there.

One of the highlights of the SNM (I still can't get used to the new title) is, not coincidentally, the "Highlights" lecture at the end of the meeting. There are several different sections of this concluding talk, but I'm most intrigued by the General NM talk given by Alan H. Maurer, M.D., from Temple University School of Medicine, Philadelphia, Pennsylvania. I've stolen the title of his talk, "2013 SNMMI Highlights Lecture: General Clinical Nuclear Medicine: Clinical SPECT/CT—Time for a New Standard of Care" for this article.

Dr. Maurer starts off with a brief synopsis of the not-quite parallel development of the otherwise similar technologies, PET/CT and SPECT/CT. PET/CT appeared much more rapidly:

The timelines of the early development of SPECT and CT are roughly synchronous. The question, then, is why has the evolutionary progress been so much slower from SPECT to SPECT/CT (>40 years) than from PET to PET/CT (<20 years)? Among possible explanations are the lack of separate reimbursement for most SPECT/CT procedures, an already large installed base of standalone SPECT units, and the need for more studies documenting clinical cost effectiveness.

As usual, money talks. If reimbursement is the same for a scan from a $300K machine as that performed on a $1M machine, why buy the latter? The bean-counters won't grasp that the more expensive machine does a better job, or in modern ACA-tainted parlance, "Adds Value" to the scan. It costs more, and you won't be getting it anytime soon.

But Dr. Maurer just changed the rules of the game. 

My overall conclusion, and one that I will illustrate with examples from presentations at the 2013 SNMMI Annual Meeting, is that SPECT/CT is a new standard of care that we should be performing on a regular basis, just as we do with PET/CT. Multiple studies at this meeting showed not only increased sensitivity, specificity, and accuracy, but increased reader confidence, decreased interobserver variability, as well as a broad range of new applications with SPECT/CT.

And illustrate he does.  Here are just a few examples lifted from the article:

A Swiss study examined SPECT/CT vs. MRI in the evaluation of wrist pain:

Experienced and inexperienced readers looked at images from 32 patients (Fig. 1). Experienced readers’ results with SPECT/CT showed accuracy, specificity, and sensitivity of 77%, 90%, and 74%, respectively. The respective figures for MR imaging were 56%, 10%, and 65% and for planar bone scan were 44%, 70%, and 39%.

A group from Alberta, Canada brought back the old tried and true Gallium study, with rather amazing results:

“Bone/gallium SPECT-CT is equivalent to contrast-enhanced MRI in the diagnosis of infectious spondylodiscitis: a retrospective study”. The retrospective study included 34 patients with suspected spondylodiscitis. Bone/gallium SPECT/CT was found to have similar sensitivity, specificity, PPV, NPV, and accuracy (94%, 100%, 100%, 94%, and 97%, respectively) to MR (94%, 100%, 100%, 80%, and 95%, respectively) (Fig. 8). Although prospective research is needed, the authors concluded that these results suggest that bone/gallium SPECT/CT is equivalent to contrast-enhanced MR imaging in the diagnosis of infectious spondylodiscitis.

Take that, MRI!

I've been promising my clinicians an improvement in parathyroid scanning once the new SPECT/CT arrives:

A group from Sapporo, Japan, experienced in parathyroid imaging

. . . compared high-resolution ultrasound, 99mTc-sestamibi scans, and multidetector CT for presurgical evaluation of multigland disease in 25 patients (8 with primary and 17 secondary hyperparathyroidism) with 78 involved glands. Fused SPECT/CT yielded the highest sensitivity of all modalities as well as the highest PPV.

Clearly, the addition of CT to SPECT allows for far more precise localization and characterization of the scintigram. It is so intuitive, it almost goes without saying. 

Somewhat unfortunately, Dr. Maurer's conclusion backed off a tiny bit from his profound observation at the beginning of his talk:

As noted earlier, I believe that just as we have established PET/CT as a standard of care, we should now be moving toward SPECT/CT as our standard of care. The presentations at this year’s SNMMI meeting reinforce this belief. At the same time, we need more outcomes and effectiveness data before SPECT/CT will be properly reimbursed so it can achieve more widespread routine clinical use.

Yes, we should indeed be moving toward SPECT/CT as the standard of care. But in truth, we are there, and even a cursory look at a SPECT without CT shows just how critical it is to pair the two. I'll go with Dr. Maurer's original sentiment. SPECT/CT IS the new standard of care. I'll even go way, way out on a limb, which will make the bean-counters tear their hair out, and the equipment-makers jump for joy: There is no longer any reason to buy a conventional SPECT camera; EVERY NEW GAMMA CAMERA (perhaps with a few exceptions for narrow, dedicated applications) SHOULD BE A SPECT/CT device. Period. SPECT/CT is now the de facto standard of care, and it is sheer foolishness to buy 40-year-old technology in its stead. How many PET scanners (as opposed to PET/CT) are being sold today? Just about none. I hope to be able to make that claim for SPECT/CT within two to three years.

Due to various bureaucratic and CON snafus, I won't be getting MY SPECT/CT until early next year. Since we were delayed so long, we were able to upgrade to the latest and greatest Siemens Symbia Intevo SPECT/CT:

You will be hearing a LOT about this beauty from me once it's installed.

I plan to provide my patients the standard of care. You should, too.

Phoneblocks...Predicted by Dalai

Back in the day, I was a Treo fan. In fact, I had probably the first Treo 600 in the state if not the entire Southeast. I spent many an unproductive hour posting on the website devoted to such things, TreoCentral.com. My avatar celebrated the transition from one Treo model to the next, although the second shows my transition to the Sanyo 6600 Windows phone, purchased so I could use LogMeIn from the phone itself, which actually worked well.

Alas, when I didn't share the joy about the release of the defective Treo 650, and its 23 or so MEGABYTES of memory, I was booed off the stage, and I went underground, posting as GWB, who was President at the time. Might as well shoot high. GWB continued to fight the good fight, trying to convince Palm One (now absorbed by HP and pretty much forgotten) to provide things like adequate memory and WiFi, not to mention a stable phone that worked. It is hard for me to imagine, 9 years later, that anyone would even think of buying a phone that was unstable, had even less functional memory than its predecessor, didn't have WiFi, and basically was junk though with a nicer screen. The majority of my opponents on the forum were so thrilled by the concept of a working Treo that they didn't want to acknowledge its rather steep limitations. Rather like the response I've seen to some PACS systems out there.

But GWB was able to think outside the Treo box on occasion, as with this post:

Do-It-Yourself TREO 650

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01/01/2005, 11:57 AM	#1 (permalink)
GWB Posts: 277	Well, not really, but here's an interesting idea... PalmOne designed the TREO, and HTC manufactures it. If you look at the FCC site and the pictures, the TREO 650 is already modular. It looks to me like the radio board can be removed and replaced, and even the chips on the radio board are from yet another maker (Broadcom). I would guess that the main difference between the GSM and CDMA versions are just this radio board (the GSM has a SIM card slot.) This got me thinking, always dangerous, I know. You have a base circuit board, a case, a keyboard. The other stuff, even the display, is more or less is just plugged in. So, is there a possibility of a Dell-model approach to making these things? I know a lot of the components are surface-mounted to save space. Could things like memory, BlueTooth, WiFi, even the processor, as well as the radio module, be made to just plug in? Then you could order it justs the way you want it, and the tech guy at Sprint could plug it all together for you, or even just order the parts and plug them in yourself? Alternatively, could they do a made-to-order TREO, where you get to specify all these things for factory manufacture? Having one company in control of hardware and software made sense for Apple, but it just ain't working for PalmOne at the moment. There are still a number of other companies making Palm OS devices. I wonder if we might ever reach the stage with a TREO that we are at with PC's, where it is very possible to build your own machine yourself, or have it built to your specs? You would then of course need a copy of the PalmOS, and that would have to come from PalmOne. Probably will never happen, but it is an interesting thought.....

Now, many years later, someone has rediscovered the Do-It-Yourself Phone. From Dave Hakkens'website and phonebloks.com comes a much more professionally-realized vision:

The concept is wonderfully simple:

DESIGNED TO LAST

Phoneblok is made of detachable bloks. The bloks are connected to the base which locks everything together into a solid phone. If a blok breaks you can easily replace it; if it's getting old just upgrade.

BLOKSTORE

It's like an app store for hardware. In the store you buy your bloks, read reviews and sell old bloks. Small and big companies develop and sell their bloks. You can buy a pre-assembled phone or assemble it yourself by selecting the brands you want to support. The choice is yours.

Since I've just ordered an iPhone 5S, I won't be buying a PhoneBlok just yet. But maybe GWB will...

Fuzzy PACS

I constantly bemoan the joys of using disks from other sites, even when they actually work. Today, I've had to deal with one that didn't quite function properly, although the fault is yet to be determined.

We had a patient who came to our GE site from a McKesson site, armed with three disks containing her imaging history. Since GE wanted $50,000 to place a dedicated CD-reader on the Centricity 3.x system, we use one of the Advantage Workstations (Version 4.3) instead to load outside studies onto our system. Most of the time, this seems to work adequately.

However, with this patient, once the data was pushed to PACS, all images, CR, CT, and MRI, came out looking like this:

I've tried changing every setting I can think of, but to no avail.

In a word, HELP!!!! Please comment below or send ideas to doctordalai (AT) gmail.com.

By the way, I was called upon yesterday to read a study remotely from the GE site via the old Centricity Web which has not been replaced for various reasons. Using it is an exercise in agony. Frankly, and I have told this to GE execs, it is the WORST PACS viewing software ever released. The images themselves do display properly, but it is balky, unstable, slow, and basically non-diagnostic when called upon to function as a viewer in the field. I'm asking GE to do the right thing and withdraw it from the market, replacing it at no charge with either the Dynamic Imaging PACS or the newer GE Universal viewer. Even eFilm would be a step up, and I HATE eFilm.

Rant over, for the moment. Thank you for your attention.

Merge: Ferro Resigns As Pharaoh

From this morning's Merge email blast:

Michael W. Ferro, Jr. Steps Down as Chairman of Merge Healthcare Dennis Brown Appointed New Chairman CHICAGO, (GLOBE NEWSWIRE) -- Merge Healthcare Incorporated (Nasdaq:MRGE), a leading provider of clinical systems and innovations that seek to transform healthcare, today announced that its Board of Directors has accepted the resignation of Michael W. Ferro, Jr. as Chairman and a Director of the Company and appointed Dennis Brown as the Company's new Chairman, both effective immediately. "I have decided to step down from my roles as Chairman and a Director of Merge Healthcare," said Michael W. Ferro, Jr. "Merge is at the heart of a large, growing and dynamic market for healthcare imaging, and, as its largest shareholder, I have a lot riding on its future success. I remain very confident in the Company, its products and its new leadership team, and my decision does not reflect any disagreement with Merge's management or Board. Rather, I have worked with Justin Dearborn and Nancy Koenig for many years and know that they can and will move the Company forward. In addition, all Merge stockholders are extremely fortunate to have an experienced and capable leader like Dennis Brown ready to step in as our next Chairman. I will be available to Justin, Nancy, Dennis and the rest of the Board in the future should they want my input. " "Although Merge's second quarter results were very disappointing, I do not believe that the current trading price of Merge common stock reflects the Company's inherent strengths, market position or long-term prospects." Mr. Ferro continued, "While I have no immediate plans in this regard, over time, I intend to explore a variety of ways to increase shareholder value, including, possibly, a going-private transaction. Of course, overall industry and market conditions, the Company's business and financial performance and the availability of equity and debt capital and other factors will affect whether a transaction would be advisable. Accordingly, neither Merge nor I can speculate or provide any assurance as to whether, when, or on what terms such a transaction might occur." Mr. Ferro served as Merge's Chairman and a Director since June, 2008, when Merrick RIS, LLC made a significant investment in the Company. Merrick RIS and other affiliates of Mr. Ferro own approximately 26.6 million shares of Merge's common stock. "On behalf of all of Merge's Directors, I want to thank Michael for his leadership, commitment and vision during his five-year tenure as our Chairman," said Justin C. Dearborn, Merge's CEO. "The entire Merge team will remain focused on the goals and plans that he helped establish, and we look forward to his continued support in the years ahead." Mr. Brown, one of Merge's longest-serving Directors, has been associated with the Company since its initial public offering in 1997. He brings a wealth of management experience and financial expertise to his new role of Chairman. Mr. Brown spent 20 years in senior management with the Allen-Bradley Company (now Rockwell Automation) in the US and Europe and 10 years as Vice President of Finance, Treasurer and Chief Financial Officer of Sybron International Corporation, a global manufacturer of Life Science products. Mr. Brown currently serves as Chairperson of the Board's Compensation Committee and as a member of the Board's Audit and Nominating and Governance Committees. "I have been involved with Merge for many years now and am a great believer in the Company, its technology platform and its highly-professional management team," said Mr. Brown. "As Chairman, I will be making myself fully available to work with the management team to achieve our goals of serving our customers, growing our market position and enhancing shareholder value." About Merge Merge is a leading provider of clinical systems and innovations that seek to transform healthcare.  Merge's enterprise and cloud-based solutions for image intensive specialties provide access to any image, anywhere, any time. Merge also provides health stations, clinical trials software and other health data and analytics solutions that engage consumers in their personal health. With solutions that are used by providers and consumers and include more than 25 years of innovation, Merge is helping to reduce costs and improve the quality of healthcare worldwide. For more information, visit merge.com. Cautionary Notice Regarding Forward-Looking Statements The matters discussed in this news release may include forward-looking statements, which could involve a number of risks and uncertainties. When used in this press release, the words "will," "believes," "intends," "anticipates," "expects" and similar expressions are intended to identify forward-looking statements. Actual results could differ materially from those expressed in, or implied by, such forward-looking statements. Except as expressly required by the federal securities laws, the Company undertakes no obligation to update such factors or to publicly announce the results of any of the forward-looking statements.

Well...it's not quite the end of an era, but...

I can only guess at the reasoning behind Michael's "departure". He does make it quite clear he's not really going anywhere, just putting down the mantle of chairmanship. Merrick Ventures will continue to own a significant chunk of Merge stock (anyone hear of a sell-off? I haven't.) Having met Mr. Ferro a few times, I've been incredibly impressed with his energy and entrepreneurial spirit. I'm going to take the high road and assume that he is off to newer things, having set Merge on a (hopefully) straight course.

An old friend pointed out the clause in the message about a "going-private" transaction. We were both reminded of the days when AMICAS was about to be taken private by Thora Bravo, a decision I cheered at the time, but one which was quashed by investors and their lawyers, to the ultimate benefit of Merge. Perhaps we will go back to the future after all.

In any case, I'm looking forward to meeting Mr. Brown one of these days. He's got some big shoes to fill.

Demos Among Friends

We got word, rather late in the game, that one of our referring clinician groups was thinking of changing their PACS. With a little nosing around, I was able to get myself invited to their meeting, where they would hear from the two vendors selected by their head of imaging. The group was only dimly aware that we have our own Merge PACS to sell, which happens to be the same system that is used at our common hospital.

The night of the demo came. I won't name the two vendors because one has a reputation, deserved or not, for taking legal action against those who speak ill of it, and I might as well not name the second. I sat beside the clinicians, their administrator and their IT guy, and pretended to be an interested bystander. In fact, even the clinicians didn't know I was there with a PACS in my pocket.

I'm going to skip over one presentation, as it was kind of lackluster, and didn't strike any chords with the clinicians. The presenters were knowledgeable, but there were certain gaps in the information, such as how the software actually runs on the client machine. Thin client? Thick client? Java? dotNet? Ummm, we'll have to check on that.

The other vendor did a much better job, a fantastic job, really, presenting the product from head to toe, and enticing the clinicians in the process. More about that in a moment.

After the salesfolk left the building, I had the chance to somewhat sneakily and sheepishly present the possibility of selling space on our Merge PACS. By this point, the air conditioning had been shut off, and the computers were about to automatically shut down. I had a brief, rather amateurish powerpoint, that I went through in 30 seconds. I then asked if the docs had any questions about Merge. They were familiar with it after all, as it is also used in our common hospital.

"No. We don't need to see a demo. We know that system. And we hate it."

Aghast, I asked why. Well, it doesn't do this. And it's hard to do that. And this looks funny.

And none of these were at all accurate. The complaints with the hospital's PACS all stemmed from the fact that these guys had NEVER been trained. Ever. Not for three minutes. Before the systems went into hibernation that night, I was able to show them levels of functionality on the Merge PACS that they had never seen before. And they were impressed.  I've got my foot in the door, at least, for their PACS services.

But let's get back to the vendor with the impressive presentation. Behind the slick, well-rehearsed demo is a product that tries very hard to be all things to all people. I frankly cannot think of a function it doesn't have.

I've used the Swiss-Army Knife analogy before, but...

Below is a photo of the Wenger Giant (which I managed to find on eBay for a fraction of its original price):



Here is the Victorinox SwissChamp XAVT, which I also found at deep discount on eBay:

Both of these are huge, have just about every tool available from their respective manufacturers, and are as solid as a battleship. You wouldn't want to actually carry them in your pocket (not even a possibility for the Wenger) but if for some reason you had to press them into service, you would have no doubt of their functioning perfectly.

Contrast the Swiss versions with this one from China. This multitool can be had in bulk for $1. Yes, $1.00.



Does it work? Well, probably. Most of the time. I'm sure the blades and the tools and such do their job, until they don't. What did you want for $1? (The Swiss museum pieces go for $2,000 and $500 retail, respectively, although smaller and more functional versions are more on the order of $50-$100.)

The properly-demoed PACS cited above is impressive for two reasons. First, it is cheaper than many, and second, it has every function, and every element of customizability known to man. The customization pages contained literally hundreds, if not thousands, of possible settings and changes.

But, remember Feature Fatigue. We end up using only a small subgroup of that vast feature set about 90++% of the time. The rest has the potential to get in our way.

And, in a mission-critical piece of machinery and software, we expect 100% uptime. While that might be unreasonable, PACS is used for emergent patient care, and it darn well better work at least 99.99999% of the time.

Sadly, the particular vendor with the flashy, inexpensive product does not have the best track record, nor should we really expect this with their price-point, although I will be so bold as to expect it anyway.

Some reviews of this particular product on AuntMinnie.com, Reddit, and personal anecdotes have not been particularly positive:

PLEASE have the admin or the clinical lead on the PACS purchase contact me directly. I'm sure the facade looks good...in fact it was this and the cheap price that sold us...

However, when you clicked a button on the RIS or PACS, many of them didn't work. Their main tech/engineer left them over a year ago and he was the only one who knew what was going on with the product as he wrote most of their code.

... I could tell you about an event caused entirely by this vendor that would make you shudder, but (they have) shown me they are much more concerned about litigation than service, so I'll save myself a frivolous lawsuit and leave it at that....

I have used no less than 6 PACS and (this vendor) is by far the worst. It's a shame too, because I prefer the customizable PACS... The idea is great but the execution is just awful. I keep waiting for a PACS that behaves like Windows---with a solid default structure with a good amount of features BUT the ability for tons of personalization, but in an intuitive manner. (This vendor) fails on intuitive and fails on solid default structure.

And there is a rather long message on Reddit which I've truncated:

Please forgive the ranting. I'm STILL livid about this and it's been roughly a year now, since the incident.

Fine when it works. Worst. Disaster Recovery. Ever. By any vendor, in my entire 20+ year career in general IT...

Overall, they have been fine. Not the highest end system, but fine for basic PACS/RIS operations. The admin interfaces are fairly simple, the user interface is also fairly simple and easy-to-use. We've not had any interoperability issues with it and it seems to comply with all PACS/RIS standards...

My experience with them train wrecked, when they outright lost patient data, then stonewalled my entire organization RE: the status of recovering data that they lost and answering any questions even vaguely related to what happened, why and how. As far as I know, it was an anecdotal experience, but they handled the entire thing very poorly...

The backup mechanism did work partially and we spent 2 weeks reloading 2 TB of data onto the server, through a USB 2.0 connection. While I'm not sure of the exact count, we did lose thousands of studies, because not only did the server-to-server sync fail, but the offsite sync failed, "at some point, prior to that" and wasn't noticed by anyone at (the company). AWESOME!

...They actually argued, "Yes, we dropped the ball entirely and lost data and kept you down for weeks due to the magnificence of our negligence, but we did support the site during the past 3 months, so we feel only a partial refund of the monthly fees are appropriate". There were other costs they did agree to reimburse the hospital for, but I have no idea of the specifics, I just know they argued the nickels, while holding their hats in their hands.

I personally and professionally fault them for the piss-poor way they handled the situation, more than the situation itself. Imo, it was grossly negligent, but ultimately, things do happen. How we handle these things is much more telling of an entity's true nature and whomever made the decisions in my situation showed me that, as a company, they were much, much more concerned about legal liabilities and how much it was going to cost them, than recovering the site/data, as fast as possible.

Note to legal department of this PACS company:  I am only copying and anonymizing information about your product posted by others. I don't have personal experience with your product, nor do I want to have any.

The clinicians are still deciding. But here again, a decision is being made about PACS systems by those who either don't use them (IT, administration), or use them in a secondary capacity (clinicians). We, the radiologists who will be reading studies off of the contraption selected need to have a say. Now, granted, I'm biased in this particular case in that I want to sell a system. But I've chosen for myself something that works well for me and the members of my group, some of whom are not quite as computer-savvy as I am, and I think I chose well.

The slicker vendor took great pains to emphasize how his company "listens to radiologists" and remakes the product to fit their needs. Which leads to 3,000 buttons and 5,000 options. I've seen this before. And I've also seen situations wherein PACS companies listen to their loudest and largest customers, and alter the product to fit that particular customer, screwing the rest of us. None of this needs to happen.

In my next article, I'm going to build on the work published by Brad Levin from Visage in on the SiiM website, and I think you'll find it is quite germane to this discussion.

QR Me

QR codes have been around quite a while. You can read about their history HERE.  The code above is for this site, DoctorDalai.com. Just scan it with your smartphone and the appropriate software, and you'll get right back...Here!

I've come up with yet another million dollar idea that I'm going to give away, and it came to me this morning while reading the Journal of Nuclear Medicine.

I still like paper journals.  They are pretty easy to manipulate and they don't take batteries. And I grew up reading them. And we're all familiar with them, and so on.  

But periodically (pun intended) I run across an article I'd like to share. Then we have to go through the joy of searching for the article online and sending the link, or if I'm really feeling stubborn that day, I might just photocopy the paper article onto more paper!

So, here's the idea, it's simple and costs nothing. At the footer of every scholarly article, and maybe just any article, let's place a copy of the QR code! Then, if I want to let my colleagues know about the latest in defecography, all I need do is scan the code and email it or whatever! What a simple way to disseminate information. Did I mention this won't cost anything?

I'm giving this idea away, but if anyone wants to pay me for it, I'll graciously accept.  By the way, here is the code to this blog post in particular:

LEAP Into PACS

From LeapMotion.com:

With a wave of a hand or lift of a finger, you’re about to use your computer in a whole new way. The Leap Motion Controller senses how you move your hands the way you naturally move them. So you can point, wave, reach, and grab. Even pick something up and put it down. Just like in real life. It’s an amazing device for the things you do every day and for things you never thought you could do. Just $79.99.

It goes where no device has gone before.

With a wave of a hand or lift of a finger, you’re about to use your computer in a whole new way. The Leap Motion Controller senses how you move your hands the way you naturally move them. So you can point, wave, reach, and grab. Even pick something up and put it down. Just like in real life. It’s an amazing device for the things you do every day and for things you never thought you could do. Just $79.99.

Basically, the LEAP Motion controller is the Kinect for computers, both PC and Mac.

When this product was announced almost a year ago, I just had to get one. So I signed up, and many months later, my little LEAP controller was delivered. It's a very nicely machined little thing, three inches long, that looks like it was made by the same folks that created my MacBook. You plug it into a USB port, load the software, and off you go.

There are various apps on the Leap Motion Airspace Store, many free and many for sale. Some are games that utilize the hand-motion control, and some form interfaces to let the LEAP control the computer itself.

I've used "Touchless for Mac" as my main software interface:

Use your Leap Motion Controller to interact with your Mac.

Touchless for Mac creates a virtual trackpad in the air. Just lift your hand or a finger to navigate your computer. Browse the web, open applications and documents, and control menu items — without touching anything.

Touchless for Mac includes intro, basic, and advanced levels, so you can choose your level of 3D interaction.

Features:

• Click by pointing your finger towards the screen
• Scroll by swiping multiple fingers in the air — left and right for horizontal scrolling, or up and down for vertical scrolling
• Zoom in and out by pinching your fingers

My thought, of course, was to see how this technology might work with PACS. In the rather poorly-acquired video below, I've used my iPhone to film a very brief interaction, bringing up a study, scrolling around, changing the windows, and playing with 3D.



You get the idea. The LEAP is a little unstable, and rather finicky, although part of my problem seems to be some interference from infrared burglar alarms and remotes in the house.

While I can't see using the LEAP as a true PACS controller in a production environment, I DO think it has possibilities for sterile environments, i.e. the surgical or IR suite.

I'll keep playing, and maybe with some practice and fine-tuning, I can make the LEAP work a bit better for me. Ultimately, however, I'm hoping someone comes up with a workable thought-based controller. Can you read my mind, folks? Rather short novellette, I'm afraid...

NOTE: Wake Forest has already displayed this concept using...Microsoft's Kinect:

A Message To Managers Everywhere, Especially Those In IT

Anthony Guerra, Editor-in-Chief, penned the following piece over at healthsystemsCIO.com. It should be required reading for everyone who manages anyone, and particularly for those in IT...

Balancing The Elements Of Leadership

“So he just sat there?"

“Yup.”

“And you didn’t know he was coming?”

“Nope.”

“And he didn’t say anything at all?”

“Nope.”

“And then he just left?”

“Yup.”

My friend Sally had recently taken on a new role in her company during which the boss of the division was temporarily reassigned. Everything had been going just fine, with Sally settling in, learning the ropes and establishing a schedule that fell within the parameters established by the company (two days a week working from home). But when it was time for Bill the boss to return, he seemed less interested in getting to know his new team than establishing his authority and control.

To start, he made creepy unannounced and silent visits to team meetings, preferring to act as fly on the wall rather than a leader looking to inspire the troops. Then, when he decided to speak, it was all negative, negative, negative — questioning what each employee had been doing, criticizing much of the work, and laughing at the schedules which had been established.

“What would you have done?” she asked me.

“Well, I would have let people know I was coming and then worked to get acquainted or reacquainted with everyone to find out how they’ve been, what they’ve been working on, and how I could help them be more efficient. I would have looked to see where my priorities dovetailed with theirs and where they parted, and worked to close the gap on the latter as smoothly as possible. It sounds like Bill is more interested in proving to his superiors that he can get his team in line than proving to his team that he’s on their side.”

“What are you going to do?” I asked.

“Well, if things keep going in this direction, I’m going to work on getting a transfer out of here as soon as possible, either within the company or out of it.”

And that’s the truth of it folks. Good people just will not stick around to be bullied by management that cares more about its own future than theirs. Can’t you just tell when a manager is more concerned with moving up on the backs of its team than backing them up? Ironically, it’s the managers best able to motivate their teams who get the best results, and thus move up the quickest. Why is this so often missed?

In leadership, there is a timeless element and a temporal one. The above represents the timeless — good leaders have always been focused on the happiness of their troops. The temporal changes with the times, and requires a deep understating of one’s environment. In our business at healthsystemCIO.com — publishing — this last week has seen a slate of stories about such temporal change:

The Last Temptation of Tina Brown

Bezos In 2012: People Won’t Pay For News On The Web, Print Will Be Dead In 20 Years

New York Times Sells Boston Globe at 93% Loss

What I can see from the above articles is that we are very well positioned, with no print product pulling resources away from what matters, and no futile attempt to make our readers pay for content. In fact, we don’t even require you to register. I mean, how annoying is it to remember your username and password for a particular site?

To be a great leader, you need both. You need to practice and preach the timeless tenants of management while being firmly embedded in the changing dynamics of your times. Only if you employ them in tandem will you have the right team — inspired and enlivened — moving in the right direction. Tina Brown couldn’t do it, maybe Jeff Bezos can.

I've always wondered why IT departments, the folks that manage computers, the wonders of the modern world, can be so, well, backward and intransigent. In my travels around the world as a self-declared expert on such things, I keep finding the same story. The front-line IT folks are often (not always, but often) quite willing to be bold, to do what it takes to make something work and work right, to innovate and use the power of their charges the computers to improve life for all. But these bleeding-edgers are held back, if not thwarted altogether, by their managers, who often haven't a clue as to how any of it works, but don't want that fact known. The have risen to the level of their incompetence, ala the Peter Principle, and rather than encourage and nurture those under them who might flourish in the right environment, they choose instead to quash any spark of innovation which might expose their deficiencies. I've even encountered a situation where an IT manager quite literally terrorized his/her charges; one would be chosen each day for "special" treatment. 

How much progress have we lost to this toadying, self-serving, even Luddite behavior? Too much.

But how to solve the problem? The underlings (for lack of a better word) fear for their jobs, and won't blow the whistle. So, I guess I must appeal to the problem-children themselves. You know EXACTLY who you are, and you are probably sneaking furtive glances over your shoulder as you read this, because you don't want your superior to see you reading my blog or anything like it. But take heed. Those under you have your number, and while they can't do anything about your restrictive policies, they can, in most cases, go somewhere else. As you keep losing them to other departments, your superiors will start to take notice, and it's quite possible that some of them actually do know what they are doing and what you are supposed to be doing.

So here's my advice.

Talk to those under you. Admit that you don't know everything about what they are doing, and learn from them. Let them show you what they know and what they can do. Become their advocate rather than their nemesis. I PROMISE this will work well for you and everyone on the entire team, and indeed, it will accelerate progress throughout the enterprise. And for Heaven's sake STOP with the namby-pamby feel-good office-speak that I outlined in a prior post. It sucks, it bores people, it turns them off, and it doesn't work. It just makes you look like a fool with a stick up your backside, and it accomplishes exactly nothing.

I'm not holding my breath, but if I can change the environment in even one IT department, then I've done my good deed for the day.

No More Surges At Merge

The PACS and HIT business can be volatile, and the nameplates on the corner-offices tend to change fairly rapidly.

Merge's most recent Earnings Report and Earnings Call (transcript here) tell a Tale of Two Merges, with the best of times hopefully ahead of them, and the worst of times behind.

The report states the situation in no uncertain terms:

Chicago, IL (Aug. 9, 2013) Merge Healthcare Incorporated (NASDAQ: MRGE), a leading provider of clinical systems and innovations that seek to transform healthcare, today announced its financial and business results for the second quarter of 2013. Merge also announced that its board of directors has accepted the resignation of Jeffery A. Surges as Chief Executive Officer and Director of the Company and appointed Justin C. Dearborn, as the Company’s new CEO. Additionally, Merge announced that Nancy Koenig has been promoted to Chief Operating Officer of the Company from EVP, Operations and also has been elected to the Company’s Board of Directors to fill the vacancy created by Mr. Surges’ resignation.

“Speaking on behalf of all of Merge’s Directors, I want to apologize for the company’s very disappointing second quarter results,” said Michael W. Ferro, Jr., Merge’s Chairman of the Board and largest shareholder. “We all strongly believe in the company, its products and its employees. Our new leaders, Justin Dearborn and Nancy Koenig, resurrected Merge five years ago, and they are the right team to get the company back on track. I, personally, plan to continue to invest in Merge, whether in response to opportunities in the market or otherwise.”

Mr. Dearborn said, “Merge’s value proposition continues to be very strong in three distinct market areas: imaging and interoperability, cardiology, and clinical trials. Our spending, on bringing innovative solutions to market, has outpaced our end user markets’ readiness for a variety of macro-economic reasons currently clouding hospital spend decision making. We saw a continued reluctance amongst large health systems to move forward with enterprise purchases. Unfortunately, this pause has overshadowed the fourth quarter in a row of very strong bookings and revenue growth from our clinical trials group.” Mr. Dearborn joined Merge in 2008 and has served as CEO, Chief Financial Officer and most recently as President and CEO of Merge’s DNA reporting segment.

In the conference call that followed, newly-minted (well, re-minted) CEO Justin Dearborn reiterated the mea culpa:

First, let me say that the entire board of Merge is extremely disappointed with the company's results. On behalf of the board, and especially its Chairman and our largest shareholder, we apologize for these results. They are unacceptable and we are working day and night to turn this situation around.

Following the acquisition of AMICAS in April of 2010, our plan was to grow our sales and marketing teams and focus on large enterprise sales or system-wide deals with longer sales cycles and lumpier but large upfront revenue. While we have had some success in the past and expect even more in the future, the market did not develop as fast as we had anticipated and no longer justifies the cost structure that we built. We believe that the large, attractive opportunities still exist in the market, but we need to scale our cost to match their timing. We will continue to focus on per-study pricing arrangements that provide for better predictability and we will deliver additional solutions in hosted environments, creating a healthier business model for Merge and our customers...

I am fortunate to have the support of the management team as well as our board. Nancy Koenig, who is promoted Chief Operating Officer and elected to the Board of Directors, knows the industry, the company and its products and can help drive the company forward on a more streamlined basis. Michael Ferro, Nancy and I worked together for 15 years in 2 different public companies. We successfully resurrected Merge 5 years ago when it had a few million dollars in the bank, rapidly declining revenues and was on the verge of bankruptcy. We, along with the existing management team, can once again grow Merge, albeit, we are starting from a much, much better position. Additionally, Steve Tolle, a 25-year industry veteran, has been promoted as Chief Product Officer. Over the past year, under Steve's leadership, we have taken important steps forward in aligning our entire solution portfolio and bringing several critical innovations to market. Steve will continue to guide our corporate-wide product strategy and will take on additional responsibility for our marketing and overall strategy for our health care offerings...

And buried deeper in Mr. Dearborn's statement,

I am fortunate to have the support of the management team as well as our board. Nancy Koenig, who is promoted Chief Operating Officer and elected to the Board of Directors, knows the industry, the company and its products and can help drive the company forward on a more streamlined basis. Michael Ferro, Nancy and I worked together for 15 years in 2 different public companies. We successfully resurrected Merge 5 years ago when it had a few million dollars in the bank, rapidly declining revenues and was on the verge of bankruptcy. We, along with the existing management team, can once again grow Merge, albeit, we are starting from a much, much better position. Additionally, Steve Tolle, a 25-year industry veteran, has been promoted as Chief Product Officer. Over the past year, under Steve's leadership, we have taken important steps forward in aligning our entire solution portfolio and bringing several critical innovations to market. Steve will continue to guide our corporate-wide product strategy and will take on additional responsibility for our marketing and overall strategy for our health care offerings.

And finally as far as personnel changes,

To ensure we continue to focus on this market and the opportunities it presents, Kurt Hammond, who has been with Merge and other affiliated companies for over 10 years, has been promoted to President and will be responsible for all go-to-market activities for our imaging and interoperability solutions. Kurt brings 22 years of health care and sales marketing experience.

I'm not sure why they left Kurt for last, but at least he got on the list! Is the role of President more symbolic than that of CEO? Merge didn't mention Kurt in the Earnings Report at all. I've actually just emailed with Kurt, and the REAL story is, "The change for me is to take over what we are calling the iConnect Business Unit. Four units under Justin – OEM/Int’l + eClinicals + Cardiology + iConnect…looking at our business in more of a “vertical” model for the go to market, strategy and P&L."  So there you have it! How many presidents can you have in one company?

Merge has just in the past few moments sent out the obligatory "don't worry" email to its customer base, which includes me:

1. Your solution and product roadmaps are safe.

We take our commitments to you seriously and the changes we have announced will not impact the product investment priorities that we have already shared with you.
None of the actions taken have impacted the teams that build, support or service our core solutions.
We have over 75 product releases planned for Q3 and Q4, including major enhancements to core product.

2. We will continue to invest in research, development and innovation at an accelerated pace.

Our solutions investments are paying off as we've recently been rewarded the Frost & Sullivan Product Leadership award for Imaging and Interoperability as well as were again named the #1 VNA in the world, this time by IHS.
We will continue to invest in product enhancements and innovations to provide you with value from your investment with Merge.
In fact, we will spend approximately 14% of our total revenue in 2013 on product R&D. This is much higher than most HCIT vendors.

3. Merge is financially sound.

We remain focused on sound financial principles. Just like any of your businesses, cost structures must continually be aligned with sales expectations.
Additionally, as we previously announced, we refinanced our debt adding over $14M of cash flow annually to our business via a lower interest rate.
And last, cash generated from our business operations in Q2 was the highest amount for any quarterly period in the last three years.

And Kurt isn't mentioned in this email, either! Let's hope he doesn't take it personally.

As a Merge customer, I welcome these changes. I got to know Nancy and Justin upon my visit to Merge following the AMICAS takeover, and I was impressed with them then. as now.  I've know Kurt since my earliest AMICAS days, and of course I think very highly of him. Michael Ferro remains in financial control of Merge, and I trust that he and the gang can pull Merge out from the financial doldrums, if anyone can. Remember, this was a company on the verge of bankruptcy, that had to be "resurrected" by Merrick Ventures. They've come a long way.

While I wouldn't have believed you a few years ago had you told me I'd be saying this, I am a (well, mostly) happy Merge customer. Godspeed to the new leadership.

Sadly, the market is jittery. Merge stock lost half its value shortly after the announcements. If I didn't have to maintain journalistic integrity, I might consider buying some myself. 

PACS Memorabilia Contest!

I'm just back from Canada, having taken Mrs. Dalai on a quick cruise of the St. Lawrence waterway, starting in Montreal, and ending in Boston. There is some truly picturesque territory up there, and some not so much. Of our brief glimpse of Canada, I'd have to say Quebec City and Halifax were my favorite spots. We might have liked Bar Harbor, Maine, if we had been able to actually see it, which we couldn't because it was completely fogged in. Oh well, we had some very nice lobstah with buttah at the Bah Hahbah Club, which made up for everything else.

If you follow me on Facebook, you might recall that we had a bit of trouble getting to Montreal. Our Delta flight had to turn around an hour into the flight due to a problem with steering of the main landing gear. The only thing worse than having to turn around for a "maintenance issue" is being met upon landing by about three dozen fire engines stationed about the runway, lights blazing. Ironically, the landing was one of the best I've ever experienced on Delta. Another plane was made available, and we reached our hotel in Montreal uneventfully at 4AM.  Did you know that the bars in the Atlanta airport close on the stroke of midnight? And when they close, they CLOSE. No amount of begging, whining, or exaggerating the situation into a near-death experience would budge the bartenders into sneaking me and Mrs. Dalai something to calm our nerves. Oh, well...

Now that we're home, we have to get back to the drudgery of life, which includes trying to clean out years of stuff stashed all about the house. While putting away the laundry from the week at sea, I stumbled across the piece of PACS history pictured above. Yes, kids, it's an official polo shirt from the late, great Dynamic Imaging! It was given to me years ago. Either they only had 2XL, or someone thought I was more obese than I really am.

Rather than donate it to the local charity, I thought someone out there might want it, as I should think it's pretty rare by this point in time. Rather than just give it away, I thought I would add a little catch. The shirt will be sent postage due paid, to the person who submits the best brief essay on the topic

"The Lessons of Dynamic Imaging". 

No restrictions of any kind are imposed on your submission, save for the fact that it must be sent in via the comment field, as I don't want any crayon-on-paper-bag formatting, or the like.

If I get no entries, the shirt WILL go Goodwill, and some residentially-challenged person (no offense intended) will be enjoying this museum-quality piece of PACS history.

I await your beautiful prose!

Bureau-Crazy

Did you ever wonder why nothing gets done in IT? I happened to be part of an email thread that illustrates the touchy-feely aspects of life in the slow lame...Maybe if we actually talked about what needed doing and then did it...

Subject: Transition is a Journey***An update on the journey

Good afternoon Team,

Our management team met this morning for our usual Monday morning meeting and had a good discussion on transition.  I would like to share some of the take-aways and next steps with you so that you are in the loop and informed.

·         Transition is more than a one-time event.

·         As leaders we can make your  journey into new territory most successful by supporting you and keeping the lines of communication open.

·         Your manager is in the role of a “change agent” and will lead by example.

·         We realize this is a work in progress and recognize that change will not happen overnight! 

o   Call schedules will be a work in progress

o   Filling gaps will be a work in progress

o   How the leadership functions is a work in progress

o   This is a journey and not a sprint!

·         Here are some things you can expect from us:

o   Transition meetings will occur over the next few weeks.  Please continue to report to the person that you are reporting to and performing the tasks related to the projects/initiatives/job responsibilities you currently have.  This includes your current call teams and schedules. Expect both managers to be formally involved in your transition.

o   There may be some teams than transition earlier than others—don’t be alarmed when this happens.

o   One-on-one rounding sessions and team meetings will continue through the process and are important avenues that you can express your concerns and have any questions addressed.

We closed out our meeting pondering the following:

“If the future is to remain open and free, we need people who can tolerate the unknown, who will not need the support of completely worked out systems or traditional blueprints from the past.”  Margaret Mead

I look forward to the journey ahead of us as we move closer to the vision!  Let me know if you have any questions or concerns.

Thank you.