Saturday, October 31, 2015

Creeping Improvement

This is a real product, by the way, available on Amazon. If PACS cures could come in a squeeze-bottle, they might look like this:

But sadly, the only sectors that get squeezed when the PACS malfunctions are the radiologists, the techs, and, most importantly, the patients.

IMPAX 6.6.1.x was installed last weekend, along with a plethora of hardware and network renovations. New cores, various new servers, some of which sport SSD's instead of spinning disks. The new dual 1Gb lines have yet to be installed.

I can report significant improvement overall, but I'm afraid we aren't quite there yet.

The good news first. We are seeing overall faster loading and transition between the last study and the next. Most of the time. We are seeing tremendous improvement in searches, which used to take up to 60 seconds, now clocking in at no more than a second or two. Images scroll faster, mostly, and are no longer slowed by having demographics/annotations activated. 6.6.x has a newer study list which will filter in the relevant priors. There is an MPR module (which is nothing new but we didn't have it before). There is now a button to save a layout as a hanging protocol.

But the picture is far from rosy as yet. As reported by the users:
  1. When pulling in a group of studies to dictate, about 50% of the time the patient data did not load correctly onto the left screen. It got progressively worse as I worked over night.
  2. Shortly after I began at 2:00 a.m. the system slowed, not to the point of before but it was clearly slower than earlier in the day. It remained this way until about 7:30 this morning. the system would periodically not accept mouse inputs for about a 5-10 second intervals as the system cycled from one study to the next, regardless of modality. The system did that "thumbnail updating" during those intervals.
  3. Approximately 10 times overnight the system would bring in the comparison study as a micro thumbnail image in the left upper corner of the screen. 
  4. We had a study pull in the wrong patient demographics/study on the left screen for a study he was dictating on the right. It pulled in the data from a study done a year earlier.
  5. Also, intermittently the proper prior did not load correctly. Example, I loaded right hip film  to read and a left foot loaded as comparison, then on third screen was a prior hip film.
  6. And finally, studies that were suppose to go into failed verification were showing up on the list to dictate and listed as new even though there was no RIS ID for the study. 
This is being addressed, and hopefully these things will be resolved. In fact, some fixes are well underway as they relate to a look-up table of body part and modality priority for the relevant prior pulls. But the business of incorrect matching of patient demographics and images is really, really serious, and in fact represents an FDA-reportable event. Need I say more?

6.6.1 still suffers from the legacy of how IMPAX does things. Tools are toggled on and off as we've seen for many, many years. I have NEVER heard ANY IMPAX user praise this approach, unique in the industry, but Agfa persists in being "special". Similarly, we still must endure the backward approach to claiming studies. EVERY other system out there give ME control of a study once I open it; IMPAX lets someone else open and snatch it away from me. I was told years ago that this was to accommodate academic sites where the professors must grab things away from residents. Guess what? WE don't HAVE residents. We are NOT an academic site, and we really don't like this machine behavior, which incidentally can lead to studies not being read because someone accidentally closes something someone else has clicked as "Dictation Started". Bad move. There is still no way to display the same series in multiple active viewports so as to show it in different window settings. The only way to do this is with a "clone" window, separate from the main display.

IMPAX 6.5.x and earlier versions supposedly had hanging protocols, but the implementation was so very bad that it couldn't be used. 6.6.1 has a new and improved version. It works, but it is severely hobbled. Unlike every other drag-and-drop hanging protocol implementation (Merge, GE UV, etc.), we are limited to displaying within the preset modality parameters. If you've set CT to display in a 2x2 format, that's the only way your protocols will work. You may NOT have the same dataset in multiple viewports. And so on. I'm quite unimpressed. It does work a bit better with MR than CT in my hands, but I read a lot more CT than MR. 

IMPAX 7, a.k.a. IMPAX Agility, will solve at least some these problems. Once it is approved as an upgrade for 6.x, that is, which has yet to happen. 

Believe it or not, I don't expect perfection. What I do expect, and even demand, is communication and  interaction. I have whined for over 10 years on this blog about the disconnect between the vendors, IT, and the physician end-users of PACS. (Same thing applies to EMR's, but that's another post.) 
Our experience is a classic example of how things go wrong when we rads are taken out of the loop. We had no good lines of communication to IT, who assumed a lot of things were OK when they weren't, and who didn't think to ask us to champion absolutely critical upgrades and expenditures. This allowed system-wide deterioration which nearly shut down a hospital. 

We had no good feedback loop back to the vendors. Since we are NOT their customers, they take their cues from IT and C-suiters who generally have no concept of radiology workflow. The hanging-protocol thing is a great example. Clearly, Agfa had no clue as to how I wanted it to work, and frankly I can't imagine anyone finds it useful. Contrast this with AMICAS PACS which had a very simple, working solution back in 2003.  Listen to your customers and they will tell you what they need. Except I'm not the direct customer, am I? 

For the past 10 years, I've tried to be the feedback loop, along with a very few others. Clearly, I haven't succeeded. We finally made progress when my colleagues who took back the night got sick and tired of the decaying situation. I tip my hat to them for this tremendous accomplishment.

Hopefully, our PACS experiences will inspire others to rise out of their complacency. Things CAN be better. You simply have to reach this point, as did someone who suffered from a different "Network" outage:

Am I communicating this properly? 

Saturday, October 24, 2015

EMR's Suck Epically!
And I'm Not The Only One Who Says So...

When something in the health-care field reaches the attention of Conservative columnists, it must be either really wonderful, or very, very bad. This time, it's the latter.

I'm a big fan of Michelle Malkin, a very articulate Conservative writer, who appears periodically on Fox News broadcasts, and the pages of In her latest column, she notes quite clearly that "Doctors Agree: Obama's Electronic Medical Records Mandate Sucks". This doctor concurs.
For the past several years, medical professionals have warned that the federal electronic medical records mandate—buried in the trillion-dollar Obama stimulus of 2009—would do more harm than good. Their diagnosis, unfortunately, is on the nose.

The Quack-in-Chief peddled his tech-centric elixir as a cost-saving miracle. “This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests,” he crowed at the time. In theory, of course, modernizing record-collection is a good idea, which many private health care providers had already adopted before the Healer of All Things took office.

But in the clumsy, power-grabbing hands of Washington bureaucrats, Obama’s one-size-fits-all EMR regulations have morphed into what one expert called “healthcare information technology’s version of cash-for-clunkers.”
Indeed. "I'm from the Government and I'm here to help you!" are some of the deadliest words in the English language. Few if any of the promises have proven to be accurate.
In 2014, RAND researchers interviewed doctors who spotlighted “important negative effects” of the EMR mandate on “their professional lives and, in some troubling ways, on patient care. They described poor EHR usability that did not match clinical workflows, time-consuming data entry, interference with face-to-face patient care, and overwhelming numbers of electronic messages and alerts.”


In Massachusetts last month, physicians decried the failure to achieve true “interoperability” between EMR systems despite a $30 billion federal investment through the Obama stimulus. Dr. Dennis Dimitri, president of the Massachusetts Medical Society, noted at a rancor-filled town hall that the mandate has “added significant time to the daily life of most physicians in their practices,” WBUR reported. “It has not necessarily lived up to expectations in terms of its ability to provide cues to physicians to make sure that necessary treatments are not being missed. It has certainly not been able to swiftly disseminate information from one clinical setting to another.”
The most ironic thing is that what was pledged was truly desirable and eminently achievable. Sadly, what has happened in the private world of medical software is magnified ten-fold when the government jumps in. I have bemoaned the sorry state of PACS software in particular for over 10 years on these very pages. The poor excuses for life-and-death patient-care software can be attributed at least in part to the fact that the end-users generally don't buy the software, and so it is written for those who do. Make the government that customer, or at least the entity that writes the RFP, and you have a recipe for disaster.

The EPIC failures of the most ubiquitous EMR tells us a lot about what really happened:
(The problems are) in no small part due to the cronyism embedded in the federal stimulus “incentives” – a massive chunk of which the White House doled out to behemoth EMR company Epic Systems, headed by Obama crony Judith Faulkner. As I’ve noted repeatedly in this column the past three years, Epic continues to be plagued by both industry and provider complaints about its creaky, closed-end system and exorbitant fee structure to enable the very kind of interoperability the Obama EMR mandate was supposed to ensure.

Now, even left-wing Mother Jones magazine reports this week that “instead of ushering in a new age of secure and easily accessible medical files, Epic has helped create a fragmented system that leaves doctors unable to trade information across practices or hospitals. That hurts patients who can’t be assured that their records—drug allergies, test results, X-rays—will be available to the doctors who need to see them. This is especially important for patients with lengthy and complicated health histories.”
Worst of all, physicians have been bribed to accept the concept of "Meaningful Use" which is simply the ability of their shiny new EMR's to transmit "anonymized data" (nudge, nudge, wink, wink) to Washington, and they are fined if they don't put the spyware in place. The American Medical Association, whose membership now comprises less than 10% of U.S. physicians, sold us out for figurative bowl of pottage, but now, too late, realizes its huge mistake:
The American Medical Association, which foolishly backed Obamacare, is now balking at top-down government intrusion into their profession. Better late than never. The group launched a campaign called “Break the Red Tape” this summer to pressure D.C. to pause the new medical-record rules as an estimated 250,000 physicians face fines totaling $200 million a year for failing to comply with “meaningful use” EMR requirements.
Malkin closes with a modest suggestion:
The Obama White House has responded by doubling down on its destructive EMR rules that punish both patients and providers. Congress must intervene. Rep. Steve King (R-Iowa) introduced a bill Thursday to repeal the draconian penalties “so that providers can get back to the business they are uniquely trained to do—utilizing their skills and knowledge to heal the sick and support the continued vitality of the healthy.”

Prescription: Butt out, Washington. Primum non nocere
Primum non nocere, by the way, is Latin for First, Do No Harm. Indeed, this is the one of the Prime Directives of medicine. Those who provide fractured software should take note. Pandering to IT and CIO's with programs that ignore the needs of the physicians who use them is tantamount to "doing harm" to patients. Abusing one's relationship to politicians in high places to sell exorbitantly-priced, crappy, dangerous spyware is even worse.

From the original Hippocratic Oath:
With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage.

Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so.
Rather Epic advice, don't you think?

Tuesday, October 20, 2015

"EHR State Of Mind"

ZDoggMD WHO????  From Dr. ZDogg's website:
ZDoggMD is a physician, off-white rapper, and the founder of Turntable Health. He’s not a businessman. He’s a business, man. OK we stole that line from Jay-Z but you get the idea. A hospitalist at Stanford for almost 10 years, Dr. Z currently resides in Las Vegas—a city he finds simply adorable.

Dr. Dogg, actually, Dr. Zubin Damania, in his copious spare time, creates poignant, biting rap videos that cut right to the heart of what's wrong with medicine today. His latest offering, "EHR State Of Mind," targets, you guessed it, EHR's, and by proxy, electronic medicine in general.

Without further ado:

Watch the whole thing. Then watch it again.

Yes, it's funny, but it's sad, and it is spot on. Here's the bottom line: Most medical software programs, EHR's, PACS, etc., are VERY poorly written. They are hard to use, they get in the way of patient care, they don't communicate well if at all to other systems, they were designed to appeal to CIO's and IT types, and ignore most anything to do with how physicians and such actually use them. Or try to use them.

I'm just waiting for the first class action suit against one or more of the companies who have shoveled these steaming piles of poor coding and even worse interfaces upon us. All it will take is the deaths of a few patients that can be directly attributable to these embarrassing excuses for software. Mark my word, it will happen. Of course, these multi-billion dollar companies will pay off the plaintiffs and keep doing what they are doing. That worked for Ford and the Pinto cases; Ford committed corporate murder rather than pay $100/Pinto to fix a fatal flaw. So it will be here. And most tragic of all, CIO's and IT folk will continue to buy from the vendors who promise the best prices, the least work for the support people, the biggest installed base, and just generally anything and everything EXCEPT being usable for the end-users. That would be us.

There are very few rogues out there such as myself and ZDogg who are alerting the public to the fact that the electronic emperor has no clothes. Clearly, we are not getting anywhere, and that is because we physicians have completely lost control of this situation. And I doubt we'll ever get it back.

Monday, October 19, 2015

IBM Goes Mac!


IBM, at one time a Windows PC heavyweight, is now deploying Macs internally and is seeing a precipitous drop in helpdesk calls.

How precipitous? Only 5 percent of Mac users call the helpdesk, compared to 40 percent of PC users, according to Fletcher Previn, VP of Workplace-as-a-Service at IBM, who spoke about the program at a conference held recently in Minneapolis.

Based on the positive results, IBM is now rolling out Macs to its employees at a rate of 1,900 devices per week. The tally so far for the four-month-old program is 130,000 Macs and iOS devices into the hands of IBM employees, according to a post from JAMF Software’s user conference, where Previn was speaking.

And IBM is managing all of those devices with a tiny staff of 24 people, which comes to one helpdesk person for every 5,400 devices. . .

One of the ironies is that IBM was a PC pioneer in the early 1980s and subsequently became one of the largest Windows PC suppliers in the world. IBM eventually sold its PC business to Lenovo and over the last decade has become a software and services company.

This on the heels of IBM's purchase of Merge Healthcare to feed images to Watson. Talk about a string of really good decisions! If it weren't for antitrust laws, the next logical step would be for Apple to devour IBM and then gobble up Microsoft just for grins. Take that, Bill Gates!


Cute! I'm sure we've done the proper licensing with @Disney. Right?

Sunday, October 18, 2015

Meeting and Networking

Cartoon courtesy of the

Early July:
Radiologists complain about deteriorating PACS speed and function. Loudly. Note that access via Web from outside the enterprise over <50 MB line works far better than connecting within the enterprise.

Mid July:
Just completed the assessment of where the reading stations are physically connected to the network. Confirmed that not only are they connected to newer switches, but every connection between the core switch and the actual devices are clean. All connections are running 1000 Mbps and Full Duplex, there are no errors on any of the ports between the core switch and the reading stations. Checked the WAN connections and those links are clean as well.

Physical network connectivity has now ruled out as a source of slowness.

Early August:
The overall global performance issues have been resolved through updating servers, workstations, and tweaking settings according to best practice configurations.

Early September:
Radiologist insists on plugging workstation directly into server at datacenter. Voila! Perfect performance!

Mid September:
  1. Network: Switched Virtual Interfaces migration to new core infrastructure (removes extra hop/loop in datacenter - to be completed by end of September). We do not know if there will be any perceived impact or benefit, but it is within the realm of possibility. 
  2. Network: Installation of additional 1 GB connection between campuses and data center (escalated with vendor requesting to have completed by mid-October)
  3. Cisco engaged to perform network assessment (to begin after above network changes are in place) which will be analyzed and Radiologist feedback obtained to determine next steps for long-term measures if image retrieval performance is not resolved through the accomplishments by the end of November.

Late September:
Switched Virtual Interfaces migration to new core infrastructure removes extra hop/loop in datacenter.  Likely that the change will not be seen by the end user.  WAN Upgrade with installation of additional 1 GB connection between campuses and data center waiting on date, anticipating mid-October.   Improved bandwidth will improve network performance.

Mid October:
“We don’t need Quality of Service (QoS) for PACS as PACS only uses 30% of the existing 1GB bandwidth, and that hasn't been a problem.  The additional 1GB upgrade had been planned since last year.

Draw your own conclusions.