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? 

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