Sunday, December 06, 2015

Exhibits At An Exhibition: PACS, HYPOTHETICALLY-Speaking

Having little time at this year's RSNA, I was able to only briefly stop in to see friends at the Visage and lifeIMAGE booths. Both products show nice incremental improvements. Visage offers deconstructed PACS, with better collation of prior studies in this incarnation. It is a viable alternative to a full-fledged PACS, IF your IT folks can handle the concept. Big IF for some. Again, there is no worklist option included; "That would make us a PACS company!" So what's wrong with that?

lifeIMAGE continues to progress, now with even better connectivity. See this nice summary from Imaging Technology News for details. Many PACS vendors offer some form of image sharing in competition with lI, but the latter does it better. I've said it before and I'll say it again:  NOT using an image-sharing system is MALPRACTICE. Period. If you never believe anything else I write, believe that.

I have stated elsewhere that if I were to need a new PACS, my list would be short, based on experience, discussion, research, gestalt, instinct, hubris, and maybe a little luck: Merge, McKesson, Intelerad, and Sectra. Unfortunately, I only had time to visit the first two.

In addition to the Code Name: Avicenna project, Merge offers the latest version of PACS, Merge 7.1, to be released in the Spring of 2016. This latest descendant of the venerable AMICAS PACS (Version 3.7 is still in use at Mass General!) includes a number of tidbits gleaned from Emageon and DR, the systems Merge has assimilated over the years. The major improvement concerns the worklist, which can be used in composite mode, with up to 10 separate worklists operating on-screen at once. And unlike a certain system we know and love, this has no IMPAXT upon the speed of the client. Rules for the next study to be read can be specified so the most appropriate (and urgent) study is the next one to be read. (The next iteration, still a Work In Progress, will further assign studies based on RVU, subspecialty, etc, and should truly be Universal across the enterprise.)

My Merge-based IT people will be pleased to know that user-management is now templated, allowing quicker assignments of permissions and so forth. And the slippery menu-driven preferences is now on a single pop-up window. There is user-level XML integration which could, for example, be used to keep windows open or closed after completing dictation.

There is a new Macro Manager that will combine multiple repetitive actions. There is advanced breast-tomosynthesis with slab-viewing and position markers, as well as PET/CT fusion.

From DR comes embedded dictation with Speech Recognition (which I won't use!), and further improvements on an already excellent hanging protocol functionality. I'm excited to say that there will no longer be the same degree of dependence on series labels (which I cannot get the techs to standardize for love, money, or prolonged tantrums); one can specify, for example, what T2 means on an MRI from Scanner Vendors X, Y, and Z, and then key a hanging protocol to show all the T2 images. You get the idea.

I proposed the HYPOTHETICAL scenario of a failing Big-Iron PACS and asked what Merge could do in such a HYPOTHETICAL situation. HYPOTHETICALLY speaking, Merge could either provide an overlay to the database of the HYPOTHETICALLY failing PACS, assuming that component retained its integrity. Alternatively, Merge could move in as the primary PACS in such a HYPOTHETICAL situation, using DICOM Q/R to retrieve priors in the near term while migrating the entire database in the background. Fairly standard, although the ability to front for a failing system might not be as facile with the other vendors. Should the users of the HYPOTHETICALLY impaired PACS have a Merge PACS somewhere, that existing system could perhaps be used as a secondary server. Also, it would be easier to create a unified worklist for all the PACS in an enterprise if they happened to be from Merge. Food for thought.

McKesson is one of those rare PACS for which we hear minimal if any complaints, even fewer than for Merge and the others. No doubt there are some cranky rads out there who could find something wrong with it, but they are a minority indeed. McKesson PACS is now known as McKesson Radiology, a regression from the old Horizon moniker. The company has a much greater presence in my home state than I knew; they might actually have the majority of PACS here, or at least a significant pleurality.

McKesson is also proud of its hanging protocols, although the emphasis in the demonstration seemed to be on the fact that once they are set up, one wouldn't need to change them. But drag-and-drop and scripting is available for those who want to tweak things. As with Merge, they are not based on series descriptors. If your mouse wheel can tilt to either side, this motion can shift sequential hanging protocols.

There is a nice embedded advanced imaging module that does "~80%" of what one gets with an external TeraRecon, most everything but vessel fly-through. It even has lesion tracking. Tomosynthesis and PET/CT viewers are fully integrated.

Add-on modules include "Imaging Fellow" which can open RIS/EMR data, and is supposed to be able to open "any other exam from any accessible database." This would allow for data mining if you were so inclined.

PeerVue was purchased by McKesson years ago and is now called Conserus. (I would have gone a different direction...sounds too much like Cons 'R Us.) This critical-result software sends texts and emails and other reminders about things that need to be seen NOW.

The "Intelligent Worklist" allows prioritization by rules as we saw with Merge PACS (although the AMICAS/Merge worklist continues to have by far the best visual clues.) This module will monitor foreign PACS, allowing a sort of unified worklist, but still launches the foreign PACS client. I think it is capable of opening the study in your McKesson PACS if you have one, but I wasn't completely clear on that one.

A collaborative tool allows instant pinging of a colleague, referrer, etc, to get them to view a study. Right now, this spawns a second viewer program, not the main PACS viewer itself. This is to be incorporated into the main viewer eventually.

For those who work from or view from home, the main client can be used, although a VPN is required. It was unknown as to whether SSL would suffice.

When asked the HYPOTHETICAL question about the HYPOTHETICAL scenario in which a HYPOTHETICAL PACS needed replacing, the McKesson folks offered up similar solutions. The Intelligent Worklist could probably access the HYPOTHETICALLY failing PACS, as long as one had McKesson for the actual reads. Of course, they would be willing to migrate the old database in such a HYPOTHETICAL situation, and McKesson has in-house capability to do so.

With the observations now documented, I shall now stray into opinion territory. Emphasis on opinion.  Or really just me babbling on.

I have no clue at this point in time if I might be involved in any HYPOTHETICAL PACS replacements. I suppose I would suggest sending RFP's to the four companies mentioned above if that HYPOTHETICAL ever occurred. My good friend Mike Cannavo, the One and Only PACSman, has some very wise and mildly cynical ideas about RFP's. Adding in my own sarcasm, basically the IT folks don't know the questions to ask on an RFP but think they do. I have just one very easy question:  "Does the damn thing WORK?" Vendors will of course respond in the affirmative, but this really requires a far more complex answer with quite a few nuances and shades of gray. Perhaps the better question would be: "Does the damn thing work the way I want/need it to work?" I would love to hear the response to that one.

Mike noted an uptick in the number of vendors offering PACS and PACS-related wares at this RSNA:
So what was new? There are more PACS vendors for sure. I would venture to say that at least 70% of the vendors at RSNA 2015 had something PACS or PACS-related. It's just a matter of time before former PACSman award winner Ernie's Welding and Fabricating becomes Ernie's Pipes and PACS.

Even though we have had some market consolidation with high-profile mergers and acquisitions, for every one vendor that gets gobbled up, it seems like four new vendors appear. How many of the newbies will be here next year is anyone's guess, but if history repeats itself and 10% remain, it's a lot.
The problem is, even though some might have an innovative feature here and there, these tiny vendors probably won't be around in a few years, and many that are maintain their viability because their products are cheap (in price, but probably quality as well) and they appeal to small operations being run by those who don't understand what it is they are buying.

Ironically, the Powers That Be at one of our places blackballed AMICAS years ago because a consulting company (someone you hire and pay $50,000 to tell you what you already think you know) told them it was "too small" and would likely be acquired. Well, they were half-right. IBM now owns Merge, which owns AMICAS, but instead of quashing it, ala GE, the acquisition has strengthened the company and the product. GE assimilated DynamicImaging, among others, cannibalizing its PACS components into the Universal Disappointment. DI no longer exists in any form. Merge, however, is still alive, being billed as "an IBM company". AMICAS PACS lives on, and continues to grow. My friends from Emageon and DR Systems might roll their eyes a bit, but at least the best of their PACS components live on within Merge PACS, and credit is given to the predecessors as is due. I'm good with that.

McKesson Radiology is in many ways at the other end of the spectrum, being one of the last Big-Iron companies. Their product list contains hundreds of entries, and PACS is far from the largest offering. Still, there is a lot to be said for having a HUGE presence in the health-care marketplace, and to have a product with relatively few complaints. (However, I probably don't even have to say that simply buying from a huGE company doesn't guarantee a quality product.) Supposedly the rule at McK is that a call to the support center MUST be answered within 3 rings. I can't vouch for what happens after that. Many have said McKesson's architecture is a generation behind, and that there are too many different clients for different purposes, but I didn't discuss that with them at this point.

I have had very nice chats with Sectra and Intelerad folks over the years. In fact, Sectra invited me to come to their headquarters in Sweden, but I could only go in July, and Sweden apparently closes for vacation that month. My contact at Sectra has since left for a different company, as folks in this business are wont to do. I do keep in touch with some good friends at Intelerad as well. It is of note that both companies demurred somewhat as to what could be accomplished when given bits and pieces of the HYPOTHETICAL failing-PACS situation.

I'm in my eleventh year of blogging about PACS, and the more things change, the more they stay the same. What worked before still works and works better, and what didn't work still doesn't work, and may even be worse. (And the attitude of IT doesn't seem to be much different at all.) Some companies listen better than others, and some even listen to the right people, the end-users of their wares, and not just the people with the checkbook.

Remember Dalai's First Law of PACS: PACS IS the radiology department. It has to work. And not just HYPOTHETICALLY.

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