Thursday, December 15, 2016

Don't Spamalot
...Or Even A Little!!!

We all know what SPAM is...unsolicited e-mail that clogs your inbox. But as with beauty, the definition of SPAM may well be in the eyes of the beholder. Or the SPAMMER.

After receiving yet another piece of shi... I mean SPAM from someone who friended me on LinkedIn for the express purpose of SPAMMING, I wrote this little article for consumption on that site:
A follow up from last year's SPAM post. DO NOT USE LinkedIn to SPAM other members. I've made the mistake of accepting contact requests, and my new "friend" proceeds to bombard me with messages and emails about their "wonderful new product/software/service/doodad/widget that I would really be interested in and would appreciate the time to contact you or whoever in your organization makes such decisions so I can share this wonderful new development...." Sound familiar?

To all you salespeople out there...DON'T MAKE THIS MISTAKE AGAIN! Cold calls, unsolicited emails, etc., etc., accomplish nothing more than pissing people off. NOTHING. We will not be buying your incredible product, but we WILL be reporting you to your boss, your ISP, LinkedIn, Facebook, or wherever your unwanted communication came from. I have never, ever made a purchase based on a cold-call or cold email, and I NEVER will.

I suspect I speak for quite a few of us out there who have been the targets of your unwanted missives. Find a different approach. Or a different business.
Needless to say, a couple of salespeople were not amused. I'll keep their names and companies private, but these were quite available on LinkedIn...

A gentleman based in a subcontinent on a different side of the world asked this in response:
Then how do you want a sales guy to approach what is your thought for a sales guy.
To which I responded...
I was waiting on someone to ask that. You MIGHT find someone who appreciates cold emails. I don't, and I don't know anyone who does. Getting one of these unsolicited emails guarantees that I will NEVER look at what you have. There is almost always a dead giveaway wherein your colleagues ask that I "forward this to the person in my organization who would be interested/in charge." That will NEVER, EVER happen. And getting names from a list you purchased is one sure way to alienate me forever. DON'T DO IT!!!! Frankly, I and just about everyone I know do NOT want any unsolicited email from sales people at all. EVER. IF your company has the next best thing, have your CEO or CTO contact me. BUT NO SALES PEOPLE. Your colleagues have done a very good job of burning that bridge.
A Sales Manager for a small IT company then wrote a rather scathing response, augmented by the fact that he once worked for a company I befriended. No names. He went off on a bit of a tear, agreeing that perhaps LinkedIn shouldn't be used for SPAMMING, but then expressed his great distress (perhaps not quite as nicely as I did) that I was casting salespeople as deplorables and trying to take food from the mouths of the salespeople's children. Just call me Dr. Scrooge, I guess. Mr. Manager went on to suggest, from knowledge acquired in his prior life, that I had had problems with ER docs listening to me which was somehow supposed to be analogous to receiving cold sales-calls. The other gentleman from overseas joined in, saying that, "customers are mean."

You can guess how well that went over with me...
Mr. Sales Manager, you might seriously want to remove that comment. Your seniors at (your company) as well as all of your LinkedIn contacts just saw your rant and your less-than savory approach to a friend of a place you used to work. Rather bad form. Same for Mr. Overseas. It's a really bad idea to call customers "mean". Your analogy is faulty, by the way. I have a relationship with the ER docs. Completely separate issue. I have NO relationship with Mr. Overseas and all the others (often from overseas, btw) who get my name off a list of emails they bought from some unsavory operation and proceed to send a barrage of unsolicited emails. It is the salespeople who participate in these bottom-feeder behaviors that have spoiled things for the rest of you. Try policing your own before getting angry and biting the hand that might feed you.
Mr. Manager yanked his post, for which I congratulated him, but even then, he doubled down...
And I think you should delete yours as well as it is still offensive.
My final answer:
You might want to actually address my complaint about sales people rather than digging in your heels and creating an even deeper hole to climb out of. No, I will not be removing this comment. Perhaps you need to read it again.
And there it stands until someone else jumps in.

I really don't like conversations of this sort, but I won't shy away from them. I absolutely, positively WILL NOT respond to a cold-call or a cold SPAM e-mail. I view this as intrusive, as a sign of desperation by the sales people involved, which tells me automatically that their product is of considerably less stature than their rosy, scintillating prose would have me believe. I cannot believe any sales person actually thinks cold-calls of this sort will actually generate any business.

Maybe there's another approach. Let's create a website for these companies to show their wares. Then those who are interested could check in periodically to see what's new in some particular category. And communications could progress from there. We could call the site or maybe Just don't send me any SPAM to advertise it!

Let me throw the question out to the audience...How do YOU feel about SPAM and cold-calls from salespeople who have found your name on some list they purchased for $.02 per click? Do you appreciate the warm, human contact? Or would you rather they leave you the heck alone? I don't think I have to tell you how I feel, but maybe I'm just a cantankerous old fool whom time and technology have passed by... So please do comment and share your opinion. Will it be "Sale of the Century", or "Death of a Salesman"? wants to know!

Sunday, December 11, 2016

Artificial Intelligence at RSNA:
I'm Sorry, Dave. I'm Afraid I Won't Be Taking Over...

After a pleasant Thanksgiving with the entire family, and a quick turn-around to Chicago, I had the pleasure of my 20th (I think) RSNA. I've likened this Meeting of Meetings in the past to taking a drink from a fire-hose, and that description stands. But as I get older, the meeting takes more out of me, and at times, I probably look a bit shell-shocked:

I tried and tried to come up with a story to pervert parody to submit in place of the PACSMan awards, since my friend Mike Cannavo is otherwise occupied this year. The "Beyond Imaging" theme offered so many different directions, I found myself with a bad case of writer's block, and so no story ensued. To me, "Beyond Imaging" is that same old tired meme that tells us to act more like clinicians so patients will love us and we'll get more stuff from the ACO's. Well, maybe ACO's are going away someday, so the joke may be on us. Again. Besides, I would be rather miffed if I found that the new motto for the American College of Internal Medicine was "Beyond Clinical Medicine" implying that they were going to act more like radiologists.

I made the rounds, attended various lectures, mainly PET/CT and SPECT/CT talks, which were quite informative, and collected an adequate amount of CME's to justify the stratospheric cost of a last-minute plane ticket, and a corner room at the McCormick Hyatt. Perhaps the most important lesson was that if you want a diagnostic CT image from your SPECT/CT, it should probably have a diagnostic CT component attached to it as the machine that produced this image doesn't:

I spent a good bit of time taking with and about Rad-Aid, and even spent an hour or so behind the desk at their booth:

Everyone who stopped by got the official Doctor Dalai Business Card, and a very enthusiastic retelling of my adventures in Ghana. In all seriousness, there seems to be a LOT of interest in giving back in this manner, and I could not be more thrilled and honored to be a part of it.

I spent only a few moments talking with my friends at Merge discussing PACS. Having had to learn version 7.x on my own whilst in Ghana, I can tell you it has some new features, such as worklists built with block structures, a novel approach. It took me some time to get used to the new back end, which now divides properties among two different management areas. With greater power comes greater complexity...

Of course, the BIG DISCUSSION all over RSNA was Artificial Intelligence, and in particular, AI as applied to Radiology. Well, let's be even more specific. There was a cloud (pun intended) hanging over McCormick, the specter of RSNA Yet To Come, which I quite presciently predicted in my 2011 RSNA Christmas Carol:
I sat down on a PET/CT gantry and bowed my head. The room spun, and when I looked up again, we were seated on a bench beside Lake Michigan. It was a blustery day, with winds one only sees in Chicago in the winter. Strangely, I felt no chill, as I watched leaves blowing through the PACSman's shadowy figure.

I looked behind me and gasped. The once-stately Lakeside Center was in ruins, shattered black pillars and glass everywhere.

"PACSman! What happened here?"

"Oy, Dalai, you need to lay off the Kung Pao, OK? Welcome to RSNA 2045," he said. "Or, well, it would have been if there still was an RSNA. Which there isn't."

"But why?"

"What did you expect?" he said. "Between the UnAffordable Care Act, the doctors' 'fix' that fixed you guys good, and all of your good friends, the clinicians, you radiologists didn't stand a chance."

"But who reads imaging studies now?" I asked.

"Geez, Dalai, why do you even care? OK, OK," he said. "You've come this far. Look, imaging reached the point where it didn't pay squat, right? So no one wanted to do it anymore. Even physicians' assistants and nurse practitioners wouldn't touch it. Imaging got so cheap that people got their scans at Walmart and everybody's data were stored in the cloud or on some vulture -- I mean, vendor-neutral -- archive. Got that? So many images were crammed into all these interconnecting networks that ... badda bing, badda boom, they grew self-aware. So, the damn computers are doing the diagnosing themselves. Whaddya think of that? End of the line for radiology."

"No, PACSman!" I exclaimed. "It cannot be! This is an honorable profession, and it cannot end this way!"
I would love to take credit for the current hysteria, which would mean that vast numbers of you out there actually read my stuff, which we all know is not the case. No, my colleagues have manifested this paranoia without my help. The demise of Radiology has been predicted for years, in various forms, from numerous causes, and with timelines anywhere from yesterday to 100 years from now. The latest incarnation of this sooth-saying comes from none other than Ezekiel Emanuel,  the physician brother of Hizzoner Rahm Emanuel, Boss Mayor of Chicago. Ezekiel has had his hand in a lot of, shall we say, progressive medical policies, and I think it's not unreasonable to say that he hates and/or despises other physicians. So it comes as no surprise that he and colleagues write in "Predicting the Future — Big Data, Machine Learning, and Clinical Medicine," in the New England Journal of (Esoteric) Medicine:
(M)achine learning will displace much of the work of radiologists and anatomical pathologists. These physicians focus largely on interpreting digitized images, which can easily be fed directly to algorithms instead. Massive imaging data sets, combined with recent advances in computer vision, will drive rapid improvements in performance, and machine accuracy will soon exceed that of humans. Indeed, radiology is already part-way there: algorithms can replace a second radiologist reading mammograms5 and will soon exceed human accuracy. The patient-safety movement will increasingly advocate use of algorithms over humans — after all, algorithms need no sleep, and their vigilance is the same at 2 a.m. as at 9 a.m. Algorithms will also monitor and interpret streaming physiological data, replacing aspects of anesthesiology and critical care. The timescale for these disruptions is years, not decades.
I will reserve my opinion of this for a few moments, but suffice it to say, it rhymes with "Wool Schmidt".

Artificial Intelligence and Machine Learning as applied to replacing aiding radiologists were the stars of quite a number of talks and debates, and trust me, those sessions were standing room only. We old folks don't like standing through 90 minute sessions, but stand I did through several.

One of the best was a mock debate between Drs. Eliot Siegel, who took the side of the humans, and Bradley Erickson, who insisted machine domination is relatively imminent. Of course, all physicians were supposed to be replaced in 1910 by the Vibratory Doctor...

I can't begin to do justice to these topics, and a quick Google search will give you more information than you could possibly assimilate in a lifetime. But the "debate" made us understand that it will take the epitome of AI, Artificial General Intelligence, to begin to replace us. And THAT probably won't arrive for a long time. In fact, people who are strong believers in such things were surveyed about when they thought AGI would actually arrive. They responded:
  • By 2030:     42%
  • By 2050:     25%
  • By 2100:     20%
  • After 2100: 10%
  • NEVER:       2%
I'm with the 2030 crowd. 

I don't want to get into the mechanics and such of Machine Learning and image recognition and such. But some of the hype has been driven by advances in Machine Vision...Some have said that because Google can recognize a photo of a dog, it's ready to read complex medical imaging. Not quite:

The dog is a big visual signal, if you will, but a subtle little fracture on a great big bone is only a couple of pixels out of thousands. Reading these exams is not as easy as it looks!

Not to belabor this, but another talk from Dr. Igor Barani, founder of Enlitic, a company leveraging Deep Learning for triage, clinical support, and other non-threatening medical applications, presented some of his work, and in this video of lung nodule evaluation you can get some idea of how the machine "thinks":

So where are we going with this? You may remember my post from last year about IBM's Watson:
Now you might say that Computer Aided Diagnosis is already here. You would be missing the point. CAD doesn't learn. Watson, being a cognitive computer, learns. It learns the way I learned to read CT's. Hopefully it will read them better than I do. Think of it this way... I went to college to learn the chemistry and physics (and for me, engineering and computer science) needed to understand higher concepts. I went on to medical school to learn how the body is put together with all that chemistry and physiology and stuff. I learned where the pulmonary arteries were, and what happens if a clot gets lodged in one. In radiology residency, I learned how it looks on a scan if that happens. (Well, to be fair, the scanners weren't fast enough for CTPA grams back then, and so we learned the concept with conventional arteriography, but you get the idea.)

One physician was overheard saying something like, "Bah. My first-year residents could get that one." Yes...A COMPUTER can match the achievement of a human that has gone through college and medical school. Let this sink in. Code Word: Avicenna shows us THAT A COMPUTER IN THE EARLIEST STAGES OF LEARNING HOW TO READ COMPLEX IMAGING STUDIES CAN MATCH A FIRST-YEAR RADIOLOGY RESIDENT.

This, people, is the epitome of disruptive technology. This is a sea-change in how radiology will manifest in the future. The implications here are staggering. To me, this is MUCH more important and noteworthy than an extra Tesla on a magnet (although a Tesla in my garage would be most appreciated) or an extra hundred slices on a CT. Code Name: Avicenna represents the most important development in our field in a very, very long time. This is a fundamental change in the way we do things. It assists the radiologist, allowing him/her to perform at the highest possible level, but does not replace us. Not for the foreseeable future, anyway.

I was right on that one, at least.

I have seen the future, and its Code Name is Avicenna. Seriously. Trust me, I'm a doctor! But if you don't believe me, just ask Watson.
I'll stand by every word of that. As it turns out, this was not my first article about Watson and Radiology...Back in 2011 I spoke of Dr. Siegel's efforts to train Watson. It seems our little computer has grown up.

So where are we now?

I spoke with several reps from IBM, and I am further reassured that HAL, I mean Watson, bears no ill-will toward us lowly humans, particularly radiologists. IBM has no plans to replace us. They said so and I tend to believe it.

Watson himself will manifest in a few different guises, which will be deployed in the coming years. There is sort of a tentative timetable, but I was asked not to reveal that on the off chance that something comes in later than expected. Software, even intelligent software, can be cantankerous, you know. And the FDA can be even more vexing.

You've already met Code Name: Avicenna. IBMerge today categorizes him as part of the "Watson Health Imaging Cognitive Solutions", and deems him "A cognitive physician support tool that suggests differential diagnoses options to help inform the physician’s decisions for the patient." This is the module that impressed me last year with its (OK, his) ability to call a pulmonary embolus on a CT arteriogram.  Once released to the public, well, radiologists anyway, Avicenna will concentrate on heart, breast, lung, brain, and eye problems. He will, eventually, launch from PACS as a radiologist assistant. Note I didn't say replacement. At RSNA, Avicenna was put to work in the "Eyes of Watson" display over at the Lakeside Building, chugging away at a (relatively) small palate of test cases. I didn't want to be too obvious about videoing the display, but here are a couple of screen shots showing Avicenna's on-the-fly "thinking" process:

Avicenna has a few new peers, also named for famous old Physicians. (No, there is no Code Name: Dalai; I'm old but not famous, nor is there a Maimonides as yet.)

Code Name: Iaso is named not for a physician per se, but for the daughter of Asclepius, the Greek g-ddess of recuperation from illness. You'll find a lot of tea-based products out there also bearing her name. She is, according to IBMerge, "(a) cognitive "peer review" tool used to detect and reconcile differences between clinical evidence and the patient’s EMR problem list and billing records with the ability to be used prospectively as well." I was told that Iaso will be looking in particular at aortic stenosis and echocardiagram results. It seems that 23% of the time, aortic stenosis is reported in the echo, but somehow doesn't make it to the EMR. Iaso will help "bridge the gaps" in information such as this.

Code Name: Gaborone seems to be named after a town in Botswana rather than a physician (IBMerge, let me know if I'm wrong about that...) Gaborone will be "(a) cognitive data summarization tool that looks expansively at available patient data sources, filters and presents the contextually relevant information within a single view." He (I assume he...pardon my gender insensitivity) will be a stand-alone product.

Watson for Oncology is making its mark outside of imaging. This product "(i)mproves clinical decision making by integrating disparate patient data and images in one workflow to drive evidence-based treatment recommendations." You might have seen the recent news about this Watson module saving a patient:
University of Tokyo doctors report that the artificial intelligence diagnosed a 60-year-old woman's rare form of leukemia that had been incorrectly identified months earlier. The analytical machine took just 10 minutes to compare the patient's genetic changes with a database of 20 million cancer research papers, delivering an accurate diagnosis and leading to proper treatment that had proven elusive. Watson has also identified another rare form of leukemia in another patient, the university says.
Not bad for a kid that never went to medical school.

The technically-named Marktation Medical Interpretation Process may "free the radiologist to operate at the top of his/her license." From IBMerge, "Marktation is a process for interpreting medical images. When a physician labels findings on an image using text or speech recognition, the text label is simultaneously stored on the image and pushed into the clinical report. Additionally, Watson anatomical image analytics enables the text label to be posted into the right position of the clinical report and automatically adds a description of the anatomical location to the physician's label. Marktation is a reading paradigm shift aiming to improve reading speed and accuracy." In other words, this module assists us rads in marking lesions. It may sound trivial, but when you're putting little cursors on little tiny lesions and reporting them all, it gets tedious and painful. This could help. A lot.

Finally, Watson has two other pals (siblings? cousins?) for us to play with. The Watson Clinical Integration Module "...aims to present intelligently compiled clinical information based on the indications for an exam as well as Watson's understanding of clinical relevance. This module aims at increasing reader efficiency and helping counteract some of the most common causes of errors in medical imaging, such as base rate neglect, anchoring, bias, framing bias, and premature closure."  The Lesion Segmentation and Tracking Module "...aims to automatically segment (outline and measure) physician-marked lesions, pre-mark new exams with the index lesions from prior exams, and produce tracking tables. The module aims to speed the interpretation and reporting of comparison exams in cancer patients and others patients whose findings require longitudinal tracking."

The details of all these many faces of Watson will come with time. I predict you'll see at least some of the modules on a PACS near you sooner than you think. I could say more, but a promise is a promise.

Nancy Koenig, General Manager of Merge (Previous CEO Justin Dearborn now runs Tribune Publishing, another Michael Ferro/Merrick Ventures acquisition, and I guess the CEO title isn't appropriate with IBM owning Merge) had this to say about our electronic friend:  "Watson cognitive computing is ideally suited to support radiologists on their journey 'beyond imaging' to practices that address the needs of patient populations, deliver improved patient outcomes, and demonstrate real-world value." And that is the antidote to the current hysteria.

Watson, Enlitic, and all the other AI's out there, are NOT out to replace us radiologists. They are tools for us to use in our quest for ever-better patient care. Nothing more, nothing less. To fear them makes no more sense than fearing radiation, electricity, hammers, guns, or tactical nuclear weapons. Used properly, they can serve man (the last on the list works as a deterrent to other, hopefully sane folks with similar toys).

Dr. Ezekiel and a few rather rabid AI sycophants on Aunt Minnie not withstanding, word of the demise of our profession is a bit premature. No one, and I do indeed mean NO ONE at RSNA, save perhaps for some star-struck journalists and a few companies with nothing real to show (like Deep-Something), claims we will be replaced by machines within any of our lifetimes. That is the bottom line. Watson and his cousins aren't out to get us after all.


This situation is a wake-up call, like quite a few others we have endured or ignored over the years. Think self-referral and AMIC. AI is powerful technology, and it has great potential to help us. Could computers someday "grow self-aware and do the diagnosis themselves"? Sure, if someday has no endpoint.

So here's my Dalai-ism on the topic, simple-minded as you might expect, but still profound, if I do say so myself:
We need to be in control of this technology.
What's our greatest irrational fear of AI? That it will take our jobs away. That the insurance companies or the government will latch onto Watson as a replacement for us cranky, expensive flesh-and-blood radiologists, and leave us shivering out in the cold, holding signs saying "Will Read CT For Food" and "Buddy, Can You Spare A Cup Of Barium?"

So it occurs to me that we aren't asking the right questions. Ignore the What and When, and ask, "HOW do we keep control of this?" I posed that very question to Dr. Siegel after one of the sessions. His answer was clear: "If we are in on the development of the technology, we will have a far greater say in how it is used. And besides, can you imagine how long it will take for the FDA to approve machine reads?" And I'm sure he's right about that. And keep in mind, there are so very many other bunches of low-hanging fruit for AI to conquer. Why should radiology be at the head of the line for obsolescence? Because Dr. Emanuel hates us, apparently. Fortunately, he has no pull with Big Blue, or Deep Anything.

So, for those fearing Big Electronic Brother, Here's my advice:  Take a deeeeeep breath, and then take a big gulp of Scotch, or a Valium, or whatever you require to climb off the ceiling. And relax. The computers are here To Serve Man.

I'm sorry, Ezekiel. I'm afraid HAL can't do that.

Monday, November 07, 2016

Home Sweet Home

I'm back home from my adventures, so these posts will go back to being boring as usual. But, I still have to tell you about my final triumph. Well, perhaps triumph is too strong a term, but we did have a bit of success. As you see in the image above, we sent a nuclear study, a thyroid scan, from the to the PACS, where it can be seen on the laptop above. This is definitely the first time this has been done at Korle Bu, and probably the first time in Accra and all of Ghana, and maybe Western Africa as well. We've made history!

But all good things must come to an end, and it was time to prepare to go home. There had been some confusion as to whom was paying for the guesthouse room. I had assumed I was, but then it seemed that I wasn't, and on the evening of my departure, it seemed that I was paying after all. That was fine, but I didn't have enough Cidi's, and had to make a nighttime trip to the ATM farm, which is not a good idea. But Ben came with and played bodyguard, and I survived the experience.

I ended up with about 500 extra GHC's, worth about $125. I thought I'd spend them at the airport, but Delta insisted we head to the gate as quickly as possible so they could conduct the third security check, pat-down included, and then make us sit for an hour before boarding. Anyone headed back to Ghana anytime soon?

The flight home was uneventful, save for the "Is there a doctor on board?" call about 2 hours before landing. A passenger had experienced a seizure, and was still in that groggy, post-ictal state. Fortunately, two real doctors got to him before I did. It was rather amusing in a perverse way to watch the NYC paramedics perp-walk the poor guy from the back of the plane and out to an ambulance (presumably) upon docking.

Since we landed a bit early, I had the brilliant thought (well, Mrs. Dalai thought of it...) to try to get on the earlier flight that I shouldn't have been able to make. I was the last standby to get on, but I did make it, and also the next back home from Atlanta, which was about to close it's doors when I got to the gate, completely out of breath. So I made it home 4 hours before my scheduled arrival. Of course, my bags didn't, but that's OK.

It will still take me a bit to process this trip. It is indeed life-changing, in ways subtle and not. I'm thrilled, for example, to eat salads and to have ice in my drinks again. And looking around my reading room today with 10 monitors and 4 computers all for my own personal use, I shake my head in wonder at the amazing largess we take for granted over here. Today was my first day back at work, and everyone asked me how I liked the trip. I had to do you answer this question? This was not a pleasure trip, and certainly much different than your average vacation. But I loved it, and I certainly hope to do something like this again. Maybe that's the best answer I can give.

Thanks to WhatsApp, I've heard from my fellow travelers almost daily, and I text with Ben several times a day. Things seem to be progressing nicely without us; our training seems to have made a difference, and that, after all, is what we hope to achieve. And I'm very proud of how far everyone at Korle Bu has come. Hey, I can brag a little..."My son the doctor!"  OK, my Ghanaian friends, but you get the idea.

Wednesday, November 02, 2016

It's Just Another Manic Monday...And Tuesday...And Wednesday...

I'm still here in Accra, this morning working on some stuff before my appointment with the Head of Nuclear Medicine here at Korle Bu Teaching Hospital. More on nuclear things momentarily.

We hit the ground running on Monday, after the emotional trip to Cape Coast the day before. We were to meet with the Head of IT and tour the facilities (Brian tells me there is a server room that is right up there with most he's seen) and speak with those knowledgeable in a locally-developed mini-EHR designed for the OB-GYN Department. But due to various scheduling conflicts and the Head of PACS IT taking ill, we ultimately met simply with one of the designers directly, who demonstrated the capabilities of their software. I was most impressed; this system is as good as any in-house developed product I've seen, and better than most.

I delivered my PET/CT talk to the Radiology residents yesterday morning, and they were as attentive as any audience I've had over the years, again asking some of the most insightful questions. Imagine how much good they could do with the actual scanner itself!

Thanks to Dr. B.'s monitoring of misbehavior of a worklist, I've discovered a glitch in the Merge PACS 7.0.x software. Worklists are comprised of a worklist "frame" (my term, but it helps me understand the new structure) and blocks that actually do the heavy lifting of determining which exams show up on the list. A worklist can contain multiple blocks, so one can create a list of all CT's and MRI's done today by combining the individual "Today" blocks. A key element in the block is the "Time Constraint" which tells the worklist the time-frame of exams to display:

The glitch, which my friends at Merge were able to reproduce, is that the Start Time Hours entry can blank itself, simply erasing the entry. It doesn't go to zero, it goes to nothing. Which fouls the block, which fouls the worklist. But now that Merge knows about it, I'm sure it will be fixed.

In the meantime, I'm still slogging away at a solution for those with limited-capacity Mac's. "Dr. Mary", one of the residents, has very graciously lent me her Macbook Air (128 Gb SSD) for experimentation. Unfortunately, the drive is way too small to accommodate BootCamp for a Windows installation, so I've tried anything and everything to work around this. Dr. B. suggested Wine, sort of a program-by-program Windows emulator. I tried this, with some minimal success on other Windows programs, but the Merge client is a large Java app, and getting Java running within Wine so as to run Merge is beyond my abilities, at least within the time I have left to make anything work. My last possibility is to use a program called WinToUSB to turn a USB Hard Drive (won't work on a flash drive, we tried) into a bootable Windows environment. The first disk we tried failed utterly, and I'm trying with another. The installation seems to always fail at the 95% mark. This is one I might have to leave in Ben's able hands. I asked "Dr. Mary" if perhaps there is a new Mac coming for Christmas. She smiled and asked if perhaps she should simply get a Windows laptop next time. Frankly, much as I love my Macs, it is probably the best thing to do if running Windows software is your main focus. Can someone explain to me why a program written in Java, supposedly a platform-independent environment, will only run on Windows? We Mac-lovers feel slighted!

On to Nuclear Medicine. As above, I will meet with the Head of Department today, and hopefully I'll have the opportunity to show her how the Merge PACS works, and explain my idea of connecting their Siemens (which is currently down for service) to the PACS. Keep in mind that here, as in much of the rest of the world, NM is a completely separate entity from Radiology, but I can tell you from long experience that having both Radiology and Nuclear examinations available to compare to each other and to newer studies is incredibly helpful. I'm expecting the same happy reaction I've seen on everyone's faces when I demonstrate the capabilities of soft-copy reading in general, and the power of this particular PACS client in particular. That alone has made this trip worthwhile.

I cannot believe how quickly my time here has passed. We have today and tomorrow remaining here at Korle Bu, and then back to the USA on Friday. (And back to work on Monday!) As I'm donating this laptop to the hospital, I probably won't have another blog entry until I'm back home. Which will allow much time for me to process what I've seen, done, and learned here. I can tell you already that a trip like this is life-changing. You cannot spend this length of time outside your comfort-zone and not come back just a little different. I've been accepted by people of a culture very different than mine, to the point that I feel very comfortable among my new friends. Yes, we stand out as obviously different, but I really stopped thinking about that after Day One, to the point that when I ran into another Obroni here at Korle Bu, my first thought was that HE was out of place. But not me. Perhaps I'll be able to wrap more words around the feelings with time.

Hopefully, I've absorbed some of the profound kindness and hospitality we've been shown on this trip. The common Ghanaian greeting is, "You are welcome!" (Which makes a lot more sense than saying it in response to "Thank you".) We really were welcome here. While I'm anxious to get back home to the family and the puppies, I will truly miss Ghana, and if they'll have me again, I do hope to return someday.

Sunday, October 30, 2016

Slave Castle

There are a few places on our lovely planet that sit in silent testimony to the horrors man can inflict upon his fellow man, and I had the honor and privilege to visit such a place today. I write this with difficulty, but it must be written. What I've felt today must rival what one feels at a concentration camp (I've yet to visit one, but I must). There is nothing but sadness at this place, the knowledge of just how low humanity can sink, how evil can take over a good man's soul.

We left early this morning for a three-hour drive from Accra in a VERY small Hyundai, over relatively good roads. The trip was uneventful, except for being stopped by the Ghanaian Police who warned Alfred, our driver, not to stop for bandits who are dressed in the uniforms of the Ghanaian Police. Got that? The scenery en route was fascinating. I have tried to take photos of the street scenes here, but I simply cannot do it justice. Picture block after block after block, mile after mile after mile, of unfinished storefronts, tables, booths, piles of coconuts, larger piles of coconut shells, smoked fish, every manner of electronics from at least 30 years ago, car parts, tires, motorcycle parts, ornate caskets, statuary, pretty much anything and everything. And every manner of vehicle, from a few Mercedes and even a Lexus GX to little carts pulled by a motorcycle chassis. And people. More people per square foot than I have ever seen in my life. Today, many were in their Sunday Best, and there were several outdoor church services to be found by the roadside. Ghana is majority Protestant, and the people are quite religious.

We arrived at Cape Coast, and with the aid of my Cities2Go app (like I know where I am in Ghana), we found the Castle, one of several on the Ghanaian shore (once called the Gold Coast) that was the center of the African slave trade. You can look up the numbers; they are mind-numbing. Millions of slaves passed through these forts/castles on their way to the New World. Many died here, mainly from disease, many more died en route. Some chose to throw themselves into the ocean from the ship, and as there were a number of them chained together, that created a similar deadly choice for all. Perhaps it was better that way. 

It should be made clear that both Europeans and Africans were involved in the slave trade. Raids were conducted into a good part of Western Africa and human beings who were just minding their own business were captured and delivered to the slavers. Prisoners of tribal wars got sent off to slavery.

The sordid list goes on. No party, save the victims themselves, were innocent in this horror. And it should also be mentioned that a majority of these tortured souls were sent to nations other than the United States. In fact, about 40% went to Brazil alone, and today, this is the nation with the second-highest number of people from African extraction. There's a lot of guilt and a lot of blame to go around.

This is a shot from within the Male Dungeon. There were multiple chambers here, each holding something like 200 men, without room to lay down, with no toilet, and with water and food delivered once a day. The three window openings provided what little ventilation was to be found.

Here is the walled-up original "Door of No Return" through which the slaves passed through to reach an underground tunnel leading to the port at the base of the castle. There are viewing areas along the castle courtyard looking down into the tunnel, allowing soldiers to monitor progress. The slaves never saw daylight from the time they arrived here until they reached the New World. If they were alive when they got there.

The "Door of No Return" was recut into a different wall, and those of African descent whose ancestors left from this place may request a "Door of Return" ceremony to mark the occasion of their visit, and bring things full circle.

You'll be happy to know that while slaves suffered and died below, the various Governors (this place was built/rebuilt/run/owned at various points by the Swedes, the Dutch, the Portuguese, and the British) lounged in this lovely room with cool sea-breezes that drowned out the stench of death coming from the dungeons.

My readers know I am not a big fan of the current occupant, but it was fitting and proper that the first American President of African ancestry visited here in 2009 and placed this plaque:

Mrs. Obama, in fact, found that her ancestors did indeed pass through this horrible place en route to America. 

A few years ago, I was in Germany, and had the opportunity to visit Hitler's podium on the Zeppelin review stand in Nuremberg. You've seen the stands in newsreels from the end of the war, when the Allies shot the swastika off the top of it. I stood there and felt some small glimmer of the triumph of good over evil. Hitler died a nasty death, and the parts of my family that left for America survived. Up yours, Herr Shickelgruber. I guess the Castle has a happy ending as well, but it's hard to see it standing in the dungeons where men and women were held like animals, where many died like animals. Our guide, Sebastian, put it thus: "The only way this could have happened was for those in power to stop seeing their captives as human." I have no better answer. But at lunch, our driver, Alfred asked this, "How could religious people do this? How could they go to the church on the grounds and then do this to people?" To that, I have no answer.

The profound sadness the Castle inspires is not pleasant, but something I think all must experience. I leave here changed a bit, a little older, a little wiser, a lot sadder. We have not learned the lessons we should have from all this. The Castle ceased warehousing people in the early 1800's, but slavery continued, and sadly still does to this very day. Not 150 years later, the Holocaust not only enslaved people, but deliberately slaughtered them as well.

But here I am in Ghana, a proud, free nation that remembers this shameful past, but goes on with life, building and growing. Maybe that is the answer after all. 

Go on with life. Forgive. But don't forget. Don't EVER forget...

Saturday, October 29, 2016

Weekend Update

I have a short report covering the past couple of days' activities, but despite the relative brevity, you may rest assured that things remain busy here in Accra!

On Thursday, Ben had asked me to look into sending exams back to the modalities in case something needed to be printed from the console and not PACS. (Brian continues to make progress in DICOM printing from Merge PACS; there is still a contrast issue with the printed films.) While I was able to find the mechanism to do this, the transmissions did not go through completely, and I think this indicates a problem with the configuration on the modality end.  However, the CT and MRI both have functions that query the PACS, which would accomplish the same thing we are attempting. I'll test the function if I can ever get some time on the scanner!
In and among that bit of tail-chasing, I was able to spend some time with the residents. A FEW are still using the Query function rather than the worklist, and several were logged in with a generic ID. I cautioned Ben and the resident that this could lead to a number of problems in the future and strongly advised that the generic sign-on not be used except in very extreme circumstances. (I was thrilled to discover the generic login and password on the backgrounds of most of the workstations!) And I made another little discovery...One of the monitors, a 30" consumer-grade HP, was set for a lower-than-optimal resolution. I grabbed the mouse and set it to the proper, higher resolution...and I was then schooled by the resident..."Doc, many thought the icons were too small at the high resolution, so we run it at low resolution to make the icons bigger..." I'm going to have to see if I can buck this trend, as the low-res causes us to lose some of the drop-downs off the lower edge of the screen. That's not a reasonable trade. Keep in mind, many/most of the stations are running on one monitor. There are several Barco's in the waiting, but their workstations lack power-supplies, which are coming. Apparently on a slow boat!

Friday was a bit more frustrating. We had meetings scheduled with various people critical to the project, but many had other obligations, and we did a bit of hurry-up-and-wait. The meetings ultimately did occur, and we had good discussions. There appears to be an in-house team developing a RIS-like program for another division, which hopefully can be adapted and interfaced to PACS. I'm to cast eyes on that on Monday.

One high point was my first lecture here at Korle Bu, an introductory talk about PET/CT, delivered to an apt (and awake!) audience of Nuclear Medicine residents, and many folks from RT as well. You have to keep in mind that the NM residency program is completely separate from Radiology, and these kids have not been exposed to CT. Still, they grasped the concepts readily, and asked some very astute questions. And they even laughed politely at my feeble attempts at humor...  While I think there is only a small chance of PET/CT coming here in the near-future, I believe everyone needs to be aware of its capabilities and know when sending the patient off to South Africa (where the closest PET/CT lives) might be worthwhile. And who knows? Maybe some very nice scanner company will donate one to this very busy (and worthy) Oncology site. Oh, and we'll have a cyclotron on the side with that, please. (Please?)

Finally for Friday, what I thought would have been an easy task turned difficult. You might recall that I mentioned putting the Merge client on the residents' laptops. Well, a couple of them have Macbooks, and I was asked if I could make the Windows/Java-based program work. But of course! I replied naively... Well, the Macs in question are Macbook Air's with 128 Gb SSD's. Oops. I'm having one of the residents try to clear 50 Gb off of her drive (she had exactly 2.5 Gb free) and I'll try to do the most minimal Windows 7 installation possible. If that doesn't work, I've found a reference to creating a bootable Win7 (or any Windoze) runtime external USB disk, and maybe that will work. This is one I might have to dump on Ben.

We are playing tourist for the weekend. We went to the Big Mall, as nice and modern as any in the States, and then had drinks and dinner at the Bojo Beach Resort, a rustic but still quite beautiful site:

Tomorrow we are off to the slave-trader castles at Cape Coast.

I suddenly realize that my time here is more than half over, and I still haven't accomplished all I came to do. So for Monday through Thursday, here's my agenda:

  1. Spend more time with the residents, smoothing out their Merge experience
  2. Give more lectures to NM and Radiology residents
  3. Connect the NM gamma camera, a 2005 Siemens, to Merge PACS
  4. Work on the Macintosh problem above.
I could spend another 2 weeks on those alone. I also come to realize, however, that I'll probably not have much reason to be asked back here, as by the time I would return, the staff will be better versed in the PACS than I am, and could probably teach me how to use it. I'm hoping there will be many more sites, assisted by Rad-Aid, that install Merge PACS, and I would love to be on site at go-live! I'm ready, willing, and able! That's the joy of working part-time, right? 

In the meantime, I bid you good night from Accra. 

Wednesday, October 26, 2016

Preliminary Status

This morning, I spent an hour demonstrating Merge PACS to the residents and those attendings who were able to, well, attend. I went over some basics of the PACS, as well as a few of the more powerful tools, and everyone seemed to grasp very quickly what I had to offer. In particular, in working with several residents in CT and MRI, I found ALL were using the worklists as I had suggested. Wonderful!!! I was able to show those in the CT reading room the ease with with they could create 3D renderings. We tried this with both thin and thick data, and of course the thins gave the best result.

While watching the workflow, it became apparent that the residents aren't the ones (generally) who mark the studies as "Read", but rather the attending does so after review. I was able to make a button (a macro, really) that mimics the "Click study Read and go to Next" Checkmark, but marks the study as in "Preliminary" status instead. I think this fits the way things are done here. The only downside is that each individual user has to place this on the client under their own login, but that's not too much of a problem.

Things are shaping up!

In the meantime, here are a few more shots of Korle Bu Teaching Hospital and environs:

Chest Clinic

Main Entrance (under renovation)

National Cardiothoracic Center

ATM "Farm" on Korle Bu Campus

Street scene outside the gates

Tuesday, October 25, 2016


Time for today's PACS opus...I can report a day of incremental progress.

All three of us met with the Head of the Radiology Department first thing this morning and then with the residents. I will have a session with them tomorrow at 8, wherein I will run a PACS demo on the big screen in the Radiology Conference Room, and take questions as I go. I think this will prove valuable and will lay the foundation for some one-on-one time later on.

The rest of my day was spent mostly in the PACS/reading room, again working closely with Dr. B., the IT-savvy resident. (Honestly, I think that when I’m done here, he will be Korle Bu's resident-advocate for all things PACS!) And thanks to my PACS admins back home, I was able to solve the problem or loading the Merge client onto Windows 10 laptops, so we now have a bunch of very happy residents!

I made several work lists, which I modified as Dr. B requested. The IBMerge PACS is so powerful in this regard that just about any worklist you can think of can made, given enough time, energy, and willingness to work through the list of check-boxes and drop-down menus. I'll be quizzing the residents (and any attendings I can reach) about their needs for more of these.

We found a few possible, temporary (I would hope) work-arounds for the lack of reports. Clearly, what we ultimately need is a RIS, but short of that there are two ways to get a report associated with a particular study. First, one could copy the typed report and paste it into the comment field of the exam's order window. This drops all formatting, and the comment window shows only four lines at a time. The other possibility is to use the “snipping” tool to create a JPEG image of the report, upload it into PACS, and the use the QC editor to merge it into the main study as an extra series. A little more tedious I'm afraid.

I worked with Ben as well on uploading fluoroscopic and sonographic images. We have some hurdles here, in that when multiple studies are loaded from the modality onto a disc or flash drive, and they attempt to load the whole thing at once, all the exams get loaded under the first patient’s demographics. The only solution to this is to load the patients one at a time (my recommendation) or manually split them later (which might be easy to forget to do and would be even more tedious.)

I noted that virtually all CT’s have a huge number of slices, some up to 2500 or so. Even head CT’s are pushing 900 and more slices for a pre and post contrast exam. I spoke at length with Dr. Buckman about this, and I would like to get everyone's thoughts as well. (I read CT, but I'm no luminary.) Dr. B. feels that the thinnest slices should be used to avoid missing tiny abnormalities. While there apparently is no significant malpractice problem here in Ghana, the residents are VERY contentious, and sincerely wish to do no harm. This is admirable to the max. But when I asked for an example of something missed because thin sections weren't available, he showed me a 2cm lesion. In my experience, the thinnest sections (the Toshiba Aquilion One produces 0.5 mm slices) are useful for exquisite reformats and CT angiography. Most of us old folks don't have the stamina to peruse 600 slice sequences 50 or 70 times per day, and I don't think there is much that would be missed by using 5mm (or even 2.5mm) reformats. Add to this the multiplanar reformats created on the scanner and also sent to PACS, and we have a situation that will deplete the SAN very rapidly. Thus, some compromise is needed. I'm thinking that with the Merge PACS ability to create reformats and renderings in the viewer, perhaps only the thin sections should be sent and nothing else. Alternatively, they could create all the reformats on the CT and then lose the thins. But this is a waaaaaay above my pay-grade so I'm going to defer to those much wiser.

Stay tuned!

Monday, October 24, 2016

Monday, Monday...

Korle Bu Courtyard

Our first daily report from Korle Bu!

We had a very good first day! (Well, Erin was under the weather in the morning, perhaps a reaction to her anti-malarial, but she recovered quickly and joined us after lunch.) We had a significant amount of hurry-up-and-wait in the morning. Ben, Mack (PACS/IT), Brian, and I made the trip back and forth to the Nuclear Medicine department several times, waiting on those we needed to see. We finally did connect later in the day. More on that shortly.

While not in transit, Brian and I spent the morning in the reading room with Ben and Dr. B., one of the residents. We were able to solve a few problems, and at least understand several more. Brian had mentioned the problem of multiple clicks required to close a study and mark it as read, and his discovery of the "check mark" button that would do this in one click. (One of those things we AMICAS users have known for years!) When working with Dr. B, we found that his checkmark was greyed out. After some experimentation and observation, we found that the button does NOT function if the study was opened via query and not from a worklist. Which brings us to the problem of them actually USING a worklist. Merge PACS has VERY powerful worklist creation capability. Basically, if you can conceive of how a worklist should look, it can be created. The downside is that as compared to the later versions 6.x, which we are still on back home, the level of complexity in crafting the darn things has increased considerably. I need to have a word with my friends at Merge on that! However, I think I have the hang of the new approach, and I was able to create a simple worklist, "Today's Studies" without too many glitches.

I worked with Dr. B. for about an hour, showing him some of the tools within the Merge Halo Viewer, and he caught on very quickly. I think similar sessions with one or two of the residents (and attendings, and clinicians, and anyone else) would work best rather than try to answer everyone's questions in a larger group. I would like to concentrate particularly on creating departmental worklists and more individualized hanging protocols. That could take my entire two weeks in and of itself.

I spent some time trying to install the Merge PACS client on Dr. B's Windows 10 laptop, but without success. I was able to download an MSI from my server back home in Columbia, and I'll try that tomorrow. Apparently no one has had any trouble with Win 7, and I was able to load Merge 7 onto my Mac running Win10 in Parallels, so it CAN be done.

Now, Erin will tell everyone about the developments within the Radiography Department, which I think are very exciting!

Erin: Very exciting. Thanks guys for making sure I as alright this morning. I am feeling so much better. I met Dr. O who is the Radiography Program Director and we had a great discussion. I donated the textbooks I had brought with me. I will be lecturing the Radiography students tomorrow at 9am on what our Radiography program is like in the States. Also, Dr. O is charged with trying to start more Radiography programs all over Ghana. I learned a lot about the status of radiographers in Ghana and will be lucky to speak to students tomorrow. I told Dr. O that it would be nice to have both of our sets of students interact with each other in the near future. I feel that we could all learn a lot from each other. Maybe even create "sister" programs with each other. Dr. O stated that he is trying to attend the RAD-AID conference on Nov. 5, which Brian and I will be attending also. I was intrigued to learn how similar our Radiography programs actually are. Hopefully the beginning of a wonderful relationship.

Me: I'll close with a paragraph about our meeting (finally!) with one of the Radiation Therapy Docs. The two NM physicians are out this week, I believe, but may be back next week. I'll be giving a talk to the NM residents on Friday. We discussed connecting NM to the Merge PACS, which she generally favored, particularly after we were able to get the client up and running on a laptop and demonstrate its capabilities. She had NEVER seen the PACS in action and was most impressed. (This thing sells itself!) We will, of course, need to defer to the NM Head of Department for approval before proceeding, but the actual connection should be straightforward. (Which I say whilst crossing mhy fingers.) We discussed as well a problem RT has had with importing planning CT's into their TDS planning system,

OK, just one more little paragraph....Never commission someone who was once paid by the word...

The topic of rapid delivery of reports arose at several junctures. Without a functioning RIS, there are very limited options. Merge PACS does have a comment field built into the order window, and a separate voice-clip property. We use the latter to provide instant gratification for the ER docs, and it could work here. There may be a way to use a "print to DICOM" program to load the resident's typed reports into the PACS as a separate series in the exam. It's not optimal but... More on this as we go. Tomorrow we have a meeting with the residents...I'm not sure if I am to lecture them on PACS or on one of the other topics I've brought with, but we'll see. In the meantime, Me ma wo adwo!

Brian: Migaso

Ben: You want to try some Twi already yeah.😉

Me: Did I say it right???😃

Ben:: You mean, did you post it right? Yeah, you did! Will be glad to hear you say that out loud!...😊
Me: I'll need coaching or Mack will laugh at my Southern Accented Twi!

More to come....

Sunday, October 23, 2016

A Quiet Day In Accra

Just a brief note...I spent most of the day at Dean's Guest House, getting over jet-lag, and talking with my team members. Brian, radiologically-trained PACS administrator, has been here a week, and has had great discussions with the folks at Korle Bu. He's made significant progress on a number of issues. Tomorrow, Erin, Radiology and NM technology educator , and I dive in and offer expertise where we can. My jobs will include working with Radiology residents, and with the Nuclear Medicine Department, primarily to get them more comfortable with their Merge PACS, and also to give a few lectures and work with them in any way the proves helpful. I'm hoping as well to be able to connect their gamma camera to PACS. Wish me luck!

Tonight, we went downtown to eat with Nathan, a former member of the Korle Bu staff Brian had come to know on a previous visit. The restaurant was fine (we had pizza of all things) but the cab ride from the 'burbs (I think...I'm not very familiar with the town as yet) was fascinating. And frightening. And amazing. I'm reminded somewhat of Lima, Peru, where the traffic was actually much worse. There, stop-signs are treated as suggestions, and traffic-lights are ignored completely. Here in Accra, these things are obeyed, but traffic is still very wild. Merging is an exercise in combined trust, timing, and terror, but somehow between judicious use of horn and gas (and rarely the brakes), everyone gets where they are going.

Accra by night strikes me as somewhat similar to many towns in the Caribbean, but much larger, with more buildings, some very new and modern, some not so much. But what stands out to me more than anything else is the number of people on the sidewalks, on the streets, milling about. I'm sure they all have a purpose in mind, but I've never seen so many people just...there. It's almost unnerving.  I'm sure I'll understand the culture more by the time I return home.

In the meantime, may I wish you Me ma wo adwo, a good evening, in Twi, (the primary local, though unofficial, language here in Ghana.)

Saturday, October 22, 2016

Made It!

Well, here I am in Ghana!  Everyone I've met so far has been great, save for the lady who was quite convinced that I had her suitcase at baggage claim. The lady at Customs wanted to be sure my suitcase full of medical supplies was indeed that, and no doubt seeing my two rolls of Charmin within upon opening the case convinced her that I was on the up-and-up. Mack and Teddy from Korle Bu IT retrieved me from the airport and negotiated the rather treacherous night traffic here in Accra to deliver me safely to Dean's Guest House, near the hospital campus. I've settled into my small but serviceable room, unpacked, and opened up a nice big Club beer, the local brew. I'll meet the other team members tomorrow. Erin is a rad tech instructor and Brian is a GE PACS administrator who has been here for a week and has quickly adapted to the Merge 7.x system. Who knows? Maybe he'll advocate for changing to Merge back home!

Tomorrow will be a down day...I'll try to get acclimated to the time-zone and the bugs. (Haven't been bit yet!!) Perhaps we'll go exploring, although that might not be the best idea...

But come Monday there is work to be done. Based on Brian's reports to the gang back home, Korle Bu is actually quite far advanced in things IT related. I'm hesitant to give my "Laws of PACS" to the residents, as there seems to be a good relationship to IT, but perhaps they will find it interesting to see what we go through back home. 

I've been up much of the past 36 hours (it took almost exactly 24 hours to get here via Amsterdam) so allow me to collapse on my bed with Sleep-Number equivalent of about 300 and rest up for whatever tomorrow has to offer.

Morning note...While editing this piece this morning, the power at Dean's has gone out three times. I'm told this is pretty common. It's amazing what we take for granted back home...

Wednesday, October 19, 2016

Agfa F***s Up

I am on the e-mail list for Agfa's Daily Blog Update, and it often contains interesting information. But imagine my surprise when THIS came through this morning:

I immediately clutched my pearls to my ample bosom and experienced a bad case of the vapors. Such language!

Agfa immediately sent out an apology:
Our sincere apologies are in order. The first article in our daily blog update today was not appropriate. We strive to bring you a wide selection of relevant articles from around the web to promote thought, present new ideas, and offer insights into the ever-changing world of eHealth and Digital Imaging. We messed up today and let an inappropriate article slip through. We have removed it from our blog, but unfortunately, could not remove it from your inbox.

Can we thank all those who brought this to our attention and please continue to read our blog updates on a regular basis.

Please accept our apologies.
No harm done, guys. But no doubt, someone is going to get fired. At least no one said, "Pu**y".

Tuesday, October 04, 2016


Wow. It's been three months since I last checked in with you, my loyal readers. All 3 of you. As you might guess from reading my ranting over the past 11-plus years, I've been in the midst of a dilemma,  in this case trying to figure out what my future should hold. There are many directions to go, many options to consider, and many needs to satisfy. But I think I've got it. Finally.

To be totally honest, my basic instinct was to retire completely at the end of the year. Which was my intention last year, but somehow I stayed on. And I will indeed continue to work for another year, although I'll cut back my weeks even more; in 2016, I will have worked 26 weeks, but in 2017, I'm planning on being in the saddle for only 22 weeks. That's enough, I think. Rest assured, however, I'll have my phone on and operational 24/7, so no one need worry about reaching me. No, I don't charge for that extra service...

So why was this decision so hard? Do it or don't, right? Well, it's complicated, and there are many factors involved. Of all of them, the financial aspects are the most straight forward. Continuing to work keeps my (markedly lowered) salary coming in, and my health insurance is provided. Since Dalai, Jr. has a $36,000/year drug habit, that drug being Remicade, insurance is quite nice to have, and even our rather high-deductible plan would set me back almost as much as the Remicade if I were paying for it directly out of my pocket. No brainers, there.

Then there's the mental stimulation. Being at the PACS station does keep me on my toes, with little time to squander on foolishness like blogs. Hopefully, with the downsized work-year, I'll be a bit better. A three month hiatus is inexcusable.

And I must add that Mrs. Dalai was quite encouraging...of me getting my saffron-robed backside out of the house. "For better or worse, but not for lunch!" as she says. Quite often, in fact.

There were some negatives, of course. Here, I must be careful in my wording. If you choose to read between the lines, I cannot be responsible for what you assume I'm saying. Capisce? Much of my hesitation revolved around numbers. Mainly numbers of exams, read and unread, daily variance in consumptions of the numbers, numbers of things on exams I did not find, numbers of times I could not complete my interpretation of an exam all at once due numbers of others coming in my office, numbers of patients reading their own reports, etc., etc. Some of these problematic numbers could be cured by throwing greater numbers at them, but greater numbers come with greater costs, and in essence, this is not an option for the for the foreseeable future. So, I could either embrace the numbers or reject them. For one more (reduced) year, I'll suck it up. After that...we'll see.

You might recall my earlier post about Rad-Aid wherein I mentioned a chance to go to Ghana. I couldn't make that trip, but I was given another chance to go, and so I shall! Watch this space for updates from Africa. My task (as team leader, no less, being the only physician on this particular expedition) is multifold. First and foremost, I will try to help with the local PACS, which thanks to a generous donation by IBM/Merge, is the same as our system. Actually, it's a version ahead of ours, so I've had to try to learn that one a bit sooner than I had planned. Fortunately, the viewer component is pretty similar, but the worklist page is much more complex, allowing construction of some rather amazing worklists. I'll still declare Merge PACS to be one of the more usable out there, and I'm sure the physicians in Accra can by now use it about as well as I can. But their system lacks one element, a RIS. As luck would have it, I gave this problem some thought when we put in our AMICAS PACS years ago, in this post from January, 2006, 10 (yes, TEN) years ago. My solution was to use PACSGear to scan a paper report and send the image to PACS as another series in the particular exam. One could also use one of several software apps out there (I cited Print2PACS back then) that would do the same thing with a digital document. Those ideas might work. It seems though that the residents in Ghana actually type their reports into a different computer, so I'm wondering if they could instead type into the PACS comment field. Much will become apparent when I'm on site. In the meantime, any ideas on this are welcome.

Task #2 involves integrating the Nuclear Medicine Department into PACS. Which means setting up DICOM link from the gamma camera to the PACS. This should be straight-forward, but somehow with PACS, nothing is ever easy. As with most places outside of the United States, Nucs is completely separate from Radiology, with all the complexity that entails.

Last, but certainly not least, I am going to share some of my limited knowledge with the rads and residents. I'll concentrate on things nuclear, since that is my area of expertise, and I've prepared a good number of lectures in that realm over the years.

I'm hoping to make a difference with this trip, both on the ground in Accra, and within my own soul. This seems to be a wonderful way to give back, and I'm hoping my efforts will be found worthy.

By the way, Rad-Aid is exploring a flying hospital concept, using not a 747, but an airship!

Sign me up for the first flight...

Let me end on a happy note. I had the opportunity to speak with a bunch of pre-meds at a local event last week. Yes, that's a good thing! These particular pre-meds were members of a pre-med honor-society, and they definitely were the cream of the crop. Based on some of my past experiences, remote and recent, I had expected a bunch of arrogant, socially-inept snowflakes, bleary-eyed from 20-hour days of study, the sort that would sell their soul, or at least a kidney, to get into medical school. I couldn't have been more wrong about this bunch. These kids (indulge me, I'm old) were enthusiastic, yes, but they were curious and introspective, well-informed, and interested in just what it is radiologists do. They had the proper balance of intelligence and humility. Their MCAT scores are no doubt high, but they maintain their humanity and their humility. In other words, they GET it. They have the instinct to be fine physicians, those to whom I would send my family and friends.

I feel more optimistic about the future of medicine than I have in a very long time.

One of those kids might become my doctor some day soon. Hopefully, one of them will go into gerontology.

Sunday, July 10, 2016

She Flies Again!

Courtesy Smithsonian National Air and Space Museum

After a long restoration, the U.S.S Enterprise flies again, in a position of honor in the revamped Boeing Milestones of Flight Hall at the Smithsonian National Air and Space Museum. The new climate controlled case (the model once was hung on wires out in the open) sits amidst quite a few non-fictional aircraft and spacecraft, such as a Lunar Lander, Yeager's Bell X-1, Sputnik I, The Spirit of St. Louis, the Apollo 11 Command Module, and some other good stuff. Why is a model of a fictional ship included here?

Yes, it's just a model, but...

This collection of wood, vacuum-formed plastic, lights, and a bit of metal and paint carries our hopes, dreams, aspirations, and at least one vision of our future. This model IS the Starship Enterprise many of us came to know and love in our childhood. The ideals set forth in the show got at least some of us through the rough times of the 1960's. Keep in mind, our first real reach beyond our planet, the moon landing July 20, 1969, occurred at the end of the original Star Trek run. Yes, I know one is real, and one is fantasy, but the dreams inspired by both will carry us to the stars. How poetic!

OK, back to Earth. There are quite a few videos on YouTube about the restoration, and I've posted just one of them below. I was quite fascinated by the computerized LED replacement lights in the warp drive nacelles. It seems the original rotating light show was created with motors and Christmas lights. The assemblies got hot enough to scorch the wood housing! How far we've come...

And now, I shall boldly go... back to work.

Thursday, June 30, 2016

McKesson Sells IT Division...
To Dump Earlier Mistake???

You've all heard by now that healthcare giant McKesson will spin off its IT division. Here's the bullet from Fortune:
Healthcare services provider McKesson said it would combine most of its information technology business with Change Healthcare Holdings to form a new company with combined pro forma annual revenue of $3.4 billion.

Change Healthcare, a provider of software and analytics, network solutions, and technology-enabled services, will contribute all of its businesses to the new company, with the exception of its pharmacy switch and prescription routing business.

Tennessee-based Change Healthcare is majority owned by Blackstone Group.

The new company will be able to offer managed care companies technologies for financial and payment solutions as well as tools for administrative and clinical management, said McKesson, which has a market value of about $39 billion. elaborates:
In a pair of June 28 announcements, McKesson said it will create a new standalone healthcare IT company in partnership with Change Healthcare Holdings, the revenue cycle management firm formerly known as Emdeon. The new entity will have estimated annual revenues of $3.4 billion, with McKesson owning 70% of the firm and Change shareholders owning the remainder.

The new firm will combine all of Change's operations with most of McKesson's Technology Solutions division, which includes its Imaging and Workflow Solutions unit, which offers enterprise PACS software as well as image management applications for radiology and cardiology. Other operations in the division include Health Solutions, Business Performance Services, and Connected Care and Analytics units.

In announcing the spin-off, McKesson Chairman and CEO John Hammergren said the move would "establish a more efficient suite of end-to-end payment and claims solutions, as well as clinical capabilities," while also "unlocking the value" of the Technology Solutions business. McKesson and Change are also positioning the move as one that will help their healthcare customers navigate the transition to value-based healthcare.

Following the closing of the transaction, McKesson and Change plan to pursue an initial public offering for the new venture. McKesson will then exit its investment in the new company.

McKesson said the spin-off will not include its Enterprise Information Solutions division, which it will retain as it "explores strategic alternatives" for the division. This business includes electronic health record (EHR) software, such as McKesson's Paragon hospital information system. McKesson's RelayHealth Pharmacy division also is not included in the spin-off.
So the new company will have PACS and some other stuff, but NO EHR. Fortune adds, "The new company will be able to offer managed care companies technologies for financial and payment solutions as well as tools for administrative and clinical management, said McKesson, which has a market value of about $39 billion." Doesn't sound like a ripe market for the PACS offering.

Why would McK give birth to a partially-formed offspring like this? Good question. AuntMinnie's Brian Casey continues:
Speculation that McKesson might be seeking a divestiture surfaced in early June, when an article in the Wall Street Journal suggested that the company might be looking at options due to pricing pressures in its core drug distribution business.

The article indicated that the Technology Solutions business had $2.9 billion in sales in its most recent fiscal year (end-March 31) and operating profit of $519 million, which is just a fraction of the $188 billion in sales and $3.6 billion in operating profit produced by McKesson's drug distribution business.

The move is a sign that ongoing changes in the industry are affecting even some of the largest players, according to Michael Cannavo, principal of PACS consulting firm Image Management Consultants.

"It is interesting to see moves by many of the larger companies to either start refocusing their core offerings or consolidating their products with other vendors' offerings," Cannavo said. "End users used to be concerned about the smaller vendors not surviving, or at least the products they bought surviving. Now the larger vendors are starting to have some of these very same issues. The sad reality is no one vendor is considered a safe bet anymore."
The Wall Street Journal elaborates:
Companies often consider separations of units whose profit margins, expected trading multiples or strategies differ dramatically from those of core businesses. It has been happening more as shareholder activists and other investors push companies to narrow their focus.

Spinoff activity peaked among U.S. companies in 2014, with a record 58 transactions worth $164 billion, according to FactSet. They have fallen off a bit since then, though in the past year several big companies have pursued such moves, including Hewlett-Packard Co., Baxter International Inc. and Xerox Corp.

McKesson has announced cost cuts and layoffs as it grapples with price pressures brought on by consolidation among its customers.
And again from Fortune:
Morningstar analysts said McKesson’s healthcare IT business never fit the firm’s overall strategy and was an impaired asset from the beginning as a result of the accounting fraud. (See below.)

“Management has not made any material investments within this business over the past several years, and to our understanding, the technology was two to three generations behind other major HCIT players,” they wrote in a note.
Let's look at a bit of McKesson history, courtesy of the Wiki:
Founded in New York City as Olcott & McKesson by Charles Olcott and John McKesson in 1833, the business began as an importer and wholesaler of botanical drugs. A third partner, Daniel Robbins joined the enterprise as it grew, and it was renamed McKesson & Robbins following Olcott's death in 1853.

The company successfully emerged from one of the most notorious business/accounting scandals of the 20th century—the McKesson & Robbins scandal, a watershed event that led to major changes in American auditing standards and securities regulations after being exposed in 1938. In the 1960s, McKesson & Robbins merged with Foremost Dairies of San Francisco to form Foremost-McKesson Inc.
Yes, they merged with a Dairy.

McK decided to get into informatics at the end of the last century. From Fortune again:
In 1999, McKesson entered the healthcare technology sector by purchasing a large tech company, HBO & Co., for $14.5 billion. Shortly after the deal, auditors discovered that HBO & Co. had been fraudulently boosting sales, eventually leading to a shareholder lawsuit that cost McKesson nearly $1 billion.
Oops. WSJ:
But after it was completed, auditors found evidence that HBO executives had fraudulently booked revenue and inflated the Georgia company’s profits. Several HBO officials were indicted on federal charges, and its chairman was eventually sentenced to 10 years in prison. McKesson shares didn’t recover to their pre-scandal levels for more than a decade.
In the meantime, McK did do something dumped the PACS that came with HBO and bought a much better product from ALI. Erik Ridley's 2002 article gives an interesting glance into those primitive times:
With PACS seen increasingly as the imaging layer of an electronic patient record, it's no surprise that healthcare information systems vendors would want a piece of the action. The bid by HIS firm McKesson Information Solutions to acquire Canadian PACS provider ALI Technologies for $340 million (U.S.) is the latest acquisition/partnership among PACS and HIS vendors.

For McKesson, the decision to reenter the PACS market reflects its desire to offer a complete electronic patient record, including support for digital image management, said Randy Spratt, senior vice president of technology and standards for McKesson Information Solutions of Alpharetta, GA.

If completed, the deal would mark McKesson's second go-round in the PACS market. McKesson Information Solutions' predecessor, HBOC, had acquired PACS developer Imnet Systems in 1998. McKesson later bought HBOC in early 1999, but abandoned the unit's PACS initiative two years ago.

The architecture of the Imnet PACS technology was not sufficient for many reasons, including its lack of adherence to open standards and lack of a practical image distribution method, Spratt said.

"We probably did not fully appreciate the depth of technical expertise that was required for the viewers and workstations of medical images as opposed to document images," he said. "Without a complete product and without the skill set and expertise, we determined that it would take more time and risk to get it to market than it would to close that product down and look for another."

In acquiring ALI, McKesson receives a true PACS success story, an independent that was able to thrive in a market dominated by larger modality and film vendors. Focusing initially on ultrasound miniPACS, ALI became one of the leaders in the niche before electing to expand into radiology PACS.

ALI implemented that expansion in part by purchasing independent PACS firm Olicon Imaging Systems in 1999. Today, ALI has an installed base of over 500 installations worldwide. While ultrasound PACS orders still make up the majority of the vendor's installed base, roughly 66% to 75% of the firm's new system revenues are being generated from radiology PACS orders, said Greg Peet, ALI's president and CEO.
Ha. I feel vindicated on several levels. I had been told for years that AMICAS was unworthy of my attention because it was a small company ready to be plucked and destroyed. But Merge bought AMICAS and IBM bought Merge, making this one of the most solid systems out there. And Big Iron McKesson is dumping its PACS. Go figure. And the McKesson PACS story itself tells us that a Big Iron (or shall we say, larGE) company can buy another PACS and make it work, rather than destroy it.

We shall see what becomes of one of the more beloved systems out there. I'm thinking it might be wise to put purchase decisions on hold for a while...