A Survivor Of Voice/Speech Recognition Speaks Out

(Dalai's note: I was approached by a colleague, and asked if I would post his VR/SR experiences online, but anonymously so he would not have the vendor in question breathing down his neck. I am more than happy to do so, and here it is....)


I will start by telling of our voice recognition (VR) experience.

About one and a half years ago we launched VR to our hospital system. It was an integrated “front end” VR product that resided on our PACS workstations. You may or may not have preconceived ideas about what quality we might have purchased, suffice it to say we purchased what for all intents and purposes, seemed to be the best VR product on the market. No we didn’t buy some outdated piece of garbage.

It was a planned 6-week launch with training provided primarily by the VR company. Initially, we were expecting things to be a little stormy; how wrong we were. First, we had scheduling problems with training, there were rads that were unavailable for training and the amount of time dedicated to each rad was short, only a few hours. In addition, the rads were learning while still having to attend to some clinical duties, which was a BIG MISTAKE.

So after a few weeks, the trainers left, there were still rads that had almost zero actual training. Our IT/IS support staff tried to help out as much as possible. It was just over a month when things in the department finally caved in. We were chronically short staffed, radiologist wise, and work wasn’t being finished. Those of us who took to VR somewhat well were being completely overrun by those who did not, both in having to field multiple near hysterical calls and a markedly increased workload. There were multiple unexplained system crashes (denied initially but fixed somewhat in a later patch) and a greatly degraded workstation performance.

We had numerous direct meeting between the administration, radiologists, and VR company. Here is what we got, repeated requests for the radiologists to document every occurrence of problems (yeah, right, like we weren’t totally swamped as it was what’s one more thing to do), repeated denials of their software being to blame for workstation slowness and crashes (of course later we would learn that yes it was their software causing crashes and system performance issues), repeated promises to fix the problems.

After almost 2 months of this I, being the “radiologist champion” for VR and about 2 seconds from a complete nervous breakdown, told myself “Either I stop using VR or I hand in my 90 day notice and look for a new job”. I turned off the VR product and told my fellow radiologists that I would no longer be fielding their questions about “how to make VR work”. The rest of the group followed suit immediately. It imploded over night. Problems that still existed at this time were:

1) Random crashed requiring a system reboot
2) Unexplained, or rather un-admitted, slowness of the workstation
3) Consistent patterns of errors in VR, it did not appear to be learning no matter how many times corrected
4) Almost no one in the department (IT/IS included) really knew how to use the advanced functions, macro generation was “trial and error”
5) Lack of advanced support, many question to our IS/IT people generated a response “I’ll send and email to VR company and see what they say”
6) Many errors sent for “transcriptionist editing” came back uncorrected, the error rate of “transcritpionist editing” was far greater than the old system. Many report errors escaped the radiologist review as well and went out finalized. Many, many months later I would learn we had some actual “transcriptionist sabotage” going on and this was NEVER disclosed to the radiologists.
7) A horrific loss of productivity in an already short staffed group.
It died for a long time; of course the hospital had a vested interest in making this work.

We recently had a visit to a “model group” for VR and got to see them in action. The model group watched us and decided to purchase the product anyway. They are a large group; they owned the transcription, PACS, and other things and “contracted” these things out to hospitals. This was a business decision by a group that owned the entire infrastructure. They did things very differently and claim a 90+% “sign off” rate. Here is what we observed and were told:

They began by sending their IT folks to the VR company for intensive training. They refused the VR company's offer to do radiologist training; they were going to handle that all in house. Prior to launch their entire IT/IS support staff had been using the product for “months” and were fluent in its use. This was before a radiologist touched it. After launch they had their trainers go back for additional training to learn to “hack” the word lexicon to overcome pattern of repeated errors. This has worked very well for them and is a process discouraged by the VR company. What we learned, to our dismay, was that VR was not just “appearing” to not learn certain repeated phrases or words, it REALLY WASN’T learning them at all, no matter how many times we made corrections manually. The "model group" placed skilled VR support staff available 24/7, to immediately respond and deal with radiologist problems with VR.

They began by doing a “staged” launch of VR, starting with sections and working 1 section at a time. Each radiologists was initially afforded a full half day of one-on-one training with no clinical duties (no phone calls, no tech interruptions, no exams needing to be read, NOTHING); after that they each received 3 full days of one-on-one training while working (they estimated a total of 24-28 training work hours for each rad). By one on one they mean the trainer was physically in the same room or sitting outside the radiologists door. They had section meetings every morning to discuss VR’s use and share tips; they relied on a lot of “peer pressure” to make things go smoothly. The entire launch was slated to take about 1 year.

The made sure their workstation greatly exceeded the VR companies recommendations. They made sure their transcriptionists were folded into other duties as they lost their need for so many of them. I would add here that prior to VR this groups report turn around was poor, over 2 days for routine stuff.

We were also told the group was now considering “financially penalizing” rads that are using too much transcriptionist editing, this was not implemented yet and the penalties they were considering was not shared with us.

We then got to observe some rads in action. It really wasn’t magic. First, they have employed radiology “assistants”. These folks do a lot of the “scut work”, phone calls and so on; they basically make sure the radiologists are not disturbed and the hospital pays for them. One rad was a “macro master” although he appeared to spend much more time looking at the VR than the exam. One rad absolutely hated the VR system, so all is not roses at this model group. The next few rads showed all the problems we have seen all along, lots of little annoying errors. Every rad admitted it slowed them down but they had “made up” for it through intense training, heavy assistant use, awesome IS support staff and excellent equipment. They did feel, well, most of them, that it was “worth it” for various reasons.

They did confirm many things we radiologists already knew. Things like the software’s inability to learn certain works on its own, or rather the pattern of making repeated patterns of errors. The VR company’s gross underestimation of the training needed and IS support staff needs. The performance issues on the VR companies “recommended” systems. Basically this is something the radiologists need to “buy into”. They did admit to the limitations of VR but that it is improving and “As long as the radiologists see continual improvement they will stick with it”. They also, on their own, identified and developed work-arounds for many conflicts the software was having with other office software products.

Where do we go from here? A few in my group had prior experiences with VR, all universally negative. I had a hope, as did the administration, that “This is such a superior product, it will be different this time”. It was very disappointing to see not only every fear confirmed, but also some new ones learned. Any trust between the VR company and the radiologists has been completely destroyed beyond repair. This experience has certainly made us much more cautious in trusting the word of any vendor, especially software vendors as I feel they may not fully grasp that they are selling a medical product and not a video game (i.e. doctors have zero tolerance for “buggy” software and more than they would tolerate a “buggy” CT scanner). So it stands with my group, many of whom now have the well justified attitude of “Hell will freeze over before I turn on VR again”. I am not sure this can ever be turned around. I hope, if nothing else, this review serves as a warning, to radiologists, administrators and most importantly VR vendors that VR is not something to be taken on lightly.

In a similar vein to Dalai Lama here are my 10 commandments for VR:

1) Voice recognition (VR) exists as only one of multiple possible solutions to address the problem of radiology report turn around time. The underlying problem being the near instantaneous distribution of images through PACS unaccompanied by the radiologist report.
2) VR will only see its maximum benefit (i.e. near instantaneous report generation) IF the radiologists self edit and sign off the majority of reports.
3) VR with or without self editing slows radiologists down. It costs productivity as radiologists are now forced to spend additional time either self editing or reviewing the VR generated reports for errors. Do not assume your radiologists are going to quietly eat this productivity loss.
4) The loss of radiologist productivity can be compensated, to some degree, by the use of radiologist assistants to do some tasks formerly done by the radiologist. Also there is a gain by the lessened need to re-review cases that have been dictated but not transcribed. Despite this there may still be a long term net productivity loss. Again, do not assume your radiologists are going to quietly eat this productivity loss.
5) Poor system performance is a guaranteed PACS/VR killer.
6) VR and PACS are by definition “beta” software. There is no such thing as a perfect PACS or VR software; there are only “acceptable” performance parameters that will improve over time. VR may never be perfect.
7) The hospital shall accept it’s responsibility for supporting VR by ensuring it’s IT/IS support staff are well versed in PACS and VR and available as long as the radiologist are working. The IS/IT support staff shall have a full working knowledge of VR and be capable of training radiologists before a radiologist ever touches the software.
8) VR requires far more IT/IS/training support that the VR companies will admit.
9) VR is not a big money saver if properly implemented. Any savings from transcriptionists will be quickly eaten up by the need for hardware upgrades, software upgrades, training and the needs for additional support staff.
10) Before implementing VR, ask yourself “Am I doing this for the right reasons and am I willing to commit additional resources, possible indefinitely, to the proper launching and support of VR?”

PACS Abuse

An observant AuntMinnie poster found this lovely little item from the Cleveland Clinic:

Sub-specialized medical care is the standard of care today. Only an orthopaedic surgeon would perform an anterior cruciate ligament reconstruction, and only a neurosurgeon would remove a brain tumor. It is still common however, for general radiologists with no sub-specialized training to interpret the images that lead to these procedures.

This lack of sub-specialized radiology interpretations previously was necessary because of the need to have a radiologist in close proximity to the imaging center where procedures were performed. Now, through the use of new developments in information technology systems, Cleveland Clinic’s Department of e-Radiology offers sub-specialized radiology interpretations to referring physicians anywhere in the country. Better quality of medicine is possible through the use of interpretations and protocols developed and performed by Cleveland Clinic sub-specialty-trained academic radiologists.

A number of factors made growth in e-Radiology possible, most notably the imaging explosion of the past few years, which is expected to grow at the rate of 8% to 10% per year into the foreseeable future. Two additional factors are the national shortage of radiologists and the rapid developments in information technology that have allowed image interpretation to occur independent of geographical restrictions.
A large portion of the imaging growth is in outpatient imaging, with an estimated half billion outpatient imaging examinations projected to be performed in 2008. In 2002, 84% of magnetic resonance, 64% of computed tomography and 98% of positron emission tomography scans were done on an outpatient basis, and these percentages are expected to continue to increase over the next ten years. Only 67% of imaging is currently done in hospitals, down from 95% in 1980. Outpatient imaging accounted for $14.8 billion in Medicare revenue for hospitals in 2001 and generated $3 billion in profits.

Radiologist shortages have been significantly resolved through the use of teleradiology. Over the past few years, dramatic advances in information technology and the availability of technology in cost-effective pricing, high-speed telecommunication lines have removed almost all geographic restrictions in interpreting images. It is now possible to send digital images securely over the Internet on a virtually real-time basis to radiologists located anywhere such telecommunication lines exist. The radiologist is then able to dictate the images using voice recognition software so that the images and report are available online for the referring physician within minutes via a HIPAA-compliant Web browser.

This is just plain disturbing on several levels. First off, the piece insults general radiologists, who are for the most part quite good at what they do. Will a super-specialized rad be better for the esoterica of his specialization? Probably, but on a day-to-day and head-to-head comparison, I thing we would find that the generalist can hold his own. I am very distressed in this regard by the use of the term "standard of care." This is a legal term, and the Cleveland Clinic is basically saying that the generalists out in the boonies are beneath that standard and are therefore committing malpractice!

Secondly, there is note of the explosion of imaging, but no decrying the self-referral that is inherant in much of the "outpatient" studies that would be included in this designation.

Finally, the anonymous author of this piece is using the advent of my beloved PACS (technically teleradiology, but they have become essentially one in the same these days) to facilitate and even justify their desire to swoop in and snatch exams away from the lowly generalists.

I always advise my gentle readers to "follow the money," and here, this is not a difficult task. Our friend at Cleveland Clinic is telling you that the lowly generalists out in the boonies can't do an adequate job, but in years past, you had to settle for this because they were the only game in town. But wait, we now have PACS, and so we are finally able to help you poor downtrodden masses who have the bad fortune to live somewhere other than Cleveland. Just sign this reading contract, and pay us our fee, and we'll all live happily ever after.

This drivel should be beneath an institution with the stature the Cleveland Clinic. It is an abuse of PACS technology to generate revenue that really belongs elsewhere. AND, it encourages self-referral in a round-about way. I do hope everyone at the Cleveland Clinic will enjoy Hillary-Care which they are helping to bring about with their greedy approach to radiology and medicine.

Stupid Pet, I Mean PACS Tricks

Image credit: http://www.skateboardingbulldog.com

It's amazing that a little glitch can cause a big pain. What's even more amusing is the fact that this particular glitch is shared by Impax 6.x and GE Centricity 2.x.

Here's the scenario...I'm looking at a CT, cine'ing through the slices. I want to change window settings, say from a mediastinal window to a bone window. Shouldn't be a problem, especially if I have the window/level preset to a keyboard shortcut. BUT...sometimes, only the slice that is on the screen will have the parameters changed, with all other slices remaining at the original level. And just why does this happen only sometimes?

Our Agfa PACS-admin actually figured this one out, and it turns out to be the explanation for Centricity's bad behaviour as well. If you did nothing else to the scan other than change with W/L settings, there is no problem, and such changes apply to all slices. However, if you happened to stop and measure something, then all bets are off. In their infinite wisdom, the programmers decided that a measurement should only apply to the slice on the screen. That makes sense, I guess, but their solution was to switch the tool application mode (my term, but it works) from applying a change to all slices to applying it to just one. And, it doesn't return to the "all slice" mode when you go back to the window/level control. This makes me do it, which as a lazy slug, I resent, and I don't even realize that I have to make this change until I'm flipping through the images and see one slice at lung windows and the rest at a different setting altogether.

I have to throw in one more little trick from Impax. At the bottom of the viewer, if you right-click on an UNMARKED point (even my Agfa PACS-Admin didn't know about this tool), you get a little sub-menu with three selections. The first is a limited history, which will bring up a list of the last 20 studies that were marked as Dictated. (This, of course, doesn't help if you lost something that was marked "Dictation started".) The second entry on this secret menu allows one to auto hide the toolbars, which I have never seen anyone use. The final entry, "Show Navigation Toolbar at the top of the screen" does just that. Sadly, there is a significant lag in the activation of any of the items, and the grouping is unintuitive enough that when I go after the history, I accidentally hit the "Show Toolbar at top" as often as not. I don't want the toolbar up there, and worse yet, it often disrupts the position of the other buttons at the top of the viewer, requiring me to log off and back on again to fix it. Really fun trick, guys.

How did we get these stupid PACS tricks? I will guarantee you that the developers didn't demo or test these options in an actual production environment. I'm sure these functions made perfect sense on paper, but they yield yet another hinderance to my workflow, out here in the real world of private practice.

Would you guys at GE and Agfa mind fixing this stuff, please?

The Best Invention Ever

TWO $1000 Mikes Disabled By 3mm Piece of Plastic...A bit of bad design

Our suburban hospital just replaced their antiquated tank with the modern, computer-based Fusion dictation system from Dolbey. This is a digital voice system, but it does NOT include speech recognition, thank Heavens.

I got there today to read out the weekend carnage, and what do I find? The laser barcode scanner on the microphone isn't working right. This microphone is a nice little piece of equipment, a Philips SpeechMike classic with barcode reader, which retails for over $1000. I asked the director of the department if we had another one, and yes, we did, but that one had a malfunctioning barcode reader as well. I peeked inside the little red window, and activated the laser scanner...yes, really bad idea for someone who makes a living with his eyes! I could see the laser, but it appeared to be hitting above the top of the window, and not getting out to scan the barcode. There is a tiny adjustment knob at one side, and this was a little loose, and didn't seem to change anything inside.

The Fusion system depends on barcoding at the moment; when we get this site on PACS later this year, the demographics should download from PACS automatically. Still, that is several months away. So, I could either figure out what was wrong, key in the accession numbers manually (by using the tiny trackball on the mike to select numbers on the on-screen keypad), or I could just do one long dictation, reading off the accession numbers and hoping for the best.

Being a tinkerer at heart, and having total disregard for warranty voidance, I took screwdriver in hand and disassembled the offending mike. Inside the bottom, pictured below, you can see the red window to the left, and a mirror to the right.

The next image is a little blurry (sorry, my phone doesn't have good macro capability!) but it tells the whole story. The black box at the top of the microphone is the laser assembly. The black bar-like thing next to the red crayon is a black diffuser, which is used to direct the beam a bit so you can hold the mike more naturally. It is supposed to sit atop the laser. But the little tiny black C-shaped thing between the two is one of two tiny brackets that holds the diffuser in place and allows the little knob thing to ratchet it and hold it in place. The problem is, this tiny $.001 piece of plastic broke right off of its base (the roughly triangular thing to the left at the top of the laser housing), and rendered the whole assembly useless. Bad design. Really bad design.

Being too lazy to do anything else, I simply left the back off of the mike, and used the microswitch that is at my thumb as seen below to activate the laser. It is a little bright, and must be pointed perpendicular to the barcode, but it works. Of course, normally the microswitch would be keyed by a plastic trigger in the base. Notice the high-tech rubber band that keeps the cord from detaching. Nothing like the feel of bare circuit board in your hands...

So, problem solved temporarily. I do expect a replacement mike, with perhaps several in reserve, until Philips redesigns this really bad implementation. And, don't even think of telling me that opening the case voids the warranty.....

You Knew Dalai Was Strange...But this really takes the cake!

A few years ago, when my son was a Cub Scout, our troop held an annual "Dad and Scout" cake contest. The only rules were that moms were not allowed to help, and that all components must be edible (by normal people). My son and I decided to take a rather medical bent, although some would call it macabre. Thus was born the idea of the Scout Patient Cake. The cake itself is red-velvet, nicely simulating tissue. The brain and heart are composed of....marzipan! Yes, Dalai's brain is made of almond paste... The lips are of the classic wax variety, the eyeballs are strips of white "AirHeads" taffy rolled into balls and adorned with frosting. Large vessels are made of strawberry licorice, and coronaries are drawn in with liquid frosting. Now the hospital blue cover was by far the hardest part of this project. This was made from fondant, a thick frosting-like material that you usually see in cakes more like this one from Krista's Creations:

That darn stuff is very hard to work with, which is probably why the cake above goes for $300. I have a feeling ours would not command that price.

Back to the Cub Scouts... prizes were awarded in various categories. Our cake took second place overall. I think perhaps the judges were afraid to award us anything less.

You'll be glad to know that even though the cake went down the dispose-all years ago, I saved the brain and the heart in the freezer, where they remain to this day. You never know when you might need one, right?

A-Wristing Technology...but do they tell time??

Image credit: http://www.internationalhero.co.uk

We all remember the comic strip "Dick Tracy" wherein the razor-nosed detective wore on his wrist first a walkie-talkie, and in later years a video-phone. I don't know about you, but I really wanted one of these when I was a kid, and nothing much has changed.

Well, actually, something has changed...technology has caught up with fiction, and there are some expensive toys available that do approach this level of sophistication.

First, there is was a watch marketed as a "Dick Tracy" special, made by Fossil:

This little $200 gem uses the MSN Direct network, a subscription wireless service that sends accurate time to the watch, as well as sports scores, stock prices, news, etc. The downside here is that the service is expensive (~$10/month), and there is no uplink back to the Internet. I'm not sure if it's still available.

If you don't want to communicate, but do want the joys of watching videos and hearing MP3's on your watch, then this latest series of watches from China might be up your alley. (My son is considering squandering some of his allowance on one of these, and if he does, I'll let you know how he likes it.) Below is a photo from http://www.chinavision.com of this rather large contraption...it's almost a video iPod with a wrist strap:

These things are only $50-$100 or so, depending on how much memory you purchase with them (they are currently available with up to 4Gb of RAM!)

The Holy Grail of wrist machines is, of course, a real wrist cell-phone, and there is finally one for sale to the masses, although the masses would need to cough up $1000 Australian (about $850 US.) This feature-packed M500 comes from SMS Technology Australia, http://www.mymobilewatch.com:

Look at these specs:

Model M500 Quad Mode, Touchscreen, Java and WAP enabled

Weight: 60g

Color: Silver or Black with Leather Strap

Screen: TFT 1.5 - inch colour touchsreen 120 x 160

Frequency: GSM850/900/1800/1900Mhz (GPRS), SIM

SMS: Full SMS and MMS functionality

MP3: Support AAC/MP3

MP4: Support Video Playing

Touchscreen with Built-in Stylus

Memory: 128MB Built-in Memory

Battery: 400mAh, Talk Time 200 Minutes, Standby Time 80 Hours

USB: For Data Transfer and Recharging

Bluetooth 2.0

This thing should work on any GSM network, including AT&T. The only downside (besides the rather outrageous price) is that one must use a Bluetooth headset, but that isn't much of a limitation these days.

There is nothing like being on the bleeding edge, especially if you can afford it! And yes, if you were wondereing, all of these wrist-marvels do tell time....

PACS Pioneers...and my brush with greatness

Image credit: http://www.legendsofamerica.com

In researching another post, I ran across this article from Imaging Economics about the history of PACS. It is a very brief synopsis of the path to today's filmless world of Radiology. I won't try to summarize the summary, but suffice it to say that PACS (although they didn't call it that until fairly recently) had its start at several centers around the world, with the perseverance of a number of true visionaries. Probably the most important single milestone was the development of the DICOM standard which (at least in theory) allows scanners from Manufacturer A to communicate with viewers from Manufacturer B. Before DICOM, everyone had a proprietary code for everything, and the PACS pioneers actually had to reverse-engineer and decode tapes, which must have been just a load of fun.

My brief contact with the "Great Ones" of PACS occured in 1992, and it was the idea of a local businessman. This gentleman owned the storage facility in which we archived the zillions of films taken over the years. He had heard of the work Bernie Huang, PhD, was doing at UCSF, and decided to see it for himself. He was so impressed that he took a couple of us radiologists, and a hospital administrator out to see Dr. Huang.

In 1992, there was no such thing as the PACS we have today. Dr. Huang's operation consisted of what we might call today a couple of mini-PACS operations, without much standardization. There was a tape jukebox sitting in the middle of the lab, workstations here and there, digitizers, and whatnot everywhere. But Dr. Huang's vision was clear...this was the future, and film was not.

When we returned home from UCSF, our "patron" asked what we thought of the whole thing. I responded, "It's great, it's obviously where we are headed, but.... The hospital isn't going to buy, let alone be able to maintain, a system comprised of loose pieces of technology. Someone has to put it all in one box before it will become practical." I'm not sure if our friend agreed or not, but he never did approach us with any proposal.

A year later, we were in negotiations with Agfa for our first PACS, and we were on our way to becoming one of the first filmless departments in the country.

Empiric's Encompass.NET RIS......The Amicas of RIS's

You may recall from a very early post that I had originally planned no RIS for our Amicas PACS. We were going to use paper and PACSGear scanning software to simulate a RIS, if you will. However, we ultimately decided that this would be rather tedious, and would not allow us to do some of the things we have grown accustomed to doing, such as editing reports. So, we went in search of a RIS. We didn't need a big bad hospital system, but we did need something. Basically, there were two requirements: the RIS had to be very easy to use, and it had to be reasonably priced. We found the the ideal combination for our purposes in Empiric's Encompass.NET product. Functionally, it is straight-forward, and easy to use, and most importantly, it doesn't get in my way. That's why I call it the "Amicas of RIS's". Amicas probably doesn't like that title, because they have their own RIS. We looked at it, and it is a great product, but it was more powerful and more expensive than we really needed for our little operation.

Now, I don't want to leave you with the impression that Encompass is underpowered, because it isn't. It is streamlined, and its interface is rather spartan. (More on that in a moment.) It does, however, have everything we needed. From the Empiric web site:

Primary RIS Functions:
Patient registration and scheduling
Embedded digital dictation
Transcription
Electronic report signatures
Auto faxing (direct or by eFax.com)
Multi-site support
Audit trails
PDA capabilities
Management reporting
Mammography tracking
Document scanning
Inventory tracking
Paper-less consent forms
Radiologist peer review functions
Film library management
Additional staff and equipment management tools

PACS/Imaging Functions:
Web viewer w/auto study retrieval
Image routing & archive management
DICOM worklist
RIS-integrated workstation

Referring Physician Functions:
On-line study requests
On-line report access
On-line image access
Optional integrated EMR

Complete Billing Functions:
Claim generation
Payment posting
Collections management
Credit card co pay capture
On-line eligibility verification

Obviously, there is a lot to this system. We have it integrated nicely to our Amicas PACS, and the two play nicely together. Encompass does have its own viewer available, and it isn't bad, but we are much happier overall with the combination.

The best part of the RIS, as with Amicas PACS, is that it doesn't get in our way. It can provide reports viewable from within PACS, which the clinicians love (and so do we). We are really thrilled with the simplicity of reviewing and signing off of reports. We log in to the system (from anywhere, as this is a .NET web-accessed program), hit the "batch sign" button, and all of our pending reports are displayed. There is the option to edit them if necessary, which is a rare need given our incredible transcriptionists, and then they can all be signed with ONE CLICK! We use Cerner at our Agfa hospital, and Meditech at the other places we cover, and the concept of "ease of use" has obviously never been heard by their developers. But it is the backbone of Encompass.

Now, I mentioned the somewhat spartan nature of the Encompass.NET interface, and indeed, it isn't particularly fancy. But I do have the honor of announcing their next interface, with screenshot below, which will make its official debut at SIIM next month. Empiric hired a "prominent West Coast GUI design firm that specializes in ergonomics" to revamp the front end. Notice the "at a glance" concept that will instantly show the user the status of each patient and exam. It's prettier than the functional design they have today (screenshots of which can be seen at their website.)

If you are in the market for a RIS, and you aren't trying to outfit the entire Mayo Clinic, have a look at Encompass. My partners and I like it, and we're rather hard to please.....

Dalai Gets Trumped!

Unbeknownst to me, there has been a game of sorts going on among some of my partners called "Trump the Dalai", wherein they have to find some piece of technology I haven't already tried. My partner Rick (well, to be honest, it was actually his wife) won the game hands down this week. For his birthday, Rick received a brand new FlipStart super-compact PC. I'll let you read the stats on the FlipStart webpage, but suffice it to say, this is a fully functional Windows XP computer that is about the size of a largish paperback book. Most remarkable for a tiny machine like this is its large screen, a "5.6 inch diagonal high ­resolution display (which) makes computing easy on the eyes, with a full view of Windows® (1024 x 768)."

When Mark, my PACS guru, got hold of this thing, he went absolutely wild with glee, and proceeded to access our Amicas server, which turned out to be just as easy as on any other laptop. You can see the results above. Note the quarter on the screen placed for a size reference. With the size of the image displayed, you might think we were using a scanner like this one:

Rest assured, however, that these are real human images from a regular old MRI. (The little scanner, image courtesy of Craig Woody, BNL, actually is a minature PET detector used for animal research.)

The screen resolution of the FlipStart is adequate for reading digital modalities such as CT, MR, NM, US, etc. I don't think I would try to read CR, but it might be possible in a pinch. Especially for rat radiographs.

Rick's prize for winning Trump the Dalai? An extra night of call! Just kidding.....

New Trix From Impax 6

Image credit: http://www.generalmills.com

Silly Agfa, Trix are for Kids, not for PACS!

In the last few days, I noticed that my profile on Impax 6.2.1.135 had changed in subtle ways. Different worklists than those I had selected were displayed, there were different columns of information within those worklists. Some of my tools and display settings were not as I had left them.





I thought I was crazy, which is probably true anyway, but now, some of my partners are noticing the same thing! Our PACS people are looking into this, but I see only a few possibilities:

1. Someone is getting in there and messing up the settings


2. There is some problem with the communication between our three production servers, and settings are getting tweaked somehow in that process


3. The data tables are becomming corrupted...seems to me things would have deteriorated a lot more if that were the case


4. The damn thing is haunted

Personally, I'm voting for #4. I'll keep you informed.

Speech Recognition...Again

Courtesy of: http://www.engr.uconn.edu/ece/SeniorDesign/projects/ecesd79/

There are a few ways to get noticed on an AuntMinnie.com discussion. Mentioning GE Centricity always draws a lot of attention, but these days, a thread talking about speech recognition will be pounced upon like Howie Mandel after some poor "Deal or No Deal" contestant opens the case containing $0.01.

A recent AuntMinnie front page article reported the results of a study from the U.K. and Germany that discovered

. . . speech recognition technology eliminated "significant delays" in report transcription and typing issues, leading to an improvement in service to both clinicians and patients. Researchers at Hammersmith Hospital and Charing Cross Hospital also concluded that a well-planned organization-wide implementation of speech recognition technology "can have a dramatic impact on radiology service delivery. . ."

In 2004, emergency room and primary care reports took three to five days to complete at Hammersmith Hospital. Finished inpatient and outpatient reports ranged from a low of three days to as many as eight days for inpatient reports in August 2004. With the advent of speech recognition technology, the time from report generation to completion declined to one to two days from January 2005 to February 2006.

This article prompted a number of responses on an accompanying AM.com discussion. A few were positive about SR, but many were doubters, including yours truly. You may remember my earlier post about SR, and I haven't changed my mind. I haven't seen any evidence to suggest that SR has improved. Articles like the above don't do much to help SR's reputation. I mean really, three to five days! That is totally unacceptable under any circumstances. Did our British friends have only one transcriptionist available? Did she have to use the loo for 30 minutes of every hour of her 4 hour daily shift? If you set the bar that low in other venues, I could be the Steeler's next quarterback! I will have to admit that SR might be able to improve the situation if things are that bad.

Fortunately, here in my little corner of the boonies, things are pretty good. Our turnaround time with Human Transcription (HT) is usually from 10-20 minutes, with STAT's coming out within 5 minutes. Of course, if there is reason to do so, we type in a prelim, leave a voice-clip, or (gasp) even pick up the phone to call the clinician. Why would we ever want to switch to SR?

Look, I love technology more than anyone else I know, and I am absolutely fascinated by the concept of the computer listening to me and converting my uttered pearls of wisdom to text, or to commands, etc. Wonderful. But if this is such a wonderful idea, why hasn't it caught on elsewhere, such as among the administrative types that are pushing it on us rads? I think the ultimate reason is this: A machine will never understand the nuances (pun intended for the Powerscribe set) and the outright inherant inconsistancies of human speech. I can dictate this: "The left shoulder, I mean the right shoulder shows no fractures" or some equally flawed speech, and it will come out OK with HT, but not with the machine. Those for whom SR works well have not only trained the machine, but moreover, they have trained themselves to dictate in a completely different way than they learned as youngsters. I personally am not that big a fan of technology that forces me to adapt to it.

I have to wonder if some of the more ardent supporters of SR on the various AM threads work for Agfa or Nuance, or if they are just low-level administrator types taking some heat for spending $300K on something that doesn't work very well.

Has anyone really added up the cost of SR vs. HT (speech recognition vs. human transcription)? I suspect that once you pay the $300K for the initial set up, add in training time and costs, cost of upgrades, cost to replace the darn thing in 3-5 years, etc., there won't be much savings with SR. That does not, of course, take into account the radiologists' time, effort, pain, and potential malpractice suits caused by using SR. But then, the administrative types that usually make this decisions AREN'T PAYING FOR THE RADIOLOGISTS so they don't really care about that. But we rads DO care. If SR is so bloody wonderful, why don't administrators as well as the occupants of the C-suite use it? Apparently, it's good enough to generate reports upon which life-or-death decisions are made, but not good enough to replace the secretaries of any of the above. Think about it, folks....

Here Wii Go!...A new pointing device for PACS?

There has been much discussion of how to point at your CT on the workstation. Most of us still use the venerable old mouse, while some have graduated to trackballs, joysticks, jog-shuttle dials, and even roller-mice.

An Italian college student by the name of Giorgio has come up with something new, that I think has great promise. Some of you have probably succumbed to your kids' pleadings for a new Nintendo Wii, which isn't all that expensive at around $200. The Wii's claim to fame is its entirely different approach to game control: the Wii-mote, consisting of a wand or nunchuck, and a little joystick control on another little pod:

You control the various games by moving the nunchuck in a natural manner. For example, hold it like a golf-club or a tennis racket and swing appropriately. A tiny accelerometer inside the nunchuck translates the motion into control signals for the Wii. Note the included wrist-strap designed to keep the nunchuck in your hand after a vicious slice, thus avoiding injury to yourself, others, and your TV.

Giorgio has hacked the Wii-mote and via a control system called GlovePIE, he has made it operate a CT display. Based on his video, he hasn't yet tried it on 3D renderings, MPR, etc, but that would be the next logical step.

Now can I get a Wii, Mom?

OOPS....We had a little downtime today...

Fortunately, I'm on vacation this week, and I didn't have to deal with the joys brought about by downtime. According to Dalai's First Law of PACS, "PACS IS the Radiology Department," and so when PACS is down, the department is down, and the patients can just cool their jets (or their hemorrhages, or whatever) until it's back. The good news is that the rads can go on a prolonged coffee break if there isn't any way to get back up again.

I don't know all the details at this point, but I do know that our newly-upgraded Impax 6.2.1.135 went down from 8AM until 10AM today. Not the best time for that to happen, if there is a good time. We are assured by our vendor, however, that the same problem will not occur again (any time soon, I assume). I find the whole situation sort of confusing, because we have three parallel production servers, and I don't really understand what took them all down at once. Maybe the Oracle is at it again?

Since the upgrade was fresh, no one thought there would be any problem of this magnitude this soon (about 52 hours after completion), and so the backup plan wasn't fully on-line. Now, we do have a test server, which was used during the upgrade itself, but I guess the scanners weren't still pointing to it. We actually had to use the venerable old (gasp) Web 1000 to get anything read during the dark age of the downtime. Fortunately, the servers where good old Web 1000 live haven't been wiped as yet; I think they are going to be converted to Impax 6 servers eventually.

Well, we survived, and we are stronger for it. Can't wait for the next episode of "As the PACS Turns (Off)".

Impax 6.2.1.135

Never let it be said that whining doesn't get you somewhere. We complained, and Agfa listened (to a significant degree, anyway). As noted in the sign-on screen above, our Agfa site bumped up to version 6.2.1.135 (6.2 for short) from 6.0.x over the weekend. The upgrade went without a hitch. Well, that was my view, because I'm on vacation, and no one bothered me! I'm told there were some problems here and there, causing the install to be completed at about 4AM this morning, instead of the anticipated 8 or 9 PM last night. Something with Oracle, I hear. (IT folks are rather like doctors. If you come in with some weird disease, it somehow is always due to a virus. A problem with Impax somehow always relates to Oracle. Personally, I would prefer the Oracle from the movie "300" but she might not prove quite as operational as what we now have. I digress....) To add insult to injury, something happened to the power at the data center this morning, and shut the darn thing down again, but that was NOT the fault of Oracle, as near as anyone can tell. I find it interesting that someone on the team was checking my blog at 1AM this morning to see if I had said something bad about them yet. Who, me???

Not counting some patches and service upgrades, this is the first major revision we have had in the six months since go-live with Impax 6. I have a list of the 113 things that were changed, but I'll spare you the joys of reading that. Let's just concentrate on what directly affects me, the target audience (at least that's how the folks from Waterloo explained the requirement of affixing a big red bull's-eye on my back...)

The single greatest accomplishment as far as I'm concerned is the reintroduction of the "simple search" for "simple-minded radiologists." Instead of the incredibly powerful but incredibly obtuse "advanced search", the easy version lets me drill down quickly to what I need. The Agfa folks were absolutely flabbergasted that we end up searching by the patient's name about 90% of the time. Well, now I can do that without going through the gawd-awful drop down menu of 100 different criteria. Unless I really want to, that is, because the advanced search is still available. See? An easy solution! Here is how it looks today (compact and expanded versions..you'll have to click them to see everything):

The list of improvements goes on for 112 other items, give or take. I do think there are some duplicates on the list, for what that's worth. Some of the other highlights include:

• Available Series Tray is now embedded based on User configuration. It was previously stuck at the left side.
• Hotkeys should now "stick", and not be erased after logout.
• Various causes of crashes have been eliminated.
• Cursor mode line now upgrades in orthogonal views.
• Should be able to open larger number of studies without slowdown.
• There is now permission to configure one's own station (and take back some RAM!!)
• New/upgraded versions of the client will download automatically when the new version is recognized.
• Column changes in Worklists are immediately saved, and applied to ALL worklists (hopefully that's what we wanted..)
• The automatic brightening and dimming of the Prior list is shut off.

Now, here are some of my pet peeves that are not yet fixed:

• Handling of two rads trying to dictate the same study. There is a temporary fix with a warning message, but an insistent rad can still override the settings.
• No easy way to get back to the last study that was on the screen. Yes, there is a somewhat hidden "history" tool, but it only works on studies that have been clicked off as dictated.
• Spine labelling. There isn't any.
• Voxar button still stays active, leading to repeated activation of Voxar3D when you were just trying to get back to the original study.
• Comparison windows still based on the cloning concept.
• TOGGLING!
• Black screen when images of a series are loading.
• Thumbnails in the Series window can be easily, inadvertantly resized, to the point of being unusable.

I could go on. 6.2.1.x represents a significant improvement, at the very least many glitches have indeed been fixed. The underlying philosophy of the program remains what it was, however, and that is something the potential buyer should be very, very comfortable with before, well, potentially buying Impax 6.

Thirty-Five Thousand Hits!

Courtesy of http://membres.lycos.fr/xenu/rtcfun.html

Visitor 35K came to my site at 1:40PM EDT today, and stayed an impressive 18 minutes, 25 seconds. He or she must have fallen asleep at the keyboard! Anyway, he is from Bekond, Germany, and was searching for the phrase "Oracle buys Agfa". It seems takeover rumours are rampant these days. As near as I can tell, Oracle is not buying Agfa. Agfa isn't even for sale, is it?

Hospital Mentality

The above is an unretouched and unedited video shot in the departmental restroom at one of our hospitals. You will note the obvious dilemma. Ah, hospital mentality...

GE Buys Agfa PACS!!!....Centri-PAX to debut soon

Just when I think there are no more surprises left in this game, something comes at me from left field.

I have it on good authority that GE and Agfa have had high level talks over the past six months, and they have agreed to merge their PACS products. The new flagship offering, Centri-PAX (Centricity is GE's system, IMPAX comes from the Agfa side) should offer the best of both worlds, without carryover of the deficiencies of each. The new hybrid will be web-based, and run on Microsoft's .NET platform. It will eliminate the need for the separate Centricity-Web now required for web access on the GE side. Centricity users will note similar DLP's (hanging protocols). 3D options will include the GE Advance Workstation (AW) platform, long promised to be ported to Centricity, or the Voxar/Barco 3D program. TeraRecon or Vital Images' Vitrea may also be purchased.

Spokespeople for both companies note the unprecedented nature of this cooperation between giants in the PACS field. "This is like Ford and GM working together on a next-generation vehicle," says Robert Pryor, President of Agfa Health Care. GE's David Henriksen, head of GE's PACS and IT division agrees: "For the first time in the history of PACS, the two biggest names in the business will cooperate to provide the best program available."

Competing companies had no comment, except to urge you to note the date of this posting. Have a happy one.

Let's Contain the Giddiness...

Image courtesy of: http://www.krepcio.com/

I try to be sensitive to the whims of my readers, and, believe it or not, I really don't like upsetting anyone. It has come to my attention that there was much intestinal disruption caused by my recent article discussing a certain piece of software. While I regret any distress I may have caused, I will stand by every word in that article. Now, those who know me well realize that I don't want any false information disseminated under my signature, and I am always responsive to documented corrections. So, if there is any factual error on that post, please let me know via the comment field below. The grapevine connection will eventually get the message to me, but it will likely be something other than what was meant to be said. (Anyone ever play Post Office?) But rest assured that when someone tells me that my product, in this case my blog, is impairing their work., I listen, and I do something about it.

Dalai's Laws of PACS

I. PACS IS the Radiology Department.

II. PACS exists to improve patient care. Its users are the radiologists and radiologic technologists. The entire goal of the PACS team is to optimize PACS function for its users.

III. Once PACS, never back.

IV. Workflow is inversely proportional to the number of buttons on the PACS desktop.

V. PACS should not get in your way.

VI. Speech recognition will be feasible when the CEO, the CFO, and the CIO use it for their correspondence.

VII. The degree of understanding of radiologist workflow is inversely proportional to the size of the PACS company.

VIII. An average PACS consultant will take 6 months to tell you what you already know.

IX. PACS should be the shared responsibility of the Radiology and IT Departments.

X. The time of delivery of a patch for a malfunction is directly proportional to the square of the severity of the problem.

XI. A true PACS Guru is worth his/her weight in gold.

XII. The PACS needs to be operable by the least technically-savvy radiologist on staff.

Some Thoughts About Marketing...and Complaints

Abercrombie and Fitch T-shirts, short-lived designs

Images courtesy of: http://www.medialiteracy.net and http://www.konformist.com

My daughter is home from college for Spring Break, so naturally, we had to go clothes shopping. (Why couldn't DRA-2005 have slashed retail prices, too?) We went to the regional hoity-toity fashion mall, and commenced charging. My poor AMEX card will never be the same.

We had one mildly disheartening experience at Abercrombie and Fitch, you know, the place with the suggestive photos of young people almost wearing their wares? Well, today, the mannequin was wearing the shirt that took my daughter's fancy. We looked all over the store--no other such shirts. We collared a sales-droid who checked in the back and--no other such shirts. We asked if we could buy the shirt off the mannequin's back--Oh no, those belong to the Visual Department, and we can't sell them. We asked a manager, and, in a tribute to consistency, we received the same story, with considerably more attitude. This made no sense to us, as the shirt had a proper price tag, and appeared ready to be set free from its bondage. So, I asked if there was someone in Corporate I could call, and I was given the number for Customer Service.


I stepped out into the mall, and called, and eventually I was connected with a supervisor named Curtis. Curtis was very pleasant and patient, and explained that yes, the displays are indeed owned by Abercrombie Central, and moreover, they are not saleable as they have been cut, re-sewn, and otherwise disfigured to look good on the mannequin. This is why they cannot be sold, not simply the ownership issue the sales kids were trying to cite. He offered to order the item and send it to us with no shipping charge, which I declined, but I did thank him for it. He asked if I would like to file a complaint, and I did. Here it is, petty though it is: Putting an item on display when there is no such item for sale within the store is really bad advertising. If I had wanted to order from the catalogue, or from their web-site, I could have done that without driving several hours to the big hoity-toity regional fashion mall. It makes more sense to remove such a display until such time as the item is actually available within the store. Curtis promised to pass along my complaint to the national office.


There are good and bad ways to market your products and your name, and there are good and bad ways to handle complaints. The shirts seen above are examples of really bad marketing. Curtis, on the other hand, properly dealt with my complaint, although I have very low expectations of my advice being followed. Still, I may someday set foot again into an Abercrombie store, and possibly even buy something, which I might not have considered without his ministrations. On the other hand, simply repeating a programmed mantra ("Corporate owns the display", "Our other customers want it that way") is not a good practice. Demeaning and discrediting the complainer, especially without dealing with the complaint, is definitely on the bad list, and can have very serious consequences such as losing the customer permanently.

I know I sound like the consumer from Hell, and I try not to be. I realize that this is an imperfect world with imperfect products built by imperfect people, and I am far from a perfect radiologist, believe me. But I have this old-fashioned Nordstrom-like belief that the customer is paramount, and at the very least deserves to be heard. He or she might actually have a valid point that could save someone some money. Or time. Or maybe save someone's life. From the Restaurant Doctor:

Stamp out inconveniences before they become irritations.

Stamp out irritations before they become complaints.

Stamp out complaints before they become problems.

Stamp out problems before they become crises.

Notice that there is no mention of stamping out the complainer!

Remember, the "C" in PACS stands for "Communication". I think this has become a lost art in the 21st Century. There is much talk, but little listening, and even less hearing, not to mention a desire to shift blame anywhere possible. That is how complaints turn to crises.

ScImage Unites The VA...and validates Dalai's idea

I have made a number of disparaging comments about ScImage over the years, based on my very unsatisfactory experience with their older products. I have agreed to bury the hatchet, given a very eloquent post on a rather unusual AuntMinnie thread by Rob Tinker, ScI's National Operations Manager:

.....Of course, Dr. Dalai, I encourage you to continue to broadcast your valued opinions to the professionals that browse Aunt Minnie’s forums but we would ask that instead of continuously bashing ScImage based on your experience with a 3 or 4 year old product, come take a look at what we are doing today, so that you will at least be providing an opinion that is relevant. I would welcome the opportunity to speak with you regarding all this, at your convenience of course.

That nicely closed a rather contentious series of posts, and set the tone for a truce if not a total reconciliation. (I still don't know who started the nasty thread, by the way, but in the end, the true nature of several AM regulars became quite clear, and that is satisfaction in and of itself.)

I remain on ScImage's e-mail list, and today I received this notice:

Los Altos, CA – March 12, 2007 – ScImage, an award winning enterprise imaging and information management company, based in Los Altos, California, announced today that the Veteran’s Health Administration (VHA) has awarded ScImage the contract for the VHA’s nationwide teleradiology program serving more than 150 Veteran’s Health Administration Medical Centers.

The ScImage solution will be deployed as a web layer on top of disparate PACS at various facilities to route exams along with prior images and reports based on dynamic business rules and will be used exclusively in the VHA’s Teleradiology Center to provide a virtual reading environment for reading radiologists and/or radiology groups. Deploying the solution in this manner will enable the VHA to surmount the shortage of qualified staff in certain geographies and provide faster turnaround. The result will be a more unified and consistent collaborative reading workflow that VHA program directors can watch and manage very closely from anywhere.

At its core, PicomEnterprise boasts one database and a shared infrastructure that simplifies workflow for multiple facilities. The solution features several time saving and innovative clinical applications for TelePACS over broadband infrastructure. “ScImage is proud to be a part of such an important project. Providing the VHA with a unified approach to medical image and information management will lead to improved clinical workflow, patient care and a lower total cost of ownership,” stated ScImage Founder and CEO, Sai P. Raya, Ph.D.

Overall, ScImage will provide an extremely comprehensive solution that is ideal for the VHA’s objective of a centralized workflow model that will enable them to have full 24x7 coverage across the United States. ScImage’s solution will be placed in VHA datacenters to provide a virtual reading environment for radiologists from anywhere while administrators can monitor reading progress, exam volumes and workflow efficiencies.

That would probably explain why this blog received so many hits from VA headquarters in DC in recent months. I would, of course wonder what other companies were competing for this contract, but in the end, that is unimportant. What is critical is what ScImage will do for the VA: unite its "disparate PACS" systems into one enterprise. Now my idea was to unite regional centers' PACS systems to accommodate the "portable patient", which in the end is similar to what ScI will accomplish. There are, of course, rather significant differences. The VA is a more homogeneous group of hospitals than even the handful in my neighborhood. They are all under the same umbrella and administration, and their patients generally migrate only within the system. Thus, what the VA (or VHA...I'm of the old school) is doing is not only desireable, but really is mandatory given their circumstance and organization. But the lesson to the rest of the health care system is quite obvious. Here we have on a national scale a project validating the idea that small hospitals won't consider.

Obviously the technology exists to connect one PACS to another, and let me see Mrs. Jones' CT from St. Elsewhere done 48 hours ago. The only thing preventing this from happening is petty hospital and IT politics, and I do mean petty. But, don't worry, when Hillary is elected, we'll have some sort of National Health Care system, and no doubt the order to connect will come from Washington itself. That might be the only good to come of it, but....

Congratulations to ScImage. This is a big one for you guys.

What Are You Searching For?Pssst...PACS companies take notice...

It is no secret that we leave a huge trail behind us when we surf the 'net, nor do I hide the fact that I look at that trail when it leads to my blog.

Many of you come straight here, having no doubt enshrined my address on your link bar. Fortunately, new readers are lured here, I mean stumble fortuitously, upon my blog via Google or other searches. I thought you might find it interesting to see what has led others to these pages. So, here are the Googled words or phrases that led here, as gleaned from the last 500 visits:

"access to medicare imaging act"
"bloomberg competitor"
"quality nighthawk" president
2006 rsna siemens leonardo
3d terrarecon
access to medicare imaging act (multiple)
agfa impax (multiple)
agfa impax 4.5
agfa mitra
agfa pacs web1000 update
agfa pacs worklist
alternative murder
american amic people
amic research associates
amicas jp2 convert dicom
an unexpected error has occurred
anyone have any info on ytb
anyone using meditech workstation on linux
aser 2004 survey emergency radiology
audiovox 6600 intermittently crashing
auntminnie sold
autralian 2007 addresses
barry gutwillig
biograph pet
blog pacs
blog vascular ultrasound discussion board
buggy and two pacs
canon "dynamic imaging" pacs
carbonite hipaa
cavernosagram
centricity 3.0
centricity pacs 3.0 demo
centricity web pacs
chain gif
chile pacs 2007 fujifilm
coronary cta credentials physicians
ct armature siemens somatom definition
dalai blog
dalai lama mercury sohard
dalai lama pacs
dalai lama radiology
dalai pacs
dalai refrigerator
deficit reduction act
deficit reduction act diagnostics
deficit reduction act imaging
demo intelerad
demo of centricity pacs
dicom guru
dicom overlay java reader
doctor dalai
doctor dalai blog
doctor dalai impax
doctordalai
dr sam friedman
dra 2005 (multiple)

dra cuts
encompass.net server error
feature fatigue
federal law against self-referral pennsylvania
free efilm unlimited license
fuji pacs negative experiences
fuji pacs unable to view all images
fuji synapse (multiple)
fuji synapse and ruler function
ge pacs server configuration
good it worklist
google auntminnie wet reads
google.com
hormel
how to mass market ytb
imaging and deficit reduction act
imaging software to read ct coronary angiogram
impax 6 (multiple)
impax 6.0 (multiple)
impax agfa
impax agfa screen grabs
impax sucks
impax viewer (multiple)

intelerad
is it illegal to give patients money for referrals?
is ytb a pyramid
isite pacs complaints
isite radiology 3.5 upgrade limitations
isite stentor image format
logmein danger
machine alternative medicine scan
madamme tussaud's
magnifying glass
manogram gun sights
matthew morgan pacs
medicare; medicaid; fraud; examples; cases; self referral
meditech magic antiquated
medview auto logout
merge efilm blog
missing link in the chain
mitra context server
multi level marketing ytb fraud
number of mri's in la
oamri
pacs
pacs blog (multiple)
pacs blogg ge centricity replacements
pacs blogs
pacs centricity
pacs idiots guide
pet scan procedures per capita
philips isite missing images
phillips stentor blog
picom doc scimage
picom manual
picom to dicom conversion
porcine
powerscribe mic
powerscribe microphone
precertification and anti-kickback laws
radiologist blog dictaphone
ramsoft pacs
reimbursement for cardiologist...diac ct angiogram pennsylvania
repeal the dra
scams ytb
scan paper documents into pacs
scimage
sectra pacs problems
self-referral imaging 2007
siemens biograph 16 reconstruction algorithms
siemens pacs problems
siemens syngo pacs issue
smart client agfa pacs
snorkeling shellfish allergy
stamp on envelope idiot
stentor activex control isite
stentor pacs blogs
stentor pacs problems
step shoot rsna 2006
syngo report awful
terarecon
terarecon isite
terarecon precision 670
terarecon voxar comparison
terrarecon
treating pets with a rife machine
victorinox israel
why buy a biograph pet/ct
ytb "like amway"
ytb amway
ytb bad idea
ytb good or bad
ytb pyramid scams
ytb pyramid scheme
ytb pyramid scheme investigation
ytb scam (multiple)
ytb scam or pyramid
ytb scams or problems
ytb sites
ytb travel fraud
ytb travel pyramid scam
ytb travel scam
ytb webinar
ytb, scam

Lititz, PennsylvaniaHome to Visitor 30,000!

Image Courtesy of the Pennsylvania Dutch Convention & Visitors Bureau

If you were wondering, Lititz is near Lancaster, and from what I gather, it is a very picturesque spot for shopping and sightseeing.

Visitor 30,000 is a regular, stopping by here at least once a week or so. Is there a hospital in Lititz?

If I were to visit, would I get the key to the city? Oh, well....

"Banned" Budweiser Commercial...And A Parody

I'm not sure why it's banned, but it appeals to my warped sense of humour.....



Now, just to show that I can take a Jewish joke, here is a Bud parody...

Spam...A Really Bad Idea That Probably Wouldn't Work ...so forget I mentioned it

I hate spam. No, I haven't tried the Hormel version lately, but I'm referring to the unsolicited e-mail garbage we all receive. I get from 20-30 spam e-mails per day, and that is probably a rather low figure. I dutifully report each and every one to spamcop.net, for all the good that doesn't seem to be doing. Sadly, I keep getting more and more each day anyway. Most of it is now the insidious "image spam", wherein the real spamvertisement is hidden in a GIF file. My filters usually catch the images before they can download, which supposedly tells the spammer that he has hit paydirt with your e-mail account.

No one seems to have a solution to this growing problem. After clearing out the 20th spam message this morning, however, a nasty thought occured to me. This is one of those things where the government has to step in and do something. So far, those efforts have been pretty lame, due mainly to the lobbying efforts of the spammers, and other bottom-feeding scum who hide behind the First Amendment. We The People simply need to convince Congress to put a stop to this scourge. Yes, I realize that much comes from off-shore, but there are certainly ways to block this with government help. I'm at a total loss, however, as to how to get Congress' attention. Now, I would never, ever, think of something like everyone in the country forwarding each and every spam to their Congressman (addresses available at http://www.house.gov or their Senators (http://www.senate.gov) or even the President (http://www.whitehouse.gov). No, I would never suggest such a thing. Certainly our government has more important things to do than deal with something that annoys just about every US citizen, and has the potential to shut down Internet commerce.

Forget I even mentioned it.

Show Me Your Worklist!

Remember the DI ad from a few months back? My friend at Dynamic just sent me this image to remind me that there are indeed other companies out there using color worklists:

This one happens to be from Thinking Systems. I had already heard about this one from RamSoft:



Even ScImage has a colorful worklist, based on this image from an ad about their version 3.0:

(I've promised the folks at ScImage to be nice and not comment on their newer products that I haven't seen; I present this image simply to show the pretty colors.)

I am still quite happy with the way Amicas implements colors in their RealTime Worklist:

Compare that to the Impax 6.0 worklist which is not terribly colorful at all:

Why am I so hung up on colors? It's simple, really. Colors give a quick, at-a-glance snapshot of what is happening out there on my PACS. What do I need to read, what is being read, etc. Yes, the text-based approaches can do this, and give all sorts of other information, but to use them requires more, well, thinking. I have a theory that colors stimulate the more primitive parts of the brain, and bypass the cortex, going straight to the limbic system. Thus, I can feel primitive rage when a red ER study comes up, and wallow in the relief of an all-green screen, indicating that everything has been read, transcribed and finalized.

How much flexibility should we have in a worklist? Good question. With Impax 6.x, we used to be able to tailor our own, until IT took that privilege away, ostensibly for our own good. We now have to submit ideas for worklists that are approved by committee. To be fair, only administrators can create and manage worklists on Amicas. Don't even ask about Centricity.

To prepare for this post, I went trolling through the net looking for screenshots of PACS worklists. It turns out that such things are much harder to find than porn. So, I'll put out the call: Send me a screenshot of your worklist! Anonymize it as necessary, and then send it to: doctordalai**AT**gmail.com. (You wise PACS people know what to do with the **AT**, I'm sure.) I'll post them and we can have a good time comparing them. Nothing like a little audience participation, eh?

Addendum

Well, here's our first entry...this is the IntegradWeb worklist from Dynamic Imaging, courtesy of my friend Brad. Discussion to follow as more of these trickle in.