The Wizard of OS

If you're here, you no doubt know about my little problem with the Big Company and so forth. I never, ever dreamed that this average radiologist from the South could cause such an uproar with a lil' ol' blog. I'm still surprised anyone even reads the darn thing at all! But, you do, and I have received a great deal of support via e-mail, AuntMinnie thread, and even the odd phone call.

We didn't have to "go here" as the kids say. So many other companies, among them Afga, AMICAS, Sectra, Emageon, Intelerad, etc. have used my comments to make their products at least a little bit better. I guess someone in this other company in question didn't think I had the potential to do that for them. Oh, well....

To those who have supported and continue to read my stuff, know that neither I or my rather amateurish but still lovable blog plan on going away anytime soon. To those who don't like my postings or have a problem with them, I only ask that you e-mail me or call me if you have questions or want to talk about it. You can also post a comment to the offending paragraph.

The way this whole scenario unfolded hurt me and my family deeply, and could have been diffused with a little dialogue. I've changed my blog postings before, and won't hesitate to do it again if I am wrong or if my comments hurt someone personally. That said, if your product sucks or I take a stance you don't like, please deal with me directly. I'm a man and I can take it. Just don't do an end around me where I have to explain my actions to others or worry about my livelihood or those of my partners being threated as happened here. As my friend the PACSMan pointed out, that is a Chicken Little way of dealing with it (although I think he changed the word little to a more "excretionary" term instead). I'm hoping that the legacy of this tempest in a teapot will be the establishment of better dialogue between all of us whose job it is to care for our patients in the best manner possible.

The PACSMan also sent me this (complete with pictures) which brought a smile to my face for the first time in several days, and has given me permission to share it with you all. I hope you enjoy it as much as I did....

Mike said, "Oy gevalt, what have you done my friend !!! Do you realize how much this whole story resembles the Wizard of Oz? It’s uncanny. Use this to explain what has happened to your blog site readers. They will fill in the blanks themselves…"

THE WIZARD OF OS

Average radiologist Dalai Lama lives an average life in an average town in the South with a hyperactive Jack Russell terrier named Blogger, along with Aunt Minnie and three colorful farm hands, Hunk, Zeke, and Hickory. One day their stern neighbor, Miss Imagination, is bitten by Dalai’s dog, Blogger. Dalai senses that Miss Imagination will try to do something dreadful, but his aunt and uncle, as well as the farmhands, are too busy with their work to listen. Dalai yearns for a better place in the song Over the Ether(net). Miss Imagination shows up and takes Blogger away to be destroyed, by order of the sheriff, over the impassioned protests of Aunt Minnie and Uncle Henry. Blogger escapes and returns to Dalai, who is momentarily elated but soon realizes Miss Imagination will return, and extract even greater revenge. He decides to take Blogger and disappear.

The Wicked Witch of the West

As they flee, Dalai and Blogger encounter Professor Marvel, a lovable but fake fortune teller who, out of concern for Dalai, tricks him into believing Aunt Minnie is ill so Dalai will not run away from home. Dalai rushes back to the farm but is knocked unconscious, inside the house, by a sudden South Carolina twister that has already forced his family into the storm cellar behind the house.

A confused Dalai awakens to discover the house has been caught up in the twister. Through the bedroom window, he sees a parade of people fly by. Then he sees Miss Imagination, also caught in the tornado, and pedaling her bicycle in midair, transformed into a witch. Moments later the twister drops the house, Dalai and Blogger over the rainbow and into OS. Glinda, the Good Witch of the North arrives and informs Dalai they are in Munchkinland. She tells Dalai he has killed the Wicked Witch of the East by “dropping a house" on her.

Encouraged by Glinda, the timid Munchkins (played by representatives of the smaller PACS companies) come out of hiding and celebrate the demise of the witch singing "Ding, Dong, The Witch Is Dead" among other cheerful songs until her identical twin sister, the Wicked Witch of the West, appears to claim the powerful ruby keyboard. Glinda magically transports the keyboard into Dalai's hands and reminds the witch her power is ineffectual in Munchkinland. The witch vows revenge on Dalai and leaves the same way she arrived, in a blaze of fire and smoke. Glinda tells Dalai, who is anxious to return home, that the only way to get back to South Carolina is to ask the mysterious Wizard of OS in the Emerald City for help. Glinda advises Dalai to never lose the keyboard and to "follow the yellow brick road" to reach the Emerald City.

On his way Dalai befriends a Scarecrow with no PACS, a Tin Woodman with malfunctioning speech recognition, and a Cowardly Lion with no PET/CT. The three decide to accompany Dalai to the Wizard in hopes of obtaining their desires. Along the way they are plagued by a forest of angry IT personnel and several failed attempts by the witch to stop them. While they arrive at the Emerald City, they are interrupted by the Wicked Witch, who flies across the sky, writing, "Surrender Dalai". The group talks to the Wizard of OS, who says that he will consider granting their wishes if they can bring him the broom of the Wicked Witch. The group then departs for the witch's castle.


Dalai comforts the Cowardly Lion

On their way to the witch's castle, they are attacked by flying monkeys, who carry Dalai and Blogger away and deliver him to the witch, who demands the ruby keyboard. When Dalai refuses, the witch tries to remove it but is prevented by a shower of sparks. She realizes the keyboard cannot be hers as long as Dalai is alive and plots on how to destroy him without damaging the keyboard's spell. As the Witch is considering on how to kill Dalai, Blogger takes the opportunity to take escape from the Witch’s grasp with Dalai crying, "Run, Blogger, run!” Outraged, the Witch screams at the Monkey, "Catch him, you fool!" but Blogger manages to escape, much to Dalai’s relief. The Witch, furious, snarls to Dalai, "Which is more than what you will, my little pretty!!!" and runs over to a large hourglass filled with red-blood sand and turns it over, gleefully telling Dalai he will die when the hourglass empties. She puts the hourglass down and runs out of the chamber, locking Dalai inside. Sobbing, Dalai calls for Aunt Minnie, saying he is frightened. Aunt Minnie appears, and Dalai tries to tell her that he is trying to get home. The witch appears, mocking and laughing at Dalai. Meanwhile, Blogger manages to find the lion, the scarecrow, and the Tin Man and lead them to the castle where Dalai is awaiting his demise. Once inside they are barely able to free Dalai and attempt an escape. The witch and her Winkie soldiers corner the group on a parapet, where the witch sets the Scarecrow on fire. To douse the flames, Dalai throws water on them, and accidentally splashes water on the horrified witch, causing her to melt. To the group's surprise, the soldiers are delighted. Their captain gives Dalai the broomstick to thank him for their liberation from the witch. Upon their return, the wizard tells Dalai and his companions, "Go away and come back tomorrow!!" Thanks to Blogger, though, they discover the wizard is not really a wizard at all, just a man behind a curtain. They are outraged at the deception, but the wizard solves their wishes through common sense and a little double talk rather than magic.

The wizard explains that he too was born in South Carolina and his presence in OS was the result of an escaped hot air balloon. He promises to take Dalai home in the same balloon after leaving the Scarecrow, Tin Woodman and Lion in charge of Emerald City. Just before take off, Blogger jumps out of the balloon's basket after a cat. Dalai jumps out to catch Blogger and the wizard, unable to control the balloon, leaves without him. He is sadly resigned to spend the rest of his life in OS until Glinda appears and tells him he can use the ruby keyboard to return home with Blogger. Glinda explains she did not tell Dalai at first because she needed to learn "if you can't find your heart's desire in your own backyard, then you never really lost it to begin with." Dalai and Blogger say goodbye to their friends, and Dalai follows Glinda's instructions to "hit Ctrl-Alt-Delete and repeat the words, 'There's no place like home'." He awakens in his bedroom in South Carolina surrounded by family and friends and tells them of his journey. Everyone laughs and tells him it was all a bad dream. A happy Dalai, still convinced the journey was real, hugs Blogger and says, "There's no place like home."

When Dalai wakes up from his trip to OS, the issue with Blogger and Miss Imagination appears unresolved and are left to the audience to interpret.

THE END

Dalai's Unpleasantness

The AuntMinnie thread concerning my "kinder and gentler" blog has me really amazed. With one minor exception, the posts have been very supportive. My friend Mike Cannavo, the One and Only PACSMan has worked the story into a wonderful allegory, which I will post in the next day or two. In the meantime, I'll duplicate my last word on the subject in the AM thread:

Well.... This is all a bit stunning.

The facts of this situation are essentially as the PACSMan has related them. After seeking legal counsel, and being told that fighting a large company was impossible, I removed any and all posts that the particular large company or clinic might find offensive. I did exactly what I was asked to do. When asked by regular readers of my blog why I had done so, I answered honestly. For my own protection, I must point out that the comments above are a spontaneous outpouring, and were not commissioned or requested by me. Frankly, they will probably get me deeper into trouble. But there's not much I can do about that.

This thread indicates a number of things to me. First, I have more friends and supporters among my readers than I might have guessed. My blog continues to get upwards of 200 hits per day, even in its "kinder and gentler" form. Second, there is a great desire for user-based information on the topics I write about. There is little if any other such coverage. Was I a little hard on a certain company? Yes, but that was borne of my frustration with their interface as well as their sales techniques. I meant no personal offense, and in fact, my posts were always directed to the company in general. I do wish that this particular company had done what Agfa has been doing for quite a while now, send their designers and engineers to sit beside me and my partners and see exactly how we work, and how their product could facilitate our workflow. That would have been a win-win situation. Third, there seems to be a tremendous amount of animosity in the radiology community toward this particular vendor. They know it, and what you see on this thread is just the tip of the iceberg. Perhaps this has never been said aloud before, and it's not something that becomes apparent in a focus group or a survey. That needs to be understood and dealt with, and not with a sledge-hammer.

It's time we all step back, vendors and buyers, salespeople, engineers, designers, techs, and even radiologists, and remember why we are all here: The goal is to provide absolutely the finest possible care for our PATIENTS. There has to be a new paradigm of involving everyone in every aspect of this process. To squabble and suppress does nothing good for those who need our services.

I trained as an engineer, and sometimes those principles can be applied to life. In electrical engineering, there is something called negative feedback. When one amplifies a signal, a small percentage of the output must be used to reduce the input. Othewise, the amplifier will continue to elevate its output until it melts. Similarly, in real life, a tincture of negative feedback keeps us grounded (not in the electrical sense this time), and helps us function properly. To quote from the late philosopher Jacob Bronowski, exerpted from his series, The Ascent of Man:

Science is a very human form of knowledge. We are always at the brink of the known; we always feel forward for what is to be hoped. Every judgment in science stands on the edge of error and is personal. Science is a tribute to what we can know although we are fallible. In the end, the words were said by Oliver Cromwell: "I beseech you in the bowels of Christ: Think it possible you may be mistaken."

All of us engineers should appreciate that.

Good night, everyone.

Stupid Things People Do For Money

Here is a light, entertaining post about a foolish fellow in my own state of South Carolina who tried to use a fake $1,000,000 bill "to open an account in an Aiken, S.C, bank. Alexander D. Smith, 31, was charged with disorderly conduct and two counts of forgery..." Photo is from the Aiken County Sheriff's office via FoxNews.com.



I never cease to be amazed at the level of stupidity and deception folks exhibit in their attempts to extract the maximum amount of money out of a particular situation.

The MILF Sale

In the "spirit" of kinder, gentler, non-confrontational, and non-controversial postings, here is some light entertainment from Spirit Airlines, offering their "M.I.L.F" Sale:

The MILF Sale

Many Islands, Low Fares - From $9* Each Way
Now is the perfect time to book that trip to paradise. Spirit is offering great, low fares to many exotic destinations at incredibly low fares - from only $9* each way! But hurry, the Many Islands Low Fares Sale ends Monday night, December 3, 2007 at 11:59 PM ET! Please see the full list of destinations below. All fares are each way, based on a roundtrip purchase and taxes, fees & restrictions apply.

Time to go back to the islands, Mon. I wonder if they have heard of the "other" definition of M.I.L.F.?

I do hope I haven't offended Spirit, or lost them any sales with this amusing, light-hearted posting....

Addendum

It seems that Spirit must have heard about that other meaning.... It seems rather ironic that they chose the "Mom" theme....

The Mom and Apple Pie Sale

With Fares From $9* Each Way
What's more good and wholesome than mom and apple pie? The only thing we could think of was a great sale with low fares to your favorite destinations - from only $9* each way. Now is the perfect time to book that trip to paradise. But hurry, mom, the apple pie and this great sale will be gone by Monday night, December 10, 2007 at 11:59 PM ET! Please see the full list of destinations below. All fares are each way, based on a roundtrip purchase and taxes, fees & restrictions apply.

Now, that's Spirit!

Welcome To A Kinder, Gentler Blog

You will notice that all controversial posts have been removed. I hope you enjoy the remaining light entertainment.

Note to my biggest fan: you win.

Amicas Lands MedQuest, Agfa Gets Premier

Normally I don't report stuff like this, but I thought this particular blurb was noteworthy.

MedQuest operates 92 imaging centers around the South and West, and they went looking for a PACS to improve productivity for their rads and clinicians. MedQuest is owned, by the way, by Novant which owns a significant chunk of healthcare facilities.

MedQuest operates totally in the outpatient space. I'm sure they were hurt by DRA-2005, but obviously, news of the demise of such operations is a bit premature. As was predicted by many folks, DRA simply forced such companies to operate more efficiently, and they chose Amicas to help with that task.

I wonder if MedQuest is considering running all 92 sites from one server? It can be done, you know....

Agfa got a big one too, but it is a little more in the realm of a potential big deal. This article from HealthTech Wire notes the "three year, multisource" contract to provide Enterprise Image Management Solutions (EIMS) to the "alliance's more than 1,500 member hospitals and 49,000 other healthcare sites." The relationship goes back to 1995, the Dark Ages of PACS.

If I understand correctly how Premier works, this is not a guaranteed sale of 50,500 installs (I don't think all the vendors put together could handle that), but rather simply a pricing deal, offering significant discounts to the member hospitals. Feel free to comment if I'm wrong about that. Still, it's nice to be on someone's good list for a change, right?

Report from RSNA V: Amicas (and a little Siemens, too..)

I'm actually going to start with the brief Siemens report. I had a chance to look at the new Symbia T16 SPECT/CT. Its footprint is MUCH smaller than that of the Philips Precedence, its bore is larger, and it does a lot of things by itself, such as QC. Set it to go at 3AM on Sunday, and the QC report will be available when you need it. Set up for a gallium scan (does anyone do those anymore?) and the proper collimators will automatically load from the tray under the gantry, and the heads will position themselves appropriately.

Software-wise, Symbia uses the Leonardo, I mean eSoft, no, Syngo, well, today it's the Molecular Imaging Workstation, MIW, for processing. I gave the Siemens folks grief about the lack of mouse wheel support, and they say it is coming. Eventually. I also groused about some problems I've been having with the PET/CT software, and they suggested I use the more generic 3D Fusion program instead of the older nuclear med version, and I will give that a try. All of this applies to SPECT/CT as well. I inquired about a thin-client, so I could properly look at PET/CT or SPECT/CT when I get a panic call from one of my colleagues. (It's good to be loved, and to have job security to boot!) So far, there really aren't any good (or cheap) options. One involves creating a virtual machine-type access to the Leonardo (I'm sticking to that term, sorry) and another involves loading the viewing software thick-client style onto the remote computer. A thin-client is in the works, but not available for the foreseeable future. So, I guess I'll have to rely on Agfa to do this, or perhaps we'll get TeraRecon, or Voxar thin-clients which will accomplish the same thing, as well as giving us a cardiac CT solution.

Coming to the Amicas booth is a little like going home; most of the faces are familiar, although the products continue to evolve and grow into great things. Version 5.0 has been released, and I've played with it on my test-server, although we can't put it on the production server until our Amicas hospital does the same. The 5.0 upgrade involved changes in server software, moving up to Microsoft Windows Server 2003, but this paved the way for the move to 5.5, and ultimately 6.0.

The big news in 5.5, due out early 2008, is a huge improvement in worklist functionality, and in particular, the way status is handled. Right now, an exam can have "status" in one dimension. It is unread, STAT, reported, whatever, but it can have only one such designation. The Amicas folks tell me that some discussion in the last Advisory Committee meeting led them to the fact that status doesn't have to be uni-dimensional, but it would make more sense to mold it to our workflow. Something can be STAT, and need extra images, and be from the ER. Thus, we can assign as many dimensions as we might need to cover the various intertwining workflows we follow daily. This is fully configurable by the site, and thus can be tailored to one's particular needs.

There are several new worklist-related tools for working with the ED, including an ED button on the worklist to go directly to the ER's preliminary report (if you can get your ER docs to cooperate, which we can't) and then there is an included mechanism to flag a disagreement. This then goes into its own worklist block, so the ER doc can be alerted, and maybe embarrassed too.

But the new worklist approach goes way beyond taking care of the ER docs. It works exquisitely well with RadStream, which I mentioned in an earlier post. Let me elaborate, based on a discussion with Dr. Mark Halsted, the radiologist from Cincinnati Children's Hospital who developed the program. (For more details, have a look at this article from Imaging Economics.) When the tech verifies a study, he or she has to fill out a brief checklist that helps assign an "acuity score" which is calculated by the program. The worklist then automatically sorts the studies based on this acuity score. The best part is that the more urgent studies percolate to the top of the list, and if I'm reading from a long worklist, the next most urgent study will come up after I close the last. And, if I'm using the Worklist Accelerator, which caches stuff in the background, I am able to read seamlessly, not missing a beat while progressing to the next-most-critical exam.

Now, it's after I'm done reading that the real impressive stuff occurs. If I need to convey a critical result, I simply click the "go to next study" button, instead of the "mark dictated and go to next study" button. A window pops up allowing me to declare this a study in need of rapid reporting. The study then drops into a worklist display block on MY computer showing that it is in progress of being called to the ordering doc (or however one wants it to read), and once taken care of, it will appear in a block noting that the critical results have been communicated. Of course, there is the complete audit trail for JCAHO's perusal, or (Heaven Forbid) that of lawyers. This is not an idle point: I have heard of cases of rads being sued for supposedly not telling the referring docs that there was finding on a patient's study. A preliminary entered into PACS might be helpful here, and no doubt that was done in these cases. But keep in mind that even calling the doc, telling him the findings, and documenting this in his report might not be enough; the doc could simply call him a liar. You see, even with a phone-call, supposedly the epitome of service, there would be no independant audit trail.

Some people prefer automation, some prefer the human touch. While Vocada Veriphy uses the former, RadStream uses the latter. The Vocada rep was almost snide in his support of automation over humans, but RadStream's use of a human in the communication equation makes rather good sense. Yes, one can automate the rules to contact Dr. Big Referrer, and Vocada will follow them. But, there is a limit to what a computer can do, and how much your referrers will appreciate the computer texting them or emailing them, or whatever. Frankly, this could contribute to the impression that radiologists are lazy, and would rather push a button and have the computer do the dirty work, instead of picking up the phone and calling them. With a human Communication Specialist (RadStream's fancy word for operator), there is the possibility of human interaction, and some on-the-fly decision making such as the referrer himself or herself needs to hear this report, not just his nurse, and the like. Yes, Vocada's automation might have some fallback rules for what to do if no one responds to the message, but it might not be enough.

While there is no set rule at this point, I believe that JCAHO prefers critical communications to be from person to person, not machine to machine. It certainly tells the clinicians that we are making every effort to get them the report as fast as possible, and as intelligently as possible. And it keeps everyone honest.

Amicas has a complementary product called VisionReach that takes care of the less critical results. Basically, the clinician can be emailed or faxed or whatever he/she chooses with the results, and the contact method can be chosen by the clinicians themselves. The emailed report can include JPEG's of key images, and there is also a link to the viewer itself. There is even a tab to allow the clinician to order a followup exam. Nothing like making it easy for them to send stuff to your site!

Carried over from Version 5.0 are a couple of additional features. The embedded Voxar 3D program has more functionality, with color presets and the ability to capture images back to the PACS system. There is also a way to easily cycle through prior studies by hitting the "-" key. Amicas only allows one prior to be visible at a time, and currently the only way to cycle is to bring up the prior list and select the one you want. This new little function will speed things along significantly.

Reading digital mammography is now FDA-approved with 5.0, but Amicas presently does not have dedicated mammo tools. Rather, one can use the regular viewer (and 5MP monitors, of course), or purchase the iRead program from Cedara. With Merge about to go under, I'm not sure how good an idea that really is at the moment.

I did get an extensive tour of Version 6.0 (I almost slipped and called it Impax 6, which would have been totally unforgivable.) I won't reveal the specifics as yet; you'll just have to wait and see. But do trust me on this: Version 6 will be one of the finest PACS GUI's ever offered, combining the easy usability of its ancestors with one heck of a lot of power. Believe it.

My advice to Amicas is quite simple...don't release this until it is ready for prime-time (unlike another Version 6 I know of), but get it ready soon. And don't sell it to GE.

The true test of a product, I think, is whether you would buy it again, having lived with it for a while. I've lived with Amicas since 2004, and I would buy it again in a heartbeat. It works, and it keeps getting better. No, I am most emphatically not on the Amicas payroll, but I am very enamoured with their products. Because they let me work the way I want to work, not the way they want me to work. It's that simple.

Report from RSNA IV: Intelerad

Here it is, my Canadian friends....I promised an update tonight, and I always fulfill my promises. Well, almost always....

My friend Rick from Intelerad was gracious enough to show me some of the improvements to be found in the latest and greatest version of Intelepacs. There has been no huge change, but a nice system is even nicer today.

Presently, my group uses the InteleViewer stand-alone program at our site that has no PACS. My boys are very pleased with it. It helps that one of them trained at ProScan, and learned speed-reading from Dr. Pomeranz himself. Dr. P. is an Intelerad user, and even was featured doing live readings from the Intelerad booth. I wonder if any fellows back in Cinci overread his live readings...

The Intelepacs worklist is a little spartan, being mainly a table of values, but there is color coding for status, and the colors can be changed at the user level. Great way to confuse your partners if they are foolish enough not to sign out of their account! Each column can be moved about, and one can sort by the column value or search for something specific within. To actually read a block of studies, simply click and drag over the ones you want, and they are sequestered to you. One can apply various worklist filters, although there is no natural division that I could see, such as a divider between one day and the next as Amicas does it. Still, this is a very usable setup.

The Intelerad folks have done something impossible; they have topped the Amicas spine labelling program. Well, it isn't a huge triumph, but they have developed a way for the computer to automatically realize if you are advancing cranially or caudally (up or down for those in Rio Linda) after starting at a particular level (which you still have to specify.) It works well.

Tab thumbnails have been added for displaying prior studies, a nice touch. There is again Voxar or TeraRecon integration. Presentation states can be saved, although one customer voiced concern about referring docs seeing how he left the window/level settings. Well, just because you're paranoid doesn't mean they aren't out to get you, I suppose, but I'm really not too worried about that.

At first, I thought the hanging protocol setup was as user unfriendly as Sectra's, but then Rick realized that I wasn't familiar with the "Capture" function. This simply captures (duh) the on-screen layout, and then you can tweak it with a complex system that is pretty much like Sectra's. But it works, and in the end, it's pretty much like Amicas' which I'm very fond of.

There is a method for ER reports to go back and forth, and an audit trail thereof. Voice clips are now included in the interface.

Bottom line, this good program has become even better, which would help to explain it's #1 KLAS rating. Not that I believe KLAS ratings, but.....

Report from RSNA III: Agfa Impax 6.4

I spent an hour or so with my old friends from Agfa, and they didn't seem to have any weapons in sight, either. My paranoia may be overstated, or at least misplaced.

We had the chance to look over some of the new stuff going into Impax 6.4, which we should receive at the end of January, 2008. There are some nice interval tweaks and fixes, which will improve the Impax experience. First and foremost is a marked improvement in the CT/MR multiplanar navigation. This will include auto-linking, and active targeting. This eliminates a significant complaint we had with 6.2, where triangulation was trying at best. Window/level and zoom parameters can also be linked. Version 6.4 will support Vista, but only if you don't have any Barco monitors. Likely a driver issue at this point. Comments, Barco? The simple search function is tweaked, and is now a bit more customizable, and usable overall. A glitch in deployment of Voxar 3D has been fixed, and I will no longer accidentally activate Voxar 39 times during the course of my reading. There is also a nice new toy, Smart seek web access. This appears as a tab or tabs in the study information are of the information screen. Basically, it is a smart browser, connecting one to various search engines such as Google or MyPACS. It is set to search on the body part or history, or what-have-you of the case up on the viewer. Could be a time saver in practice.

Agfa is working on an EMR display, called the Impax Clinical Module (we were assured that the button labeled ICM could be renamed), which requires a server box called the Enterprise Clinical Dashboard. No, I don't know how much that might cost.

A rather important new option is the incorporation of Vocada's Veriphy critical result reporting program. What Vocada (now owned by Nuance/Dictaphone) lacks in spelling ability, they make up in usefulness of their product. Veriphy is an automated system that will follow pre-set rules to notify our illustrious referring clinicians of a critical result. One can set the system to send a text with a phone number to call to get a voice clip, for example, or even send an email. This step is documented, as is the clinician's response, so the JCAHO requirement for an audit trail is fulfilled. Since this is about the only way to graft such a system (including voice clips) onto Impax, I was impressed. There are similarities to Amicas' RadStream, which the Vocada salesman poo-pooed, but in some ways RadStream works better, as it reprioritizes cases based on pre-test criteria. But you can't get RadStream for any other PACS at the moment, so it is somewhat of a moot point. Anyway, while Veriphy is a separate program, Impax will automatically log you into it upon startup.

We were also shown Works In Progress, many of which looked quite promising. Dr. K, one of our finest MSK rads (all of our rads are fine, by the way) was quite intrigued with ORTHOGON, a wizard based orthopedic measurement program. Basically, one selects the measurement to be taken, say a Cobb angle, and the program shows via a big red dot where to put the cursor next. It's easy enough for a caveman Nuclear Radiologist to use. "Follow the bouncing red dot" was the watchword.

Agfa is developing its own PET/CT and Virtual Colonography programs, and both look very promising. The PET/CT will perform autoalignment, and should work with any two datasets, no matter their modality. There is a very nice method of growing a volume of interest about a lesion, which seemed to work quite well for SUV's, as well as volume measurements. There is a report generator module as well. I have two complaints about their implementation, though. First, the blending control involves clicking over the word "Blending" at the bottom of the viewport, then dragging to control. Give us a button or a slider, please. Secondly, they are using hot-spots, areas on the viewport that will control various functions. Again, I prefer buttons. I need to see where I'm going.

The Virtual Colon piece is nicely done too, incorporating features that I have seen in some high-end products like Viatronix. In particular, there is an indication of what parts of the colon you have seen, and what you haven't, which could be critical.

AND......coming in 6.5......spine labelling! We saw a brief video of how it will work, and it will be OK, rather similar to Amicas' version, but not quite there. I asked why it has taken several years to reach this point, and was told that it took a great deal of programming to detect interspaces and such. Which is funny, because most other spine labelling programs just interpolate. Don't overthink things, guys.

So, there are many improvements coming for us Impax users. We're still toggling, though....

Report from RSNA II...Sectra

The good people at Sectra asked me and Mike Cannavo, the One and Only PACSMan, to review their latest and greatest, IDS7, and we were honored to do so. I won't repeat the alternative name that their head of US operations, John Goble, gave to one of their non-PACS products, but it proved to us that Mr. Goble has a sense of humour, in addition to running a fine operation. You might recall that when Philips dumped Sectra for Stentor (I don't believe in political correctness, and I call 'em as I see 'em), Mr. Goble posted a letter to Aunt Minnie (which I lifted for the blog) in which he promised continued support for all of the Philips/Sectra customers who feared they might be thrown out into the cold. I gather that Mr. Goble has followed through on his promise with flying colors. In addition, he took the high road, never once trashing Philips for their decision. (I almost said abandonment, but that's a bit severe, and Sectra has prospered. Sometimes, a divorce is good for the kids.)

Anyway, IDS7DX, the radiologist version of the new software, looks uncannily like IDS5, which is the version I saw at SCAR (back then it was SCAR) in 2003. Charlotte, the apps person conducting the demo, told us that this was deliberate. Sectra wanted to preserve the look and feel of the product that was familiar to its users, but wished to update the code to .NET, and freshen and "Windowize" the GUI. This they have done, and apparently they have won an award for excellent .NET implementation. I have said disparaging things about Agfa doing similar things, carrying look-and-feel forward in version after version. I'm complementing Sectra on their efforts because they haven't recapitulated esoteric functionality, as Agfa did. Some things work, some don't, and you have to keep very close tabs on your users to find out which are which.

Anyway, as a .NET program, the new Sectra client may be downloaded via a single click, from anywhere. The same client works for everyone. No separate web-appliances need be used. Preserved is the open API construction that allows Sectra to use a large number of third-party modules, such as Voxar 3D and the like. JPEG 2000 compression is utilized as well, and for the Sectra authored volume rendering program, still in beta, Open GL rendering is performed. Nothing like using a $300 commercial card instead of a $2,000 proprietary version!

Worklists are definable at the system, role, and user level (which is what Impax 6.x was supposed to do, but doesn't.) Very complex worklists can be built through drop-downs. The worklist pane of the extensive (and to tell the truth somewhat busy) information screen does not seem to have state-indication (ala Amicas) but you have the entire list of worklists in the pane to the left of the active worklist, and a study can be dragged-and-dropped from one worklist to another. All panes on the information screen can be resized. There is a study-dependent document or comment field. There is also a blank window that can be filled with the html document of your choice, such as a calendar, stock ticker, or Dalai's PACS Blog.

The viewer component is quite similar to the 2003 version, although it seems able to handle large studies with ease. There is the ubiquitious (these days) extensive right-click menu which can be configured to your heart's content, and one can even change the alt-keystrokes for shortcuts. I must admit I still have some problems with this concept, as I did in my old review of IntegradWeb from the late, great DI. Perhaps it benefits those who have a dozen PACS systems and would like to force the keyboard shortcuts and whatnot to match each other, but maybe the industry should find a standard approach? Oh well, I digress.

The viewer is as usable as any, and more so than many. Hanging protocols, however, need work. There is a way to set up custom protocols, but it is rather cumbersome, requiring the use of a series of drop-down menus that contain every possible series description, and then dragging the various series representations to a mock display. Trust me, it is not user-friendly. Sectra apparently assumes that radiologists won't want to do this themselves, and they are correct on that.

Bottom line is that for Sectra, the port to .NET was successful, given that they did not otherwise massively alter a GUI that wasn't bad to begin with. The worklist display needs some updating, and the hanging-protocol setup needs to be revamped, but otherwise, I could like this. More than some other systems I know altogether too well....

Report from RSNA: Part I of ????

I made it to Chicago without much difficulty. As a matter of fact, Delta got me here 10 minutes early, and didn't even lose my bag! Not bad for the busiest travel day of the year.

I have yet to attend an educational session, but I'm headed straight to the Cardiac MR talk as soon as I finish this little entry.

One major change I've seen at RSNA is literally around my neck; the badges now have RFID tags, which lets the powers that be do some sort of monitoring of the attendees. No doubt this information will be used for proper ends, such as making sure that we actually do attend the educational stuff for which we are requesting credit. Personally, I'm worried that GE is using the tags to locate me when their snipers are in position. Nah, that would be too easy.

So far, I've had a quick look at the Philips Precedence SPECT/CT scanner. The darn thing is huge, and I'm not sure it will fit the room where it would need to go. I'll see the Siemens Symbia in detail on Wednesday, but I already know it's considerably smaller.

------

I stopped in at Amicas for a brief chat, and got to see the latest implementation of RadStream, the critical results software. It is very well done, and solves a lot of reporting problems we have at most hospitals. I've gone from a skeptic to a true believer on this one. My real appointment with Amicas is on Tuesday, so I'll have more to report then.

I wandered by the Dynamic Imaging booth, noting with sadness that this is the last time it will be a separate installation. I had a chance to talk with several of my friends, who now sport GE badges. I didn't see any weapons in view, so I accepted the invitation to see some of their latest and greatest stuff. Now, I'm not going to do anyone's product justice in my RSNA reports, since I'm going to try to write them on the fly as it were. But I can tell you that their version 3.7 has some great new stuff. There is a PET/CT reading module that is really well done, basically one of the best implementations of such software I have seen, and I can't wait to get my hands on it at our GE/Centricity site. There has also been improvements in the hanging protocol setup, and there are new overlay options that allow, for example, more optimal display of MR Spectroscopy. I even saw a peek of I5 in alpha form, which uses the same viewer, but tries to do what Agfa did on the information screen, i.e., provide all important info at a glance. They even have a "Coverflow" like display of image series. Frankly, this prototype was a little "busy" for me, but they are on the right track.

As for the integration of DI products with GE, this is still in flux, but DI promised me that they will give me a letter to post that will outline the approach they will take. I know what I'd like them to say, but..... Actually, the fellow in charge of integration of the two product lines was sitting at the table, listening to me wax poetic (that means babble) about the joys of Centricity, and especially Centricity Web. I get the feeling the GE brass hasn't a clue about some of the problems I deal with daily with respect (not) to their products. Now they do.

I've been here at McCormack for about four hours now, and I've met about two dozen folks that read my blog. Many of them had never met me before, and I hope they weren't too disappointed. Frankly, it always surprises me that anyone reads this thing. I'm just posting what I see, filtered through my biased keyboarding fingers. Really, if I've made someone think, or at least laugh, then I've done my job. If the PACS industry is hanging on my every word, well....no one would be more surprised than me.

More to come from cold, cold Chicago!

What Dalai Wants for Christmas

Well, Hanukkah, actually, but I try to be eclectic at this time of year.

I have loved Swiss Army Knives from the first time I saw one as a child. They are fascinating devices, and of course, the more blades and tools, the better.

You may know that there are two competing companies making these little jewels, Wenger and Victorinox. Click HERE for a full history of the Wenger operation, and HERE for the Victorinox story.

Wenger periodically offers an Elite version for collectors and so forth, and this year, their masterpiece is like nothing you've ever seen, at least available for sale. In fact, it is noted in the Guiness Book of World Records:

Here are the specs:

• 85 Implements110 Functions
  2.5" 60% Serrated locking blade
  Nail file, nail cleaner
  Corkscrew
  Adjustable pliers with wire crimper and cutter
  Removable screwdriver bit adapter
  2.5" Blade for Official World Scout Knife
  Spring-loaded, locking needle-nose pliers with wire cutter
  Removable screwdriver bit holder
  Phillips head screwdriver bit 0
  Phillips head screwdriver bit 1
  Phillips head screwdriver bit 2
  Flat head screwdriver bit 0.5mm x 3.5mm
  Flat head screwdriver bit 0.6mm x 4.0mm
  Flat head screwdriver bit 1.0mm x 6.5mm
  Magnetized recessed bit holder
  Double-cut wood saw with ruler (inch & cm)
  Bike chain rivet setter, removable 5mm allen wrench, screwdriver for slotted and philips head screws
  Removable tool for adjusting bike spokes, 10mm hexagonal key for nuts
  Removable 4mm curved allen wrench with philips head screwdriver
  Removable 10mm hexagonal key
  Patented locking philips head screwdriver
  Universal wrench
  2.4" Springless scissors with serrated, self-sharpening design
  1.65" Clip point utility blade
  Philips head screwdriver
  2.5" Clip point blade
  Golf club face cleaner
  2.4" Round tip blade
  Patented locking screwdriver, cap lifter, can opener
  Golf shoe spike wrench
  Golf divot repair tool
  4mm allen wrench
  2.5" blade
  Fine metal file with precision screwdriver
  Double-cut wood saw
  Cupped cigar cutter with double-honed edges
  12/20-Guage choke tube tool
  Watch caseback opening tool
  Snap shackle
  Mineral crystal magnifier with precision screwdriver
  Compass, straight edge, ruler (in./cm)
  Telescopic pointer
  Fish scaler, hook disgorger, line guide
  Shortix laboratory key
  Micro tool holder
  Micro tool adapter
  Micro scraper - straight
  Micro scraper - curved
  Laser pointer with 300 ft. range
  Metal saw, metal file
  Flashlight
  Micro tool holder
  Philips head screwdriver 1.5mm
  Screwdriver 1.2mm
  Screwdriver .8mm
  Fine fork for watch spring bars
  Reamer
  Pin punch 1.2mm
  Pin punch .8mm
  Round needle file
  Removable tool holder with expandable receptacle
  Removable tool holder
  Special self-centering screwdriver for gunsights
  Flat philips head screwdriver
  Chisel-point reamer
  Mineral crystal magnifier, fork for watch spring bars, small ruler
  Extension tool
  Spring-loaded, locking flat nose-nose pliers with wire cutter
  Removable screwdriver bit holder
  Phillips head screwdriver bit 0
  Phillips head screwdriver bit 1
  Phillips head screwdriver bit 2
  Flat head screwdriver bit 0.5mm x 3.5mm
  Flat head screwdriver bit 0.6mm x 4.0mm
  Flat head screwdriver bit 1.0mm x 6.5mm
  Magnetized recessed bit holder
  Tire tread gauge
  Fiber optic tool holder
  Can opener
  Patented locking screwdriver, cap lifter, wire stripper
  Reamer/awl
  Toothpick
  Tweezers
  Key ring
  Actual Size: 8.75. W x 3.25. L
  Weight: 2lbs 11oz
  Limited lifetime warranty
  Made in Switzerland

So, GE and Agfa...if you're in the process of selecting my Christmas gift, this is what I really, really, REALLY want. Remember, it's the Wenger Giant Swiss Army Knife™ V1.0, Model #16999. Oh, the price? Only $1,200.00. But I'm worth it, right?

A Very Scary PET/CT Scan

Here is an axial PET/CT fusion sequence performed on a 36 year old woman with a history of melanoma. Does anyone see anything interesting?

I had known this patient was to be scanned, and she had been extensively counselled. I didn't realize, however, that she was on schedule for this particular day. Imagine my loss of intestinal control when I started scrolling through this study.

While I don't know for certain, this has to be one of the only, if not THE only, PET/CT scans depicting a twin gestation in the literature.

A Weird PET Scan

.

Above, you will find the uncorrected and the corrected coronal images from a recent PET/CT scan performed on a GE Discovery ST. The patient is a young man in his 20's with newly-diagnosed lymphoma. There is some distortion in height due to the way I saved it, so ignore that. Notice, however, the intense, diffuse, homogeneous skin activity. This is not unusual for a non-attenuation corrected image, but we should not see this degree of activity in the corrected version. The study was repeated the next day with the same result. The patient had not eaten, wasn't cold, and had even been given Ativan. GE says nothing is technically wrong, and the patient must have something wrong with his skin. I asked the Siemens apps people, and they said there was obviously something wrong with the processing. Do I detect a little bias?

I'm at a loss here, folks. Anyone have any ideas???

Disconnected!Dalai's Laws In Action...

My friend and colleague Henry (that is his name, but he doesn't go by it) called me a few hours ago. "Dalai," he said, "I've got bad news and worse news for you. The Bad news is that the downtown campus of one of our hospitals just got cut off from the Internet. Some ditch-digger severed a main AT&T cable, and we're completely dead. The Worse news is that YOU are on call! See ya!" Actually, he didn't just leave at that point, but he did his best to inform all possible clinical services, and especially the ER, that PACS would be dead. Fortunately, the hospital's suburban campus is still online, and we can divert the patients over there. For the moment. So far, I have only had to be rude to the downtown Nucs tech, who didn't get the word and did a V/Q anyway. I was able to send our guy who gets done at 8PM over there on his way home, so all is not lost, and the normal V/Q will be read in a timely fashion.

This is a wonderfully unfortunate demonstration of Dalai's Laws of PACS, in particular, Laws I and IV. Law I, "PACS is the radiology department" is quite obvious when PACS is dead. All we can do is look at the CT console for those direst of emergency cases that can't be shipped out. I suppose we could film the hundreds of CT slices....nah. Because Dalai's Fourth Law says, "Once PACS, never back." We are not going back to film. Ain't gonna happen.

We can do little but wait for AT&T to fix the communication problem. We were told that could take from 2 to 8 hours. Right now, we're at 9 hours and counting. What should we have done here? This is a situation that is foreseeable, but not easily solvable. We have backups upon backups, but we don't have a backup for the most critical component of all in a web-based system: the Network! While it is the Internet that failed here, we would be just as dead if our LAN failed, so I'll group them together. In today's case, however, it was obviously the WAN that croaked. At this point in time, there aren't too many alternatives for broadband access. In my town, we have DSL, run mainly by AT&T, and cable, run mainly by Time Warner. There are various permutations with MetroE's and Frame Relays and such, but ultimately, all of these require physical lines, wires, fiber optic cables, or whatever, and those can be cut. The only other possibilities would be satellite internet, which is relatively slow and expensive, or a direct microwave connection to an ISP, which would be fast but still expensive. (No, I don't have time to pull the numbers, being on call and all, but trust me on this.)

I'm thinking WIMAX, the promised nationwide WiFi system, might solve this problem. Put an antenna on the roof, and you're connected. It would certainly have avoided an entire hospital being shut down by a ditch digger. Although I suppose a lightning strike or other such event could knock out WIMAX as well. Maybe we need to go back to dial-up?

The only good to come of today's experience is that we are able to tell the ER docs to think long and hard before they order useless studies. OK, we didn't use the word "useless" but the message got across. Maybe the mentality will sink in. Probably not.

Night of the Living Democrats!...Starring Me and a Host of Celebrities!

The geniuses at JibJab have done it again with a series of do-it-yourself (sort of) videos. Above is one of a zillion possible permutations. See what you can do with it! There's also a version for Democrats, if you happen to be of that persuasion.

I just had to try it myself....

Intelerad Is User 50,000!!

On October 26 at 9:14 AM EDT, someone from Intelerad in Montreal, Quebec, became user number 50,000. Congratulations to the lucky reader. I'll be sending out your prize momentarily. You are now the proud owner of a 30-day trial version of the InteleViewer Workstation software! What's that? You already have one? Oh well...

We continue to use InteleViewer quite successfully at our site that still has no PACS. For $500 annually, I think it beats eFilm hands down. Frankly, for $5000 annually it would beat eFilm hands down. Outside of open source software, this is the best deal around for the smaller operation.

October has been the best month yet, and it isn't even over! Check out the stats:

If you guys keep reading, I'll keep writing. What a deal!

The Road To PACS....Or Ruin

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

Every year, my friends at AuntMinnie.com review the various radiological offerings to be found at RSNA. Since I seem to make the trek to Chicago every year for this extravaganza, I appreciate AM's attempt to distill the thousand plus booths down to the hundred or so that I can actually visit. I actually do attend the education sessions at RSNA, which can be quite a frustrating experience with literally 50 of them going on simultaneously.

I have taken the liberty of copying AuntMinnie's PACS Preview and posting it below:

Agfa HealthCare(Booth 4106) Agfa HealthCare will highlight six suites of its Impax portfolio, each targeted at specific healthcare segments, at the 2007 RSNA conference.

Amicas(Booth 2583) Amicas will feature version 5.5 of its Vision Series PACS network and introduce version 2.0 of its Vision Reach module in its RSNA booth this year.

Ashva Technologies(Booth 6421) Ashva Technologies of Plymouth, MN, plans to showcase version 2.0 of its iMagic ultrasound image management software at this year's RSNA conference.

Aspyra(Booth 3307) Aspyra will feature new versions of its AccessRad RIS/PACS and AccessNet PACS software at the 2007 RSNA meeting.

Brit Systems(Booth 3503) Brit Systems will highlight a workflow package for outsourced radiology reading applications at the upcoming RSNA conference.

Carestream Health(Booth 2513) Carestream Health of Rochester, NY, plans to showcase the latest version of its Carestream PACS offering in its RSNA booth this year.

Cedara Software(Booth 1316) Cedara Software will feature its C4 integration platform and development tools for software developers at the 2007 RSNA conference.

Cerner(Booth 1365) Cerner of Kansas City, MO, will showcase developments with its ProVision Workstation at this year's RSNA meeting.

CoActiv Medical Business Solutions(Booth 5741) CoActiv of Ridgefield, CT, will emphasize its Paperless-PACS concept, which adds paperless capability to its Exam-PACS line, in its RSNA booth.

Connect Imaging(Booth 6551) Connect Imaging of Honolulu plans to debut PACS Dashboard in its booth at this year's RSNA conference.

DR Systems(Booth 2165) DR Systems will highlight new mammography features on its Unity RIS/PACS platform at the upcoming 2007 RSNA show.

Dynamic Imaging(Booth 4765) Dynamic Imaging will feature upgrades to its IntegradWeb line at this year's RSNA conference.

EBIT AET(Booth 3339) Italian vendor EBIT AET will present enhancements to its Risolution RIS/PACS portfolio at the 2007 RSNA meeting.

Eclipsys(Booth 6959) Expect Atlanta-based Eclipsys to focus on enhancements to its Sunrise PACS line at this year's RSNA show.

Emageon(Booth 8508) Emageon of Birmingham, AL, will spotlight its RadSuite Express PACS offering at McCormick Place in Chicago.

Empiric Systems(Booth 5738) Empiric Systems of Morrisville, NC, plans to demonstrate version 5.0 of its Encompass.Net RIS/PACS network in its 2007 RSNA booth.

Fujifilm Medical Systems USA(Booth 1129) Fuji will highlight the latest version of its Synapse PACS software at this year's RSNA conference in Chicago.

GE Healthcare(Booth 1729) Expect GE to feature its recent acquisition of PACS vendor Dynamic Imaging. On the product side, version 3.0 of Centricity Imaging-PACS will be highlighted in the company's RSNA booth.

Healthy Information Technology(Booth 8938) Healthy-IT of Newport Beach, CA, will feature upgrades to its TelePax offering on the RSNA show floor.

Heart Imaging Technologies(Booth 3588) HeartIT of Durham, NC, will bring its WebPax VS package to this year's RSNA meeting in Chicago.

IMCO Technologies(Booth 4183) IMCO Technologies of Pewaukee, WI, will highlight software upgrades on its IMCO-PACS at the 2007 RSNA show.

Infinitt North America(Booth 8520) Infinitt of Phillipsburg, NJ, plans to direct RSNA attendees to its Cardiology PACS offering.

Integrated Modular Systems(Booth 3204) Integrated Modular Systems (IMSI) will feature its ImageWebGate service, as well as several upgrades, at this year's RSNA show.

Intelerad Medical Systems(Booth 4759) InteleRad Medical Systems of Montreal will come to McCormick Place in Chicago armed with new features for its IntelePACS and InteleViewer software.

Intuitive Imaging Informatics(Booth 3965) Intuitive Imaging Informatics (I3) of Los Angeles will feature enhancements for its Rational Imaging and ImageQube PACS lines at the upcoming RSNA show in Chicago.

McKesson Provider Technologies - Medical Imaging Group(Booth 2542) McKesson will present the latest releases of its Horizon Medical Imaging and Horizon Cardiology packages at the 2007 RSNA meeting.

Medicor Imaging(Booth 3295) Medicor Imaging of Charlotte, NC, plans to introduce its MiPACS MedView image distribution software at this year's RSNA meeting.

Medsynaptic(Booth 1051) Medsynaptic of Pune, India, will feature its Web-based MedSynapse PACS line in its RSNA 2007 booth.

Medweb(Booth 3959) Medweb highlights for this year's RSNA meeting include upgrades to its Dashboard application and a 3D/4D WebPACS offering.

Merge Healthcare(Booth 1122) Merge Healthcare of Milwaukee will display a range of RIS/PACS offerings at the 2007 RSNA conference in Chicago.

Meta Fusion(Booth 6456) Meta Fusion will feature upgrades to its Helium RIS/PACS application at the upcoming RSNA meeting.

MIMvista(Booth 4174) MIMvista of Cleveland will present its RT-PACS offering in its RSNA booth this year.

Neurostar Solutions(Booth 3582) Neurostar of Atlanta will focus on enhancements to its Virtual Radiology Network (VRN) at the RSNA conference this year.

NovaRad(Booth 3202) NovaRad of American Fork, UT, will spotlight version 7.0 of its NovaPACS software in its RSNA booth.

Philips Medical Systems(Booth 4129) Philips Medical Systems of Andover, MA, will demonstrate versions 3.6 and 4.1 of its iSite PACS line of PACS software at this year's RSNA meeting.

Radlink(Booth 4711) Radlink of Redondo Beach, CA, will tout its ThinPACS network for single or multilocation office practices.

RamSoft(Booth 4303) RamSoft will show new versions of its One RIS/PACS and PowerServer PACS offerings at the 2007 RSNA meeting.

Rogan-Delft(Booth 6908) Rogan-Delft of Veenendaal, Netherlands, plans to showcase a range of additions to its View Pro-X (VPX) viewing application.

ScImage(Booth 2551) ScImage of Los Altos, CA, will emphasize updates to PicomEnterprise, as well as mammography and advanced visualization tools, at this year's RSNA show.

Sectra(Booth 6513) Swedish PACS vendor Sectra will feature version IDS7/dx of its PACS diagnostic workstation software in its RSNA 2007 booth.

Siemens Medical Solutions(Booth 7713) Siemens will direct RSNA attendees to developments with its syngo platform, as well as a range of advanced visualization software.

Thinking Systems(Booth 4583) Thinking Systems of St. Petersburg, FL, will debut new PET/CT and cardiac imaging functions for its ThinkingPACS line at this year's RSNA meeting.

Visage Imaging(Booth 2591) Visage Imaging, a subsidiary of Mercury Computer Systems, will place its Visage PACS/CS into the limelight at the 2007 RSNA conference.

Visus Technology Transfer(Booth 8401) Visus Technology Transfer of Bochum, Germany, will present new enhancements for its JiveX system on the RSNA show floor at McCormick Place.

Voyager Imaging(Booth 4050) Voyager Imaging of East Hawthorn, Australia, plans to focus on the benefits of its Voyager PACS image data prefetching technique.

I'm not seeing many new names this year, but perhaps the good news is that the vast majority of this rogue's gallery were present last year. I'm personally thrilled that Jive-X PACS made it another season.

To give Mike Cannavo, the One and Only PACSMan some fodder for his annual awards, just look at the names of some of the other systems. iMagic? Is that how it works? Carestream? Sounds like something a urologist might prescribe. MedSynapse? Uh, Fuji, are you taking note of this? Oh, Medsynaptic is based in Pune, India, and is likely out of the reach of trademark infringement suits. I notice Visage/Mercury doesn't mention their acquisition of SoHard software from Germany anymore. Helium PACS? Does it float, or do we talk funny after inhaling it? Eclipsys has Sunrise PACS; isn't that somewhat of a contradiction in terms?

I always thought the name "Freedom PACS" would be great; freedom from tyranny, freedom from bloatware, freedom from things that get in your way, and so on. The title is for sale, cheap.

The roadmap naturally notes the acquisition of Dynamic Imaging by GE, and we're all anxious to see how the booths merge. The sad fact is that if everyone who has ever been associated with DI (including users, potential buyers, lookie-loo's like me, etc) gathered in a corner of the GE booth, they might well take up about 5% of GE's massive plantation on the exhibit floor.

The way things are going, the 2015 RSNA PACS roadmap will probably be a lot shorter: GE, Siemens, Philips, maybe one or two others. These behemoths will have gobbled up everybody else. I have the feeling, though, that open source PACS, or at least vendor-neutral archives might reinvigorate the smaller operators in this game. We'll see. In the meantime, I really think Connect Imaging needs to bring me out to their place in Honolulu to have a look at their PACS Dashboard and other offerings....

Will Work For PACS...When National Healthcare Just Isn't Enough

Bandaged from head to toe to show the importance of the new PACS technology at Seaforth Community Hospital, Don Morton, of Seaforth, adds to the total as donations came into the Seaforth Legion or were called in to CKNX radio during the annual Healthcare Heroes radiothon held on Saturday. Photo by Susan Hundertmark, courtesy http://www.seaforthhuronexpositor.com/

You won't hear about this in many places, but PACS is a pretty expensive proposition. So what is a small hospital with limited funds going to do when it decides to take the plunge?

If you work at the Seaforth Community Hospital in East Huron, Ontario, you hold a Radiothon!

The Seaforth Community Hospital foundation came very close to achieving its goal of $50,000 with $49,713 in donations during the annual CKNX Healthcare Heroes radiothon on Saturday.“It was a very successful day with just terrific community support,” said foundation chair Ron Lavoie on Monday. . .(S)ome of the larger donations included $5,000 from the Seaforth TD-Canada Trust, $2,500 from the Seaforth CIBC and $1,000 from the Seaforth Lions Club.

PACS technology allows diagnostic tests, including nuclear medicine, CT scans, x-rays and ultrasounds to be produced with digital images, which can then be transferred electronically.Adding in the amount raised at Saturday’s radiothon, the foundation has raised $175,713 of its goal of $213,283 for the first phase of the PACS fundraising.When the first phase is achieved, Lavoie said the next three years will be spent working towards the second phase - $350,000 towards a new x-ray machine for SCH.

Dr. Heather Percival, a physician on staff at Seaforth Community Hospital, who apparently is not a radiologist, noted:

"This technology is absolutely essential. It’s important to keep us at the same level as the city hospitals. Without this technology, we are back in the so-called dark ages,” she said. Percival pointed out that small towns have to work hard to fundraise for up-to-date technology, pointing out that some U.S. cities have more MRIs than the entire province of Ontario.

OK, everyone, take note. This is the end product of National Health Care. Radiothons to buy PACS systems. No doubt the Foundation will be holding a bake-sale to continue to fund their PACS. They will eventually have to pay for a viewing station, electricity, Cat 5 cables, and so on.

The US health-care consumer probably would never consider phoning in a donation to pay for his or her scanner. I really think some out there are anticipating Hillary-care with glee, thinking the government will give us the same level of service we get now, but for free. Sure. Right. Just ask the fine citizens of East Huron how much "free" care they're getting. You might want to ask them how much tax they pay, in addition to radiothon donations. I wonder if said donations are tax-deductable in Canada?

Free My PACS

Walt Mossberg from the Wall Street Journal discusses problems caused by restrictions wireless companies place on customer's phones. Courtesy of http://www.wsj.com.

I generally agree with Walt Mossberg's technology assessments, published in the Wall Street Journal. I am not, however, a Palm Treo aficionado like Walt is, and I think he needs to get himself a new cell-phone. But that's a minor disagreement.

Cell-phones are the topic of Walt's latest rant, Free My Phone, published in today's WSJ. Walt is disturbed about the limitations placed on technology by the US cell-phone carriers:

Suppose you own a Dell computer, and you decide to replace it with a Sony. You don't have to get the permission of your Internet service provider to do so, or even tell the provider about it. You can just pack up the old machine and set up the new one. . .

This is the way digital capitalism should work, and, in the case of the mass-market personal-computer industry, and the modern Internet, it has created one of the greatest technological revolutions in human history, as well as one of the greatest spurts of wealth creation and of consumer empowerment.

So, it's intolerable that the same country that produced all this has trapped its citizens in a backward, stifling system when it comes to the next great technology platform, the cellphone.
A shortsighted and often just plain stupid federal government has allowed itself to be bullied and fooled by a handful of big wireless phone operators for decades now. And the result has been a mobile phone system that is the direct opposite of the PC model. It severely limits consumer choice, stifles innovation, crushes entrepreneurship, and has made the U.S. the laughingstock of the mobile-technology world, just as the cellphone is morphing into a powerful hand-held computer.

That's why I refer to the big cellphone carriers as the "Soviet ministries." Like the old bureaucracies of communism, they sit athwart the market, breaking the link between the producers of goods and services and the people who use them.

To some extent, they try to replace the market system, and, like the real Soviet ministries, they are a lousy substitute. They decide what phones can be used on their networks and what software and services can be offered on those phones. They require the hardware and software makers to tailor their products to meet the carriers' specifications, not just so they work properly on the network, but so they promote the carriers' brands and their various add-on services.

Now, the tie-in to PACS is obvious, and this really parallels the argument I presented in my older post, "Euros, Assumptions, and Greek Islands," wherein I bemoaned the fact that one cannot place an interface from Company A on Company B's archive.

It's somewhat ironic that I should be taking this stance. Remember my post about my visit with Dr. Bernie Huang? When I saw PACS in its infancy, it seemed to me that the only way it would be practical would be to package it in one box, i.e., sell the archive, the viewing stations, and probably the wires themselves as one package. I have to think I was right at the time, and in fact this approach represents about 99% of the PACS installs out there at the moment.

But today, PACS has matured and things have come full circle. There are vendors that make great GUI's, but are said to have weak back-ends, archive architecture, and some that have just the opposite reputation. Some use Windows components, and some use Sun/Unix based Oracle databases. There are SANs, NAS's, tape drives, DVD archives, and so on. Yes, I'm throwing a number of disparate elements into this mix, but you get the idea. Why should we be married to one company for every aspect of the PACS solution? Right now, the answer is that the vendors have us locked into the status quo. If you don't agree, just call your vendor and tell them you are going to migrate to another company's GUI. The only way to do so is to forklift out what you have and transfer all the data to the new system, GUI, archive, and all. Not so easy. It's just like trying to take your AT&T phone and migrating it to Sprint. You can't. It's not technically possible, because they are incompatible systems. At least PACS data can be migrated after a fashion, although any peculiarities in the way data is stored (like compression, for example) will bung up the process. (For a fantastic discussion of databases and archives and migration thereof, please have a look at Mike Cannavo's latest Aunt Minnie article, "Exploring PACS Secrets -- Straight talk about archiving and data migration.")

The thought of opening up PACS in the manner proposed is probably giving execs for the major vendors chest pain, or perhaps something lower. They will claim that this concept will interfere with patient care because their system won't work as it should. I respectfully disagree. Mossberg cites a similar decoupling in the telecom industry, that worked quite well:

We've been through this before in the U.S., though many younger readers may not recall it.

Up until the 1970s, when the federal government intervened, you weren't allowed to buy your own landline phone, and companies weren't able to innovate, on price or features, in making and selling phones to the public. All Americans were forced to rent clumsy phones made by a subsidiary of the monopoly phone company, AT&T, which claimed that, unless it controlled what was connected to its network, the network might suffer.

Well, the government pried that market open, and the wired phone network not only didn't collapse, it became more useful and versatile, allowing, among other things, cheap connections to online data services.

I suspect that if the government, or some disruptive innovation, breaks the crippling power that the wireless carriers exert today, the free market will deliver a similar happy ending.

And the same for PACS.

To Boldly Go Where No Man Comes Back From....

As DeForest Kelly, Mark Lenard, and James Doohan have discovered, the fame of Star Trek is fleeting at best, and eventually one must shuffle off this mortal coil, and go to the Great Beyond. Of course, James Doohan did indeed make it into space postumously, as his ashes were sent on a suborbital flight along with those of astronaut Gordon Cooper and 200 others.

But short of that, how can a Trekkie take the Star Trek Universe with him or her when he beams off this planet for the last time?

Eternal Image, maker of funerary for the passionate, has the following solutions:

The Star Trek Casket is designed after the photon-torpedo case used as Mr. Spock's casket in Star Trek II: The Wrath of Khan (image courtesy of: http://www.mikedunn.com):

For those so inclined, the 24th century reminescent Urn might be the best place to put your ash(es):

These items will not be available until next year, so please refrain from dying until then.

Amicas Gets New Prez....

My friend Peter McClennan, President and COO of Amicas, apparently will depart that position at the end of the year. I was tipped off last night to check Amicas' SEC filings, and discovered this:

(b) On October 1, 2007, AMICAS, Inc. (the "Company") notified Peter A. McClennen, the Company's President and Chief Operating Officer, that the Employment Agreement between Mr. McClennen and the Company dated March 28, 2005 (the "Employment Agreement") would not be renewed. The Employment Agreement provides that either party is entitled to give written notice of an intention not to renew the Employment Agreement prior to its expiration date, December 31, 2007, provided that such notice was given within a specified time frame. Mr. McClennen's employment with the Company will cease as of December 31, 2007

I think that's legalese for "they are parting ways".

I've come to know Peter over the years, and he is very capable and personable. He has nicely overcome his GE background and I think really helped to put Amicas on the map. I would hire him if I could afford him, which I can't.

I have only two bones to pick with Amicas as run by Peter. First, he appears to have supervised the removal of the beloved Green Amoeba logo:

The replacement is just not as catchy:

Secondly, Amicas has blamed DRA-2005 in large part for lackluster sales. I have had some discussions on this topic with some of the other execs at Amicas, and I guess we'll agree to disagree.

Dr. Steve Kahane, Chairman and CEO, will take over Peter's duties come January. Steve is also incredibly capable and personable as well, and I'm sure he'll do just fine. He is no newcomer to this sort of thing, having headed Datamedics and VitalWorks in the past.

I hope Peter doesn't go back to GE, but if he does, maybe he can turn around some of the mentality that gave us Centricity as it exists today. (More on that in an upcoming post!) Best of luck! I'll be glad to write a letter of recommendation, although a letter from this Dalai Lama might not be exactly helpful....

A Record Month!

As you know, I keep track of visits and such via Sitemeter.com. This month has ended with a bang, showing the most visits ever. I'll keep writing it if you keep reading it!

Falling Down

Image credit: http://en.wikipedia.org/wiki/Image:Falling_down.jpg

A significant portion of my business lately has come from Falling Down. No, not the old Michael Douglas movie, but rather the actual falling down of patients, mainly the elderly. I cannot tell you how many dozen examinations I have read over the past several weeks that were prompted by an old person falling. The average age for this particular problem is creeping up, although the range is widening overall. I'm seeing more and more exams on those in their late 80's and early 90's, although I haven't seen any on those 100 and over for a while.

According to the CDC as quoted by eons.com, falling down is "the leading cause of injury-related death in people over 65, primarily the result of hip fracture complications. (B)y by 2020, medical costs from hip fractures alone—resulting from falling accidents—are expected to cost the healthcare system between 20 and 50 billion dollars." Big problem. Really big problem.

It may be a stupid question, but why do old people fall down? And how can we prevent this from happening? There are several answers out there....

From www.laterlife.com, we find this:

Scientists at the University of Birmingham have been investigating this troubling phenomenon, and they’ve found that vision plays a part.

It seems that the normal thing to do, when walking through cluttered environments, is to look ahead to locate safe places to put one’s feet. But older people need to look much sooner to these targets, possibly through a slow-down of reflexes or a need to make sure that the way is clear.

Result is, they are in danger of looking ahead before they have sufficient visual information to negotiate the step immediately in front of them. And this makes for a higher risk of tripping and falling.

The eons.com article adds:

There are intrinsic changes associated with the aging process. The changes that increase the risk of falling are a degrading musculoskeletal system, sensory function, and gait changes associated with aging.

There are actually many factors that contribute to slip-and-fall accidents in the elderly. Medication side-effects can cause balance problems or dizziness, which can lead to falling. Elderly people have more chronic illnesses. Arthritis, for instance, is one of the major factors in falling. Pain associated with joints can cause falling. Fatigue, osteoporosis, dementia, and all sorts of things that more commonly strike the elderly, can lead to falls.

As my wife's grandfather, who passed away at age 93, used to say, "Getting old isn't for sissies."

So, what can be done about this? There is a long list of precautions to consider, such as these exerpted from the eons.com article:

Minimize changes in walking surfaces, and use slip-resistant coverings

Use lighter-colored floor surfaces to create color contrasts between walls and floors

Increase lighting and reduce the contrasts in lighted areas

Securely install grab-bars positioned for support

Don't wax floors

Avoid climbing and reaching to high cabinets

Always keep a night-light on in your bathroom

Use bathroom rugs with nonskid backing

Install light switches at the top and bottom of stairs

Be sure carpeting is tightly woven and installed so it doesn't move or slide

And so on. Perhaps the most important recommendation for the older generation is to maintain good health, and not to let the fear of falling get in the way of exercising, and enjoying life. You see, there's a lot more to look forward to as we get older than having some cranky radiologist read your hip radiograph!

Sniping for Fun and Profit

Cute, isn't it? But that's actually not the sort of sniping I'm talking about. Rather, I am referring to those low-lifes who are my nemesis on eBay... Let me elaborate.

I love dabbling on eBay. I love to pick up bargains, hard-to-find collectibles, necessities of life, what have you. Now, I'm not addicted or anything; I can quit any time I want to. Really. No, really!

Anyway, for years now, I've been trying to find an affordable piece of the Star Trek universe, preferably one that had something to do with medicine. Perhaps a screen-used scanner, or Dr. McCoy's uniform, or surgical scrubs. These things do appear on eBay all the time, and I have bid on a few. But, I haven't won any of them, and it's all because of the bloody snipers!

So, what's a sniper? eBay itself offers this definition of sniping:

Placing a bid in the closing minutes or seconds of an auction-style listing. Any bid, placed before the listing ends, is allowed on eBay. To protect yourself from being outbid at the last moment, enter the maximum amount you're willing to pay for an item up front, and eBay will bid automatically for you, making sure you're the high bidder until your maximum is reached. This system is sometimes called proxy bidding.

eBay has no problem with this practice, and why should they? The seller is happy, the sniper is happy, it's only the unsuccessful buyers like me that aren't happy! But think about how this works, and you may see it from my point of view.

When an item is listed for auction on eBay, a time limit of one, three or seven days is selected for the sale. Bids trickle in over this period. But, it is at the last possible minute that the sniper swoops in and tries to outbid, leaving others no chance to top him or her. Now, eBay's response about the proxy bidding system is well-taken. If I can only stomach spending $500 for McCoy's old tattered uniform, then that's what I bid as my maximum. But I'm going to feel really bad when Mr. Sniper cuts in 10 seconds before the auction is over and gets it for $501. This is the problem with the system: there is always someone out there willing to pay just one more dollar (or five when things get into the higher priced realm) for the item in question. In addition, some of these auctions end during working or sleeping hours (No, they are NOT the same, thank you), and it is impossible for me to sit on the computer and snipe, or snipe back, as the case may be.

There are those who live and die by sniping, and justify the practice till the cows come home. This site, for example, basically says that snipers aren't doing anything wrong, so leave them alone. Personally, I disagree. There is a certain degree of unfairness, of violating the spirit of the thing, by sitting and laying in wait, ready to outbid the bidder by the smallest increment possible. Why is it unfair? Because there is no possibility for said bidder to "fight back", except perhaps to place a ridiculously high proxy limit. Maybe that is the answer after all.

Technology has provided a solution, or perhaps aided the problem. There are a number of automatic bidding programs out there that will electronically snipe for you. I won't link to them because I think it is a nasty practice, but feel free to Google the concept yourself.

So, since I'm not happy with the status quo, how would I change things? In my bidding travels through the net, I have found a site for guns and knives and such called GunBroker.com. (You would be amazed at the weapons available on the 'net!) They have a little something called the "15 minute rule":

In a typical auction setting, there is always a called out counting that happens to allow buyers time to decide to place higher bids. This 'final call' is reset each time someone places a bid. . . .(B)ecause of delay caused by the Internet and other possible technological speed bumps, we have a 15 minute final call time.

. . .If there is bidding activity on the auction within fifteen (15) minutes of when the auction is scheduled to close, the auction automatically switches into a special mode analogous to the 'going, going, gone' period of a live auction. In this mode, the auction is automatically extended until there have been no bids placed within fifteen (15) minutes. . .The 15 minute rule makes auctions more fair, by allowing all bidders an equal opportunity to place their best bid. In other online auctions where an auction ends exactly at a given time, some bidders will hold their bids until the last minute or so, in the hope of winning an item on the cheap. This is referred to as 'sniping'. The 15 minute rule gives all bidders an equal opportunity to place their best bid on an item before the item closes. This way, no bidder loses an item to sniping, and the seller can be assured that he has gotten maximum value for the item.

In a recent survey, a feature similar to our '15 minute rule' was the #1 most-requested feature addition that eBay (R) users would like to see added to the eBay (R) site.

I'm really not sure why eBay won't do this. It seems a great deal more "fair" than the sniper system. Perhaps eBay is worried about auctions continuing forever, but I really doubt that would happen. At least every participant has a fighting chance, and isn't guaranteed to get away with something based on a loophole. (Remind you of any other practice I've been writing about?)

Oh well, I guess I might as well get hold of one of those sniping programs....

Entertainment in Rome

Observed just off the Piaza Navona. You've seen the white-clad "statues" of friars, and even the "Statue" of Liberty played by street-mimes. Here is something truly different....

The Ultimate Pointing Device

I have posted here and there about the various pointing devices on the market and how they work (or don't) within the PACS environment. They all attempt to translate your thoughts into motion on the screen in some manner. Wouldn't it be nice to eliminate the mechanical middlemen and just "think" your way through a study?

As reported in Medgadget, our friends at Microsoft are working on just such a project. No, their goal is not a new PACS interface, of course, but this would certainly be a great application for such technology.

The project is in a very preliminary state, but the essence is this:

We have built software infrastructure that acquires the signal from our EEG devices, transforms our data into relevant features for our machine learning algorithms to build predictive models, and classifies new data in real time. The system also allows us to easily store, playback, and visualize raw as well as classified data.

They have used this primitive prototype to control various tasks, including playing the video game Halo. That's not bad.

Some comments made on this topic suggest that the technology will be used for mind-reading, and other nefarious purposes. I seriously doubt, however, that such capabilities will be present for quite a while, as in decades at least. Would you trust Microsoft with the keys to your brain? Perhaps, as long as they don't try to apply patches or service releases!

In the meantime, consider the possibilities of powering through your daily stack by concentrating on the images. I guess this means I'll be even more sedentary than I am already. Maybe Microsoft can come up with some virtual muscle stimulation.

Don't Even Ask About Today's Special.....