Toledo

Jamie Farr, MASH's "Max Klinger," Number One Fan of the Toledo Mud Hens (photo courtesy http://mash.sipe.cz/)

There's some mud of a different sort being slung around in Toledo these days. As documented in the longest thread in AuntMinnie.com history, a company called Imaging Advantage was hired to cover radiology at the three hospitals of the Mercy System in Toledo. Imaging Advantage, IA, displaced Consulting Radiologists Corporation, whose radiologists had served Mercy for 50 some-odd years. But this isn't just a simple business deal, and everyone in private practice radiology needs to hear the story. I'm exposing my small but loyal and extremely intelligent readership to the situation in hopes that they will spread the message even further. Since the Aunt Minnie thread has reached over 2000 posts, with almost 90,000 hits, I'm going to do you the favor of attempting to distill the story down to manageable length. This is a very long story, and I'm sure you don't want to read about every last little detail. Still, what happened in Toledo has repercussions for all private practice radiologists, and the word needs to be spread. I've been reading and participating in the Aunt Minnie thread, and I've been in touch with the radiologists involved, thanks to the organizational skills of AuntMinnie user Dr. Sardonicus.

Let's start with the timeline of events. Sometime last October, a consulting firm was brought in to the Mercy system to look at radiology. No one seems to know precisely the name of the consulting firm, but the few faces seen by radiology at the time seem to belong either to IA personnel or to members of RCG, the latter a consulting group run mainly by radiologists from the Massachusetts General Hospital. Keep that connection in mind.

Fast forward to May. "Spartandoc," the head of CRC (I'll keep to the AuntMinnie nicknames where possible, although real names have been published), was called into the office of the Mercy CEO, Dr. Imran Andrabi, a family practitioner by trade, and told that IA was taking over.From "T. J. Lewis," a member of CRC:

We were told by the administration on Tuesday morning 5/19/09 that we were out on 6/8/09. If we wanted we could become employees of IA. No contract was seen and no details of call or compensation have been given. We are a group of 19 rads in Toledo OH. We staff(ed) 3 hospitals in a system, one of which is a 550 bed inner city teaching hospital and trauma center.

Depending upon whom you believe, IA has either made a go of it, or has blown the deal completely. From the Toledo Blade, 6/28/2009:

To date, Imaging Advantage has about 15 radiologists, all of whom have at least 90-day contracts, at Mercy's three Toledo-area hospitals, and it is working to permanently fill positions by early September, Dr. Andrabi said. More radiologists are working at Mercy now than before, he said, and all off-site test-reading is done in the United States.

There were rumours, which were unsubstantiated, that there would be off-shore reading, or ghosting. This apparently is not the case. But the rads on the ground are apparently all from locums services, at least those that were mentioned in the Blade article, and don't work directly for IA. A significant amount of work is apparently being performed by NightHawk Radiology, although it is impossible to tell just how much is being read, and how much is transmitted out.

How things are going on the ground at Mercy is difficult to determine. You see, there was a gag-order placed on all personnel within the radiology departments, supposedly to avoid HIPAA violations. Somehow, I don't find that believable. But word has trickled out, and it isn't encouraging for IA or MHP fans. Various reports, mainly posted on Aunt Minnie, tell of lots of misses, interventional cases backlogged to a terrible degree, radiologists unavailable for consult, and so on. This is to date anything but a success story.

What happened here? Why was the existing group, CRC, ditched in favor of an unknown? The reason that is circulated is turn-around-time, in essence, it is implied that CRC couldn't get the reports out fast enough. Dr. Andrabi was quoted on this topic in the Radiology Business Journal:

He says that MHP signed with Imaging Advantage believing that radiology report turnaround times needed to be lowered to serve both patients and referring physicians. “We needed to go to a different management model to enable us to do that. For the concept we looked at, we needed teleradiology as an adjunct to on-site physicians to meet turnaround times. From the time something is performed in radiology until the referring physician has it in hand should be no more than 4 hours,” he says.

But even Dr. Andrabi, as quoted in the Blade, realized that there were reasons for CRC having TAT's that appeared to be longer:

One key difference is that Imaging Advantage radiologists working at Mercy will not reread interpretations done overnight by the teleradiology firm it uses. That saves time, although it eliminates a second look, said Dr. Imran Andrabi. . .

The turn-around-time argument is lame at best, and appears to have been rigged at worst. Houdini-Rad, another CRC member posted this:

TAT at MHP was from order entry to signed report. At St. Anne Mercy ave. TAT was less than 24 hrs. Administration broke down TAT's by modality and whined about TAT for speciality MRI, msk, breast, etc. and for CTA's. The problem with CTA's with over 1000 images the PACS would crash. I was once trying to go over a stat CTA of the aorta with a cardiovascular surgeon at the level 1 center and had to load the case on 5 reading stations and as one would crash we would go to the next. He couldn't believe we had this problem and that it was allowed to go on even after our complaints. This surgeon left Toledo last fall. We were given no slack if we were waiting for appropriate outside studies or path reports. As you know getting this info can take days. Thus increased TAT.

I have learned that the PACS in question was an older Kodak Carestream, for whatever that's worth. This is a PACS blog, after all!

The conclusion most will reach is that the MHP administration wanted to get rid of CRC, and replace them with IA, and used TAT as an excuse to do so. The only question now is, WHY?

From what I can gather, the radiologists of CRC have an excellent reputation, and there were no service problems. They were working with some problem equipment, such as the PACS noted above. The only demand I can document is the request for TeraRecon or a similar system, and CRC even offered to buy this themselves. But to no avail.

We do know that a consultant appeared at Mercy in October, 2008, and it is thought to have been RCG. This is important. While Imaging Advantage theoretically has no relation to RCG or Mass General, there were several principals who seemed to have their feet in both camps. IA does tout their use of Tele3DAdvantage (note the rather similar name) which is the "retail" 3D lab from . . . Mass General. I find it very interesting that Tele3D uses Visage, a fine, but significantly less-expensive system than TeraRecon. From ImagingBiz:

One company that has built its advanced visualization platform from the ground up on thin-client technology is Massachusetts-based Visage Imaging, a subsidiary of the Australia-based informatics organization Pro Medicus Ltd. Early on, Dreyer was named head of the medical advisory board at Visage. He says that he quickly began to stress the importance of scalability . . . For two years, Dreyer says, MGH worked with Visage in clinical trials to achieve functionality that would meet the hospital’s needs.

And now we start to understand. . . From the Blade article:

But Dr. Andrabi said that by contracting with Imaging Advantage, Mercy not only will get test results more rapidly but also will have access to other advanced technology.
For example, Imaging Advantage has a contract with Massachusetts General Hospital for three-dimensional radiology rendering services, with images from other hospitals sent there to be converted, he said.

Imaging Advantage plans to extend the service to Mercy, where radiologists will read images converted into 3D at Massachusetts General, Mr. Hashim (CEO of IA) said.
The arrangement will allow Mercy doctors to tell more quickly what problems patients have without the Toledo system having to invest money and time in technology, Mr. Hashim said.

Interesting. Did Mercy dump CRC to avoid buying a system that costs less than $200,000?

Imaging Advantage touts their relationship to Mass General, something that an administrator might find appealing. What else do they offer? Their website tells us:

Imaging Advantage is a market leader in providing comprehensive radiology solutions to hospitals, imaging centers and radiology groups. We focus exclusively on two goals: enhancing existing radiology services in local communities (by introducing 'best in class' services and incorporating local groups and radiologists into our program) and achieving excellence in patient care.Our solutions include: practice management, radiologist staffing, day and night final read teleradiology, subspecialty and quality control programs, and uniquely tailored programs to increase patient throughput, reduce costs and increase market share.

Our team members are graduates of Harvard, Yale, Stanford, Cornell, Columbia, Wharton and other excellent institutions.

Imaging Advantage managers are advised by luminaries in business and medicine including former Cendant CEO and Chairman Henry Silverman and Dr. Alexander Margulis, one of the most respected and acclaimed radiologists in the world. Our Medical Advisory Board consists of a select group of the country's leading radiologists.

Imaging Advantage has a contract with Massachusetts General Hospital (MGH) Radiology to provide 3D rendering services. MGH has representatives on the Imaging Advantage Medical Advisory Board and a separate Oversight Board for 3D. This reflects MGH's interest in promoting the 3D work where MGH has 10 years of experience delivering centralized services.

Imaging Advantage is 100% US-based and all teleradiology exams are read domestically by US board certified radiologists.

Imaging Advantage assists clients in competing during difficult economic times. We market our clients' radiology department services through symposia and through our nationally recognized Public Relations firm.

From the Radiology Business Journal article:

Imaging Advantage CEO M. Naseer-Uddin Hashim says, however, that there is a lot of excitement attached to thinking another way. “Radiology, the way it’s practiced, is very static,” he says. “I think it should be dynamic; that’s our model. Give the local physicians the tools, the technology, and the resources to serve the patient better. I believe you, [the radiologist], are part of a dynamic system throughout the United States. I’m going to put you into that network.”

Hashim describes himself as a former practicing attorney turned entrepreneur. Imaging Advantage began in 2006, he says. He was reluctant to discuss Imaging Advantage’s clients other than MHP, but agrees that the number could be called “several dozen.”

Imaging Advantage, Hashim says, might partner with a radiology group, take over the group, or (as in the case with MHP) take over the radiology service contract with the hospital. Whenever it has taken over the contract, he says, it has always offered jobs to the radiologists in the existing group, which it tried to do with Consulting Radiologists Corp in Toledo. He says that it was unusual for radiologists in the existing group to turn Imaging Advantage down cold, as the Consulting Radiologists Corp physicians did. “This is the first time this has ever happened, where the whole group has decided they’re going to hold off,” he says.

Interesting. If CRC was so bad, why were they worthy of being hired back? And, more important to the wider question, where does IA make its money?

Hashim denies that what Imaging Advantage was doing amounted to a predatory commoditization or corporatization of the practice of radiology. “We’re exactly the opposite,” he says. “I start by working with the local radiologists and saying, ‘Let me make you indispensable.’” Adding teleradiology into the mix, he says, eases the burden on the local radiologists and improves turnaround times on reports. “When you improve turnaround times, you serve patients better,” he says. “The other thing is that you’re removing stress because radiology is a bottleneck, so you’re improving the entire hospital system.”

Hashim says that no payment was made by MHP in the Imaging Advantage takeover. Asked how Imaging Advantage makes money, he mentions efficiencies. “In certain cases, we may also participate on the technical side of the deal,” he adds. “If we increase the volume and efficiency, everybody wins.”

Word that escapes the gag suggests that no one is winning, least of all the patients of the Mercy system.

But what of this "new paradigm"? AuntMinnie user "Jerry Goler" posted a great analysis:

This business model is nothing new. RSJ (Reich Seidelman and Jannicki) and Team health were doing it in the late 90's. Pretty simple...put up booths at hospital administration conferences promising hospital administrators radiology services. There are a large group of administrators who just want power and control...easiest to do with the so called hospital based specialties. Then put out an RFP, which is rigged. The new group gets the contract, gives the old members a chance to keep their jobs. Pretty good chance one or two people will do so, because they have kids in school, etc.

RSJ did this in Sioux City Iowa in the late 90's, destroyed a group but one radiologist had just finished building a customized home to care for...had to stay. Then they rotate locums in and out, and use telerad while trying to entice people to move there and keep 40% of what they make. Of course, it doesn't work, but they walk out a million dollars ahead. Optimal (a group similar to IA) does same thing.

Reason this model works, by the way, is that enough radiologists are out there willing to look the other way and step into these contracts. And they are not competitive ...exclusive contracts are anything but.

. . . As for the rads in Toledo. . .don't know the market, might not be practical, but now would be a good time to build outpatient imaging centers and take the business back. It will be a couple of years, but the hospital will fail because this model sucks. But it will take that long and that much money loss until the board figures it out and dumps this administrator. . .

Goler goes on to say (concerning TAT):

Sure and begorrah, it's blarney. But this is just part of the script. Bet that the rate limiting factor for radiology reports was not the radiologists,but the hospital's fault. They make up something that sounds good to board members, and the uninformed. Then they start slamming the local rads. The consulting group says it's just trying to help, make it a win win situation.

The game is lost at this point, and it will be a minimum of two years before that becomes evident to the general hospital board and employees. The administrator bet his reputation on this working, and using the model right now to see what other docs it can be applied to. The business plan is akin to a pimp, a prostitute turned madam, and a stable of prostitutes. There are about 4800 hospitals in the United States...or a pool of 4800 administrators trying to climb their way up the food chain to the next bigger paycheck. They can do two things to show their value . . . building projects, and getting control of doctors. Madam's make their cut from a big slice of the girls working on their backs and knees. Very profitable business model...service oriented.

Nice visuals.

I would urge you to read as much of the AuntMinnie thread as you can, as there are even more details.

I still don't know what the underlying cause of CRC's ouster really was. There has been all sorts of speculation ranging from a friendship of the principals involved, to kickbacks from IA to MHP, to "arrogance" of Spartandoc ruining a 50-year relationship. There have been at least 5 "new" posters on AuntMinnie supporting IA/MHP, which were so laughably done as to make most of us certain that they were created within the offices of IA itself.

My personal guess (and Mr. Lawyer, it is only a guess, based on my own craziness, and not supported by any fact) is that IA promised some form of return of professional fees back to MHP couched in terms of "savings", as well as the "savings" on 3D rendering. Certainly, the administrators liked the idea of contracting out radiology with better "control" than they had over the group on the ground. Throwing around the Mass General name certainly helped IA's case. The TAT thing was simply an excuse to get in the door, and we know that TAT numbers are easy to manipulate, based on how you actually calculate them anyway.

The Mass General does keep coming up in the conversation:

Imaging Advantage touts a relationship with Massachusetts General Hospital (MGH), Boston, Massachusetts, to provide 3D rendering services. Andrabi says that the MGH service is not yet up and running at MHP. (Spartandoc) says that the MGH connection was used repeatedly during the transition to reassure clinicians at MHP of the quality of Imaging Advantage.

“I think that’s scary for the entire field of radiology", (Spartandoc) says. “The name MGH evokes top-notch, cutting-edge radiology. It’s one of the shining stars. I think it’s frightening that this shining star is leading the way to the commoditization of radiology services.”

But isn't this "just business"? (And typical academic behaviour?) No. A good group was tossed out in what appears to be an unscrupulous manner. I think most of us have good relationships with our administrations, but. . . It is all too easy for those in the C-Suite to be swayed by fast-talking, slick operators with JD's and MBA's. IA is simply the latest example of a bunch of enterpreneurs who think they are smarter than the rest of us. The plan is simple: find radiologists who will work cheap, become the middle-man, and pocket the difference. All the better if the original rads feel compelled to stay on, working harder than they did before for less money. Consider this the Enron-gambit of radiology. It is an unsustainable model, because the guys on the ground get burned out very quickly, but by that time, IA will have made a million or so for its efforts. It can then just walk away from the whole thing.

Thwarting such little Madoff's isn't easy. To do so, we have to perform at our best (a given), and we need to have good relations with our administrations. They need to know how hard we work to add value to the patients' care. There will always be a rogue administrator here and there who falls for the patter of a company like IA. The only defense there is to make sure all rads are aware of just what the IA's of the world actually are, and how they operate. Would you want to work for them? I wouldn't, and I would look askance at someone who did.

CRC is landing on its feet, more or less:

In the end, (Spartandoc) says, Consulting Radiologists Corp decided to downsize, and none of its radiologists signed with Imaging Advantage. Some have left for other jobs, two have gone on sabbatical, and two took early retirement, Cervantes reports. Volume at Consulting Radiologists Corp’s imaging center has gone up 50% since Imaging Advantage took over at MHP, and hospitals competing with MHP are seeing volume increases too, he adds. “They are still without radiology directors at all three Mercy hospitals,” (Spartandoc) says. “I know because I have filed a complaint with the Joint Commission.”

(Spartandoc) thinks that Consulting Radiologists Corp, in its downsized version, will survive. He says that the response to its loss of MHP business from the radiology community has been surprisingly strong. He says, “I’ve had phone calls from all over the country.” His callers realize that the corporate takeover/teleradiology business model, he says, “is bad for patient care, and they’re trying to stop it as soon as they can.”

I wish them well. But for the grace of God go we all.

The Absolute Worst Commercial Ever Made

I finally got around to installing Internet Explorer 8 a few weeks ago. It seems to work OK, although I'm still having some trouble getting used to the tabs vs. windows thing. IE 8 offers a Private setting that lets you view websites without leaving a path, something some of my readers probably wish they had used over the years.

It seems that some people surf to sites they wouldn't want their spouse to know about. The thesis of the following Microsoft ad is that these sites are horrid enough to make the spouse, well, sick to her stomach. Now, the implication that the likely subject of the unacceptable website makes the wife ill is something I won't even try to deal with.

WARNING: This is a really, really, REALLY disgusting commercial. But it actually did air.

I'm writing this on my son's Macintosh, by the way...

Happy Fourth, everyone!

PACS Rumours

In my hallowed position as the Dalai Lama of PACS, I am occasionally in receipt of information that cannot be immediately verified. If I'm in a cantankerous mood, I will post it, although now in my older, more mellow years, I do so with the caveat that the stuff is strictly unsubstantiated rumour.

With that disclaimer in mind, here are some new tidbits:

First, word on the street is that GE has been unable to integrate the Dynamic Imaging IntegradWeb GUI to the Centricity back-end or to the IDX RIS. They are still trying to do so, but it ain't working as yet. Another GE purchase bites the dust?

Second, word on a different street indicates that Philips is developing a new PACS, centered around its XIRIS Ris product. It was noted that Philips hasn't done much to Stentor iSite since its purchase several years ago. iSite might just disappear, or perhaps it will be for sale. Then Sectra could buy it!

Third, Agfa has appointed me head of product development. Nah, I made that one up.

Please feel free to comment with rebuttals, additional scuttlebutt, etc. No death-threats, please.

The Leica Freedom Train

There are thousands of noble, honorable, and ethical people who saved the lives of Jews and other targets of the Nazi regime during the Holocaust. The story of Ernst Leitz, of the Leitz company, maker of the famous Leica camera, has come to light only in the past several years, and it is a study in heroism somewhat more limited, but equally praiseworthy, to that of Oskar Schindler.

As soon as Adolf Hitler was named chancellor of Germany in 1933, Ernst Leitz II began receiving frantic calls from Jewish associates, asking for his help in getting them and their families out of the country. As Christians, Leitz and his family were, of course, immune to Nazi Germany's Nuremberg laws, which restricted the movement of Jews and limited their professional activities.

To help his Jewish workers and colleagues, Leitz quietly established what has become known among historians of the Holocaust as "The Leica Freedom Train," a covert means of allowing Jews to leave Germany in the guise of Leitz employees being assigned overseas.

Employees, retailers, family members, and friends of family members were "assigned" to Leitz sales offices in France, Britain, Hong Kong and the United States. . .

The "Leica Freedom Train" was at its height in 1938 and early 1939, delivering groups of refugees to New York every few weeks.

Then, with the invasion of Poland on Sept. 1, 1939, Germany closed its borders. By that time, hundreds of endangered Jews had escaped to America, thanks to the Leitzes' efforts.

This heroism came at no small cost to Leitz, his family, and his staff:

(M)embers of the Leitz family and firm suffered for their good works. A top executive, Alfred Turk, was jailed for working to help Jews, and was freed only after the payment of a large bribe.

Leitz's daughter, Elsie Kuhn-Leitz, was imprisoned by the Gestapo after she was caught at the border, helping Jewish women cross into Switzerland. She was eventually freed, but had endured rough treatment in the course of being questioned. She also fell under suspicion when she attempted to improve the living conditions of more than 700 Ukrainian slave laborers, all of them women, who had been assigned to work in the plant during the 1940s.

The family and the company likely survived because they were providing critical optics for the Nazi war-effort.

Why has this story only recently surfaced?

According to the late Norman Lipton, a freelance writer and editor, the Leitz family wanted no publicity for its heroic efforts. Only after the last member of the Leitz family was dead did "The Leica Freedom Train" come to light. It became the subject of a book, "The Greatest Invention of the Leitz Family: The Leica Freedom Train," by Frank Dabba Smith.

These are true heroes. The Talmud, the archive of thousands of years of Jewish wisdom and law notes:

Whoever destroys a soul, it is considered as if he destroyed an entire world. And whoever saves a life, it is considered as if he saved an entire world.

This was told to Oskar Schindler, at least in the movie version of his story, and certainly applies to the Leitz family as well.

My next camera is going to be a Leica.

Blog SPAM from. . . GE?

Periodically, I get a comment from an old post. This morning, this comment came through from "Jared" on one of my old posts about Centricity upgrades:

Great post. I especially found it interesting. For this matter, once I discussed with one of my friends, http://www.geonlineservicesite.com/ not only about the content you talked about, but also to how to improve and develop, but no results. So I am deeply moved by what you said today.

There's only one problem. "GE Online Service" has nothing to do with PACS. It doesn't even come from GE, but it seems to front for GE Money, GE's loan division.

Running a WHOIS on GEonlineservice.com, which is the site that is prominently advertised on geonlineservicesite.com, shows:

Domain Discreet

ATTN: geonlineservice.com

Funchal, Madeira 9000-039 PT

AND a WHOIS on geonlineservicesite.com yields names which I ought not publish.

So... geonlineservicesite.com and geonlineservice.com may not really belong to GE at all, and therefore the spam might not be GE's fault. Could they actually be paying for low-quality spam-type advertising? A little digging by my friend Mike Cannavo, the One and Only PACSMan, found this link:

KETTERING, Ohio — July 14, 2008 — GE Money and Brother International Corporation, a leading manufacturer of home sewing and embroidery products, today announced a new multi-year relationship to provide consumer credit through the Home Design program offered by GE Money’s Sales Finance unit.

The private label credit card, available at participating Authorized Brother Innov-ís Dealers nationwide, offers special financing options, including no payment and deferred interest promotions. Longer term promotions are available seasonally. Additionally, cardholders can view their accounts and pay bills online via http://www.geonlineservice.com/.

Tell me why Brother and GE are united behind a website with domain registered to someone in Portugal, with some rather spammy links elsewhere?

I expect GE to track these sites and do something with them, because this is VERY poor advertising for GE, especially the part where I get spammed. They do care about that sort of thing, I think. They could give me a 0% loan for my troubles, by the way.

"Stroke" Diagnosed By GI Bleeding Scan

50-ish year-old male undergoing labeled RBC scan for GI bleed. Scan is positive for, well, something other than a bleed. . .

SIIM in 3D!

Due to various reasons, a new puppy being first and foremost, I was only able to make it to this year's SIIM for one day. Fortunately, I was able to maintain my dignity, amidst a week's worth of house training, and I caught myself before praising any product with the phrase, "Good poo poo!"

Sadly, I didn't get to see as many toys as I had hoped, and I didn't get to stop to see several of my friends in the business. I'll have to rely on others to tell us, for example, if PACS-IW is available yet (rumour on the floor was that the integration to IDX, I mean Centricity RIS-IC still doesn't work, but that is as yet unsubstantiated).

The images above show a the race-car-shaped USB key (and its instruction sheet) given to all attendees, containing all the documentation of the meeting. No tree-killing paper syllabus for us! Of note is the wonderful admonition to:

Be careful when unplug USB Flash Disk. If USB Flash Disk is unplugged suddenly while data is being read or wrote, data may be lose.

I guess I don't always speak the King's English either.

I have to wonder what the carbon-footprint of manufacturing hundreds of little USB cars might be. . .note the logo on the roof which tells us that this was a custom job and not just an off-the-self product. Yes, the USB's are reusable, but if we REALLY wanted to save some bucks and the environment, how about just giving us free WiFi (it was $10 per day, I think) and let everyone download the stuff without further ado? Sometimes, the tree-hugging ecological outlook doesn't go beyond what looks good on the surface.

SIIM this year suffered from lower attendance than was seen last year, probably due to the economy, but also there might have been the fact that there isn't much to do in Charlotte after hours. I'd rather be in Toronto, personally. My friends at PACSAholic have done their usual impeccable analysis of the situation. The exhibit floor was packed with vendors, yet several, Fuji in particular, were notably absent. The floor was NOT packed with customers, as one might see at RSNA.

I only made it to two lectures, but I did sit through them from beginning to end. The first was the Keynote General Session, "The Design and Failure of Useful Things" by Henry Petroski, PhD. This was an interesting journey through the development of simple things like paper clips and straight pins up to the Kodak Carousel slide projectors. Sadly, Dr. Petroski quit at that point, and it was as if no one had told him that this was a meeting concerned with PACS. Oh, the places he could have gone with my concepts of Lego PACS and feature fatigue! The take-away message was that new products are developed to take care of deficiencies in the old products, and developments in new technology come from limitations in current technology. True enough.

The second session graced by my presence was a debate amongst five participants about "Who Actually Owns Imaging?" The session is summarized superbly on the STAT READ blog. The participants outlined the basic arguments for radiology-centric, IT-centric, and even clinical-department based ownership. The most compelling argument came from Paul Chang, M.D., developer of Stentor PACS, who called for enterprise IT ownership under the affinity matrix model. I would present it as a way to own the piece you understand best, with meetings periodically to make sure all is running well, as well as accountability for those involved. My interpretation is really back to what I've been saying all along, ownership has to be shared.

My visit to the exhibit floor was dedicated mainly to advanced visualization, otherwise known as 3D. I did stop in at the Amicas booth, which had a lot of new faces freshly imported from Emageon. I was very impressed with the grasp of the Amicas philosophy and product these new kids displayed. The big news beyond the actual release of Version 6 (Amicas PACS with Halo viewer) is their new vendor-neutral archive. It's rather hard to demo something like this, but their press-release states:

AMICAS Enterprise Content Manager is an enterprise clinical image management and information storage platform. Successfully deployed at many major hospitals and healthcare systems throughout the country, Enterprise Content Manager offers a vendor-neutral archive with proven scalability and interoperability capabilities that supports a broad collection of comprehensive electronic medical record (EMR) deployments.

"The demands on the infrastructure of imaging providers have never been more intense," said Paul Merrild, senior vice president of marketing and business development at AMICAS. "Given the impact of higher exam volumes and an explosion in the average size of imaging exams, the pressure to scale and support multiple imaging departments with a standards-based solution that is integrated with the provider's overall EMR strategy has never been more acute."

"AMICAS' vendor-neutral archive solution addresses these problems with a proven, standards-based infrastructure that supports multiple departmental PACS solutions - all while lowering the total cost of ownership of an imaging infrastructure over time," said Mr. Merrild.

Key features of the Enterprise Content Manager platform include:

Massive scalability with proven performance managing billions of exams throughout the country - representing petabytes of storage - via a high-availability architecture

Proven compatibility as a vendor-neutral solution with many major radiology and cardiology PACS vendors, which offers a lower total cost of ownership for the enterprise

A highly compliant, standards-based architecture with strict adherence to the IHE framework and protocols, which helps providers avoid costly data migrations as clinician preferences for departmental solutions change

Proven support for numerous provider EMR solutions at many institutions, including some of the largest healthcare systems in the country

I'm glad Amicas is on board with IHE. Amicas is not the first with a vendor-neutral archive, but it deserves serious consideration as we progress head-long into EHR-land.

Agfa has some interesting things to see. IMPAX Mobility, a rebranded version of EasyViz by Medical Insight of Copenhagen, is a limited viewer designed to be independent of platforms (no JAVA, .NET, etc.), utilizing only 1.5 MB of code, which utilizes server-side rendering for faster loading and response. It will integrate better to EHR's than big ol' IMPAX 6, and it has some fairly decent tools including limited 3D capability. You can demo EasyViz by signing up with Medical Insight. It does require an additional server attached to your PACS.

There is a second, even more limited viewer under development called Xero, which uses AJAX and is browser independent. It allows varying window/level and zoom within a browser window. This is geared toward Agfa's version of the vendor-neutral archive, which is in the works as well.

I started my 3D software hunt at the Agfa booth, a good place to start given the fact that if we actually get to buy anything this year, it will attach to or integrate with our IMPAX 6 installation. Right now, we have the Toshiba/Voxar software package loaded on each workstation. This would be replaced by Agfa's "Volume Viewing" module with full MPR, curved and oblique recons, VR, and so on. It works more or less like Voxar but with one little problem: The tools are embedded into the margins of the image. For example, there is a faint little hand icon that lives at the top of the image window; you click it to access the "pan" function. I didn't like this sort of thing when I used it on ScImage, and I don't like it here, either. Too much skirting all over the screen, you know. The PET/CT module has similar controls, and goes a step farther (behind, if you ask me) by having the blend function controlled by clicking and dragging over the word "Blend" at the bottom of the image. Uh....no. As of yet, one can only view one PET/CT at a time, without the ability to compare old and new. That's coming, I'm told. There will be auto-registration of any two modalities, not just PET and CT, with the adanced Fusion/Registration program.

As for cardiac work, Agfa sells the HeartLab product, and to do coronary work, HeartLab opens a window into.....the TeraRecon server, which you have to buy if you want to do coronaries.

Which takes us to TeraRecon. This is pretty much the 900 pound gorilla of the advanced imaging field. I won't even try to do it justice in this brief description, but suffice it to say that there is a considerable degree of automation, and that most functions are available over the network via thin client. The number-crunching is performed server-side. TeraRecon uses Dell 2900 and 2950 servers with a proprietary rendering board. Adequate bandwidth is needed for thin-client access, miminum of 3 MBPS, more optimally 5-6 MBPS for advanced functions. The product is sold by the number of simultaneous users. This can be deceptive. I predict that only a few rads at a time would access the system. However, once we get the surgeons and the like on board with this, we might have many more folks banging on the servers. It's a good inducement to go for the unlimited package, which is pretty pricey.

With TeraRecon's Aquarius iNtuition package, you get automated coronary evaluation and report generation, and automated virtual-colonoscopy processing as well. There is similarly mostly-automated reporting of stent evaluation, (EVAR) which supposedly can generate $300 reimbursement per case. The PET/CT tools are a little limited with manual registration of an old and new study required, although autoregistration is said to be in the works. Brain perfusion is available with pnumbra overlay. Tera has all the usual 3D bells and whistles, with automated table and bone removal, and relatively easy production of pretty 3D movies.

The other big player in the 3D sandbox is Vital Images. However, as I reported a long time ago, we owned several Vitreas, and when one broke, I couldn't get anyone from Vital to call me back. They found me on a cold call years later, and still didn't have much to say. Sorry, Vital, since you didn't have time for me, I didn't have time for you.

I have made a bit of fun of Visage Imaging in an old post, mainly because their old parent, Mercury Computing, bought a German company named SoHard, and I just couldn't let that go. Visage is now owned by Promedicus of Australia, by the way. Maybe we'll call Visage CS the 800 pound gorilla. It offers a significant part of the TeraRecon palatte, exceeding it in some areas, for a much lower cost.

Visage uses HP servers, with a Windows database server, and a Linux rendering server. Each rendering server can handle six concurrent users. Like TeraRecon and Voxar, the thin-client can be integrated to Impax 6. Toolbars can be configured and the whole thing runs on one or two monitors, as you wish. There are the features we have come to know and love, like one-button removal of ribcage and scan table. The degree of automation of a coronary exam is not quite that of TeraRecon, but it still works quickly and cleanly. There is no automatic stenosis detection, a deliberate move, as the Visage developers felt that too many errors were introduced by the detection algorithm. There will be automatic detection of the coronary tree in the next version, or so I'm told. Calcium scoring is semi-automatic; the program finds the calcium densities, and one then "lassos" the artery to select the proper vessel. Brain CT perfusion is automatic, just select an artery and vein, and off you go.

Visage does better with PET/CT than TeraRecon at the moment, and almost exceeds the performance of MIMVista, which is to me the gold-standard. As with MIM, Visage has the capability of auto-registering a new to an old PET/CT, as well as registering the PET component to the CT component. The one thing it doesn't do is automatically propogate the marked lesions from the old to the new exam, but there are provisions for doing this manually, and then giving the percent-difference in volume (and I think SUV as well).

Visage prides itself on using off-the-shelf equipment, particularly the latest in nVidea video cards. The service/upgrade program routinely replaces the video card with the latest and greatest.

Based on what I've seen, our choice between Visage and TeraRecon will be made primarily on funds. TeraRecon is a more powerful product, but Visage is right up there, with maybe 85% or so of Tera's functionality. Visage is considerably less expensive. I won't say how much cheaper, but "a lot" would be a reasonable description. If you have lots of cash to spend, go with TeraRecon, but if money matters, and it does for most of us these days, Visage is a very reasonable alternative.

We plan to bring both workstations in for a side-to-side comparison (shoot-out!) and I'll report on the results when that happens.

If there is something you saw at SIIM that I didn't mention (the vast majority of toys, sadly), please enter a comment with your take on it.

I'm not sure I'll make it to SIIM 2010 in Minneapolis, but look for me at RSNA this year. I have to get data to feed my audience somewhere!

Dalai's Goin' To SIIM!

I haven't been to SIIM since it was SCAR, back in 2003. Somehow, the stars didn't align properly until now, and with this year's meeting in nearby Charlotte, I'm planning to be there for at least part of the time.

We have a new addition to the family, Sophie, who is keeping me busy in the meantime. She is a Havanese, a breed that came to this country via Cuban immigrants. We were going to name her "Cohiba", but that didn't seem to fit her personality. At 8 weeks old, she can sit on command, but there are still a few things she does without command that need work.

I do plan to be at SIIM on Friday and Saturday, and I promise, I'm going to spend some time in the educational sessions. But Caveat Vendor, I'm going to be wandering the exhibit floor, looking for the new and the different. If there's anything you think I should have a look at, please let me know in the comment field below.

Sadly, I'm hearing that many companies, such as Fuji/Empiric, won't have a presence at SIIM, a sign of the economic times. Still, there should be a lot to see, and I'm really looking forward to it.

See you in Charlotte!

Dalai's PACS Reading Room

Note the revised Dalai! Xtra-Normal, the site I use for these inane animations, needs to get some new characters, but in the meantime, I'll work with what I've got. It's the dialogue that's important!

Strike Up The Band(width)!

When I first became active in the PACS world, I adopted a goal from my senior partner/mentor: "Sit here, read there". This was to apply to every site, every examination in our enterprise. Today, we have met that goal, both with our group-owned system, and with PACS provided by the hospitals. I can indeed sit at any site within our realm, and for that matter, at any broadband-connected computer, anywhere, and peek at any particular study that takes my fancy. When you think about it, that is quite an achievement.

All of this interconnection requires, well, a connection! That would be the various networks and portals into the Internet. As I have pointed out in a previous post, aptly titled Disconnected!, when the network is down, thus PACS is down, and therefore the whole department sits idle except for extreme emergency cases.

We are feeling the pressure of the network in another way. One of our hospitals has somewhat suboptimal internet connections to the outside world. We have tossed blame back and forth as to why their web-based PACS can be viewed but slowly at remote sites, and why our web-based PACS (both Amicas, by the way) crawls when viewed from within their walls. Trying to view the Agfa Impax of the other hospital system from within the problematic facility is just that, trying.

As yet, we have no good reason for this to be happening. The IT folks at the institution in question have switched us back and forth on various lines and channels, this one having no net-nanny or port-blocking, that one having X speed, another having yet more different parameters. All we know is that the situation is deteriorating rapidly, and we have to do something. To use the buzz-words that get everyone's attention, our ability to deliver health-care is being impaired, and this needs to be fixed.

At this point, our main option is to buy our own network. Our system lives in a neutral spot, external to all hospitals. We are on the brink of purchasing Metro Ethernet lines, also called MetroE's, with point-to-point access for our system. This would also give us direct, very rapid access to our own PACS, and should significantly improve the connection to the hospitals, at least we expect it to do so. At a cost of tens of thousands of dollars per year, we don't want to do this and see no benefits!

There might be one last option. Our state is participating in the Rural Health Care Pilot Program (RHCPP) which is designed to link under-served primarily rural hospitals with fiber optic broadband. The network-challenged hospital has apparently signed on to this initiative, and anticipates a great boost in service. However, I'm not sure we would qualify to participate:

Palmetto State Providers Network ($7.9 million)—This project will connect healthcare providers to a fiber optic backbone to enhance simulation training, remote intensive care unit monitoring, and medical education in South Carolina.

I suppose we could sign up to read from any rural hospitals that are properly equipped to transmit out to us. That would be a win-win situation.

In the meantime, we're about to spend a lot of cash for some local bandwidth. At least one part of the economy will be stimulated. . .

DoctorDalai.com On Kindle!

Vanity knows no bounds. In the old days, to make it to print, one had to have an agent, and probably some reasonable amount of talent. Or, for the truly desperate, there were "vanity publishers", who would for a large fee print up a hundred copies of your version of the Great American Novel.

Today, all it takes to be published is a computer, a Blogger.com account, and the foolish notion that someone else might want to read what you're writing. Which is where you, my beloved readers, come into the picture.

There are lots of options for access to this, my favorite blog. First and foremost, you can find me with your computer, right here at DoctorDalai.com. This applies as well to iPhones, iPod Touches, PocketPC's, and even the occasional Blackberry.

But hold on to your shorts, and let loose your wallet. Today, there comes a new option: The Amazon Kindle! For only $359, you can have a pencil-thin slab of 1500 books, or for $489, you can have a larger screen DX version with enough space to hold 3500 books! Of course, if you already have an iPhone, you can download the Kindle app which does a pretty good job of simulating the real thing.

The Kindle has wireless access (with no extra charge) that lets you download books, magazines, newspapers, and so on, for a fee, of course. And now, you can download blogs as well! Here's the teaser for mine:

There is just one catch: If you access DoctorDalai.com through your Kindle, it'll cost you $1.99 per month. Of course it's worth it, right?!

Spock With Sex Appeal?

Image courtesy of: http://lostdiscsradioshow.myfastforum.org/

Things are getting a little out of hand, in the opinion of yours truly, a Centrist/Conservative Trekkie.

I accept the fact that the media is very enamoured with our new President; they helped him get elected, after all, so they might as well hide any buyer's remorse they might have. But Newsweek's Jon Meacham has gone waaaaaay over the line. In an article reviewing a conversation he had with Mr. Obama, Meacham quoted the President as saying, "he saw the new Star Trek recently because 'everybody was saying I was Spock.'" Argggggh! Not Everyone! But the sacrilege goes further:

. . . (H)e appears resolved to keep playing the role—Spock with global sex appeal—that has gotten him this far.

OK, that's just. . . WRONG! Raise my taxes, cut my income, but don't mess with Star Trek! And besides, if you wanted Spock with sex appeal, look no further:

Super Google!

I remember when AOL's WebCrawler and AltaVista were the best of the best for searching the 'net. Then came Google, and the on-line world was never the same. Google today has a huge web-footprint, if you will, dominating the search engine business, and most every other area of the net it touches via ad-driven accessories. Why, this very blog is hosted by Google!

Google can find everything, it seems, but the one thing it cannot do is answer a question. That seems like a daunting task, but there is a new approach with a fine pedigree.

From the Times Online:

A revolutionary new search engine that computes answers rather than pointing to websites will be launched officially today amid heated talk that it could challenge the might of Google.

Wolfram Alpha, named after Stephen Wolfram, the British-born computer scientist and inventor behind the project, takes a query and uses computational power to crunch through huge databases.

The service can compute the distance between two cities, the population of a country at a specific date and the position of the Space Shuttle at a given moment. The user does not have to search through links provided by the engine; the answer comes immediately and, if appropriate, is accompanied by charts or graphs. What it does that Google, at the moment, cannot do is provide answers to questions that have not been answered already.

Wolframs stated goals are anything but modest:

WolframAlpha's long-term goal is to make all systematic knowledge immediately computable and accessible to everyone. We aim to collect and curate all objective data; implement every known model, method, and algorithm; and make it possible to compute whatever can be computed about anything. Our goal is to build on the achievements of science and other systematizations of knowledge to provide a single source that can be relied on by everyone for definitive answers to factual queries.

WolframAlpha aims to bring expert-level knowledge and capabilities to the broadest possible range of people—spanning all professions and education levels. Our goal is to accept completely free-form input, and to serve as a knowledge engine that generates powerful results and presents them with maximum clarity.

WolframAlpha is an ambitious, long-term intellectual endeavor that we intend will deliver increasing capabilities over the years and decades to come. With a world-class team and participation from top outside experts in countless fields, our goal is to create something that will stand as a major milestone of 21st century intellectual achievement.

Uh, yeah. ALL SYSTEMATIC KNOWLEDGE??!! This is bloody amazing, and over-the-top ambitious. I think it's going to take a little while to get there. Still, this thing is pretty powerful already.

Try "Pi to 1000 digits" and you get

Result:
3.141592653589793238462643383279502884197169399375105820974944592307816406286208.
99862803482534211706798214808651328230664709384460955058223172535940812848111.
74502841027019385211055596446229489549303819644288109756659334461284756482337.
86783165271201909145648566923460348610454326648213393607260249141273724587006.
60631558817488152092096282925409171536436789259036001133053054882046652138414.
69519415116094330572703657595919530921861173819326117931051185480744623799627.
49567351885752724891227938183011949129833673362440656643086021394946395224737.
19070217986094370277053921717629317675238467481846766940513200056812714526356.
08277857713427577896091736371787214684409012249534301465495853710507922796892.
58923542019956112129021960864034418159813629774771309960518707211349999998372.
97804995105973173281609631859502445945534690830264252230825334468503526193118.
81710100031378387528865875332083814206171776691473035982534904287554687311595.
62863882353787593751957781857780532171226806613001927876611195909216420199

I checked, and it's the right answer. I put in my last name and found

Basic information for the United States:

Rank: 857th

Fraction: 1 in 7326 people 0.014%

Number: 36,833 people

Ethnic fractions:

White 96.54%
Mixed 1.26%
Mestizo 1.22%
Black 0.46%
Asian 0.4%
Amerindian 0.11%

But when I tried to search for Doctor Dalai, I get "WolframAlpha isn't sure what to do with your input." Which is probably appropriate.

This is one of those "works in progress" that is pretty impressive from the beginning. It isn't Google as yet, but sooner or later, WolframAlpha will surpass it's rival. In the meantime, it's a pretty darn good math homework helper. Give it a try at http://www.wolframalpha.com/. Happy computing!

Devilish Illness

Patient with chest pain. Perhaps there's a bit of a problem with a mortgaged soul as well?

DoctorDalai.com Reviewed!

Slowly but surely, the word spreads about my wonderful blog!

My compadres at the "Radiology Technician Schools" blog took on the difficult task of reviewing 50 radiology blogs

. . . by radiologists, sonographers and industry professionals (which) reveal the ups, downs and nitty gritty details that you would want to read before making a huge decision such as a career path. Check out these top 50 blogs and see if diagnostic imaging is in your future.

Wow. Now, I might be encouraging (or discouraging) someone from entering radiology, radiography, sonography, etc., etc. What responsibility! I'm not sure I'm worthy, but read the review of my site (which was only ranked #4, but to be fair, that's pretty darn good in this rarefied company):

4. Dalai’s PACS Blog – This humorous blog begins with an alternative meaning to the PACS acronym: “Pain and Constant Suffering.” Mixing tongue-in-cheek ad medical analysis, reasons to embrace or avoid medical technology, and more awful medical spam, this site is a buffet of entertainment.

Well, I might have gone so far as to say I'm offering a salad-bar of entertainment. Buffet does sound better, though (except when some relatives of mine pronounce "buffet" as BOO-FAY, but that's another story for another time.)

Many thanks for the kind words. It still amazes me that anyone actually reads this thing, but I'm really glad you do.

Star Trek

Kirk and the gang, although Spock was otherwise occupied.

You knew I would, of course. I went with my son to see the new Star Trek movie on opening day. Somehow, I was able to wait until 10PM to watch in the theatre with the digital projector. Since you've all been anxiously awaiting my review. . .

The very, very short, Twitter version: "GO!"

The longer version: This is a very, VERY well-done movie, at least from the standpoint of a long-time Trek fan. I've been watching Star Trek since I was in second grade, a wee lad of 7, and this is the best episode/movie of the entire franchise. Period. Some have said this is the best science fiction movie ever, and I might be convinced to go along with that opinion. This is what Trek would have been with the film technology of today. The essence of the show, its personalities, its relationships, and so forth are faithfully reproduced, and enhanced. And there is action, a heck of a lot of action. And lots of toys, equipment, and a shiny new Enterprise. I must confess, I had a smile from ear to ear when the new ship appeared, in a scene totally remniscent of the first Star Trek movie from 1978. At least this time, J.J. Abrams kept the pace going, far better than the counterpart from almost 31 years ago.

As you have probably heard in the preliminary reviews, two phrases have been bandied about, "Star Trek Reboot" and "This ain't your father's Star Trek." I'm not going to provide any spoilers, but suffice it to say, both statements are true and accurate. Mostly. You'll understand when you see it. And you should. Five stars from Dalai.

What's On Your Workstation? . . .And Visitors From Waterloo

Courtesy CapitalOne.com

The gang from Waterloo recently came down to come visit me, an average radiologist, at my average hospital in our average town in the South. No, the two gentlemen in the photo above are not our visitors from Canada, but serve to illustrate a different point which you will encounter below. Unlike the last visit, no one had any trepidation about visiting this adorable little fuzzball. In fact, someone actually whipped out a camera to document the event. A tiny liberty was taken, as you will note (click the image for a larger version):

Of course, two can play that game (definately click the image to see what mischief I've wrought):

The Team theoretically came to observe several of us actually use the latest update, the installation of which truly went really well. We did get to chat a bit, and they also were able to videotape my partner, Dr. Killer, use their system as only he can. Hopefully, they had a high-speed camcorder for the purpose. As it turned out, the day they were at the same facility I was at, they had the joy of watching they entire system come to a screeching halt. Literally. Agfa believes in automatically updating its client software, with a little sniffer program living on the client machine constantly on the watch for a new edition. All well and good. Now our update was on the weekend, and many offices are closed then. So, come Monday morning, 1,000 computers (give or take 100) went online and wanted their updates, bringing the system to its knees. This has apparently been solved by placing the software update on a new server separate from our three load-balanced production servers. My solution is to turn off the sniffer on my computer.

The gang did discover a glitch in the update: studies on the worklist will seemingly randomly select themselves, a minor annoyance. This has been fixed with a minor service release. It's nice to have the experts onsite at times like these!

My understanding is that our latest and greatest (6.3.1.409x) has fixes for stuff that is still broken in 6.4.x, which is still in testing itself. We might just wait for the first service release for 6.4 before taking that plunge.

When my Canadian friends first walked in the door, I had our Amicas client running on an Agfa workstation. I sheepishly closed it, but they just laughed and shrugged. Which brings us to the next topic, "What's On Your Workstation?"

Later that day, I attempted to load an updated Amicas client (our Amicas hospital finally upgraded to version 5.x) onto a different Agfa workstation, which required a new Java Runtime Enviroment (JRE). This was one of the few Agfa stations that had a partial lock-down: some software, including Java, could not be changed without permission from On High. When I sought such permission, I was told that Agfa would not allow this, because it would "affect the warranty on the workstation." Well. I guess I've been told, eh? But the story is somewhat deeper.

I don't have a copy of our site's service contract, or warranty, for that matter. A search of the Agfa site yielded this fairly generic warranty document. Here are the pertinent clauses as near as I can extract from the legalese:

2.6 The Service Provider shall be under no obligation to provide the Services to the extent that such Services are required for:

2.6.1 problems arising as a result of the Buyer's negligence or default or because of accident, neglect, misuse (including without limitation unusual physical or electrical stress) or the failure of power supplies, external electrics, air conditioning, anti-virus software, use of incorrect consumables, and any other causes (other than ordinary use) not due to the negligence or default of the Service Provider;

2.6.2 Equipment which has been maintained, modified, altered, adapted, developed, repaired or howsoever changed (including, without limitation, attempts to maintain, modify, alter, adapt, develop, repair or otherwise change the Equipment) by or on behalf of the Buyer by parties other than those that are authorised to carry out such changes;

2.6.3 problems arising from any changes unauthorised by the Service Provider that have been made to any software supporting the Equipment (including, without limitation, adding additional third party peripherals, adding RAM, modifying applicator software or upgrading third party software to non-supported versions); and

2.6.4 problems arising from the removal of or reinstallation of the Equipment at the Buyer's premises by parties other than those authorised to carry out such removal/installation.

I'm no lawyer (thank Gawd!) but my read of this legalese suggests that the warranty is intact if one leaves the primary software (and supporting sofware) alone. Since Impax uses .NET, and Amicas uses Java, you would expect no particular conflicts, and all should be well. In fact, we have been loading Amicas clients side-by-side with Agfa on our home machines for years with no associated problems. (And I think some of my colleagues have loaded Amicas onto some Agfa workstations at the hospital here and there, although I certainly have no further knowledge of such things....) If you were to walk into our reading rooms, you would find all sorts of amusing software on Agfa, Amicas, and even GE workstations. I'm sure this is the case everywhere else as well.

Like running your iPod on a plane before you reach 10,000 feet, I think this is sort of a non-issue. However, IF it is truly affecting the "real" software, beyond stealing some RAM here and there, the proper answer is to completely lock down each and every vendor-managed workstation, in every installation, everywhere. Otherwise, let's just carry on as we have been for years.

What's on YOUR workstation?

PACS Updates, The Best of Times, The Worst of Times

Well, OK, maybe it wasn't that bad, but it was close. Our largest hospital system just installed the latest Impax 6.3.x service update. This operation gives us 71 improvements over the last iteration, some of which include:

Cycle list redesign
When the Cycle list contains many patients, each with a large number of studies, the list can get quite long; finding the desired patient becomes difficult. To solve this issue, the Cycle list has been redesigned. Each patient is now listed with their studies hidden. To view the studies of a patient, click the + next to the patient. To open all of the studies for a patient in the Image area, in the Cycle list, click the desired patient. To open a specific study, expand the studies and select the desired one.

Wildcard for Keyword search in Advanced Search
Keywords are descriptive tags that you can add to a study. Later, you can search for the study using these keywords. To enable the ability to search on keywords without using an exact match, the following conditions have been added to the Keywords criterion in Advanced Search:
1. Contains
2. Does not Contain

Fixed issues:

Slow performance of IMPAX Client when selection of studies is opened in the Image area. When a selection of studies is cycled into the Image area, the amount of time it takes to display them significantly exceeds the amount of time to display a single study.

Series logic broken after combining series in Available Series palette and spanning from one to two monitors. Combined series jumps back to the first series after spanning from view one monitor to view two monitors.

Removing column from Text area Study List causes IMPAX Client to crash. Removing a column from the Text area Study List causes the IMPAX Client to crash.

Study level prompt on dictation interlock is not working correctly. Study level dictation interlock does not behave as desired. Active worklist does not function in this case. As well active worklist is using study based notification when it should not.

Unable to view priors when they are partially cached. Relevant priors cannot be viewed if the study is partially cached; these priors can be viewed after the study is fully cached.

Prior is selected instead of current study when Image area is opened. A current study has a prior study attached to it, the current study is in the local cache, and the prior study is not in the local cache. When attempting to load the current study into the Image area, the prior study is displayed instead.

Active Worklist does not work when cycled studies are also priors of newest study. Active worklist does not always perform correctly when cycling several new studies with relevance on.

User profile is corrupted, not able to see scout images. The user profile in ADAM is being corrupted after logging into the Client a few times. The Actual Width in ADAM for IMAGE_AREA_SCOUT is replaced with zero so the user is not able to see the scout images.

There are numerous fixes for Mammography as well. Obviously, this was a very, very necessary update, and so far this morning, it is functioning nicely.

So, from whence comes my acerbic attitude? I guess you had to be here, but for the six hours of the upgrade, my life was not as much fun as it could have been. I was stationed at our trauma center, the busiest hospital in our enterprise, where the normal workflow is hectic at best. There's nothing like the joy of clicking off the last study on your list only to find ten more have appeared. Obviously, any minor annoyance or disruption becomes major at a place like that.

I'm not going to go into the specific mechanics of the update, mainly because I don't have a firm grasp of them, and moreover, I'm not sure I care that much. I do believe the process involved our Oracle database, the heart of the operation, as it were. What I know for certain, however, is that for the six hours of the update, we were running off of the axillary test server (which had already been updated), and functionality was quite limited.

Because the central database, the Oracle, was out of commission, image data was limited to the new studies, and a preload of the last few week's worth of priors. Could I get a study from four weeks ago? NO. Were there any reports available? NO. Well, yes, but not on PACS. To get a prior report, AND to get an accession number, AND to get a history (if the techs didn't provide such, which they didn't), we had to log into our RIS, which happens to be Cerner RadNet. There is a reason we avoid doing so routinely, which has to do with the fact that it likes to crash, and it is rather unintuitive. Can you guess, even with tool tips, what these buttons do?

The fourth button from the left is the "Radiology Order Viewer", and that is where old reports live, in case you were wondering.

So, for six hours, we were functioning, but in a rather hobbled fashion. Every one of the roughly one hundred studies that came through during this time had to be augmented by this manual drudge though the RIS. You can just imaging how much fun that wasn't.

Now, I don't mean to cast aspersions on our PACS team, nor upon the people from Agfa handling this update. They worked very hard, and did a bang-up job getting us through this (although one of our people had a giant flyswatter ready to whack me if I got too whiny.) No, the problem is in the philosophy of how updates and upgrades work.

I will have you refer back to Dalai's Laws of PACS, specifically the First Law: PACS IS the Radiology Department, and the Third Law: Once PACS, never back. Alter the function of PACS, and you destroy your established workflow, and ultimately impede patient care. Taking PACS away, or even hindering it in the slightest is a really bad idea. The busiest radiology departments cannot have this level of disruption, even for an hour, let alone six hours, or longer.

Updates are necessary and even desirable. They fix problems and deficiencies, and at least sometimes enhance the product. BUT there has to be a better way to handle the upgrade. Frankly, I'm not aware of any particular company that has totally painless updates/upgrades as yet, but perhaps they will listen and learn.

There are multiple architectural issues that necessitate a partial shut-down as we experienced. Probably the most important factor is the existence of the single central database. Beyond this, the rather complex connections between PACS and RIS denied us the ability to hook up the test server to the RIS, even temporarily. Speaking from an only semi-educated standpoint, it seems that we need some additional redundancy, such as a back-up database for these situations. We should already have one, for disaster recovery, yes? So, why not press it into service for this particular non-emergent emergency? Reconciling the changes made to the backup during the downtime should be fairly straight forward. Now, this does assume that the backup is on spinning disk rather than tape. Perhaps what I'm proposing is the establishment of an intermediate database, that holds, say, the last year's worth of data. I don't think this would be all that expensive, folks. And, while I'm no HL-7 guru, I should think that an alternate connection to the test-server (or a fail-over server for that matter) ought to be possible as well.

Bottom line: PACS updates should be a lot less painful than they are now. I don't think it would be that difficult or expensive to make that happen. Like many other problems in this business, this probably hasn't been addressed because no one has yelled loud enough until now. OK, I'm yelling at the top of my lungs! Do you vendors think you could have this fixed by the time of the next update/upgrade? I would really, really, appreciate it. Otherwise, I might have to have a bigger tantrum, and that wouldn't be dignified. Or pretty.

Dalai Is On Twitter!

I've finally succumbed to peer pressure and become part of the Twitter network.  Frankly, I'm trying to figure out where it fits into my world of blogging and the occasional Facebook post.  Feel free to subscribe if you have absolutely nothing else to do.  You might find an occasional word of wisdom.  Or not.  

Still Following The Green Brick Road

As a frustrated Centricity user, I have been waiting and waiting for our upgrade to Dynamic Imaging, I mean Centricity PACS-IW. We just underwent the upgrade from Centricity 2.x to Centricity 3.x. I will freely admit that this was a major improvement; studies appear MUCH more rapidly on the worklist, and transfers to the AW (Advantage Workstation) occur in a few seconds rather than a few minutes. Sadly, the GUI hasn't changed much at all.

I would really like to have Web DX to replace ol' Centricity. However, it seems that legacy Centricity sites will have to buy the IW upgrade, and I don't think my site has done so at this point. Oh well. I'm finding that only a few test sites have Web DX today. Since I'm not at a pilot site (can you imagine GE using me for that?) I can't yet get my grubby paws on Web DX, even if I had the dough available. But that doesn't stop GE from advertising the heck out of Centricity IW, and even receiving awards for the integration of the DI system. From the DI, I mean the GE website (even though it is still http://www.dynamic-imaging.com/) comes the following:

“GE Healthcare is uniquely positioned in the marketplace with one of the leading edge RIS/PACS technologies and a collaborative, internal synergy within the Centricity group that continues to strengthen GE’s position in North America and abroad,” says Nadim Daher, Senior Industry Analyst, Frost & Sullivan. “The multifaceted growth strategy that GE has put into effect capitalized on the strategic DI acquisition and revitalized the company’s imaging informatics business in a mature market segment. . .”

“GE is honored to accept this award from Frost & Sullivan, which validates the success of our Dynamic Imaging acquisition and demonstrates that this was just the right accelerant to our winning business strategy,” says Don Woodlock, Vice President and Global General Manager, GE Healthcare IT Imaging Solutions Group. “This strategy includes leveraging Dynamic‘s acclaimed Web-based PACS across numerous US and global market segments, and integrating the Web-based diagnostic viewer with advanced streaming technology to Centricity PACS.” In addition to this Frost & Sullivan award, GE Healthcare’s Centricity PACS-IW was named Best in KLAS-PACS by analyst KLAS Research and has maintained a #1 PACS ranking from analyst MD Buyline for nearly 3 years.

I love how the acquisition instantly propelled the name "Centricity" from the bottom of the KLAS charts to the top, even though the product is totally different, and not even available yet. But that's show biz, folks.

Anyway, I am still eagerly awaiting my chance at Centricity IW/Web DX. Really. Bring it on! Please!

. . . Priceless

I've just returned after a few days in Naples, Florida, where we went for my Mother-In-Law's big birthday that ended in zero. (The number was somewhat more impressive than my decade-birthday of a few months ago.) Naples is a great place, with nice people, beautiful beaches, blue ocean vistas, and incredible restaurants. Many thanks to Ray and Rick for recommending Truluck's, truly a find.

Speaking of travel, I tried to discover the disposition of the flight-attendant who became ill on our return trip from Costa Rica. Delta, following strict HIPAA rules (just can't get away from that, it seems) wouldn't tell me a thing, but did send me two in-flight drink coupons for my efforts. I've heard about docs receiving free tickets and such for responding to in-flight emergencies, but that apparently is a thing of the past. But no matter. Let's see.....

• Spending three hours standing up in the back of the plane ministering to patient with minimal equipment---$14 in drink coupons.
• Anxiety over the patient's condition---beyond calculation.
• Knowledge that you did the best you could under the circumstances---Priceless.

Eagle-Eyed

This is an ad, obviously, for a teleradiology service called EagleEye Radiology. My Eagle-Eyed friend, Mike Cannavo, the One and Only PACSMan, noticed that the EagleEye teleradiologist is doing his teleradiology from film. Of course, the EagleEye teleradiologist also has a stethescope, so maybe he's a little confused overall.

Someone could make a killing with an ad agency that actually understands medical products and services.

ADDENDUM

Reader Mike O. spotted the intrepid "radiologist" above in a few more stock photos from iStockPhoto.com:

Ah, the captions that come to mind. . . "Why is my pee blue?" "Who's been screwing with my Tinkertoy?"

I'm not sure why EagleEye just didn't use the photos of their own docs. . . although we radiologists usually do like to remain in the dark.

Sectra Spam

Here's a bit of a lesson in how NOT to advertise.

EXPHYS07 posted a comment to my post Dalai Down South, an article which didn't mention PACS at all, but rather talked about my trip to Costa Rica. EXPHYS07 not only placed his comment somewhat inappropriately, but he managed to post the same thing FOUR TIMES. Here is part of what he said:

Sectra IMTEC, AB and Sectra, NA is a relatively small to mid size PACS company that has the second largest install base in the world. It also boasts one of the best balance sheets in the industry coupled with an intensive collaborative R&D program with top Scandinavia Universities and Medical Imaging Scholars. Their original launch into the PACS market began with a reseller agreement with Philips Medical Systems and within the last 7 years they have launched as an independent company that develops, markets and sells RIS-PACS, Mammography PACS, Ortho PACS coupled with a second division that primarily develops and markets secured communication technology to the Government Sector and boasts a contract with NATO and other ministries of defense contracts around the world...

Feel free to read the rest of the text either in one of the FOUR entries, or on EXPHYS07's blog, appropriately titled PACS, where the first and only post consists of the same text.

EXPHYS07's profile reveals that he works for. . . Sectra. No surprise there. He has even become a follower of my blog, which is very kind. So, some friendly advice in return: Please don't spam. Posting multiple copies of the same text, especially when it is your main blog page, is not cool. Comment once, and just provide a link to your page. That will suffice. And try to attach it to an appropriate post. As near as I could tell, there isn't much in the way of PACS in Costa Rica, although it is quite possible that Sectra has a presence there. Why EX chose that particular article is a mystery to me. Unless he is shooting for the Costa Rican account.

Sectra has a very good PACS, but maybe the company needs to work a little more with its reps on advertising and marketing.

MORE Reasons To Avoid Speech Recognition

A recent JACR article by Quint, et. al., noted that "More than 20% of our reports contained potentially confusing errors, and most radiologists believed that report error rates were much lower than they actually were." In response, Peter Marcovici, M.D., a radiology resident at UCSD writes about his own in-house survey. On a scale from 1-5, with 1 being "strongly disagree" and 5 being "strongly agree," his results were as follows:

1. I am satisfied with our VR software: 2.2
2. Our VR software increases my productivity/efficiency at work: 1.9
3. Our VR software decreases my productivity / efficiency at work: .2
4. Using our VR software introduces errors in communication: 4.2
5. I have seen errors in prior reports that I attribute to our VR software (not diagnostic errors): 4.4
6. I have been notified by a clinician because of an error due to our VR software: 3.8
7. I have seen an error attributable to our VR software that has significant clinical implication: 3.8
8. I have had to addend a report because of an error generated by our VR software: 4.1
9. Macros in our VR software increase completeness: 2.9
10. Macros in our VR software decrease accuracy: 3.6
11. Using our VR software enhances patient care and safety: 2.3
12. Our VR software increases potential for malpractice: 3.8
13. Our VR software allows for more time for teaching, learning, and attending conferences: 2.0
14. When reviewing reports generated by our VR software (before finalizing them), I notice errors which need correcting: 4.1
15. When comparing alternative systems (i.e., human transcription services), our VR software is . . .
a. Faster: 1.8
b. More accurate: 1.8
c. Leads to more confusing reports: 3.6

He concludes:

Does it make sense for radiologists to divert their gaze and attention to a third screen to edit thousands of words of text daily?

I conclude: NO! Which is no surprise to anyone.

Bye Bye Birmingham

I have some sources within the newly acquired Emageon offices in Birmingham. It helps to have trained at UAB, the incubator of what eventually became Emageon PACS.

It seems that Amicas will close this office, and will let go several of the folks that work there, albeit with fair severance packages. My understanding is that user support remains pretty much intact, so you Emageon customers need not worry at this point.

No doubt this is a necessary move, and all my inside contacts are expressing understanding of this fact, and hold no ill-will toward Amicas. After all, if Amicas demonstrates the expected hybrid strength following the acquisition of Emageon, they might get the chance to return. Well, maybe. My crystal ball isn't so great with business issues. But these are good people and they will land on their feet. I wish I had enough PACS business to hire them myself!

I guess the rule in business is to do what you must do, no matter how difficult that might be. Sort of the way it is in medicine as well.

The Doctor Dalai Show: Enterprise PACS

Dalai Embraces Agfa!

Sometimes being a pest can work to your advantage. I've been yowling for years about the various deficiencies in Agfa Impax 6. I am proud to tell you today that they have listened to my ranting, and plan to introduce Version 6.6.6, (which I affectionately call the Dalai Edition) which will solve most if not all of the difficulties we have had with Agfa. This product will supercede most of the other PACS GUI's on the market.

Let me outline what V666 will do:

1. No more "X-box" errors.
2. Priors and reports from the earliest days of the archive will be accessible.
3. Proper function of worklists, with indicators for studies available and already being read
4. Elimination of possible double-reads due to poor study sequestering
5. Built-in MPR, 3D, etc, with intuitive function of cursors.
6. Instant on-line priors.
7. No decompression artifacts.
8. Functioning and intuitive hanging protocols.
9. Intuitive tools, with elimination of mega pallette of crap no one uses
10. Easy upgrade/patch installation.
11. Elimination of "toggle" mentality.
12. Others too numerous to list.

Yes, folks, today, Agfa is my new favorite PACS. They have listened to me, and fixed everything that was wrong with their old systems. V666, the Dalai Edition, will make a believer out of you as it has with me. Starting today, I will begin replacing all of my other systems.

Yes, take GREAT NOTICE of Today's Date, because it's the only time you will hear a statement of this magnitude!