Farewell To Chicago and RSNA 2011

Even though it's a bit chilly down here in the Deep South, it is still considerably warmer than Chicago, and it's good to be back home.

My major concentration this trip was on Advanced Visualization, in preparation for our Shoot Out coming in January. I looked closely at the four major vendors involved. I got to meet the CEO's of three of the companies, and had prolonged demos at the same three. One company has invited me to its headquarters, which I must decline while we are in the midst of the decision process. I'm sure I'll still be welcome even if we chose one of the "other guys"...

On other topics...I was really amazed at the number of people who recognized me and/or admitted to being regular readers of this blog. I know I disappointed several of you by not making it back to your booths, and for that I apologize profusely. Contact me earlier next year, and I'll try to do better.

Finally, you may have heard by now that my good friend Mike Cannavo, still the One and Only PACSMan, has gone corporate. He now works for one of the large PACS companies (no, not that larGE company) and has had to hang up his pen. Mike wrote the annual RSNA wrap-up column for AuntMinnie.com for many years.  Now that he has retired, so to speak, I have been offered the chance to take over this prestigious piece. Rather than try to duplicate Mike's inimitable approach, I decided to go quite far afield with a piece of fiction and parody. So, without further ado, please enjoy my first (and possibly last) AuntMinnie RSNA column:

An RSNA 'Christmas Carol'

December 1, 2011 -- For years, the PACSman Awards were an annual tradition inAuntMinnie.com's coverage of the RSNA conference. With the PACSman hanging up his typewriter last year, the baton has now passed to the Dalai Lama of PACS, radiologist and blogger Dr. Sam Friedman, who shares his unique RSNA experience.

CHICAGO - The PACSman was gone, and radiology wasn't looking too good either, no doubt about it. The somber, funereal atmosphere in McCormick Place at the RSNA conference was pervasive, even palpable.

Radiologists wandered the halls, heads bowed, hoping to learn something that might make them a better hospitalist, or pathologist, or whatever the Affordable Care Act might actually support. But there were still some bright spots here and there. A new scanner, a novel technique. A shred of hope for some disruptive technology.

I entered the Technical Exhibit Hall, hoping more for some free candy to quiet my rumbling stomach than any particular revelation. I was immediately swarmed by salesmen in ill-fitting Men's Wearhouse suits.

"A happy RSNA to you, Dalai, would you be so kind as to have a look at our wares?"

"Bah, humbug!" I replied, looking for something to scrounge, or even some swag to take back to my family -- a key chain, a little flashlight, anything to justify my trip to this drab, cold place.

"But Dalai, this is the most incredible of all radiology meetings!" they said. "Surely you have found something amazing here!"
I shook my head and kept walking. There was nothing wonderful here. Why did I choose imaging anyway? Because I loved the field? Ah, the foolishness of youth.

Finding no solace, I turned on my heel and returned along the Grand Concourse to the North Building. In a small basement classroom, I found the session I was seeking, an uplifting little talk titled "Tales of Alleged Radiology Fraud and Abuse."

I settled into the chair and pulled out my iPhone, hoping to find a pleasant email from home. Instead, there were three angry emails from my PACS administrators, all expressing escalating desire to serve up my partners as Christmas dinner for the local wildlife.

As the speaker droned on about the loopholes in Stark II, I found myself becoming drowsy, and to my embarrassment, my head nodded, my chin hit my chest, and I shuddered, startled back awake once again ...

But ... something was wrong, very wrong. I looked about. The harsh lines of the plain McCormick Place classroom were gone. Rather, as I looked around, the room was plush and even gilded. The chairs were comfortable. A man with a bushy mustache at the podium was wearing a suit with narrow lapels and an even narrower tie, and he was speaking about the "revolutionary EMI Mark I." There was a heavily pixelated image on the screen that seemed to be a brain, but it was not very well defined. I blinked. On the podium, emblazoned in gold, was the inscription "the Palmer House Hotel."

Wait! The Palmer House? EMI Mark I? How was this possible? The Mark I was introduced at the RSNA annual meeting in ... 1972! Could it be?

"You bet your ass, goombah!"

I turned to the source of the booming voice next to me.

"PACSman!" I cried out in surprise. "How did you get here? How did I get here?"

It was then I noticed that while he was there beside me, he wasn't quite all there; I could see through him to the gentleman seated two chairs away. He was bound in Cat-5e cable, with broken hard drives lashed to his feet. Strangely, no heads turned in annoyance over our conversation.
"Dalai, buddy, you ate some bad shrimp last night," the PACSman continued. "I told you not to go to any parties put on by the big companies, but does anyone ever listen to me? Oh well, it's nothing but a thing anyway."

"But PACSman, I thought you were gone!" I exclaimed. "Why are we at an RSNA from 40 years ago?"

"One thing at a time, bubbie," he said. "Yes, I've departed your world for one I think will be better. Live and learn, or maybe die and learn, heh? As for the why, look up, friend. You've been brought here to RSNA Past so you can remember the joy and love you once had for medical imaging. Can't you feel the electricity in the air? This was the day when CT became king! Cross-sectional imaging, baby! It all started here!"

Indeed, I could feel the excitement creeping up on me. It was none other than Dr. Sir Godfrey Hounsfield himself speaking to the enraptured crowd at the Palmer House ballroom. What I wouldn't give to have been there -- I mean here -- I mean, whatever.

I listened for a few more moments, but again, my head started to nod, and once more I awoke with a start. I was back in the modern McCormick Place, but instead of re-emerging in the small classroom, I was seated in the cavernous Arie Crown Theater, front row and center. And the gaseous apparition of my friend the PACSman was seated next to me. Clearly, my strange journey wasn't over.

"Hey, Dalai! Pay attention," he admonished. "The president of the American Medical Association is schooling you guys about how much trouble you're in. Something about triple jeopardy and not getting paid. Sounds like a triple whammy to me."

And he was right about that. I couldn't take any more of this. I got up and walked out, magically disturbing no one, the PACSman trailing behind, broken hard drives clanking at his feet.

We wound our way over the bridge to the Grand Concourse, then wandered aimlessly to the Technical Exhibit Hall in the South Building. Before long, we encountered a booth that easily covered the area of a football field. There were hundreds of black-suited, brown-badged gents milling about, looking for anyone wearing the coveted blue-rimmed name tag. I had one on, of course, but I was now accustomed to my invisible status, and I expected to remain unaccosted. The shiny new scanners, lights blinking, spun their tubes in futile pursuit of customers.

"PACSman, what are we to see here?" I asked.

"Isn't it obvious?" he asked. "Here's the deal. No one knows where healthcare is going, so we're all going to start enjoying Thanksgiving again for the first time in 75 years. Instead of freezing our asses off, we'll do an interactive virtual conference with scheduled demos and everything. No muss, no fuss, and no 'free' meals. As a bonus, system prices will drop 30% because vendors won't have to pay for RSNA. It's sheer brilliance, I tell ya!"

I sat down on a PET/CT gantry and bowed my head. The room spun, and when I looked up again, we were seated on a bench beside Lake Michigan. It was a blustery day, with winds one only sees in Chicago in the winter. Strangely, I felt no chill, as I watched leaves blowing through the PACSman's shadowy figure.

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

"PACSman! What happened here?"

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

"But why?"

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

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

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

"No, PACSman!" I exclaimed. "It cannot be! This is an honorable profession, and it cannot end this way!"

I sat back down on the bench, staring at the frigid breakers on Lake Michigan, the wind whipping through my spectral presence by the ruins. I slowly drifted off to the crashing of the waves.

"Dammit, Dalai, watch what you're doing!"

I looked up quickly. The PACSman was standing next to me, very much alive and quite solid, nursing his foot, which I had apparently stepped upon in my delirium. We were in the Technical Exhibit Hall once more. Again, something was different. The booths were lit more brightly than ever before, the scanners positively glowed, and the salesmen were all grinning and patting each other on the back. The customers with blue badges were smiling too, several making excited cellphone calls, clearly happy with a deal they had just made.

"What ... what's going on?" I mumbled, totally disoriented by this, the final shift back to reality. But it was a different, better reality than the one I had left but a moment ago.

"Gawd, Dalai, you really need a cup of coffee or something," PACSman said. "They just announced record sales for this RSNA. All the big boys have sold more scanners in the past three days than they had in the past five years! It's a damn miracle!"

"Yes, PACSman, yes!" I exclaimed. "It had to happen! So many of us love radiology. What a relief! How were we rescued?"

"Probably something to do with that first Tuesday in November, goombah," he said. "Hey, I'd like to stand around and shoot the breeze, but I have to get back to my new home away from home. I'm in a good place now ... good company, good people, good product, and all that jazz."

As he walked away, he turned, smiled at me, and said, "Hey Dalai, guess who gets the Flashdance Award?"

I laughed, thankful that some things never change ...

I ambled my way to the glass portal of the Grand Concourse. The sun was shining brightly, and the traffic cops had shed their slickers in the warm afternoon.

I went outside and walked down by the Hyatt for a ways, then looked back at the sparkling edifice of McCormick Place. I couldn't help but notice the huge banner: "Welcome to RSNA, 2012."

In addition to regular posts in the AuntMinnie.com PACS Digital Community Forums, Dr. Friedman also maintains a blog at www.doctordalai.com. His observations and opinions are entirely his own.

I guess I should probably keep my day job....

Vital: Denoising Is NOT Dose Reduction

After my visit to Kang and HealthFortis, which, by the way is associated with lifeIMAGE, I had the chance to wander over to Vital Images, and discuss our upcoming Shoot Out for Advanced Imaging. I must have been in the company of the right people (hear that, John?) as before I knew it, I was introduced to the CEO and to the EVP of Sales. After the pleasantries, I had the chance to really look hard at some of the things I needed to see, and had a really informative chat with our intrepid (and beleaguered, mostly by me) salesman and technical folks. I left knowing much more that I started with, but I'm going to leave the feature-list for the report of the Shoot Out itself.

One thing I do want to publish right now, though, is some information about denoising. Vital has a really nice denoising subroutine, which will take a noisy scan and smooth it out. Vital made it clear to me, however, and said that absolutely I have their permission to broadcast to the world, that this is NOT dose-reduction software. All it does is make an image that is degraded for whatever reason (NOT to include deliberately degraded) look prettier. No guarantees on whether data is lost, although almost certainly there won't be much lost at all, but users are urged to toggle back and forth between the pretty and the not-so-pretty pictures.

Where the idea of using denoising for dose-reduction came from, I'm not sure. I don't believe Vital ever promised this at all. I think in retrospect we must have found it perusing information from Clarity which DOES promise that one can lower the parameters to levels that produce crappy dose-reduced scans and then "rescue" them with their box, which performs digital filtering on the images:

Clarity is server-based and seamlessly integrates into your existing DICOM network. During installation of the Clarity solution, dose-optimized protocols are established on the CT scanner(s) to deliver desired image quality at reduced dose levels. Low dose images are transferred from the CT scanner to a Clarity server that resides on your DICOM network. Based on desired results that have been pre-determined by your Radiology staff, Clarity algorithms enhance image quality and automatically route the final images to their intended destinations.

I'm not buying it. In either sense of the term.

Much obliged to the good folks at Vital.

CPOE So Easy A Caveman Surgeon Could Use It!

Whilst cavorting with old friends at lifeIMAGE (see the previous post), I had the chance to connect with another old friend, Kang, formerly one of the technical gurus of AMICAS, now CEO of his own little company, HealthFortis. (He's working with another AMICAS alum, Dmitry, whom I sadly didn't get to see this trip.)

Kang, having created some wonderful stuff AMICAS over the years, needed a new challenge, and he picked a big one: CPOE, aka Computerized Physician Order Entry. (Some say "Provider" instead of Physician, which clearly tells us physicians that we are no longer held in particularly high regard, but whatever.) CPOE is clearly a tough nut to crack, as one must create software that physicians (even surgeons and, yes, even orthopedic surgeons) will have to use to order stuff for their patients. Keep in mind, these are guys (and gals) who are used to scribbling something illegible on a piece of paper over the course of three seconds, and then faxing or maybe throwing it (literally) at someone with the full expectation that their intentions will be telegraphed magically. Of course, sometimes they will lower themselves to simply barking said orders at someone, in person or by phone, with the same somewhat unrealistic expectations of completion.

Now that EMR's and such have taken over, computerizing this process in the form of CPOE is felt desirable, and even necessary. But no one asked the physicians about this, and therein lies the path to big trouble.

Our largest hospital system instituted Cerner Millenium CPOE over the past few years, and the physicians to a man (and woman) seem to hate it with a passion. I'm on the CPOE committee for one of our other hospital systems, and we are struggling with the joys of trying to crowbar a entry process into the ancient legacy MediTech Magic program, you know, the one that ports a 1980's green Data General window to Windows. I'd rather be the bagel delivery-boy for the Gaza district.

Kang nicely outlines what is wrong with pretty much every CPOE product out there: it tries to make docs do things differently, and, trust me, docs do not want to do things differently. Why are we forcing them to take 5-20 minutes and 59 mouse-clicks to accomplish what they once did with a piece of paper and a pencil in 3 seconds? The intelligent approach is to first make it easy for the physician to use CPOE, and then leverage all the nice things that an electronic approach can deliver. This, of course, includes "Decision Support at the Point of Decision." Brilliant!

HealthFortis takes a very simple approach. There are just a few points of entry, but they spawn everything appropriate to taking the order, and all of the entry boxes allow for free-text, much like Google, with a list of possible entries building and then narrowing as you type. To find your patient, you might simply type Do Da, which would bring up Doctor Dalai, among other less interesting people. Select the patient and then a simple window appears, wherein you enter the diagnosis and, if you wish at that point, the exam to be done. Here's where the magic starts.  Suppose you enter "AA".  The program gives a few possibilities, such as "AAA", which we then select. You are then given a list of possible exams, ranked by ACR recommendation codes from 9 (good choice) to 1 (you have to be kidding!). Clicking the exam you want spawns an order in HL-7 to be delivered back to your HIS/EMR.  If the condition/symptom isn't quite so specific, the program brings up more data and options to help you decide. Of course, you can still override this and forge on ahead with an arteriogram for little toe pain, but you will definately get a "1" for that choice, and you will be told just why that is inappropriate.

There is included some nice stuff like searches for recent orders of the same type (did you really want to repeat the CT for the 10th time this month?)

Right now, the system is in its infancy, having been online for only a few months, but it is growing, and I'll predict there will be rather wide-spread acceptance. The order-sets for the moment include more radiology exams than anything else, at least as I understand it. Kang did outline a heuristic learning function, which will help grow the database; as more and more entry-pairs are collected, the system will learn which are being used most frequently, and make them more easily available.

This is one of those offerings that is elegant in its simplicity and usability. I'm not sure it will be ready for full hospital use in time to derail MediTech, but it possibly could be deployed at least to physicians ordering stuff from outside the hospital. I'll take that for now.

Make it easy and they will come. Guaranteed.

Disruptive Technology

I'm sitting at one of the RSNA Bistro venues, having just spent $20 on a mediocre buffet meal which did at least consist of some mildly healthy alternatives. I've got a couple of things to tell you about, some from the meeting, of course, but one gleaned from FoxNews while perusing the net over lunch.

Let's start with the fun stuff. I think I've stumbled across the next revolution in photography, and truly this is a disruptive technology. I'm referring to the new Lytro camera, which uses "light field" imaging instead of regular old, well, light.  Here are the three models, the middle version having 16 GB of storage for 750 images, and the others coming in at 8GB for 350 images.

I'll refer you to Lytro's site for an explanation of what goes on in this little box.

Basically...

Capture living pictures with the press of a single button. By instantly capturing complete light field data, the Lytro gives you capabilities you've never had in a regular camera...

Since you'll capture the color, intensity, and direction of all the light, you can experience the first major light field capability - focusing after the fact. Focus and re-focus, anywhere in the picture. You can refocus your pictures at anytime, after the fact.
And focusing after the fact, means no auto-focus motor. No auto-focus motor means no shutter delay. So, capture the moment you meant to capture not the one a shutter-delayed camera captured for you.

And here is what you can create. Click anywhere on the image to refocus, double-click to zoom.

This is the start of something big, I think, although it will probably take quite a while for this to migrate into mainstream photography. Of course, it took quite a while for digital to overtake film. You saw it here on DoctorDalai.com first.

On to things Radiologic.

I attended a seminar on the lifeIMAGE LINCS, the lifeImage Network Cloud Service, narrated by CEO Hamid Tabatabaie, former CEO of AMICAS if you didn't know. LINCS is now fully operational, and it is being used at multiple centers. Hamid showed us a live view of user stats, and the system is quite impressively active. For the full explanation, check the lifeIMAGE website. In brief, the system facilitates easy, HIPAA-compliant sharing of studies between institutions, with the idea of empowering physicians themselves to "be the network". Most every permutation is considered, as long as someone in the equation has a LINCS account. The study can be sent or received with a few clicks among LINCS members, and if a "foreign" study is to be imported to LINCS, appropriate electronic paperwork is presented. A study can then be nominated to be uploaded to PACS, pending approval by whichever human you designate.

Two partnerships offering viewer options and more were announced:

• lifeIMAGE is demonstrating a technology intergration with Vital Images, an advanced visualization and analysis software company, which shows Vital’s FDA-cleared universal viewer launching from LINCS. The two companies are also exploring a collaboration to provide on-demand access through LINCS to advanced visualization tools and comprehensive clinical solutions for cardiovascular, neurovascular and oncology imaging.
• lifeIMAGE also has partnered with ClearCanvas, a leading provider of innovative diagnostic imaging applications, including Picture Archival and Communication Systems (PACS) and workstations. ClearCanvas offers a free version of its diagnostic workstations in an open-source format, as well as an FDA-approved clinical version, that will connect the 15,000 members of the ClearCanvas community to lifeIMAGE.

In my own humble opinion, this places lifeIMAGE on the road to creating a Cloud-based PACS, although when I suggested this to Hamid he just smiled and shook his head. Maybe someday.

lifeIMAGE literally offers us a life-saving (and disruptive) technology, and that is NOT an exaggeration. At our trauma hospital, it is more likely than not that a patient will arrive with a CD from St. Elsewhere that has not even been reported, and probably not even reviewed. And sometimes, that CD won't even load. In the best possible circumstance, we the rads spend 10 minutes loading the CD and reviewing it with the house staff. In other cases, the patient is rescanned, the new scan interpreted, and then reviewed with the residents, adding 30-40 minutes to the process (and doubling the radiation dose if anyone cares about that.) Of course, in the worst possible scenario, the patient could well be dead 20 minutes after arrival in the ED if he is the victim of severe trauma. What would we give to have the images in hand and reviewed before the patient hits the door? A few dollars goes a long way, and that's what lifeIMAGE costs when distilled down to the basics.

Not to sound histrionic, but isn't the patient's life worth that? (And no, I don't get a kickback from Hamid.) This is damn good technology, and you should, you MUST look at it.

My second disruptive technology is one you can't buy, directly, that is. Fovia sells their 3D technology not to end-users like me, but rather to PACS and Advanced Visualization companies, including Merge (where I use a limited thick-client version on my PACS), as well as GE, and Vital, among several others. The full version of their engine operates as a thin-client with server-side processing, and it works very, very well. Fovia has taken a very logical approach. "Which would you bet on as the best investment," asked Ken, Fovia's CEO, "a system that uses proprietary graphics cards, one that uses off-the-shelf gaming video cards, or one that uses the CPU of your computer and leverages Moore's Law?" Ken's answer, of course, is number three.

Fovia has bucked the system, going against the prevailing paradigm of proprietary graphics cards (viz TeraRecon) or gaming cards (nVidia, etc.) and does the graphic processing with a server's CPUs. This may seem counterintuitive at first, but stop and peek inside your computer. Even the little MacBook Airs now have a dual-core processor, and what you can buy for $1K on the street (well, don't buy it on the street, but you get the idea) outstrips anything you could have purchased for $10K 5 years ago. Add multithreading to the mix, and you can see that leveraging your investment based on the assumption that CPU's will become more powerful makes considerably more sense than assuming any other factor will accelerate to the same degree. Fovia notes a 30-50 fold increase in the speed of their product over the last 5 years, based in part on the rapid growth of CPU processing power. Fovia's system is highly scalable and flexible...the more CPU's, the faster it runs. Given Intel's recent announcement of a 50-core chip, the speed of processing might be as close to instantaneous as possible.

You will agree that Fovia's High Definition Volume Rendering (HDVR) can produce some powerful images as you will see in this gallery page iframed from Fovia (if it doesn't load, go to this LINK):


Fovia's claim to fame is the use of a frequency domain-based algorithm, for the techies among us. This involves "deep supersampling," rendering each voxel 32,768 times.  Sounds pretty involved to me.

While you can't buy Fovia directly, you can buy some products which use its technology. As an aside, I discussed with the execs the possibility of Fovia creating its own GUI, its own wrapper for the incredible viewing software. The answer? "Others have suggested that..." I guess we'll have to wait and see. But for the moment, they do a darn good job in the background.

ADDENDUM:

Dr. Robert Taylor, CEO of TeraRecon, sent me this comment on the dedicated-card vs. GPU vs. CPU debate:

I read your blog this AM and noticed the barb from Fovia about proprietary cards. To set the record straight, I just wanted to point out, TeraRecon also has a full SW option and we only use the VolumePro (VP) because it happens to be dramatically better than using software and scalable. We can now render over 70,000 slices in real time (the combination of many users working at once) from a single 2U server thanks to this technology. Today, and for the foreseeable future, that's impossible with SW (Fovia, GE, Philips) or GPU (Vital, Siemens).

When the sledgehammer (VP) is not required, we also have the nutcracker (SW), and this is why we have sold hundreds of laptop-based systems that work without a graphics board in sight. We also hope and expect that one day CPU technology will be able to do what is needed, and we're fine with that. It's the application that matters in the long run.
Thanks!
Robert

RSNA 2011: Siemens Hints At The Future

I mentioned something in the last post about attending the Siemens Media Breakfast, and I promised to elaborate.

As a quasi member of the press, perhaps we should say vanity press, I was once again invited to the annual media event. Being on my new eating program, I didn't take much advantage of the proffered breakfast, but I did listen intently to the talks given by Hermann Requardt, President and Chief Executive Officer of Siemens Healthcare, and Gregory Sorensen, MD, Chief Executive Officer, Siemens Healthcare North America.

There were the usual announcements and scanner refreshes/updates.  The Siemens Biograph mCT gets some new software to allow better quantitation and reproducibility. We are told that this is the best selling PET/CT on the market today.  Wish I had one. The Biograph mMR, the PET/MR scanner, has been installed at 10 sites with 20 pending orders. Wish I had one of those, too, but a $5M expenditure is not in my future. While it was said that the mMR has no competition, Philips apparently has one about to be approved, and GE did announce one in the works.

Two new CT scanners were announced, the Somatom Definition Edge, a single-source scanner utilizing the new Stellar Detector, with 0.3mm routine spatial resolution, and the "business class" Somatom Perspective, a 128-slice state-of-the-art machine with low dose imaging and a lower price point.

There will be two new Acuson units, the cheaper S1000 and the top of the line S3000, the latter having built in automatic fusion to other modalities.

There is a new association with Eli Lilly to distribute the latter's amyloid tracer via Siemens' PET NET network.

The syngo family is mobilized, in other words, it can be accessed remotely, via computer or iPad or whatever. Supposedly mobile apps will allow manipulation, although on the exhibit floor, there was a some hemming and hawing as to how much one can or cannot do on an iPad.

More important than the machinery are the rather candid observations offered by the Siemens execs.

Dr. Requardt opened with a statement that we all know is true: Healthcare spending at current levels is not sustainable. In developed countries, there is the desire to decrease costs, but in emerging countries  there is need to increase access to health care. Siemens sees a "sweet spot" wherein the two curves meet, and they plan to position themselves to take full advantage of this. Turning the conventional paradigms around, Siemens now views therapy as the driver of imaging, and using industrial terminology, healthcare becomes a "project" business, wherein innovation is the solution and not the problem. The disconnect between diagnosis and treatment lead to increased nonconformance costs, and a shift to emphasize therapy my better satisfy patients' needs and wants.

Dr. R rather humbly (or not) noted that Siemens had "misdirected" some investments because they didn't realize the healthcare sector was "not fast enough to respond to technology". Hate to say it, but this implies the sector wasn't smart enough to grasp some of what Siemens offered. Or perhaps what Siemens gave us here and there wasn't what we needed at the time. Particle therapy was cited as a case in point. Siemens developed/created/improved the technology, but it hasn't sold well. Apparently, this was NOT one of the "non-regret" moves Siemens wants to see in the future.

I've already alluded to the statement about PACS. "We will focus on core secgments," said Dr. Requardt. "RIS/PACS today is a commodity these days, with dramatic changes in network environments. Our future investments will reflect this." Is Siemens dropping out of the RIS/PACS market? It seems that with every vendor now offering a Vulture Vendor Neutral Archive (VNA), Siemens no longer wants to compete (much?) in this space.  Sad, given the fact that the new syngo.plaza might actually be their first workable interface.

Dr. Sorenson took over, describing the demographic "wave" of aging Baby-Boomers (hey, I'm one of them!!) 80% of healthcare costs are for older patients, and Medicare is decreasing spending. Imaging expenditures are being cut back in particular, with still some increases for primary care. Dr. Sorenson describes imaging reimbursement as a bubble: reimbursement was so high that it created its own demand. (To be fair, the equipment companies, including Siemens, need to stand up and acknowledge the role they played in dangling those reimbursements in front of clinicians as incentives to purchase their scanners.)

In what I find to be a rather ominous, but still realistic, approach, Siemens plans to address the increased scrutiny we docs are now experiencing, mainly from governmental sources. This drive masquerades as a drive toward minimizing "practice variability". IT tools will move us toward evidence-based, rational care. Reading deeply between the lines, our systems will tattle on us physicians if we stray from the government (or third-party payer norm, whatever that is. Big Brother will be watching us. Now, I don't blame Siemens for this, and being a good Capitalist, I will even applaud them for blazing a path to profit through this mess. But I'm still not happy about it at all. It's probably time to retire.

Siemens will spend 1.4 Billion Euro on R&D this year, and it certainly shows. That's actually just about the same number as their reported profit.

Finally, Siemens, the German company, now manufactures half of its CT's in China. "We make it wherever it's adequate to make it." The factories in China are 100% staffed by Chinese nationals, and the facilities are identical to their German counterparts. Far better to invest in China than to be the main investment, I would say.

I wonder what Siemens will bring us next year?

View From The Balcony..

I'm back at RSNA for what must be the 13th or 15th time since my first time way back in 1990.  Or was it 1989? Back then, the meeting spanned the entire Lakeside building, which was all there was of McCormick Place at the time.

Today, many of the BIG vendors have reoccupied Hall D of the Lakeside building, although I'm seeing a lot of empty space in the periphery of the North and South exhibit halls.

I'm sitting up on the Balcony Cafe in exhibit hall.  It's quieter up here, the wifi is strong, and there are numerous power outlets. My iPhone 4 is gobbling up battery power, thanks to iOS 5.0.1, and I've stolen Mrs. Dalai's Macbook Air to facilitate reporting from the floor.

The atmosphere here is pretty vibrant, and there seems to be a lot of interest at the booths, although I have no idea of how much money is actually changing hands.

I've been to several educational sessions already, and I've spent some time on the floor.  There isn't a LOT thats new, but there are a few interesting things here and there. I'll have a separate report on the Siemens Media Breakfast later, but their big news involves the introduction of two new CT scanners.  And, there was a remark made in passing almost concerning the act that RIS/PACS is now a commodity, and as such it may not justify quite the same level of investment it once did. That's unfortunate, as syngo.plaza might actually be Siemens' first functional PACS.

I've had a look at one of the two SPECT/CT candidates, and while its bone SPECT images haven't improved much, there are some other minor improvements.  I'll have a peak at the other one tomorrow or Wednesday.

A friend of mine who works at McKesson had me take a look at their latest PACS GUI. While it's busy and has maybe too much customization, I'm coming to appreciate what it can do; it's a very powerful interface, and if I needed to replace a PACS, it would be on my short-list of competitors. McK has finally decided to converge the various clients, so the view is more or less the same no matter if you access the PACS from home or office. So far, no iPad client, but there is something pretty revolutionary in the works, although apparently not yet enough of a work-in-progress per se that it can be seen by the likes of me.

Probably my greatest accomplishment today was to connect the folks of Blackford Analysis to a major PACS vendor. The rest is up to you, mates!

What has surprised me most of all is the number of folks who remember me from earlier interactions, and continue to read the blog. I continue to be humbled by the fact that anyone actually looks at this thing, but you all have my deepest gratitude for doing so.

Tonight, dinner with some old friends, and then meeting up with some other old friends. My daughter might even be able to break away for a moment and join us!

I'm tired already, and it's only Monday at RSNA...

Your Village CalledTheir Radiologists Went To RSNA

I'm on my now-annual trek to Chicago for RSNA. I go every year now that my daughter is in school up there in the frigid North.

(As an aside, I think I've come up with a wonderful idea viz-a-viz the horrendous weather in places like Chicago and Buffalo. We need to swap cities with Mexico. Chicago could trade places with, say, Cancun, and New York City and Mexico city could easily flip-flop. No? Well, darn..)

I've been bombarded with advertisements from a sampling of the zillions of vendors out there in the imaging space, and you might hear about some of these when I submit The Dalai's to Aunt Minnie. More on that later.

There is one marketing communication that is just so far off the wall, I have to let you know about it even while I'm still in the air.  I won't name the name, but the ad comes from one of the publishing houses specializing in things radiologic. Where they came up with this idea, I haven't a clue, but here's what you could see if you happen to be in the right place tomorrow at the right time:

RSNA Tribute Flash Mob – Monday November 28 at 9:45 AM
Haven't you all wanted to participate in a flash mob? Here is your chance! We have created an RSNA Tribute song (and dance) to be performed on Monday morning at 9:45am right before the exhibits open. If you have never heard of a flash mob, here's the story:

The music ("R-S-N-A" to the tune of "Y-M-C-A" – EVERYONE knows this song!) starts and just a couple of people start dancing and singing along…gradually more and more people join in and before you know it there are a whole bunch of folks rockin' out. So you are wondering what you have to do? Just click on the link below. We've posted the very basic dance steps (don't worry, they are quite simple) with music. You don't have to be a singer – the music has been professionally recorded and will be broadcast at full volume! We will have the expert support of some Chicago college dance students, so you won't be alone and you can just "follow the leader" as they dance! We plan to have a short rehearsal in Chicago. Our goal is to record this to relive the celebration, and laugh (a lot). We are quite sure that this will be a first for RSNA and we feel that it is the duty of all (the) family members to bring a bit of liveliness to this staid and somber meeting.

Here are the new lyrics, butchered sung on YouTube:

And for those far more coordinated than I, here are the dance instructions:

I'm probably going to be in an educational (OK, I'm trainable if not educable) session when this goes down, so I'll expect reports and links to videos of the actual event.

Frankly, I think I need to pervert rewrite YMCA myself...

Hey Doc, My Ass Hurts, Oy Vey!
I need me a CT TODAY!

Ummm...never mind...

Addendum...It actually went down!

Hat tip to Ken from Fovia.

iPads From Our Futures Past

Apple loves to sue people and companies that even hint at coming close to imitating their stuff. The latest prolonged battle targets Samsung, whose Galaxy Tab is said to be a "slavish copy" of the iPad. In response to several legal defeats, Samsung is slightly modifying the Galaxy to prevent anyone from possibly confusing it with an iPad. Not that anyone would have.

If you are at all interested in the legal machinations, check out THIS article from Mashable.com.

Samsung, to their corporate credit, has come up with a novel defense that might just work in the courts. Samsung claims that the "look and feel" of an iPad has been around quite a while, as we see in this clip from Stanley Kubrick's SciFi masterpiece, "2001, A Space Odyssey":

And that's not all.  Consider Star Trek's various "Padd's":

and.....

And even from the Original Series!

Yup...there's nothing new under the various suns in the Star Trek universe.

Oh, by the way, there's a tablet out there that doesn't get much mention, but I think was truly the original, forming the basis of a lot of things we deal with today:

Top that, Apple!

Another Shoot-Out, Or, A Requiem For Advanced Imaging

Shoot-Out at the OK Corral

The word has gotten out to some of our potential vendors, so I might as well go public. We're having another shoot-out, and it should be quite interesting.

Our larger hospital system seems to have found some funding for an advanced imaging product of some sort, and somehow your friend Doctor Dalai has become the point-man in the decision. Initially, we were going to go with a bundled solution, as we need a few CT scanners, not to mention my beloved SPECT/CT scanner. Sadly (for the vendor in question), some of the initial prices ("good only for the next 10 days!") were way out of line, and so we are unbundling the purchase. I am thus free to pursue the best-in-breed of Advanced Imaging and SPECT/CT.  Someone else gets to worry about CT.

There are only a few choices when it comes to SPECT/CT, and I've reviewed them before. But advanced imaging is another story.

To create the atmosphere for a fair and balanced decision with respect to advanced imaging software, we will arrange a "shoot out" between some of the major vendors and their products.  I say "some" because we don't have enough room or time to showcase every possibility, so we are limiting the scope to a few programs that seem to have potential to accomplish what we need to do. A side-by-side comparison seems much more efficacious than the series of 20-minute demos we've been enduring. Plus, some of the vendors have been, shall we say, a teeny bit aggressive about placing their product for a prolonged demo, to the point that we were to accommodate about a half-a-dozen servers and 5 IP addresses. That might be the next step, but we need to be absolutely certain that our needs will be met before we start opening up rack-space in the data center.

The format will be similar to the Stanford PET/CT competition I wrote about a while back, with the vendors processing data we provide on a real-time basis. We will give them a script to follow, so we can see the same things done on the different machines, and then of course there will be some time for the vendors to do their own thing.

The script is still in flux, but I have a number of things that we need to see, and a few that we would like to see. In no particular order, here's what's on the list so far:

• One-button processing, or as near to this ideal as possible. Of course, there must be a way to go back and manually alter anything that needs altering.
• To the greatest degree possible, the system must be operable/viewable from anywhere, and any platform (PACS station, laptop, iPhone, iPad, Android phone or tablet, and whatever else comes up in the near future.)
• There must be complete and total integration with IMPAX 6.5 and beyond, our illustrious PACS.
• Procedures will include (but certainly not be limited to):
• Brain perfusion
• PET/CT viewing
• Full cardiac/coronary work-up
• Virtual colonography
• Bone subtraction/transparent/translucent rendering
• AVI creation

Suggestions for other items are welcome, although vendors need to be circumspect on this.

In addition, we have been tempted by "dose reduction" or "denoising"software, which is included in some of the advanced packages. I've discussed the concept earlier, and frankly, I still don't like the idea of dropping the quality of a scan in hopes of rescuing it later. So, to me anyway, this will not be a critical component. If it comes with, fine, if it doesn't, also fine.

The tentative schedule for the shoot-out is set for early January. Ambulances will be at the ready for the fallen.

The Match Game

Once in a great while, something comes across my virtual e-mail desk that gets me excited, and when you reach my age, getting excited is rare and possibly dangerous. Nonetheless, when I saw what the folks from Blackford Analysis (http://www.blackfordanalysis.com) had to offer, I definitely got a thrill.

Blackford comes from outer space, almost literally. Their origins are in the astrophysics world, and their break-through technology is called MOPED:

Blackford Analysis’s core technology is MOPED, an algorithm developed in astrophysics to tackle analysis of immense datasets. The patented approach involves compressing the huge datasets while retaining all information needed to solve a problem – allowing speedups of many orders of magnitude over traditional techniques.

The technology comes from astronomical surveys, where instruments capture gigabytes of images per hour. This information is generally interpreted by comparison with models, essentially complex formulae driven by a set of parameters, which reproduce the observations.

Parameters might be the mass of a galaxy, or the distance it is from Earth, and there will be some combination of parameters that produces a modelled image that is very close to that actually seen through the telescope. Situations like this are called ‘parametric modelling problems’.

MOPED’s particular ability when solving such problems is that it speeds up the step that determines how well a given combination of parameters recreates the image.

After the initial compression, the time taken for each combination changes from being set by the number of pixels to being set by the number of parameters. If 10 parameters were to be determined by an image taken by a modern digital camera with 12 million pixels, the calculation would be more than one million times faster.

This means that problems that were too slow become possible, often solvable in real-time. As datasets become larger, and the cost of the hardware resources required to tackle them rocket, the case for MOPED is even more compelling: the powerful algorithm vastly reduces that hardware cost.

So what does this have to do with imaging?  It seems that we can apply the algorithm to matching volumes, such as two CT scans!

Developed by Blackford Analysis, the medical imaging technology makes it possible for radiologists to anatomically link small features such as lung nodules between studies for the first time within the PACS.

While the radiology imaging software will also align CT and MR from any part of the body, instant anatomical alignment in the chest is a major breakthrough, given respiratory movement and the requirement for a deformable registration.

Blackford Analysis’ technology greatly reduces the time it takes to compare current and prior studies, a drain of radiologist’s time as volumetric datasets increase in size and complexity and become ever more commonplace.

A key advantage of the software is that it designed for integration in the existing PACS environment so radiologists can use it without having to interrupt their natural review processes by moving to another workstation.

Crucially, the alignment is achieved without any alteration of the raw slice data so radiologists don't need to worry about the authenticity of what they are reviewing.

A video is worth at least 10,000 words:

Blackford is thinking outside the box.  In all of the other registration programs I've seen, an attempt is made to match the entire volume of the old study to the new. Because patients are not rigid (their bodies aren't, anyway) this doesn't work so well. Some software will attempt to distort the data-set to achieve a fit, which could conceivably distort the findings as well.  Blackford takes the novel and proper approach of an instantaneous point-to-point mapping, finding the exact spot on the old study that I'm seeing in the new exam.  Brilliant! That's really all we need in the end, isn't it? And it does appear to work quite well. And to have it actually integrated into the PACS viewer would be incredible.

I hope to meet with the folks from Blackwell at RSNA and see the thing live and in action.

PACS vendors: you WANT this in your product. You really do. Jump on it now.

Contact r
info@blackfordanalysis.com
B

For The OWS Crowd...

It just isn't FAIR!!!!!

Hat tip to Dr. Sanity.

Dalai Gets Schooled By Merge

Nanak, my PACS guru, recently asked for permission to attend a MERGE PACS training session. The description looked so good, I wanted to attend as well:

Merge Healthcare, the leading developer of information technology to create a better electronic healthcare experience, invites you to attend a specialized training session. During training, our technical experts will walk you through a deep dive of the technology’s features and functionality so you gain the critical skills necessary to maximize your investment in Merge solutions.

What: MERGE PACS KNOWLEDGE QUEST – SUPPORT 2011
Where: Daytona, Florida

Learning objectives:

• Systems Overview - PACS Components
• Server Maintenance
• Definition of logs and what they mean
• Advanced trouble shooting techniques
• MWL Filtering (how it works)
• Creating advance transfer rules
• Managing Image volumes and watermarks
• RTWL filtering
• Management Tools

The two-day session was held at Merge Southern Headquarters in Daytona Beach, Florida:

As it turns out, this is also Merge's main support site, and so we got to see the "prairie-dog village" as Nanak calls it, where the support folks do their thing:

We had the opportunity to meet in person many of the folks who had been taking care of us and our system for the past few years. We also discovered the secret of their seemingly unlimited energy:

We also got the chance to have dinner with my friend Mike Cannavo, the PACS exec formerly known as the PACMan. (Mike now works for The Man at a big-name vendor.)

The course itself was frankly slightly above my level.  While I do have administrative privileges, I don't dabble too much in the back-end of our system (presently Version 5.0) or the hospital's (version 6.0.4), but I did find it quite valuable to learn more about what goes on there. There are some places I'm not going to tread, and even Nanak doesn't like to dive into the DB2 database, which can be dangerous indeed, but we now know more about how to do so if need be.

One major change between our 6.0.4 and the latest 6.2 is that the name AMICAS is slowly being relegated to the trash bins of history and my failing memory.  The new sign-on screen reads thus:

 

Perhaps I should moonlight as a PACS admin with my new education. Nah...radiology is probably easier. But I did learn a particularly valuable lesson: Nanak really knows his stuff.  Throughout the whole class, he was helping me understand what was going on, and it was pretty clear he has a huge grasp of this stuff. Remember Dalai's IXth law: 

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

In Nanak's case, that's a lot of gold. But still absolutely true.

iGrieve With Thee: Steve Jobs Dies at 56

(Image credit: http://www.FoxNews.com)

Steve Jobs has passed from this world, presumably a victim of the islet-cell neuroendocrine tumor he had fought for many years. The genius (and I don't use the term lightly) behind Apple Computer was a young 56 years of age.

FoxNews has a very complete biography here. It's hard to believe that this one man had such an impact on our day-to-day lives. Some have called him the 21st Century Edison, which may be somewhat of an exaggeration, but still is fitting.

Steve (we all feel like we knew him, although few of us ever got to meet him or work with him in person) was not so much an inventor as a perfecter. He actually invented none of the products we remember him for, but he made them accessible, usable, and sometimes even fun. The personal computer had been around for years in some form or another, but Steve (and his then-partner Steve Wozniak) distilled it into the Apple II, one of the first home computers that actually did something useful. Then came the Lisa, the first stab at a home computer with a graphic interface, which was met with less than stellar response. But in 1984 came the Mac, and the rest is history. 

The other iconic products from Apple were similarly perfected. The iPhone came well after various PalmOS, Symbia, and Windows smartphones, but Apple improved the experience to attract millions of users who would otherwise still be using RAZRs. (I won't get into the iOS vs. Android debate.) There were dozens of mp3 players out there before the iPod came along, but Apple now completely rules that space.

Apple had some rather spectacular failures as well. The Newton (of which I was an early adopter) never really worked as desired. Here's an article about the Newton and seven more Apple goofs. Anyone remember the Pippin?  At least I never succumbed to that one.

The recent release of the iPhone 4S, Steve's last imprint on Apple, shows that Apple still may not predict the market with perfect accuracy. The remake is really much more phenomenal than it originally seemed.  Better processor, better camera, more memory, better antenna system, and Siri, the latter of which in some ways brings to fruition some of the original magic conceived for the Newton projects.  See this video from 1987:

...and compare to today's Siri:

It only took about 25 years to bring this futuristic technology to the future.

But Apple is taking somewhat of a hit over what is really a significant upgrade...because users were expecting a new screen and new case. A 4 inch screen and a more streamlined case would have gotten big accolades; huge new tech innovations are getting a "meh". You can rest assured that the iPhone 5 will have a new form-factor, hopefully not introduced too late to smash the competition.  Personally, I'm satisfied with the iPhone 4 housing.  As Steve once said, it is "like a beautiful old Leica camera".

My friends (and even Mrs. Dalai) have asked me what I think will become of Apple now that Steve is gone. I'm hoping for the best, really. Steve must have left some documentation of how he thought things should work, and his hand-picked successor, Tim Cook, seems quite qualified to carry on the traditions. There are enough brilliant people working for Apple that I can't imagine it will founder much, if at all.  I have great faith in their people to carry on. You can rest assured that the motto for the foreseeable future will be:  "What Would Steve Do?"

Perhaps my greatest regret about Steve's untimely passing was voiced by AuntMinnie user Elegiac:

Imagine what he might have accomplished had he focused his creative energies on developing solutions for medical informatics. It is hard to imagine how much more productive we all would be if we used a unified and properly designed PACS/VR/RIS/EMR system created by people who placed value on an integrated work environment which just works. What could have been.

Indeed. PACS vendors take note.

A hat tip to Radio17 who reminds us on the AuntMinnie thread that 3D advanced imaging is one of Steve's Pixar legacies as well. From an ACR article about Elliot Fishman, M.D.:

The Brooklyn native (and Yankees fan) arrived at Hopkins in 1980, and by the mid-1980s, began working in 3-D medical imaging. He characterizes the state of the art back then as “pretty limited.” Looking around, Fishman approached and began partnering with Pixar Image Computers (and later, with Siemens), where a cadre of elite researchers was doing seminal work on computer visualization using ultra-fast proprietary computers. Fishman’s contribution was to help Pixar adapt its massively complex technology to the medical front. Ultimately, Pixar shifted its focus away from medical computing, but its groundbreaking work opened the door for a host of scientific revolutions. In time, Pixar would enjoy tremendous commercial (and critical) success making such movies as Toy Story, Finding Nemo, and Cars.

Recalling those halcyon years of around-the-clock work, Fishman says, “The people at Pixar were the smartest people I’ve ever worked with, anywhere. I’m talking 11 over 10 — just incredibly unbelievable.” But he reserves his warmest praise for Pixar CEO (and Apple Computer founder) Steven Jobs. “He is a remarkable visionary and also one of the most charismatic people I’ve ever met.”

“One of the highlights of my career,” he continues, “was giving a named lecture at Stanford University. Steve came to my one o’clock lecture on 3-D imaging, which I’ll never forget. I figured I’d be speaking to radiologists, so even if I was wrong on some technical point, they might not know the difference. But with Steve there, I realized that if I made a mistake … ‘Oh, my God, if I say something wrong, he will definitely know.’”

Rest in peace, Steve.  You will be missed.

Honey From The Cloud

This is Merge week, it seems, due in no small part to the Merge Live Client Conference 2011, going on right now in Chicago. I would have been there myself, except Merge accidentally scheduled the meeting right up against Yom Kippur (which begins the evening the conference ends, Friday, September 7) making it difficult to attend.  No worries, RANZCR did the same thing this year.

Today's announcement outlines something Merge is giving away for free. While I have commented on the magnanimity of some of Merge's principals before, I think it's safe to assume that Merge hopes to attract new, paying customers with this sweet offering.

And sweet it is, at least in name. Merge's Project Honeycomb promises to become "The nation's largest medical image sharing network," and given the price, it might get there. Here is the video explanation:

Kinda cute, but how will it work? The explanation for the media is here. Basically, Honeycomb is a free repository for images, according to the press release:

Merge Healthcare (NASDAQ: MRGE), a leading provider of enterprise imaging and interoperability solutions, today announced Merge Honeycomb, a revolutionary new cloud-based service that will enable users to upload, download, view, and share medical images – at no cost.

“With Merge Honeycomb, we’re harnessing the cloud in a way that encourages and enables faster collaboration among all healthcare stakeholders, resulting in a true improvement in the delivery of care and reduction of costs,” said Jeff Surges, CEO of Merge Healthcare. “With the largest network of imaging clients by far, Merge is taking this important step to connect the healthcare industry and expand interoperability.”

Announced today at the Merge Live 2011 Client Conference, attended by over 500 healthcare professionals, Merge Honeycomb will be the nation’s largest medical imaging sharing network and is open to anyone. Merge Honeycomb will officially be launched at the Radiological Society of North America (RSNA) Conference in Chicago in November, 2011. Users can pre-register now for this free service at www.merge.com/honeycomb.aspx.

Merge Honeycomb will solve a myriad of costly healthcare challenges. It will reduce the need for duplicative scans, which costs the industry an average of $35 billion a year and exposes patients to harmful and unnecessary radiation. (According to a 2010 study by the Center for Devices and Radiological Health and the U.S. Food and Drug Administration, the radiation level in one CT scan of the abdomen is approximately the same as 400 chest x-rays.)

Merge Honeycomb will also eliminate the archaic practice of using patients as transport vehicles. The need to burn X-rays, CT Scans, MRIs and other images onto CDs will be a thing of the past. When a physician needs to view images, they can log into the image sharing network via any web browser.

It also speeds the time to treatment. Referring physicians will be able to view images in realtime and make diagnoses accordingly. And because the network is permission based, images can only be viewed by those who have been granted privilege.

It is a component of iConnect, the larger (and not free) overall package:

Merge iConnect facilitates the sharing of content and results across the continuum of care. Available in vendor-agnostic modules, Merge iConnect uniquely leverages existing investments and provides added functionality when needed to deliver access to any image, anytime, anywhere. While there are many niche imaging solutions in the market, Merge iConnect is the only comprehensive suite that delivers true interoperable image exchange and management.

With Merge iConnect, healthcare images are moving at the speed of life through the power of the cloud, enabling an enterprise imaging strategy. These images are easily archived, available on demand and accessible at the point of care, which means frustrations like waiting for images and unreadable CDs are history.

The interface looks a little "Facebook-ish" to me:

But maybe that's the intent, as everyone knows how to use Facebook. (Let's hope Merge doesn't contract with Zynga to create X-RayVille or something foolish like that!)

We all know that "The Cloud" really isn't something ephemeral in the sky, but rather a server and storage farm in some bunker somewhere. Did Merge buy its own farm (hopefully not from a Zynga user) or is it buying space from Amazon Web Services or some similar provider?

ADDENDUM:

For some reason, Merge takes its time in posting its own press releases on its own site. Global News Wire has this October 6 release:

Merge Healthcare (Nasdaq:MRGE), a leading provider of enterprise imaging and interoperability solutions, announced today that it has selected Dell as a preferred provider of cloud computing services, storage and enterprise hardware products to simplify information access, management and archiving among its portfolio of image interoperability solutions.

Through its secure cloud-based Unified Clinical Archive solution, Dell manages more than 4 billion medical images and studies for healthcare organizations. Utilizing its cloud-based health information technology, Dell will host Merge Healthcare's Project Honeycomb, the nation's largest medical image sharing network. With Project Honeycomb, providers can upload, download, view and share diagnostic quality medical images – at no cost.

For providers who want on-premise image management, Merge has certified its iConnect Vendor Neutral Archive (VNA) on Dell's DX Object Storage platform, providing intelligent access, storage, protection and distribution for the fixed digital image content managed by Merge Healthcare's iConnect VNA. The data and storage management features inherent in Dell's systems combined with Merge's iConnect offering will enable healthcare providers to manage their critical medical images in a highly secure and efficient manner.

Merge will integrate its solutions within the DX platform, using Dell's capabilities to provide a highly-available, cost-effective VNA offering. By utilizing the data management features of the DX, iConnect VNA will offer advanced features such as federated storage, business continuance and nested image retention and deletion strategies.

Anyway, why again do we want this?

With Merge Honeycomb You Can:
•  Eliminate the need for patient-borne CDs
•  Provide VPN-free exchange of images
•  Share diagnostic images securely via the Internet
•  Easily view outside studies
•  Eliminate waiting for images
•  Eliminate image format incompatibility
•  Reduce duplicate exams
•  Speed time to treatment
•  Increase referrals
•  Reduce IT complexities associated with sharing exams

Hmmmm...sounds a lot like the mission statement for LifeImage:

lifeIMAGE enables the secure and on-demand exchange of medical imaging information from anywhere and with anyone. We provide a multi-purpose, SaaS platform to healthcare institutions, physicians, and patients to exchange information directly or integrate the information with their EHR or PHR systems. Our goal is to eliminate the need for duplicate imaging exams and avoid unnecessary radiation.

To do this, we offer applications that can be incrementally adopted to help with the transition to electronic exchange of imaging information. Our services solve image accessibility challenges inside and outside a facility’s firewall. Throughout, we are meticulous about confidentiality, privacy and HIPAA compliance.

Their solution is not free, but I have this sneaking suspicion that Merge Honeycomb, while a stand-alone module, will be far more useful and usable in the context of iConnect, and in the end won't be quite free either.

Having no hands-on experience with the new Honeycomb, I can't begin to tell you which is better, and no doubt both Merge and LifeImage will prosper with these approaches.  To me, Dr. Dalai, Average Radiologist Extraordinaire, the key will be transparency. In other words, the system that gets the foreign images into MY PACS most easily wins.

Honeycomb? The folks of my generation might think of the cereal first:

The younger, more tech-savvy set might associate the term with the latest flavor of the Android OS.

I've never understood much about marketing or name-selection.

Oh, by the way, at the bottom of the press release, in the fine print, we see this disclaimer:

Merge Honeycomb as described herein is a works-in-progress. Merge Healthcare is not legally obligated to develop or continue to develop such works-in-progress that may include the features and functionality described herein.

Perhaps that's standard boilerplate language, but it seems a bit strange in a big announcement such as this. Oh well, never hurts to cover one's bases, eh?

Hat-tip to Mike Cannavo, the Once and Former PACSMan, since I don't seem to be on Merge's e-mail list these days.

UPDATE!

Fellow blogger PACSMatt (Matt Granger) attended the Merge Live! event, and adds much to our knowledge of Honeycomb:

I had a chance to demo the Honeycomb product directly and I am impressed.  The feature set is right on for this initial product release.  It has a social network "LinkedIn" feel to it and users are able to self register to create an account.  A URL auth process follows and then you can access your free account. Although not verified, initial screenshots seem to show that "free" accounts can upload up to 10 GB of imaging data.  Once logged in the user is presented with a log view screen of activity that has occurred with any images they have shared to other users.  You can invite other users via e-mail to join Honeycomb or search for existing users.  The search screen segments the search results between users you know (similar to 'friended') and global users accounts you haven't shown any relationship to (yet).  

Uploading files is very easy as long as you have physical access to the DICOM files themselves.  Once uploaded you can share the files to one or more users in your group.  The sharing process has granular controls that allow you to decide how long the share is active for and whether or not the 'shared' users is allowed to download those files as DICOM objects or not.  Either way the user can view the images through Honeycomb:

Images that are shared to end users are viewed using Merge's iConnect Access zero footprint viewer.  Let me stress that this viewer is an amazing PACS image viewer.  I have been involved with testing version 2.5 of the iConnect Access viewer for some time now and this week I was able to see the feature set in Access 3.0 which is in use in the Honeycomb product.  It's truly a zero foot print viewer completely executed in JavaScript in the browser.  Support summary:  No Java needed, no ActiveX needed, yes IE, yes Chrome, yes Mozilla, yes iPhone & iPad, iffy on Android (for now) and no on Blackberry. It's an excellent browser and I regret I didn't get any screenshots for you. It has mote than ample toolset including cine, zoom, measurement tools, multiple viewports, full screen viewing.  It's beautiful.

Did I mention that this is free?  Are you considering any other image sharing services right now?  Don't.  This is free and it rocks.  Just go to www.merge.com/honeycomb.aspx and sign up to be notified when the services launches next month.  Here's a direct link to Merge's PDF document more details.

More information about the future phases of Merge Honeycomb came out today, too, as the implementation phases were shown at the "Merge Live!" event. Below is a screenshot from their presentation.  Phase one and live usage will be in place by RSNA this year.  Phases 2 & 3 relate to a tighter integration of Honeycomb to their iConnect Access platform.

Many thanks for the info, Matt!!!!

I received a comment as well from an anonymous reader (no one wants to admit reading my stuff, it seems):

What I'm curious about, is that lifeIMAGE already announced a similar offering to the American Society of Echocardiography (free), with plans to expand it to all? Not sure.

I'm not sure, either. I'll post what information I find on this. Sounds like LifeImage may have something up their collective sleeves...

What, Merge? No Dalai?

A friend received this press release early today, and ironically, it is not yet anywhere to be found on the Merge.com website (as of 9:30 AM EDT) (UPDATE:  It's finally online.)

Merge Healthcare Announces Creation of Clinical Advisory Board

Expert Panel to Provide Patient-Centric Solutions to Improve and Streamline Delivery of Care
CHICAGO, Oct. 4, 2011 (GLOBE NEWSWIRE) -- Merge Healthcare (Nasdaq:MRGE), a leading provider of enterprise imaging and interoperability solutions, announced today the development of an Advisory Board to share clinical expertise and provide consultation on new models of care and emerging trends focused on the patient-centric experience.
The Merge Advisory Board will focus on the fact that diagnostic images make up a significant and critical part of the diagnostic process, yet today, the exchange and sharing of these images is inefficient. This inefficiency fragments the healthcare process which contributes to delays in care and skyrocketing costs. The Merge Advisory Board will also address patient safety and quality of care through, among other things, focusing on the fact that patients' radiation exposures has doubled over the past 20 years and developing solutions that reduce such exposure.
Consider the realities of diagnostic imaging:

• Healthcare organizations generate nearly 600 million diagnostic imaging procedures annually;

• One CT scan of the abdomen exposes a patient to the same amount of radiation as approximately 400 chest x-rays; and,

• $100 billion of annual healthcare costs are related to diagnostic imaging tests – but an estimated 35% ($35 billion) represents unnecessary costs for US patients and insurance providers.

The Merge Advisory Board is led by Dr. Cheryl Whitaker, Merge's Chief Medical Officer; co-chaired by Dr. Paul Chang, Professor of Radiology and Vice Chair, Radiology Informatics at the University of Chicago Medical Center; and, Dr. Keith Dreyer, Vice Chairman of Radiology Informatics at Massachusetts General Hospital.

"We are extremely fortunate to have experts from these prestigious organizations advising the Merge team," said Jeff Surges, Chief Executive Officer of Merge Healthcare. "We look forward to the clinical dialogue that will develop, and to incorporating their knowledge and expertise into the image interoperability solutions we provide to clients and the healthcare marketplace."
"Merge believes in a patient-centric healthcare experience, and empowering physicians, patients and providers to proactively manage this healthcare," said Dr. Cheryl Whitaker, Chief Medical Officer at Merge Healthcare. "I look forward to working with this distinguished group of leaders to ensure we continue to develop solutions that simplify and improve the care process."

The Merge Advisory Board consists of the following imaging and healthcare experts:

Dr. William Boonn

Chief of 3D and Advanced Imaging Lab

Hospital of the University of Pennsylvania

John A. Carrino, MD, MPH, PhD

Associate Professor of Radiology and Orthopaedic Surgery

Johns Hopkins University School of Medicine

Dr. Paul Chang

Professor of Radiology

Vice Chair, Radiology Informatics

University of Chicago Medical Center

Dr. Keith Dreyer, MD, PhD

Vice Chairman of Radiology Informatics

Massachusetts General Hospital

David Mendelson, MD

Chief of Clinical Informatics MSMC

Professor of Radiology

The Mount Sinai Medical Center

Eliot Siegel, MD

Chief of Radiology and Nuclear Medicine

Veterans Affairs Maryland Healthcare System

Timothy Zoph

Chief Information Officer and Senior Vice President of Administration

Northwestern Memorial Hospital

What? No Dalai?

To be fair, this is a list of PACS luminaries, the likes of which you will find nowhere else, and the likes of me probably doesn't belong even reading such a list.

We see some very familiar names here.  Dr. Chang is quite famous in this space, in no small part for creating Stentor, developed at the University of Pittsburgh for $9 Million, which was bought by Philips for $45 Million and became iSite. He's now at the University of Chicago, and wouldn't you know it, they use iSite, according to one of my readers. I do not know offhand if Dr. Chang has had much hands-on experience with AMICAS Merge PACS.

Dr. Dreyer does have time on AMICAS Merge PACS, as Mass General uses AMICAS Merge PACS 6 as their web-client, something their old but functional Agfa 5.x doesn't have. His contributions to PACS are multitude as well, and he is perhaps the best choice to help Merge navigate the Meaningful Use maze. Dr. Dreyer has been a big proponent of Visage, so we may get to see how these two products play together.

Dr. Siegel is very well known in this venue.  Rumor has it he will be sending Watson to the Advisory Board meetings as his proxy. The Baltimore VA has Centricity, and the University of Maryland has Agfa IMPAX.

Johns Hopkins still has Emageon PACS as near as I can tell, but the one really BIG NAME radiologist I don't see on the list, Elliot Fishman, M.D., complained (in 2007) about Emageon's inability to handle more than 100 slices before choking. Of course, that led him to use the Siemens Leonardo InSpace workstation.  I don't know what PACS is in use at Hopkins today, however.

Dr. Boonn's University of Pennsylvania appears to have Siemens PACS, although I don't know if it is the new syngo.plaza or some older product.  (UPDATE:  I'm informed that U Penn now has Centricity.) As far as advanced imaging, the HUP website notes quite an arsenal:

Post-Processing: GE Advantage Windows, Vital Images Vitrea2, TeraRecon AquariusNet and INtuition, Siemens MMWP (Leonardo) and syngo.via, and QMass. Our 3D and Advanced Visualization Lab is staffed by four dedicated technologists who assist with workstation training for visiting fellows.

I couldn't find any reference to the PACS used at Northwestern (UPDATE: Northwestern uses Centricity), and Mount Sinai uses GE, I assume Centricity of one flavor or another, although I found mention of the use of OsiriX as well.

I certainly cannot fault Merge for choosing this very impressive panel as its Clinical Advisors. I don't think one could do much better, and this is the level of expertise I would expect to work with Messrs. Surges and Dearborn, not to mention Mr. Ferro, assuming he's working on this stuff at the moment.

I will certainly offer my services should there be some minor subcommittee formed that concerns itself with day-to-day operations of PACS software out here in the boonies.  On that, I am somewhat of an expert myself. (Just ask Agfa.) I'm at your beck and call, folks.  You know my number.