The Health Care Law Dissected

Note: Tim Farrell is a radiologist practicing in Virginia. In his own words, he's "done a lot research on the 2010 Health Care Act for a lecture I'm giving at a medical meeting in a few weeks. It's taken me several months to complete the research. In preparation, I compiled a lot of notes, put together in outline/text form.

I know that it's lengthy, but in it I've briefly outlined the history of health care reform, reviewed the reasons behind reform and tried to condense the highlights of over 2,500 pages of legislation.The analysis is my opinion, based on my position as an "insider" in the medical profession who has had to deal with the insurance industry and the state and federal legislature for more than 15 years. A lot of it seems like basic common sense to me.

It's an interesting read, if you're into that type of stuff. If not, it will be boring as hell, so it's your decision whether to read it or not. After spending THIS amount of time on it, I know the law about as well as one can (and a good bit of the stuff "going around", is false)."

Without further ado....

Healthcare Law

Another Correct Prediction

In my February, 2008 post titled "A New Cellphone Accessory", I requested that someone invent a combined bluetooth headset and video camera, mocked up as below:

On this occasion, I was only a few years ahead of my time.  Behold the Looxcie (Look-see, get it?) wearable camcorder:

Looxcie takes a sound-bite/tweet approach to video.  It is always on, but if you see something you wish to capture, press the button on the back, and Looxcie saves a clip of the last 30 seconds it, ummmm, saw.  It can also function as a bluetooth headset.

Phone app is now available for Android devices, and support for iPhone and Blackberry is coming soon.

All this can be yours for $199.  Visit http://www.looxcie.com.

RadNet Buys eRad

I seem to have a lot of contacts in the PACS business, so many that they keep turning up in unexpected places.  I received a note yesterday from a friend at eRad to let me know that the Greenville, SC-based RIS/PACS company had just been bought out by outpatient imaging provider RadNet.  About 5 minutes later, I received a phone call from Ranjan Jayanathan, RadNet's CIO to tell me the same thing.  I met Ranjan a few years back, when he still worked for Dynamic Imaging (and there still was a Dynamic Imaging).  He walked me through one of the best product demonstrations I have ever experienced.  (I wonder if that particular product will ever be seen again, eh, Ranjan?) 

I've got an appointment with Mr. Jayanathan next week to discuss this acquisition further, as I think the story is newsworthy for my illustrious readers.  Stay tuned!

Doctor Dalai's Health Minute

As a physician, I am supposed to help patients, at least periodically. While I would like to think I do so every working day, I have two personal experiences outside of radiology to report, which I think will benefit you, my faithful readers.

First, let's deal with a bit of technology. In perusing Medgadget a few weeks ago, I came across this intriguing tidbit:

Solar-Powered Toothbrush Supposedly Makes Toothpaste Obsolete

Researchers at the University of Saskatchewan have developed a solar-powered toothbrush that doesn't require toothpaste. At the base of the brush is a solar panel, which transmits electrons to the top of the toothbrush through a lead wire. These electrons react with acid in the mouth, breaking down plaque without the help of toothpaste. It is an advancement of a model described 15 years ago using a titanium dioxide rod which released electrons when illuminated. The researchers are currently recruiting 120 teens to test the brush. The model is named Soladey-J3X and is manufactured by the Shiken company of Japan.

I had a peek at the Shiken web-site, and my curiosity was really piqued:

After a bit of back-and-forth with the Shiken rep, I was able to purchase a sample version, as full production and distribution of the J3X has not yet ramped up. I've been trying it for the past couple of days, and...the damn thing works! I've been using a Philips Sonicare brush, recommended by my dentist, for many years. After two days with the J3X, my teeth feel significantly cleaner, with a definite (although subjective) decrease in my perception of film/plaque as compared to the Sonicare. And this clean feeling lasts all day. I'll keep you informed, but I think we have a winner. I am adding a bit of toothpaste at the end of brushing to keep all my lovely teeth fluoridated, and to keep my breath from lethal levels, but so far, this new toy does what it promises. And it looks really modernistic to boot! (I have the blue one.)

Moving now to the other end of my aerodigestive tract, I finally did something every 50 year-old needs to do: I had my colonoscopy. Sadly, I am actually 51.5 years old, and so this little party was a bit belated. That could have been a disaster, as you will see.

The worst part of the procedure was, of course, the prep. I mean, the induced diarrhea is bad enough, but drinking a gallon of GoLYTELY is sheer torture. This crap has a faintly salty taste and slimy consistency, and by the time I had my last 8 oz. cup of the stuff, I was ready to croak. My green Jello tasted wonderful after that.

The procedure itself is easy as can be. The worst part is anticipation, and the insertion of the angiocath for the IV. After that, a pop of Demorol and Versed sent me off to La-La land, and I awoke in the recovery area with some minor gas pains but no other discomfort. I do have a millisecond-flash of memory from the test itself, in which I think I complained of cramping. That's it. Well, I did get a little woozy about 48 hours later, probably a delayed reaction to the drugs, which gave me an excuse to bail early on Rosh Hashana services. Fainting in Temple is bad form, you know. But I'm absolutely fine now.

Another famous physician, Dr. Mehmet Oz, of the Dr. Oz Show, just recently had his colonoscopy. Being a TV celebrity, he had to do his on time, at age 50. Rather frighteningly, Dr. Oz had an adenomatous polyp, which is considered precancerous, although the potential for malignant degeneration is rather low. Still, someone with as healthy a lifestyle as Dr. Oz is considered at low risk for development of polyps, and of colon cancer. If he can get one, we should all worry.

And indeed, my encounter with the Big Black Snake yielded a polyp as well:

Behold my sigmoid colon, and a 1.8 cm partially-pedunculated polyp within. My gastroenterologist snared this little sucker, and sent it off to pathology. He then skipped town for a much-deserved vacation. Fortunately, I have access to most of the local EMR's, and against my better judgement, I checked the path myself. This is, of course, a bad idea, but thanks to God, Dalai's Polyp was hyperplastic, and this is the most benign variety, with very little chance of ever turning malignant. Still, as the little SOB was over 1cm, I'm compelled to repeat the colonoscopy every three years instead of every five. Since my son has Crohn's Disease, and must be scoped every year or two, I get no sympathy at home for the increased frequency, and frankly, the procedure wasn't really a bad experience at all. I do hope, however, that there are some advances in the prep by 2013.

I want you all to learn from my experience. I was very, very lucky. Had Polly Polyp been adenomatous, I would be in greater danger for having been a wimp delayed my colonoscopy 18 months past the point I should have done it. So, if you are close to age 50 (or 45 for African-Americans), call your gastroenterologist and make the appointment ASAP! Don't fool around with your health. Colon cancer is almost completely preventable, but far more so if the precursor lesion is caught in its very early stages. Don't die young because you are afraid of the prep or the discomfort. It isn't that bad, and this procedure could save your life. Literally.

Now, as a radiologist, I have to add one more thing: Based on my experience, I'm going to skip virtual colonography, and go straight to the 'scope. VC is a good procedure, and it would have found my little friend with ease. But, I would have had to wait for another appointment, and I would have had to reprep.  And, VC involves radiation. Had I come out negative, I might be singing a different tune, but for me, for the moment, the Big Black Snake is my new best friend. Apologies to VC affectionados world-wide.

I suppose my next foray into self-improvement will involve CCTA. Hopefully I won't fall asleep from the beta-blockers.

The iPad--Radiology's Sharper Image?

I'm still naive and vain enough to be impressed when something I wrote makes it to a real publication, i.e., a professional operation hoping to sell copy or at least advertising, and not self-published like my blog.

The good people at AdvanceWeb recently asked me to write a piece on the available iPad radiology viewers.  Since their budget didn't allow them to buy me my own iPad, I stole my son's while he was in Australia and proceeded to download any and all viewing apps I could find.  At this stage, most are dedicated to the iPhone, but they work adequately well on the iPad.  There were a few pleasant surprises in this little technical odyssey, including the discovery of Calgary Scientific, which seems to "get it" far better than most in this particular venue.

I have to let you know that the title of the piece was selected by the editors over at AdvanceWeb.  Let's hope the demise of the Sharper Image stores has no bearing on the success of my writing.

To avoid copyright problems, and to keep from having to reproduce the images in the article, I will simply provide you the link to the AdvanceWeb site:

http://imaging-radiation-oncology.advanceweb.com/Features/Articles/The-iPad-Radiologys-Sharper-Image.aspx

I hope you find it interesting.  Let me know if I've inspired you to go out and buy an iPad!

The Actor Playing...ME!!

Chad Einbinder, Image Courtesy IMDB.com

Every so often, it pays to Google ones' self.  You never know what you might find.  As it turns out, there was a character in Episode 8 of the first season of Grey's Anatomy which aired on May 15, 2005, named....Sam Friedman!  Sam and his screen-wife Doris were the parents of an Orthodox daughter Devo (played by Lisa Kaminer and Sarah Hagan, respectively), who didn't want a valve-replacement from an un-kosher pig.  

Chad, has had a fairly busy, if non-descript Hollywood career, with several minor guest-starring roles in several TV episodes, and more recently Neanderthal #3 in "Night at the Museum, Battle of the Smithsonian".  Playing me, I mean Sam, probably was adequate prep for that one. 

So tell me folks, who is better looking, my alter ego Chad, or me? Don't everyone shout at once...

Another eBay PACS

A while back, I found an ad for a Dynamic Imaging PACS on eBay.  I don't know if it ever sold, but the opening bid was $45,000. 

On a lark, I tried searching for PACS on eBay again today, and indeed there is another system available.  Actually, the seller has two separate but identical listings for the same package. 

Here's the deal:

Brand New PACS system for an affordable price. buy it complete for $8,999. purchase includes hardware, software & licensing. one year complete parts & labor warranty. Order today and have it up and running in 48 hours. Contact Rudy at (see the listing) to get this great deal. STOP buying jackets, STOP buying films, STOP printing & faxing reports. GO DIGITAL Today!. this system will pay for itself in 1 month. be ahead of your competition and offer your physicians instant access to their referred patient images & reports. your success story starts from here. Contact Rudy at (see the listing) TODAY!. Do not pay thousands of dollars more for another system with less features. this is the one and only PACS you need for the life if your imaging center. Future Proof. Feature Rich, Affordable.

Here are the specs:

Included With Your PACS System:

• UNLIMITED Patients
• UNLIMITED Studies
• UNLIMITED Users
• UNLIMITED Referring Physician
• HIPPA Compliance
• Modality Work List
• Auto Route
• CD/DVD Burning
• Digital Laser Label (uses laser to print your clinic's logo & Patient's information on CD's/DVD's)
• iPhone Compatible. (access your PACS server, view images, read reports from your iPhone. Anytime, Anywhere.)
• Windows, MAC, Linux Compatible.
• Referring Physician Portal for your physicians to log-in and view the images for their patients, download reports or print images if they want to.
• Full imaging center Reporting System. Based on modalities, referring physicians, date, Application Entity (AE), patient ID or any combination.
• Web Based Radiologist access. your radiologist can read from any computer at any location at anytime.
• Built-in VPN server. secure connection for outside access. e-Film, digital jacket or any other dicom viewer software.
• Optional HL7 Interface

Server Configuration:

• AMD ATHLON 64 X2 5200+ C2 2.70GHZ
• 2GB DDR2 800 PC6400 HYPERX MEMORY
• Windows Server 2003 Standard Edition
• Your Choice of 2TB Hard Drive (RAID0) or 1TB Hard Drive (RAID1). Need more storage? No Problem we can upgrade your storage to meet your needs.
• Optional UPS
• Virus, Spyware, Malware, Firewall Protection
• One Year PARTS & LABOR warranty   

Optional Modules & Services:

• Dragon Naturally Speaking Voice Recognition Software
• Transcription System. Available in both digital (digital recorders) or analog (dial-in)
• Remote Server Backup

What a deal!  I'm particularly intrigued by the UNLIMITED stuff.  I have to pay license fees and buy more storage on my SAN to add patients.  Has Rudy found a way to store an UNLIMITED amount of data on the server?  When you say UNLIMITED, it should mean UNLIMITED, yes?  Well, Rudy?  What say you?

I'm also taken with the thought of a platform-independent PACS.  Rudy was kind enough to include a screen-shot of his GUI, something many vendors never get around to doing, by the way. 

This is a rather busy interface, with cute and occasionally informative icons.  No doubt there are tool-tabs in actual use.  I would assume this was designed by an engineer working with a graphics designer, with no radiologist in the immediate neighborhood.

You'll notice the title-bar refers to this viewer as "RemotEye".  A quick googling reveals the source:  NeoLogica, from Italy.  NeoLogica also provides PACS Connector to connect RemotEye to any DICOM server: 

Thanks to the PACSConnector software option, RemotEye can now be deployed as a "ready-to-use" solution, without requiring development of custom integrations for a specific DICOM server or archive.

Searching for patients and studies, sending DICOM files to server, reporting, downloading and displaying images from server and all operations typically supported by RemotEye are now available through the special module developed by NeoLogica: PACSConnector.

PACSConnector works as a bridge between the DICOM server (PACS) and the RemotEye client, implementing the DICOM protocol on one side, and the RemotEye-specific HTTP/XML protocol on the other side.

RemotEye now also supports a new integration mechanism, based on the HTTP and XML standards. This mechanism is particularly suitable when RemotEye shall be configured as the viewing front-end for a DICOM back-end system or archive. In this mode, RemotEye sends queries to the back-end through the HTTP protocol, based on the search parameters entered by the user in the search window. After performing a query on the DICOM storage archive, the server will send XML-formatted answers to RemotEye, containing the matching patients, studies, series and images. RemotEye will now be able to retrieve and display the relevant studies and series, as requested by the user, even using compression techniques. In order to better support this new integration mode, RemotEye is now also able to execute as a Java Web Start application, in addition to as a Java Applet.

The Java origins explain the cross-platform abilities.  Rudy doesn't tell us which DICOM server is in use, but I would assume it is NeoLogica's LogiPACS. 

Is this worth $9K?  Well... I'm not sure how much the software costs, but the hardware isn't much more than $1,000 or so.  If you're capable and adventurous, you can use open-source PACS software, such as Conquest and/or ClearCanvas (about which I know virtually nothing) for free.  There's also the free OsiriX client, which can be used with the free dcm4che server.  I'm not sure what the FDA implications might be, however.  You could also use the free PacsOne (their capitalization, not mine) system.  I downloaded it and they proceeded to cold-call me while I was in Costa Rica, costing several dollars and souring me on their product.  Other low-cost solutions (at least initially) include using remote servers as we see with Co-Activ. 

I guess PACS is now a mainstream product, with its regular appearance in eBay.  I'll be really impressed when we can buy a system at Wal-Mart, along with the EMR they already sell.

Two Hundred Thousand Hits!

Visitor 200,000 arrived at my blog very early this morning.  He or she was searching for an image of the "O.K. Corral" and stumbled upon my entry of the same name.  The viewer was no doubt disappointed in the contents, although perhaps the old-timey picture below was what they sought:

It only took five and one-half years to get to this point!  Maybe I can accumulate a million hits by, oh, 2020 or so?

SCRU-Verse

We live in a Broadband world, and ultimately, it shouldn't matter whose pipe dumps the bits and bytes into your lap.  Thus, when AT&T's U-Verse became available in my neighborhood, I thought it was time to jump ship from Time Warner Cable.  After all, even the rather pricey Business Class was only delivering about 4-6 Mbps, and 50+ channels of non-HD.  For the same price, I figured I could go with Ma Bell and get a better deal.  So I did.

Before I dive into my personal tail of woe, I need to tell you  just what U-Verse actually is.  From ATT.com:

AT&T U-Verse® uses fiber optic technology and computer networking to bring you:
* Advanced digital TV
* High speed Internet
* Digital home phone service

It's basically a big data pipe like I said at the beginning, delivering the goods via fiber and DSL instead of cable. The TV end of the package is pretty good, with innumerable digital and HD channels.  They are all full of the usual mind-rot, but having 200 or 300 channels of mind-rot has to count for something.  And you can record them for playback on any TV in the house.  AND there's an iPhone app for remotely programming the recorder, which is also great for impressing your less-than-technical friends. 

Since Mrs. Dalai doesn't like to deal with change (you know who she didn't vote for), I arranged the switch-over to take place while we were en route back from Peru in mid-June.  Thank Heavens for my PACS guru, who gave up most of his Saturday to supervise this fiasco.  It seems that even though my neighborhood is "U-Verse ready," the fiber or whatever hadn't quite made it down to my end of the street, so that had to be, ummmm, laid (which sets up the theme for what's to come) before any other progress could occur.  Then, because I had two phone lines which were billed separately, the BIG AT&T BILLING COMPUTER wouldn't allow voice to be activated.  Even so, they got the TV (and associated boxes and DVR and remotes and so forth) running nicely, and the 18Mbps internet came up properly as well.  (I actually max out at only 14Mbps for my download speed, but that's still a lot better than where I was.)

So far, so good.  All the while, the old POTS (plain old telephone service) analog lines were working nicely as well.  Sadly, I tend to ignore the old maxim that tells us the enemy of "good" is "better." More importantly, there were lower prices and lovely rebates to be had for those who added on U-Verse Voice (which is really Voice Over Internet Protocol, VOIP, using the shiny fiber broadband pipe.)  Thus, I insisted, over Mrs. Dalai's wise protest, upon having Voice put on as well.  This was not a good move.

We've had U-Verse voice up and sort of running for about a month now.  It works, but it has glitches.  Our particular glitch involves a strange buzzing feedback when the victim on my end speaks into the phone.  Of course, that doesn't start until about 5-10 minutes into a call.  It is INCREDIBLY annoying, and ultimately intolerable.  I've had AT&T out to look at everything about 5 times, and I've been on the "chat" with Tier 1, Tier 2, and all of the other Mouse-ke-Tiers on about 30 occasions.  Every time, they bounce the 2Wire Residential Gateway (a big fancy router), which disturbs Mrs. Dalai's Farmville activities, and thus creates even more grief in the house than the malfunctioning phone itself.  And every time, the phone acts properly for the first five minutes of a call, just enough for Nahtanoj, I mean Jonny, to sign off on our case, and then.....   BUZZZZZZZZZZZ.

By this afternoon, I had had enough of this nonsense, and got downright pushy with Haripol, I mean Paul, the Tier 1 helper du jour, and demanded that they come out and fix it or yank it.  I was trying to do this from work, and Paul kept asking me to unplug and plug in phone wires, which we've done 50 times before.  I typed in all caps to show I meant business:  "NO!  I WON'T!  YOU SEND SOMEONE OUT TO FIX THIS DOG OR I'M GOING BACK TO TIME WARNER!!!"  To which Haripol replied, "OK, but if the tech does what I'm telling you to do, and that fixes it, we'll charge you $50."  He didn't need the computer to hear me squawk about that statement. 

Ultimately, we got someone out to look at it one more time earlier this evening.  All I can say is God bless honest people.  The gentleman from AT&T got to our house, examined the tangle of red, green, yellow, and black wires, and said, "You know, I'm finding this situation quite often, where the digital phone just won't install properly in some houses."  Well, I'll be darned.  You mean to tell me the damn thing actually might not work?  I'm not crazy?  Of course the latter determination is not in AT&T's scope of operations, but the former turns out to be the case.  Our new best friend from Ma Bell went on:  "AT&T rolled out VOIP before it was ready.  When you hook up the old wiring in the house to the digital output, you have done little more than create a huge antenna, and it picks up any strong radio signal in the vicinity.  I was just at a house on the other side of town that couldn't work with U-Verse Voice at all because the guy next door had a big CB base station." 

Eureka!  That is why the interference and bad behavior doesn't start right off, although for the life of me, I can't imaging what RF source is causing the problem.  Whatever.  U-Verse Voice has to go.  I've put through the order for the phones to be switched back to POTS.  And they darn well better not try to take my rebates back, either.  I've already used the stupid VISA gift cards!

Here's my revenge on U-Verse.  I'm telling everyone I know:  DON'T GET U-VERSE VOICE!!!  Not until the technology improves!  Seriously!  This isn't ready for prime time.  Of course, even if I get everyone to avoid U-Verse Voice, the victory is pyrrhic at best as POTS costs more.  But sometimes you have to stand up for your principles. 

Hear that, Nahtanoj???

Reagan Was Right Again

Hooked Again

Hooks seem to be popular at my hospital this week.  Here we have an abdominal radiograph of an eight-year-old boy with "ingested foreign body".  No doubt the hook was made in China. 

You Should Have Seen The One That Got Away...

DoctorDalai.com "Noteworthy"!

DoctorDalai.com has been up and running for five and one half wonderful years.  Most bloggers jump into the blogosphere with great enthusiasm, submit several highly informative posts ("Went to the washroom, successfully") and then return to cyber-oblivion.  But I've kept blogging all this time, defying the odds, and several larGE vendors.  Basically, writing this thing keeps me sane, even though it may drive some others out there a bit batty.

As the only radiologist blogging more or less exclusively about PACS I still have a unique niche.  But it seems that social networking is becoming more and more popular in our field as discussed in the July edition of RSNA News:

Social media—defined as websites driven by user participation and user-generated content, such as blogs, networking sites like Facebook and the Del.icio.us bookmarking site—are offering radiologists new ways to network, interact and stay connected to each other and the general public.

Sites with a medical imaging focus include "Radiolopolis," billing itself as "The International Radiology Community for Education, Research and Clinical Practice," and "Radiopaedia," radiology's answer to the popular Wikipedia website. Blog topics range from the gadget and technology updates on "A Radiology Geek's Blog," to images and discussion from a consultant radiologist in the United Kingdom who writes the "Daily Dose."

The article goes on to discuss the potential for HIPAA violations online (don't discuss specific patients!) and for marketing opportunities.  And,

"Currently, image sharing is cumbersome with many time-consuming steps," Dr. Choy (a co-founder of radrounds.com)  said. "Social media can enable simpler and faster image sharing which has the potential to improve patient care. Other radiology software platforms such as online reference tools, reporting systems, radiology information/hospital information systems and scheduling software can also integrate social media tools to improve communication between physicians for better patient care."

It seems that I've reached the threshold of RSNA's attention, as my blog rates mention in the last paragraph:

A sampling of other noteworthy radiology networks, resources and blogs include:

Flickr (www.flickr.com): Interactive photo sharing site with massive storage capacity and the ability to connect contacts around the world.

radRounds (www.radrounds.com): Radiology and medical imaging professional network for building relationships in clinical practice, education, career, research and industry.

Daily Dose (radiologyimages.blogspot.com): Images and discussion offered by a consultant radiologist in the U.K.

Dalai's PACS Blog (doctordalai.blogspot.com): This site from "an average radiologist in an average practice in an average town in the South," suggests an alternate acronym for PACS: "Pain and Constant Suffering."

MRI Metal Detector Blog (mrimetaldetector.com/blog): MR imaging safety director Tobias Gilk offers information on ferromagnetic detection and MR imaging safety and screening.

Not Totally Rad (nottotallyrad.blogspot.com): Known for "Shedding Light on Invisible Imaging," the blog was founded by anonymous interventional radiologist, the Samurai Radiologist, who was featured in the November 2008 issue of RSNA News (rsnanews.RSNA.org.)

I'll take noteworthy.  Sadly, a review of the hits from the time of this article's publication showed very few referrals from the link above.  I guess RSNA News readers got bored before they reached the bottom of the page.

Doctor Dalai and the Demo

Dalai's First Law

PACS IS the Radiology department. 

Agfa IMPAX 6.3 has been completely dead for the last three plus hours.  This takes down a Level One trauma center, and two other smaller hospitals.  So far, I have no explanation, and no end in sight.  The trauma center might have to consider a Code Yellow, as we have seen in Western Australia. 

I'm thinking we need to reconsider the concept of distributed architecture, which was discarded for the central archive and production processor model which is currently betraying us.  Even with three redundant application servers, we are down and dead. 

I have no further comments at this time.  I will let everyone know what happens when we get back up and running, although there will be a very large number of studies to be read when that happens.

I will invite Agfa to submit their narrative of these events once the dust settles.  This will, I'm sure, prove interesting and informative.

ADDENDUM:

We seem to be back up, after three and one half hours of downtime.  I've got some work to do, if you'll excuse me...

Agfa Fixes Problem! One Down, 1,000,000 To Go...

In a previous post, I bemoaned the fact that Agfa IMPAX 6.X has about a million buttons with about a zillion permutations as to how they could be arranged. 

This turns out to be more of a problem than I thought.

You see, for the past year or so, we've been experiencing significant lags in PACS response, especially on the workstations with four high-res Barco monitors.  New workstation computers and new back-end software helped to some degree, but the lag was still there. Dr. Killer, our finest and most aggressive power-reader, was fit to be tied.  Even more than usual, that is. 

Now comes word from Waterloo that the etiology of this problem has been discovered.  It seems that years ago, when IMPAX was first installed (it only seems like decades), a customized Radiologist Role was created, adding most of the available tools (see image above) to the toolbars.  That was found to be unwieldy, and unnecessary tools were removed from the rad's accounts.  However, IMPAX, being the really intelligent program that it is, remembers that all of those lovely buttons were once there, and goes through the entire list of buttons each and every time we change a study.  To fix this little problem, all we have to do is delete the Radiologist role (not the radiologist, as some in IT and at Agfa might wish), reset our Application Servers, and then log back in.  Of course, each doc will have to customize the refreshed account all over again.  What fun that will be!   Since mine isn't all that slow, and I appreciate a little break in between studies, I'll probably stick with what I have.

So, tip of the hat to Agfa, and especially the good people in Waterloo.  Many thanks for taking care of this.  Anyone want to fess up as to who wrote this into the software?

The Doctor Dalai Show Revisits The iPad For Radiology

Meeting in Chicago

As usual, it has taken me far too long to get this report to you, but I only have one laptop up here in the North Woods, where I'm playing Camp Quack (pediatrician) for the week.  Naturally, Mrs. Dalai's Farmville crops will suffer if they aren't tended to constantly, and so I have to wait until the plowing and harvesting is complete before I can do something so mundane as post to my blog.  Beaucoup thanks, Facebook.  Love ya, mean it.

I did finally get to Chicago, accompanied by our intrepid salesman, and former PACS administrator, Garn.  As an aside, Garn's family has been very close to my group over the years, his dad and sister having sold us our very first Advanced Video Products/eMed/Access teleradiology system in the ancient, pre-Dalai era.  Garn earned his keep on this trip, literally running through three terminals to hold our USAir flight from Charlotte to Chicago that departed about 3 minutes after we arrived from South Carolina.  (I got stuck behind some slow-pokes on the moving walkway.)  That's what I call service.

I love Chicago, but I wouldn't want to live there.  Traffic from O'Hare downtown was murderous, even at 8 P.M.  For better or worse, my daughter loves Chicago and does want to live there, and will shortly begin a four-year stint at Northwestern Medical School.  (You don't want to know what that will cost, but we're talking yet another delay in my retirement.)  I had the chance to scope out her apartment building, and I was glad to see that security wouldn't let me in.  You have to find some peace wherever you can when you send a small (4'10") child to live in the big city.  It's going to be a long four years.

Merge Headquarters is in a very nice, new building just south of the Chicago River, with a great view of Grant Park.  We were fortunate enough to catch the Taste of Chicago in progress down in the park, and had a great lunch there, instead of sandwiches in the airy conference room.

Comparing Merge Central to the old AMICAS headquarters in Boston's New Balance Building is an apples vs. oranges exercise.  The new Merge office has miles of glass, with all executive offices completely visible to the hallways.  At AMICAS, the offices were, well, offices, and the place had a more informal dot.com-era feel with more free-form workspaces.  Yes, everyone at Merge wears a dark suit, a white shirt (although I saw a few renegades with pinstriped shirts), and a requisite orange tie, or scarf for the ladies.  The Merge logo is everywhere, and I quickly gave up on my grand idea to suggest a corporate name change.

You see, this Merge is not your daddy's Merge.  When the Click/Merrick folks (Messrs. Ferro, Dearborn, et. al.) took over, they remade Merge into a completely different company than its predecesor.  No more financial shenanigans, and no more anything but a drive to turn the old framework into a billion-dollar company.  I think they have a good chance to do it, too.  But when us old folks (like me and Mike Cannavo) think of Merge, the spectres of the past and visions of eFilm on every monitor loom close to the surface.  I'll say it here: Merge might be better off renaming itself AMICAS, but there seems to be a significant investment in things orange and blue, so I'll drop that line of thought.

I had the opportunity to meet with some old friends from AMICAS, Paul Merrild, now Senior Vice President - Marketing Corporate Strategy, and Kurt Hammond, VP Sales.  Justin Dearborn, Merge CEO was present, as was Nancy Koenig, now Executive VP for Sales.  Alas, Mr. Ferro could not be there, but I was told he had recently returned from Washington and various White House meetings.  More on that shortly.

When you've questioned a big company publicly, as I've done here, it creates an uncertainty, a degree of apprehension, that can only be defused by a face-to-face meeting.  I'm sure the Merge folks (maybe even the old AMICAS guys) were expecting this version of Dr. Dalai:

Of course some will say after reading this piece that this is what Dr. Dalai had to drink in Chicago:

Which is true?  That is in the mind of the reader.  To be enigmatic, I'm reminded of the pilot episode of "Fantasy Island".  Mr. Roarke's assistant, Tattoo, was asked what he thought of his employer.  Tattoo said, "Some call him..." (Tattoo points to Heaven), "and some call him..."(Tattoo points down).  "And what do you call him, Tattoo?"  "I call him Mr. Roarke."

The truth is, as usual, somewhere in between.  We had a good, frank discussion, I came away impressed, and the Merge folks probably were slightly relieved.

On the wall of the Merge conference room are 60 framed patents from the Cedara division in Toronto.  About 45 of these are for various imaging processes or devices, and 15 are for master data management.  I believe Merge considers the Toronto office, and the 120 engineers (including 12 DICOM experts) located there, one of the most important parts of its operation.  (There are 50 more engineers out in the field.)  Cedara provides a number of OEM'ed products sold to the likes of GE and other big vendors, distributing Merge products much more widely than I had imagined.  But in the realm of RIS/PACS, I was told that Merge is now the Number Four vendor, behind GE, Philips, and McKesson.  They claim a rather large footprint of 1500 hospitals, and 2200 Imaging centers, for almost 4000 "points of presence".  I don't think this includes the ubiquitous eFilm users, either. It does represent a coming together of several cultures, Merge, AMICAS, Emageon, etc., with all that entails for the company.

I'm hoping this high figure doesn't include eFilm, as I'm not a big fan.  However, Merge loves eFilm, which it acquired in 2002:

In 2002, Merge also acquired a Canadian software developer eFilm that developed medical imaging and information workflow products and services. eFilm provided Merge with a software-only image viewer that could be downloaded over the Internet. That acquisition allowed Merge to attain its goal of becoming a global leader in diagnostic imaging software tools by achieving a record 20,000 downloads of its eFilm Workstation software in 2002. eFilm Workstation displays diagnostic images, using a standard PC and monitor, and provides exceptional navigation and viewing tools for optimal radiological interpretation. 

Someone at the table jokingly called eFilm the "Duct Tape of PACS" and then instantly regretted providing me with a pithy quote for the blog.  But most of us, especially males, appreciate the comparison and find it complementary, so here it is in print.  The analogy is apt:  a duct tape repair will hold, but it might not be pretty, and neither is the eFilm interface.  But it does work, and it brings in significant (and easy) revenue for Merge.  Apparently it is quite popular in other countries such as Brazil where there is only 5% penetration of digital imaging.

Merge has a far-reaching long term outlook, which will utilize their know-how in various fields to provide solutions to other vendors, such as Meditech and Allscripts, as well as for the various 'ologies, Cardiology, Anesthesiology (perioperative monitoring software), Pathology (storage for the rather large images of tissue slides, etc.), and Gastroenterology (in the form of storage for endoscopic images).
While Merge doesn't want to get into the HIS and similar ends of the EHR business, they wish to be complementary to those who are in that space.

The patient experience will be an important part of Merge's future, and they have a very nice patient kiosk up and running.  It can do everything from check you in to dispense a CD-ROM of your recent imaging studies.  In fact, it was this technology that Michael Ferro was trying to get the White House to understand as one aspect of the Meaningful Use of EHR technology.  Merge is also trying to get PACS wedged in there as well.

I had a brief demo as well of some of the CAD products from Cedara, including a very nice system for breast MRI and liver CT and MRI.  I gave Merge the Million Dollar Idea after seeing these programs:  rework the engine for PET/CT.  The autodetection and so forth would work perfectly in that venue.  I'll gladly accept $500K for this really great suggestion.  Small bills, please.

The ultimate plans for PACS involve Enterprise Content Management (ECM), a vendor-neutral archive developed by Emageon that came with AMICAS, as the main repository.  For the clinicians at least, a Web Access platform will overlay this, providing a zero-client viewer via AJAX (and not Flash) technology, with fast server-side rendering.  Note that this is not an appended web server (ala the bad old Web 1000) but an integrated viewer.

A related product promises to help with the portable patient problem I've been bemoaning for years.  The "Outside Study Gateway" is useful for trauma and other transferred patients with outside exams, which encompasses just about every patient in my experience.  This is to be accomplished as part of PACS, since the PACS is already in place, you know.  It should be capable of operating without a VPN, which to me, having people that can do VPN's at my beck and call, isn't a big deal.  I believe module actually requires an add-on server, which will cost extra, but if it works as advertised, I would strongly recommend that you buy it.

But what I really came to Chicago to discover was the future of AMICAS PACS, and I think the answer here is satisfactory.  The Merge people feel that Merge and AMICAS were more complementary than competitive, except in the realm of RIS/PACS.  Everyone agrees that AMICAS had a great PACS, and Merge had a good RIS.  These two programs, respectively, will be the go-forward products.  Everyone at the table wanted to be certain I deliver this message clearly, so I will quote verbatim:  "The approach to RIS/PACS will be the consolidation of the best practices of all of the applications into a single platform workflow and viewing solution."  Well, there you have it.  All Merge RIS/PACS customers, including those using AMICAS PACS, Fusion PACS, or RadStream (from Emageon) WILL BE SUPPORTED, and will have an upgrade path.  How much the upgrades will be wasn't mentioned.  What I will call AMICAS 7 will ultimately include the best of all worlds, blending the best of the legacy products, and using the ECM as the back-end.  (In discussing this with my PACS administrator today, we wondered how this will affect the way AMICAS currently stores images, with DICOM going to backup and JPEG2000 on spinning RAID.  Perhaps everything will now be DICOM, which would require a larger online storage facility.  Fortunately, storage is cheap these days.)

Feeling I had to be at least a little ornery, I questioned whether Merge would be able to graft the AMICAS front-end onto the Emageon ECM.  After all, our friends at another larGE company have yet to successfully do something similar with the new GUI they bought a few years back and their shiny new LINUX back-end.  I got a few laughs with that one.  Basically, Merge feels that the ECM is a very different animal than the LINUX thingie (technical term mine), more DICOM-friendly, and more amenable to having other interfaces plugged into it.  (I refrained from asking if I could get IMPAX 6.x to plug into it, too.)  The ECM should have better standards, and an interface has already been created for the Camtronics/AMICAS Vericis cardiac program.

At this point, in the meeting, I felt cautiously optimistic.  I was impressed by way my old AMICAS friends have transitioned into this new reality, as well as Ms. Koenig's and Mr. Dearborn's enthusiasm for where the company is and where it's going.  Merge will not only make a go of all this, but will actually succeed mightily.  But now I'm now going to share with you the best part of the show, and the person I met that completely and totally "gets it".  I'm referring to Luc, the Director of Patient Experience.  After the talking points and the white-boarding, and so forth, Luc walked me down a corridor, and opened an unmarked door.  Inside the long, narrow room, were....Video Games!  There were various driving games, a machine that played multiple legacy games, and a coin-operated version of Guitar Hero.  Luc asked me which I thought was the most popular, and flailing a bit, I pointed to the multiple game console.  80,000 games in one box is not to be sneezed at, right?  Well, Luc laughed a bit and shook his head.  No, the most popular game is the machine with the simplest, easiest-to-use interface, which would be Guitar Hero.  So what was the point of this lesson?  Simply this:  To create an interface, especially for patients, but quite applicable to physicians, one must simplify, but still have a complete understanding of how the thing had to work in the hands of the users.  It was not enough, Luc said, to bring a radiologist or two into the company and see how they like things.  Rather, it is necessary to go observe how the radiologist uses the GUI in the hospital, in his environment.  Only then will it be apparent how things should work.

Looking back, I'm not sure if Luc was thinking more about the patient-kiosk interface we were about to see than the AMICAS PACS interface that is already here.  But I still think he gets it, and by extension, I'm hoping Merge does as well.

This is a different path than I hoped to be following six months ago, but I'm more and more hopeful that it is a good one.  I know that my favorite AMICAS developers have been working to impart their knowledge about Version 6 to the Cedara folks in Toronto, and for that I will be forever grateful.  Certainly this was above and beyond the norm for a departing employee, but that's the sort of people they are.  With some luck, their colleagues in Toronto will prove to be worthy successors.

So, did I drink the Kool Aid?  Nah, I had a Diet Pepsi at the Taste of Chicago...

Inca Trails and Tribulations

Dalai's Note: As I posted earlier, we made it to Machu Picchu...for only two hours. Here is the story as told to the tour company, whose name is being withheld...for now. Ah, the joys of traveling in Third-World nations.

To:  Tour Company
 
From: Dr. Dalai and Friends
 
RE:  Recent trip to Peru
 
We recently traveled to Peru with an itinerary and services provided by your company.  With the advent of the strike in Cuzco and subsequent travel restrictions, we experienced the following alterations in our schedule:
 
1.  Time at Machu Picchu limited to two hours.
2.  We were not able to stay in the Sanctuary Lodge, but instead spent two nights in the three-star Casa Andina Classic Hotel in Cuzco. 
3.  We did not receive meals that were to have been provided at the Sanctuary 
4.  We did not experience the Sacred Valley Tour.
5.  We traveled a day earlier to Lima (Friday 6/18) and spent that night in the Casa Andina Private Collection Hotel. 
 
Additional payments and refunds must be evaluated in light of these changes.
 
We need to discuss the way in which your agency dealt with the strike and subsequent events.  It should be clarified that the strike was not by Peru Rail per se, but rather by the General Workers’ Confederation (Cgtp), Peru's largest union.  It was a precautionary measure for the Ministry of Tourism to suspend the rail service linking Cuzco to Machu Picchu.  The Minister stated that this was done “in order not to expose travelers to potential acts of violence”. 
 
Your agents in Peru were aware of the strike, but initially told us it would not extend into Friday, June 18.  It was not until we were actually touring Machu Picchu that our guide began hinting that the strike would be in effect through Friday, and when I spoke with the agent in Lima by cell-phone, she was certain it would go into Friday.  She did offer some hope that the Sanctuary, owned by the same company as Peru Rail, could arrange for our evacuation on Friday.  As we held unrefundable airfares, we felt we had no choice but to leave Machu Picchu emergently on Wednesday.
 
We took what we were told was the last train from Aguas Callientes to the hydroelectric station at 1:15 PM that day, with assurances that a van would meet us at the station no later than 4PM to take us back to Cuzco.  (As an aside, the guide's phone ran out of charge.  We tried to use mine (at international rates) but I could not get a consistent signal.  The guide also asked us to pay her $8 train fare.)  By 4:30, she informed us that she had to take the last train back to Aguas Calientes because she had a group coming in on Saturday June 19.  She left us with the number of her discharged cell phone, as well as that of the driver who was supposedly en route to pick us up from the station.  She asked Jose, a railroad employee manning the station, to watch out for us while we waited.
 
The hydroelectric station stop has very few amenities, although it did have a restroom that our guide didn't know about; instead, she sent us 400 meters up the tracks to use the facilities at a tiny restaurant.  Ultimately, The driver appeared at 7PM, 5 hours after we had arrived.  I had attempted to call your Lima representative with no luck, and finally called our Galapagos outfitter, who had referred us to you.  He was able to reach one of your offices, and someone, after several attempts, contacted me via cell, informing us that "due to the strike" (which was not to start until midnight), the driver had to take alternate roads and was delayed, but he was on his way.  We learned that much of the delay was simply due to the very poor condition of the roads between Santa Theresa and the station.  We were tired, dirty, and most of us had been stung or bitten multiple times by tiny black insects, which left painful lesions that we still have today, a week later. 
 
The ride to Santa Theresa was one of the most harrowing of our lives, over narrow paths with no barrier to adjacent drop-offs down to the river, and "bridges" over rushing water that could barely accommodate the van.  We did arrive in Santa Theresa, transferred to another van driven by another driver, bought a snack and used the restroom with the urging that we had to get moving quickly to avoid the strikers.  We then had a SEVEN hour ride over similarly treacherous "roads" with no stops for bathrooms or food.  At one point, not far from Santa Theresa, we were stopped behind a stalled car, and had to allow a truck to pass the other way, with literally an inch to spare.  As we came out of that particular pass, we were stopped by a two men and a woman who knocked on the window.  Our driver opened the door to these strangers, who claimed (and ultimately proved to be, we think) Americans stranded and needing to get back to Cuzco.  We allowed them to join us.  We were stopped at least four more times by police, and at each stop our driver got out and showed his papers to them.  At one of the stops, the police shined flashlights into the van, scaring the youngest child in our group.  Just outside Cuzco, Leo stopped and got out to talk with some men who flagged us down but were not wearing uniforms.  We finally reached our hotel in Cuzco at 3:30 AM.
 
Your company and its agents did not handle this situation well.  We realize that the strike itself was beyond your control, but there are several additional factors that caused us great distress.  There was an inexcusable lack of disclosure, communication, and information, which becomes more and more apparent as we review the facts of the situation:
 
1.  Strikes happen often in Peru.  From the US State Department:

Political demonstrations and labor-related strikes and marches regularly occur in urban and some rural areas and sometimes affect major highways. They can also cause serious disruptions to road, air, and rail transportation. Demonstrations are often – but not always – announced in advance. While these activities are usually peaceful, they can escalate into violent confrontations. As a general rule, it is best to avoid large crowds and demonstrations. Visitors are encouraged to keep informed by following the local news and consulting hotel personnel and tour guides.

The date and duration of the strike was known to other tour agencies, who adjusted the schedules of their clients so they would be in and out of Machu Picchu without difficulty.  Why did your company not have these details? 
 
2.  You placed our party of eight, including children, in unnecessary danger with the treacherous van ride back to Cuzco.  We were not informed of the degree of danger we were to experience by traveling at night, on back "roads" barely worthy of a foot-path, let alone the direct danger of being confronted by strikers.  In addition, the State Department notes:

Crime also occurs on roads, particularly at night and outside urban areas. Clandestine, impromptu roadblocks can appear on even major highways, where bus and automobile passengers are robbed. The risk is even greater on rural roads after dark.
 
Road travel at night is extremely dangerous due to poor road markings and frequent unmarked road hazards. Drivers should not travel alone on rural roads, even in daylight. Convoy travel is preferable. Spare tires, parts, and fuel are needed when traveling in remote areas, where distances between service areas are great. Fog is common on coastal and mountain highways, and the resulting poor visibility frequently causes accidents. Inter-city bus travel is dangerous. Armed robbers, who force passengers off buses and steal their belongings, sometimes hold up inter-city buses at night. Bus accidents resulting in multiple deaths and injuries are common, and they are frequently attributed to excessive speed, poor bus maintenance, and driver fatigue.

3.  The second driver placed us in further danger by opening the door of the van to non-uniformed people he didn't know.
 
4.  Neither of the drivers that night spoke English.  Had my daughter not been capable of understanding Spanish, we could very well have been in even deeper trouble. 
 
We placed our trust in you, anticipating a safe adventure and visit to one of the new Wonders of the World.  Your agents betrayed that trust, and disregarded our safety, literally placing our lives in jeopardy, not to mention depriving us of all but a glimpse of our destination that was something I had waited forty years to see.  We do not believe their intent was malicious, but the situation was handled in a manner that can only be termed incompetent. 
 
I believe proper compensation would be a refund of ALL monies paid to you, as well as a letter of apology from your owners, for the complete and total, and nearly tragic failure of your agents to deal with a situation you should have anticipated.  
 
We await your response.  
 
Sincerely,
 
The Dalai Family

Please Stand By...

I'm currently at 30,000 feet, using Delta's GoGo inflight WiFi service, en route to the North Woods where I will reprise my roll as Camp Doc, or Quack as the kids there put it. I guess my reputation precedes me. Look for the writeup of my visit with Merge shortly.