Orphan Radiopharmaceuticals And Other Libations

It has been a few years since I've made it to the Society of Nuclear Medicine annual meeting, so long actually that the Society has since changed its name, and is now called the Society of Nuclear Medicine and Molecular Imaging, I personally think this was prompted by the unfortunate amusement among the puerile (like yours truly) related to the original title's initials. SNMMI just doesn't have the same ring to it, but they don't ask me about these things. 

The exhibit hall is about 1/50th the size of the massive trade show at the RSNA, but most of the big players have a presence.

Herr Großkopf, the huge animated head, graced the Siemens booth, touting Amyvid. My new Intevo SPECT/CT was perpetually scanning a rather eerie half of a patient, also created by the geniuses of Legacy Effects. (By the way, if you want to see more on the production of Herr Großkopf, try this YouTube video:  http://youtu.be/L3gE1Zp9Vt8

It is a humbling experience to sit in the educational sessions presented by those quite a bit smarter than I am, and realize just how much I don't know. But somehow, we average rads/NM physicians do manage to muddle through. We can't all be the best of the best, but I'm grateful to those who are the best for their willingness to share their expertise with the rest of us.

I'm often asked how Nuclear Medicine differs from Radiology. The simple answer is that with the latter, we somehow externally energize the body, or pass energy through it; an X-ray is taken by passing the beam of radiation through the body and detecting what is blocked and what is transmitted. With MRI we spin your molecules, and with Ultrasound, we bounce sound waves off your tissue interfaces. You get the idea. 

Nuclear Medicine is different. Here, we inject some radioactive stuff (in the case of PET, we use honest-to-God antimatter) into your body, or make you drink or eat it, breathe it in, or in some cases instill it into places God did not intend us to instill things. We then use very sensitive detectors to see where the stuff went, how long it takes to go away, and so on. In the proper doses, some of the agents can be used for therapy as well. The stuff we give you is called colloquially a radiopharmaceutical, basically a drug with a radioactive atom attached to it, or in the case of radioiodine, the radioactive isotope of the element itself, delivered as sodium iodide, is given to scan, treat, or even ablate the thyroid, which gobbles up iodine, radioactive or not. 

The bottle of wine above isn't really a radiopharmaceutical, but I found it amusing as the term MUGA refers to a Nuclear Medicine heart scan, generically known as a Multiple Gated Acquisition. There were dozens and dozens of new scanning agents being discussed at this meeting, and at least some of them will be approved eventually for general use. Hopefully. That process takes a long, long time, and I'm told new drugs require a $4 BILLION investment each. Given this, you would think that a successful product would be celebrated and propagated.  You would be wrong.

One of the big areas of research in diagnosis and therapy involves labelled monoclonal antibodies, basically a radioactive atom attached to a natural molecule that targets some particular tissue. These so-called magic bullets have been somewhat disappointing overall, not quite magic after all. But some have worked, and in particular, a couple of these compounds, Zevalin and Bexxar, directed at treatments of some forms of lymphoma have really performed quite well. The antibody seeks out the tumor (actually a particular protein on the tumor surface) and the radioactive atom blasts away. For once, the term "cure" can be tossed around for patients who had failed other regimens. Zevalin uses yttrium-90, while Bexxar uses iodine-131 as its nuclear bomb, so to speak. 

I've administered both of these therapies. They are horrendously expensive, with pricetag of the pharmaceutical alone exceeding $26,000. Medicare paid us perhaps $15-17k, so there is a potential loss on every dose which much be made up by charging those with other coverage upwards of $100,000.  I've had more experience with Bexxar, and that experience has been good. We've achieved a number of complete remissions and we had no deaths that could be attributed directly to Bexxar. Our one Zevalin patient did not survive, but that is most likely due to the fact that this therapy wasn't applied until that particular patient was at death's door. Another shop in town did quite a few of these therapies, ending several years ago; some of the patients are now coming back with white cell depletion, a known complication when you are placing radioactive stuff right in the marrow. It's a problem, but one that they wouldn't have had without this therapy because they would most likely be dead.

One of the lectures this week at SNMMI touted the virtues of Bexxar, noting that as compared to Zevalin, its administration offers at least an attempt at radiation dosimetry. We give tiny doses to see where it goes and how fast it is eliminated, and base the final dose on that data. It's not complete, but it takes an army of physicists to do better, and out in the field, this is pretty advanced stuff.

Sadly, Bexxar, a very good treatment, is being pulled off the market. Why? Because the $100,000 per dose radiopharmaceutical couldn't turn a profit.

Jamie Reno, a Bexxar patient himself, writing in The International Business Times, bemoans the loss:

The discontinuation of Bexxar is an extreme example of a lifesaving drug being eliminated due to its relatively low profitability. In most cases, when a pharmaceutical company concludes that a niche drug is not making enough money, the product is sold to another, smaller company which continues to make it available. But continued availability is left to the discretion of the company (or companies) that owns the rights to the drug, which is how pharmaceutical companies can withhold potentially lifesaving experimental drugs that have not yet been approved by the FDA -- often, due to concerns that a potential problem resulting from such use could jeopardize the drug's ultimate approval.

Luke Timmerman, on Xconomy.com, traces Bexxar's history:

Bexxar, developed in the late ‘90s by South San Francisco-based Coulter Pharmaceutical and acquired in 2000 by Seattle-based Corixa, had a lot going for it. The drug was aimed at a protein marker called CD20, which was already a validated molecular target for cancer, based on the success a couple years earlier of a so-called “naked” antibody from Genentech and Idec Pharmaceuticals, rituximab (Rituxan). Corixa had a well-respected CEO in Steve Gillis who attracted scientific talent, and raised lots of cash. It had a Big Pharma partner in Glaxo to help it manufacture and market the drug to the fullest.

{snip}

Corixa, unable to turn Bexxar into a profit center, ended up being acquired by GlaxoSmithKline in 2005.

Without boring you with reams of positive data, suffice it to say that Bexxar worked, and worked well. There was talk of using it as a secondary or even a primary therapeutic agent, rather than a last-ditch hail-Mary for those who had failed all other regimens. But it was not to be. Timmerman continues:

But there was a catch. Oncologists who saw these non-Hodgkin’s lymphoma patients could prescribe rituximab at an infusion center, along with chemotherapy. These doctors made money on every patient that went through their infusion center. Prescribing Bexxar meant they’d have to forgo that revenue stream, and refer the patient to a nuclear medicine pharmacy or radiation oncologist who could handle Bexxar or Zevalin.

“There were complicated logistics with having oncologists refer to another part of the healthcare system they normally didn’t interact with,” Rivera says. “We couldn’t get them to change their habits. The doctor would usually say ‘Oh, I’ll give the patient another course of R-CHOP’ (Rituxan plus a specific chemo regimen) instead.”

Younes, the chair of lymphoma at Memorial Sloan-Kettering, has heard the story about oncologists rejecting Bexxar because they didn’t want to refer patients to medical centers that might be seen as competitors. He says that point is “exaggerated” and notes that oncologists refer patients to other specialists all the time. He points to other problems with Bexxar’s commercialization. “It’s almost a comedy of errors,” he says.

Are we to believe that the very people who were supposed to be saving patients walked away from a cure over profit? I'm trying hard not to... There were other factors, though:

There was a muddled clinical trial strategy, Younes said. Multiple trials were opened up to expand Bexxar usage, which may have been well-intended, but the plan ended up confusing physicians about where the drug was most useful, Younes said. A lot of clinical trials were sponsored, making it possible for many patients who might have paid to get the drug to instead get it for free. Then at one point, Glaxo abruptly shut down all the trials, Younes said.

“They ended up pissing off a lot of people,” he said.

There were headaches in manufacturing an antibody that was linked to radiation. The radioactive piece of the drug came from a supplier in Canada, and the occasional snowstorm would throw the whole supply chain out of whack, causing patients infusions to be delayed, Rivera said. That was a big inconvenience for some patients who sometimes had to drive hours for a scheduled infusion at a big academic medical center, Rivera said.

So what constitutes bad sales? Reno gives us the numbers:

While Bexxar saved this writer’s life in a clinical trial in 1999 with virtually no side effects and has saved many other lives, sales of the drug did not meet GSK’s expectation. Catalina Loveman, GSK’s director of U.S. external communications, oncology, told IBTimes that total sales of Bexxar in 2012 in the U.S. and Canada were approximately $1 million; for comparison, the blockbuster drug Viagra earned Pfizer a reported $2.05 billion in sales in 2012.

Everything is relative.  I guess it didn't occur to GSK that those who survive lymphoma might eventually become Viagra customers. Oh, well. I guess a few thousand lives pale in comparison to a few million...well, need I say it?

Zevalin will remain on the market because its owner has a different outlook:

Like Bexxar, Zevalin has also struggled in the marketplace. In the third quarter 2013, Zevalin’s profits were $8 million. But unlike GSK, Spectrum Pharmaceuticals, makers of Zevalin, is committed to keeping this drug on the market.

“What is happening with Bexxar is virtually unprecedented,” said Spectrum’s chief operating officer, Ken Keller, who came to Spectrum a year and a half ago from California-based Amgen, the world's largest independent biotech company. “I do not know of a single example of a drug company that has walked away from a drug that is this effective. Typically, when a company gives up on a treatment that works this well, they will a find a smaller company to sell it.”

Keller acknowledged that neither Bexxar nor Zevalin has been able to break through and become the blockbuster drugs that he says they both should be.

“I’ll be honest: We don’t gain a lot of value from Zevalin,” he said. “We have the data that shows how well it works, but it has still not caught on with many doctors. However, Spectrum will continue to manufacture Zevalin because our CEO [Raj Shrotriya] is on a mission to make RIT the standard of care for lymphoma in the U.S.. If this were only about finances, it could lead to different decision. But this treatment saves lives, and we believe we have an obligation to cancer patients. They deserve to have access to it.”

Why was Bexxar quashed? Only GSK really knows for sure. Maybe their Board of Directors all own stock in Spectrum. Information from a friend of a friend of a friend of a cousin of a sister of a guy who knows something indicates that the move was deliberate and based purely on profit or the lack thereof. Maybe someone looked into the zillion pages of ObamaCare as currently morphed and decided GSK would NEVER see any profit, let a break-even point, on Bexxar.

It occurs to me that this whole episode (put very nicely) represents a complete disservice to our patients. We have in Bexxar a VERY good treatment, a lifesaving treatment, and it was scuttled because oncologists wouldn't use it, and they wouldn't use it because they couldn't make money on it, so neither could GSK. Does anyone else find this sickening?

But I'm prompted to think outside the box.

I've become mildly addicted to Kickstarter and Indiegogo, crowd-funding sites that promote anything from researching burritos to sending people on a one-way trip to Mars. (I've personally helped fund a couple of smart-watches that haven't come to fruition and probably won't, and a few other frivolous items.)

I don't know IF GSK would consider selling the rights to Bexxar, and if they would, I don't know how much they might want for something they buried in their corporate backyard. If the price was reasonable, I would buy the rights myself and find a way to get Bexxar back on the market. Assuming the price tag is a bit above my weekly allowance, the next step might be a Kickstarter campaign for interested parties to pick up the tab. This would include not only people like me who want Bexxar to be available, in my case as a physician, but also patients and their families as well. It would, of course, be critical to attract folks who have connections in the pharmaceutical industry who could actually put Bexxar back into production.

To my knowledge, this has not happened before. We've all heard of orphan drugs, but I can't think of any/many that were actually completely suppressed in this manner. Nor have I ever heard of a consortium of the type I propose above rescuing a valid treatment from oblivion. But this needs to be done, and I challenge you to join me to do it.

GSK? Docs? Patients? Family members? Are you listening?

Accelarad Nuance Makes It Official

Dear Accelarad customer,You should have received an email from me on Monday of this week, when I provided our customers an early insight into the announcement that Accelarad is now a part of Nuance Communications. At this time, I wanted to provide you some additional information and invite you to learn more.

You can read the full press release here: (Nuance Unveils PowerShare – April 17,2014)As discussed, this new union brings together our cloud-based medical image sharing technology and Nuance’s PowerScribe radiology reporting and communication platform. The partnership will give you, our valued customer, access to Nuance’s expansive healthcare technology and professional services, while continuing to provide you with the proven software and solid relationships you have come to expect from Accelarad. With this partnership, Accelarad’s SeeMyRadiology solution has been rebranded to align with the Nuance diagnostic brand, and will be part of the Nuance PowerShare Network. To learn more about PowerShare | Image Sharing, sign up to join one of our webinars.

Most importantly, know that the products and people you have come to rely on will not change. Accelarad's leadership team and valued employees will be deeply involved in creating a smooth transition for our customers, and our focus remains on making sure you continue to receive the excellent service you deserve.

Thank you again for your support and confidence in us. We will keep you informed about any incremental changes along the way and are open to your feedback.

Sincerely,                

Willie Tillery, CEO, Accelarad 

Rodney Hawkins, General Manager, Diagnostic Solutions, Nuance

For your viewing pleasure, here is the press release:

Nuance PowerShare Network Unveiled for Cloud-Based Medical Imaging and Report Exchange
Industry’s Largest Medical Imaging Network Helps Providers and Patients Coordinate Care and Share Information Across Distances and Disparate Healthcare Systems

BURLINGTON, Mass., – April 17, 2014 – Nuance Communications, Inc. (NASDAQ: NUAN) announced today the immediate availability of Nuance PowerShare™ Network, the industry’s largest cloud-based network for securely connecting physicians, patients, government agencies, specialty medical societies and others to share essential medical images and reports as simply as people exchange information using social networks. Nuance PowerShare Network promotes informed and connected physicians and patients who can instantly view, share and collaborate while addressing patients’ healthcare needs.

“Organizations are being tasked to communicate efficiently both in and out of their networks to provide clinical insight to physicians beyond one person or office to a much broader team involved in the continuum of care,” said Keith Dreyer, DO, PhD, FACR, vice chairman of radiology at Massachusetts General Hospital and Chair of the American College of Radiology (ACR) IT and Informatics Committee. “Nuance PowerShare Network addresses the information sharing challenge physicians face today with a network that supports things we’ve dreamed of doing for years,” he adds.

Fully Connected Patients & Providers
Nuance PowerShare Network is already used by more than 1,900 provider organizations for sharing images via the cloud using open standards. Made possible through the acquisition of Accelarad, this medical imaging exchange eliminates the costly and insecure process of managing images on CDs and removes silos of information in healthcare that inhibit providers from optimizing the efficiency and quality of care they provide. Anyone can join the network regardless of IT systems in place to instantly view and manage images needed to consult, diagnose or treat patients, enabling clinicians to more seamlessly evaluate and deliver care for patients who transition between facilities or care settings.

Nuance is already used by more than 500,000 clinicians and is a critical component within the radiology workflow and a trusted partner for 1,600+ provider organizations that rely on Nuance PowerScribe for radiology reporting and communications. Healthcare organizations that use Nuance PowerScribe, a group that produces more that 50 percent of all radiology reports in the U.S., can immediately leverage their existing investment and begin sharing radiology reports along with images, such as X-rays, MRIs, CT scans, EKGs, wound care images, dermatology images or any other type of image. This simplifies secure health information exchange between multiple providers, patients and disparate systems without costly and time-consuming interfaces, CD production or the need to install additional third-party systems.

“The challenge of sharing images with interpretive reports is something we’ve heard about consistently from our customers and EHR partners, and we know Nuance PowerShare Network will overcome this major obstacle, helping physicians treat patients more efficiently and effectively,” said Peter Durlach, senior vice president of marketing and strategy, Nuance Communications. “This nationwide network, one that is fully integrated into the EHR workflow and already connected to approximately half of all clinicians producing diagnostic imaging information, is a ground-breaking solution that delivers immediate benefits at an unprecedented scale to our healthcare system.”

“Integrated image and report sharing helps us deliver quality care and drive down costs especially when patients transfer from one facility to another. Whether at their desktop or on their mobile device, our physicians can see the study that was done along with the interpretive report, which provides the information they need to treat the patient and avoid duplicate testing,” says Deborah Gash, vice president and CIO, Saint. Luke’s Health System in Kansas City. “By integrating this with our EHR, PowerShare will enable physicians to manage inbound imaging through one point of access and login. Physicians in our 11 hospitals and 100-mile radius referral network see this cutting-edge technology as a way to deliver the highest level of patient care,” she adds.

To learn more about the PowerShare Network and the new image sharing solution, visit http://www.nuance.com/products/PowerShareNetwork to join one of our webinars. Connect with Nuance on social media through the healthcare blog, What’s next, as well as Twitter and Facebook.

Definitely an interesting constellation of services! I wonder where this might lead. Ironically, Rodney is also an old friend from the AMICAS days...

Film at Eleven...But I Need It NOW!!!A Bigger Share Of Image Sharing

A long time ago (November, 2005 to be exact), sitting in a radiology department far, far away from most of you, I bemoaned the problem of the "Portable Patient" in one of my early AuntMinnie.com articles:

Of the thousand daily frustrations I experience as a radiologist, perhaps the most painful is that of the "portable patient." You see, patients migrate from hospital to hospital, from clinic to clinic, and from office to office. They may be searching for a second opinion, a superspecialist, someone who will give them the particular answer they seek (some want to hear good news, some prefer bad news), convenience, drugs, or some combination of the above.

As often as not, they acquire a mountain of imaging studies along the way. When asked why they had a particular study at a particular site, the answer is invariably, "My doctor told me to have it there."

Add to that the dependence on our ERs for emergent (or maybe just impatient care, as I like to call it), and the ER's love of imaging studies. Put them together and you've got a collection of the patient's imaging studies spread across a city or even a state.

I was pretty smart back then, identifying a problem that many folks far wiser than I have been trying to solve since. And last year, I authored a follow-up article:

I've introduced you to a portable patient, and you can see what happened to her because no one knew about the examinations she had already undergone. She was irradiated, magnetized (probably less of a problem), and scared to death (arguably more damaging than radiation) because we have no way to connect the dots of her various studies.

Well, that isn't quite true. We do have ways -- we just aren't using them... Many years ago, when our old PACS needed replacing, I suggested to the IT types that the three hospital systems in our average town in the South combine efforts to create a single citywide PACS to serve all three hospitals and, particularly, all of their patients. I was told by the illustrious chief information officer that we couldn't even think of working with one of the other hospitals because it was "suing us" (which wasn't quite a lie ... they were challenging a certificate of need application). Millions of dollars and patient welfare down the toilet over C-suite egos.

There were and are other approaches. As an alternative to a central repository, connecting one PACS to another isn't that hard. The best way to do this -- and fulfill all HIPAA requirements in the process -- is to use an image-sharing system such as lifeImage (my personal favorite by a mile).

Don't even bother to suggest that CD-ROMs solve anything. They don't. They get lost, they get broken, they don't always load, the patient forgets to bring the disk, or the original imaging site forgets to send it, and darn, they're closed today...

At one of the clinics we staff, the clinicians come at me at least twice a day, every day, with an outside CD. After three years, I finally was able to convince the powers that be to load the damn things into PACS and merge the data with local exams. But the clinicians don't want to bother with waiting for the disks to load -- they want results now. In my opinion, CDs aren't even worthy of being drink coasters, given that huge hole in the middle. (And their older PACS rejects a significant percentage of the disks anyway.)

{snip}

Here's where I'm going to anger a lot of people, and this is of course why you like to read my rantings. The following is something that needs to be said, however, and I'm going to say it.

Given that ...

• Not knowing that the patient has had prior studies leads to unnecessary imaging
• Unnecessary imaging may expose the patient to unnecessary radiation, costs, and anxiety
• Unnecessary radiation is bad for you, as is anxiety
• We have ways to share prior studies

... then it stands to reason that today, in the 21st century, shirking our responsibilities to the patient in this aspect of medical imaging is malpractice. Yes, I used the "M" word. But that's exactly what it is. We are not doing what we should -- and what we must -- for patient care. It is high time to apply technology that has been around for a long time to unify patients' records, imaging and otherwise.

We are harming our patients out of ignorance, out of hubris (why would they go to any doctor/hospital/clinic other than me/mine?), and out of greed (I get the revenue if I repeat the study!). This is completely unacceptable...

Forgive the massive regurgitation of the last post, but you must acquire (or reacquire) the mindset of the necessity of image-sharing.

If you wondered if exams were really repeated under the "portable patient" scenario, let me assure you that they are.

A study from western New York showed:

(A)pproximately 90% of duplicate and potentially unnecessary CT scans were ordered by physicians who have little to no usage of the HIE when combining slices of users with less than 500 queries in 18 months. An opportunity therefore exists to reduce the number of duplicate CT scans if the physician is utilizing HEALTHeLINK to look up information and recent test results on their patients prior to ordering more tests. In addition, this also highlights a need to get more physicians participating and using the HIE in a meaningful way as more than 70% of duplicate CT scans were ordered by physicians who did not query HEALTHeLINK.

Another study from the University of Michigan found:

RESULTS:
In our sample there were 20,139 repeat CTs (representing 14.7% of those cases with CT in the index visit), 13,060 repeat ultrasounds (20.7% of ultrasound cases), and 29,703 repeat chest x-rays (19.5% of x-ray cases). HIE was associated with reduced probability of repeat ED imaging in all 3 modalities: -8.7 percentage points for CT [95% confidence interval (CI): -14.7, -2.7], -9.1 percentage points for ultrasound (95% CI: -17.2, -1.1), and -13.0 percentage points for chest x-ray (95% CI: -18.3, -7.7), reflecting reductions of 44%-67% relative to sample means.

CONCLUSIONS:
HIE was associated with reduced repeat imaging in EDs. This study is among the first to find empirical support for this anticipated benefit of HIE.

That's a lot of repeat studies. And a lot of excess radiation. We can wait for the study to be delivered from the outside place, or the outside CD to be loaded ("Film at Eleven") or we can redo the study. None of these choices are optimal. We can all see that.

So...Now that you've gone through the indoctrination, we can proceed.

I've known Hamid Tabatabaie for many years, starting back when he was CEO of AMICAS. (I guess that dates me. Like Mrs. Dalai's grandfather who died at 93 after having outlived 5 of his internists, I've gone through two subsequent AMICAS CEO's and I'm on my second or third Merge CEO. Justin, you'd better hope I get out of this business soon!) Hamid is one of the visionaries behind web-based PACS, of which AMICAS Merge PACS is still one of the best examples. Today, he heads lifeIMAGE, my favorite among the image sharing companies out there.

The story is making the rounds that Nuance, one of my least favorite companies, is diving into this arena, with the purchase of Accelarad. From Hamid's blog (I guess everyone has one now):

I spoke with a friend today who is now the sixth person to have heard rumors about Nuance entering the image sharing market. He thinks it will announce the acquisition of a small Atlanta-based company imminently. I know the target company rather well, think highly of the founders, and I’m happy to see them finally reap some benefit from their 15-year-old startup odyssey. They started out as a small PACS company and then carved out a niche by selling data center based teleradiology PACS, which I think delivers the great majority of its $6M or so annual sales.

This little company is apparently Accelarad. More on them in a moment. Back to Hamid:

We (lifeIMAGE) started out working with innovators and early adopters who believed in our cause. We believe in eliminating duplication of imaging, avoiding delays in care and excessive radiation, and improving quality of care for patients. To realize our goal, we build software that helps make medical images part of a patient’s record and helps physicians access imaging histories conveniently, from any setting. We’ll soon announce our fifth anniversary as a well funded, privately held company, with many remarkable results that make our team very proud...

..(I)mage sharing for serving radiology, with 25,000 or so US radiologists, where Nuance has its major presence, has been around for a long time. Innovations in teleradiology are well past their prime, so, we at lifeIMAGE do not see a disruptive opportunity to innovate in that area. We are focused on the far broader need, which exists among large health systems that need to avoid the cost and problems associated with repeat imaging orders. Their ordering physicians, our end-users, are non-radiology image intensive specialists who need access to patients’ imaging histories in order to reduce the rate of repeat exams. 

The cure for the portable patient indeed.

Recently, I’ve been fascinated with what professor Everett Rogers called “the law of diffusion of innovation.” It basically spells out that there is a point at which an innovation reaches critical mass. “The categories of adopters are: innovators, early adopters, early majority, late majority, and laggards.[1]” The early majority buy into a technology when it’s been well vetted by innovators and early adopters first. Every innovative and disruptive company looks for the sign that its technology has started to be adopted by the “early majority.” Nuance’s entrance into the image sharing market is an indication for me that the market is getting ready for broad adoption, validating what we already see in the lifeIMAGE customer statistics. Professor Rogers suggests that once 16% of the market has signed up for a technology, that’s when the early majority starts to adopt. Current lifeIMAGE customers represent nearly 16% of all US physicians...

lifeIMAGE is the most utilized image sharing network, designed for use by physicians across a wide range of clinical disciplines—neurology, orthopedics, cardiology, oncology, surgery, etc. Our position is unique in that our engine of innovation is fueled by this population of doctors, who encounter patients with outside imaging histories on daily basis. We also help providers with patient engagement strategies and lead the way in providing access to patients who can in turn share their imaging records with providers of their choice. So, indeed new market forces may very well validate the market and expedite adoption of our disruptive and expansive technology, innovation for which is guided by multi-disciplinary specialists, including radiologists....

When I was CEO of AMICAS, our team spent some time studying the concepts around disruptive technology. Its definition in Wikipedia is, “A disruptive innovation is an innovation that helps create a new market and value network, and eventually disrupts an existing market and value network (over a few years or decades), displacing an earlier technology.” That is what our web-based PACS was back in 1999.

To me, being rather more concrete than some, a "disruptive" technology is one that interrupts my workflow, and nothing could fit that definition better than what Nuance is really known for: Speech Recognition, also incorrectly known as Voice Recognition. Here we have a technology that displaces the human transcriptionist, freeing the hospital from the tyranny of employing said human and paying their salary and benefits. It dumps the work of transcribing and editing onto the radiologist with no increase in pay for the effort. And it barely works. A friend who is totally enamored with SR tried to show me how wonderful it functions in his enterprise. I watched him focus his entire attention onto the report screen, which was three monitors away from the radiographic image he was supposed to be interpreting. Yah, this is great and wonderful stuff. Now it does speed things along. My friend claims to be able to read 300 exams in 8 hours with <1% error-rate because of his beloved SR. I'll simply say that it wouldn't work that well in my hands.

I'm digressing, but for a reason. Nuance and the other SR vendors have made inroads into hospitals and other imaging emporiums with their disruptive technology. They ride in on the white horse of decreased turn-around time (TAT) which warms the cockles of the administrative types who live and die by picayune metrics like that. In addition, they convince these folks that it's CHEAPER to have the computer do the job than a cadre of benefit-sucking humans, and that's all they need to say.

I'm sure Nuance wouldn't enter the image-sharing market if they didn't think it would be lucrative. Few in this business (including me) do things for free out of the goodness of their hearts. As Hamid implies, Nuance's entrance to this space validates the concept, and I think validates lifeIMAGE as well, which I maintain does it better than anyone.

Accelarad seems to have the basics down, and Nuance has apparently made the GE-like choice of buying the technology en bloc rather than developing its own. Fine with me. Here's their description:

Our medical imaging solution combines the ease of social networking with the clinical precision and security that medicine demands, making medical image sharing with patients, colleagues and other organizations easier than ever. Accelarad allows you to quickly and securely upload, access, manage and share medical images from any Internet-connected computer, mobile device or via our app. So you have images and reports from any originating institution, physician or system at your fingertips from a single portal, allowing you to focus on what you do best–delivering patient care.

They say all the right things, and I'm sure the product does what it says it does. However, I'm equally sure that lifeIMAGE does it better:

Don't just take my word for it. Look at their website and arrange a demo.

In many ways, Nuance's entry presents an opportunity for lifeIMAGE to get its foot into (or back into) doors that might otherwise be closed. I've tried to become a lifeIMAGE customer. I believe in their system, and I know most of their people, many of whom brought me AMICAS years ago. But I cannot convince those that control the purse strings that image sharing is a critical necessity. They see that lifeIMAGE has a cost associated to it, nominal per patient though it is, which can be eliminated by someone sticking the CD-ROM that came taped to the trauma patient into a workstation. IF it works. IF it came at all. But happily, if there wasn't a CD-ROM to be found, well, gee, we'll just have to rescan the patient and CHARGE for the privilege. In other words, image sharing LOSES them money on both ends. But it is still best for the patient, and I'll stick to my inflammatory statement above: it is malpractice NOT to utilize it.

It may be that with Nuance pushing the concept using the sales force that sold the bean-counters on SR, proper consideration will finally be given to image sharing at places that shunned it before. Then, we can have the real discussion as to which company does it best. I've had many an argument with those who say only the large PACS companies will survive. In the image sharing space, there are no large companies as yet, although Merge's iConnect and Honeycomb are good starts. The entry of Nuance into the field could be a game changer...for the company that does it right. We'll see. Film at Eleven.

ADDENDUM

I am without a doubt getting old and I'm not completely on my game, the game of paranoia, that is. Normally, I would have seen this possibility, but it took a friend to analyze the data and inform me of the consequences. Here is what he said (he wishes to remain anonymous for obvious reasons...):

I pushed hard for an "outside study" solution. We were regular victims of Philips PACS non-DICOM CD's every night from a particular hospital. We looked at both lifeIMAGE and Accelarad, and went with the latter and it works well for us. However, the Nuance purchase suggests to me that they want to be a complete 3rd party reading group, and replace groups like Optimal. Once they can share images well, dictate reports and disseminate results, they become a radiology department for anyone. I'll bet they start advertising over-reads/consults by big institution names before it's all over.

It just looks to me like they are assembling the pieces of the puzzle to become "Uber Radiology". The video mentions/shows a graphic for telemedicine; that screams 3rd party. Any site can be set up to just put their system as a destination on each modality. Boom, you send them your images, they can be read. It's not even a "PACS to PACS transfer" but a replacement PACS. No onsite storage is needed, just the Nuance cloud.. oops until the internet is down and you don't have your images anywhere...

Hey, just because you're paranoid doesn't mean they aren't out to get you...

And Yet Another ADDENDUM

Interesting coincidence...Nuance just hired someone to "document, share and use" clinical information per their recent press release:

BURLINGTON, Mass., – April 7, 2014 – Nuance Communications, Inc., (NASDAQ: NUAN) today announced that it has named Trace Devanny as president of Nuance’s Healthcare business. Mr. Devanny will oversee Nuance’s largest division and lead its efforts to deliver a more seamless approach for healthcare professionals to document, share and use clinical information. He will report to Paul Ricci, Nuance chairman and CEO.

“Our healthcare business presents a significant opportunity for innovation, leadership and growth in today’s dynamic healthcare environment,” said Paul Ricci, chairman and CEO of Nuance. “As a healthcare technology industry veteran, Trace brings a powerful skillset that combines operational excellence, team development, customer engagement and a strategic vision. I look forward to working with him to lead Nuance and our healthcare business through its next phase of growth.”

Mr. Devanny has more than 30 years of executive leadership experience in the healthcare IT industry, having held executive leadership roles in multi-billion dollar, international healthcare organizations. He joins Nuance from TriZetto Corporation, where he served as chairman and CEO. At TriZetto, he drove revenue and bookings growth in excess of 20 percent and led the organization through a business and sales model transition. Previously, he held several executive roles at Cerner Corporation, most recently as president, over an eleven year period where he was instrumental in growing the company and revenues from a $340 million business in 1999 to a $1.8 billion healthcare IT leader. Earlier in his career, Devanny was president and COO of ADAC Healthcare Information Systems and held a series of executive positions with IBM and its healthcare business. He holds a BA degree from the University of the South.

“Improving quality of care while driving down healthcare costs is one of the most significant challenges that providers face today. Nuance is advancing these initiatives through innovative solutions that make it easier for providers to deliver patient care,” said Trace Devanny. “I look forward to working with this talented and ambitious organization to build on our momentum and make an even greater impact on the healthcare system at this important point in its history.”

Only the paranoid would put this together with my friend's speculation and see anything interesting...  What? Me? Paranoid? NEVER!

Unretired

Courtesy Wikipedia

You may recall my earlier post declaring my retirement within two years.

Fuggedaboutit.

I had attempted to start my retirement clock, and we had some long discussions on the topic. In the course of the discourse, various factors were mentioned, introduced, revealed, discovered, or otherwise made to appear which had not been present before. The cost for officially entering the short-term glide-path became more onerous than I thought it should.

Therefore, my request is now withdrawn. When my numbers and the stars align properly, I'll be giving my 90 day notice. That might be tomorrow, or it might be 10 years from now. So much for a heads-up to allow for planning, hiring, etc.

And this time, you may disregard the date of the post.

Merge Announces...

In my daily barrage of email came this announcement from Merge, which you can also find on Yahoo Finance:

CHICAGO, Feb. 21, 2014 (GLOBE NEWSWIRE) -- Merge Healthcare Incorporated (MRGE), a leading provider of innovative enterprise imaging, interoperability and clinical systems that seek to advance healthcare, today announced that its Board of Directors has appointed William J. Devers Jr., president of Devers Group Inc, as a director, effective immediately.

"We are very fortunate to have a new director with such a considerable amount of business and software experience added to the Merge Board of Directors," said Merge Chairman Dennis Brown. "Bill's knowledge and vision will make him a significant contributor to helping Merge execute the business plan it has formulated to increase its market position in enterprise imaging and interoperability. We believe that his strategic insights and guidance will be critical as we look to increase shareholder value."

Devers was the CEO of Trans Union Credit Information Company. He left Trans Union in 1983 and started Devers Group as a vehicle for his private investments. Devers group began with an acquisition strategy, acquiring software companies in various vertical markets. Prior to divestitures, Devers Group had revenues of approximately $100 million and employed approximately 700 people.

Over the past 30 years, Mr. Devers has bought and sold over 20 software concerns, including sales to EDS, Klopotek (Berlin, Germany), DBS Systems and others. Currently, Mr. Devers manages DGI Private Equity Ventures, LLC, serves on the Board of Directors of Ryan Specialty Group, Lurie Children's Hospital of Chicago, the Big Shoulders Fund and is a less than 3% non-voting shareholder of Merrick Ventures. In addition, Mr. Devers serves on an Advisory Board at the University of Notre Dame and is a Trustee of the Museum of Science and Industry in Chicago.

Italics are mine. Mr. Devers sounds like an excellent addition to the Merge team. But I'm a little intrigued by the mention of the buying and selling of software concerns. Are we announcing more than we are announcing?

Hat tip: TOAOPM

Mamas, Don't Let Your Doctors Grow Up To Be Assholes...(Or Is It The Other Way Around?)

From Aeon Magazine comes an interesting and somewhat overdue piece on one of Medicine's worst-kept dirty little secrets: Doctors (and nurses) can be mean, and that impedes patient care. 

The author, Ilana Yurkiewicz is a third-year medical student at Harvard,  and blogs for Scientific American. She does bioethics research at Harvard, and her work has been published in the Knee-Jerk (I mean New England) Journal of Medicine. Clearly, she has the credentials to speak of what she speaks.

Her Aeon article, Why Rude Doctors Make Bad Doctors, is a must-read for anyone in this business. Ms. Yurkiewicz bemoans the culture that allows and even encourages bad behavior, and points out how it might end up damaging the patient, not just the tender ego of a doctor-wannabe.  

One doesn’t have to work in a hospital long to experience or observe some form of disrespect. This is hardly a secret. The bullying culture of medicine has been widely written about and portrayed in popular media. In one study, published in 2012 and conducted over the course of 13 years at the David Geffen School of Medicine at the University of California, Los Angeles, more than 50 per cent of medical students across the US said they experienced some form of mistreatment. Behind closed doors, we share advice on whom to hang around and whom to avoid.

At the start of my third year of medical school, when we would finally enter the hospital wards, we had an orientation: ‘Wear a raincoat,’ the doctor standing at the podium advised. I could expect to get rained on.

Those of you reading this who are not directly part of the health-care universe might not be able to relate. But most of you will understand. The myth of the malignant surgeon throwing instruments is not all that far from the truth. These days, the flying projectiles are mostly verbal, and sometimes subtle, but they cut just as deep.

Most of my friends in medicine have witnessed flagrant episodes of hospital bullying and have juicy tales to tell. But medical disrespect is usually far less dramatic, dished out in the form of ‘micro-aggressions’: exasperated sighs, a sarcastic tone, the dismissal of alternative ideas. It’s the subtle put-downs about a trainee’s competence that erode confidence; the public shaming for an incorrect answer on rounds; or the denial of simple privileges such as taking a chair or reading a chart. It’s the psychological effect of being called by your rank instead of your name, or having it made clear that your presence is a burden instead of a help. It’s being ignored. It’s other team members looking on when the disrespect occurs, afraid to challenge it and defend those lower on the totem pole. These are the acts that affect our state of mind in small but cumulative ways. This is the stuff that creates a culture.

You learn to deal. This is how it is. That’s the system. It’s ingrained. You excuse bad behaviour with the platitude: ‘That’s just the way (s)he is.’ You appreciate from your elders that it could be much worse – at least they can’t throw scalpels at you anymore.

And it was bad enough in my day. I dodged a lot of it, but I felt, saw, and heard enough to confirm Ms. Yurkiewicz's observations. As a medical student, and even as a Radiology resident, I have seen the snide looks and snarky remarks flowing like sewage from the more arrogant and nasty of residents and attendings downhill to the objects of their scorn. And I've been the victim of this, often deservedly, often not.

But it is also much more dependent on the communication and relationships among different members of the team. Now, enter the culture of disrespect. Suppose an attending physician makes withering critiques or unreasonable requests. A resident, hoping to avoid such abuse, slowly but surely starts to hold back. She holds back some questions for fear of burdening and, under the constant stress of being scolded, becomes immersed in details of efficiency. Whether she intends it or not, she gives off vibes of unavailability, spending hours hunched over a computer in the physician’s conference room cranking out progress notes and scheduling patient appointments. Meanwhile, a patient starts to take a turn for the worse, but it’s not completely clear-cut – his vitals are just a bit off, his belly seems distended, and he complains of abdominal pain but is also known to the team as someone who complains. The nurse hesitates to voice her concerns to the resident, who is swamped doing paperwork and updating discharge summaries exactly the way the attending prefers. The patient continues to go downhill, and by the time word gets out the patient is much sicker – and needs to be treated far more aggressively – than would otherwise have been the case.

The more you fear being caught in a mistake, the more likely you are to make more, and to cover them up. Rather than worry about harming the patient, the young skull full of mush learns to dodge bullets directed at him, and the patient be damned.

When someone is unpleasant or demeaning, something switches in the minds of those on the receiving end: they sacrifice honest communication to save face. I’ve seen it in action so many times that the pattern has become predictable. Preoccupied with fear of appearing incompetent, team members keep uncertainties under wraps.

{snip}

The link between harsh words and medical errors was reignited in 2012 when Lucian Leape, professor of health policy at the Harvard School of Pub­lic Health, published a two-part series in Academic Medicine. ‘A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect,’ Leape and his co-authors asserted. ‘Disrespect is a threat to patient safety because it inhibits collegiality and co-operation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.’

It’s not that jerky personalities are reserved for those at the top. There are nice people and mean people at every rank. But in a system dependent on the proper functioning of hierarchy, it works like this: when anger and intimidation flow down, information stops flowing up. The chain of communication becomes clogged.

It bears repeating in large font:

In a system dependent on hierarchy, it works like this: when anger and intimidation flow down, information stops flowing up.

And THAT is when the mistakes propagate further and faster, and the patient is the one that suffers. Ironically, the perpetrators often realize that this is the case:

In another study by Rosenstein and O’Daniel, nurses and physicians self-reported behaving badly in near-equal numbers. Most felt this behaviour resulted in increased errors, lower quality of care, and lower patient satisfaction. Seventeen per cent could name a specific adverse event that occurred as a direct result of disrespectful behaviour.

You are probably asking at this point, "WHY does this happen?" The answer, like so many in medicine, is TRADITION. For many years, interns, residents, and even medical students were kept up for days on end, struggling just to stay awake, let alone actually learn something and treat sick people. This tradition lasted for years and years, mainly because their elders did it too. Medicine, being more of an apprenticeship than anything else, can sometimes ignore facts that contradict long-held opinions:

Yet despite such (bad) outcomes, many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence. That fear is good for doctors-in-training and, by extension, good for patients. That public shaming holds us to higher standards. Efforts to change the current climate are shot down as medicine going ‘soft’. A medical school friend told me about a chief resident who publicly yelled at a new intern for suggesting a surgical problem could be treated with drugs. The resident then justified his tirade with: ‘Yeah, yeah, I know I was harsh. But she’s gotta learn.’

Bottom line, this crap kills. And it needs to change.

We can no longer deny the facts. Bad cultures lead to bad outcomes. Jerks do not make good medicine. They foster a backwards atmosphere that degrades trust, tarnishes open communication, and promotes cover-ups.

Creating a culture of respect is not just about feeling good, for its own sake. It’s better for patient care.

There are solutions out there, mainly dealing with individual, solitary incidents. But how do you change a culture?

...(W)e should put an end to the premium that the medical establishment places on saving face. This is a hazard. It feeds the egotistical environment that can lead to ignoring input and failing to ask for help. It creates doctors who value looking like they know what they’re doing at all times more than actually doing what is best.

(W)e should be getting to the root of the behaviour. Why do people behave badly? Some are just jerks. Some imitate jerks. But we also can’t ignore a system that takes loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones. We have to call attention to the external factors that can contribute. The lack of sleep. The poor hours. The system that overbooks and overworks.

The suffering we see among our patients overshadows our personal pain, but...

Environments such as these persist in part because of our unique vantage point in taking care of others at some of the worst points in their lives. How can I say ‘I’m tired’ or ‘I’m hungry’ or ‘He hurt my feelings’ in the face of such profound human suffering? Yet it’s hardly absurd to ask for better working conditions. When working in a system that treats us all humanely, we’re more likely to be humane to each other, and to our patients.

I'm not the world's best radiologist, although I think I hold my own. This will sound like whining, and it is, but I truly think I would have been a better physician, and a better radiologist, had the culture been different. Had my many mistakes (and we've all made them in this business) been used more as teaching opportunities, and less as excuses for public humiliation, I think I would have learned more from them. To be honest, the majority of my mentors in medical school and residency were indeed wonderful teachers, with the gift of making you happy you had made the mistake they were correcting. But I had a few, and they tended to be the BIG NAMES in the field, who would take off after any answer and any action that was less than perfect. As one of the more mediocre trainees, I got a lot of that from these people.

In radiology, our mistakes are laid out for all to see, available at the click of a mouse. Arrogance has no place here. Every single radiologist has missed more stuff than any of us will admit. It is part of being human, and having by definition limited knowledge and limited perception. Some of us are certainly better than others, and I can tell you who in my group has the fewest misperceptions (not me) and who has relatively more (also not me, at least on good days). Pointing out the mistakes of others in the current climate helps no one but the trial attorneys. Sadly, a corollary of this whole discussion is that the same arrogant, nasty SOBs who think they are God's gift to humanity are quite happy to point out to their patients when someone they deem beneath them has not performed to their standard. Why do this? Because they can. Because the rest of us don't call them on it. Because sometimes they are right, and we did make a harmful error.

I've addressed this in a prior post, wherein I address those in the big medical Mecca who took it upon themselves to tell a patient I had missed something...when I had done no such thing. Some would advocate legal action for this libelous stuff, but I don't believe in social engineering via the legal system. What we have to change is indeed the culture of what boils down to bullying. As Ms. Yurkiewicz puts it:

Instead of looking away sheepishly when our colleagues are mistreated and apologising for bad behaviour with tired mantras, we should push back. Bullies have ripple effects. Medical students mimic the behaviour of residents who mimic the behaviour of attendings until a problem with attitude can extend from a few people to an entrenched culture. Instead of riding that wave, we could shun bad behaviour. This is easier said than done. But cultures change because people within commit to changing them; it won't come by decrees. A culture that shames bullying makes the bully look like the bad guy, rather than making the recipient look weak.

Of course, I'll be long-retired before we see this sort of sea-change in medical culture. But it is reassuring to know that it might be coming after all.

Brad Adds...

Dalai's note: As my earlier post was prompted in large part by my friend Brad Levin's discussions of PACS deficiencies, I gave him a heads up upon its publication. Brad zeroed in on this snide comment..."As an aside, some have suggested that IT-savvy departments assemble their own PACS from off-the-shelf components. To that, I can only say, "BWWWWAAAAAHAHAHAHAHA!" Good luck, folks. Not going to happen for the foreseeable future, at least not in my enterprise.” He wrote the following response which is most worthy of your attention. Without further ado, heeeeerrrrrrreeeee's Brad!

Clearly you are skeptical, but I assure you, this is not the future ---it is happening now in a big way. In fact, the strategy of "Viewer + Worklist + VNA" is largely representative of Visage’s target market in the US, where dozens of the largest systems, outpatient chains and rad groups are contemplating (and contracting) this approach to imaging. We’re breaking down barriers and conventional wisdom, but hear me out. It first started with VNAs, right? No one thought you could disassociate/separate the archive from PACS, but that’s just what happened. Emageon’s Super DICOM Archive (now Merge) did it first, and was very successful. Then Acuo and TeraMedica, and several other players did the same. It’s an anomaly for large systems today not to have a VNA, or not to have a strategy to get one. Most of the VNAs out there are at large, complex systems, that have now centralized their images (almost all of these are DICOM centric, but increasingly non-DICOM images are being (or are wanting to be) stored too). With the rise of EMRs (mostly Epic) and the demise of RIS, it’s natural for workflow either to be totally removed to a third party system with a universal worklist, or to have workflow driven by the EMR. Visage 7’s integration to Epic, for example, is really, really good and is as good, or frequently better than, many traditional RIS integrations. Today, there are several options available for dedicated universal workflow engines – Medicalis, Clario, Primordial, PS360 to name a few. Everything else that you would traditionally consider PACS functionality, less workflow and archive, can be found in a single enterprise viewer. Of course I am partial, but that viewer is Visage 7. [Note: I haven’t found any so called zero footprint viewers that come even close to comparable functionality, and while legacy PACS vendors try to disassociate their viewers to compete for new business in the “Viewer + Worklist + VNA” model, they typically fail, because their viewers were not designed to be backend agnostic.]

Visage 7 has all of the “typical” native services for ingest of all radiology and cardiology modalities/images (DICOM and non-DICOM), DICOM Modality Worklist, QA, DICOM forward/routing, integration, multi-dimensional viewing, viewer customization, mobile support, hanging protocols, user management (AD integration), federation, high availability, and incredible speed for massive scale. A single platform, thin-client viewer for all workflows: diagnostic, clinical (EMR launch), advanced viz, mobile. We also offer an archive, but in today’s US market, most customers have their own VNA and aren’t interested in an archive from Visage. That’s perfectly fine. In other global markets, VNAs are not as prevalent, so our archive is more frequently implemented.

…For example, it’s very liberating for us to tell customers that have gone to VNA, and gone to Epic (or another major EMR), that they can replace the army of viewers they’ve assembled over the years with one viewer, one thin-client for everyone.

…We’ve architected a single central instance of Visage 7 (e.g., one backend server, plus “x’ number of render servers powered by GPUs), to serve imaging across large distributed systems, serving up millions of studies per year, to thousands of users, eliminating the need for PACS silos at every location like legacy approaches. ... Imagine the savings and access benefits this delivers? There’s no routing of data to desktops, it’s all server-side and streamed as users need it incredibly fast. When new versions of the viewer are available, it’s a simple automated update of the client. Visage 7 doesn't run in a browser, so there’s no conflict with the minutia of the version of this browser and that browser, and the adequacy of HTML 5 support, or the need of a specific plugin. Visage 7 runs on both PC and Mac, with exactly the same client. Because we’re server-side, we NEVER tell users to upgrade their workstation disks, RAM, processors, operating systems, etc. We don’t care, since we’re server-side. Performance is not related to the client capabilities. The savings are huge and a real transformation.

This is the future, at least in the large systems. It provides the liberation from a single vendor, single PACS silo approach that has strangled the industry since the early days. Will this propagate to the local independent community hospital and small outpatient practices? Probably not, but consolidation is eating up the small practices anyway into larger groups that are gravitating to this approach. PACS is fun again when you’re changing how PACS is perceived and delivered. It really is.

Did You Ever Wonder Why...? Andy Rooney Looks At PACS

I obviously have a knack for getting on paper what a lot of people have thought and didn't realize they thought. And they say, 'Hey, yeah!' And they like that.

Andy Rooney

I don't pick subjects as much as they pick me.

I'm not sure how much of a knack I have for anything these days, but I've always been inspired by the gentle, yet biting humor of the late Andy Rooney. And so, this piece is dedicated to his memory.

"Did you ever wonder why...?" The opening clause that sunk a thousand fools, righted a thousand wrongs, and warmed the hearts of thousands. Today, I'm asking you, my dedicated readers, both of you..."Did you ever wonder why we can't make a better PACS?" And I'm hearing you respond, "Hey, yeah! Good question, Dalai!"

Let's try to answer it.

Vegetarian - that's an old Indian word meaning lousy hunter.

I don't want to toss out a blanket indictment of every PACS from every vendor. Clearly, most of them work most of the time and do most of what we want them to do. So we settle and tell ourselves we didn't really want our PACS to function any better than it does. But I think we are still left with the vague feeling that things could be improved. A lot. And in fact, I'm not alone in this impression. Bruce J. Hillman, MD, and Bhavik J. Pandya, PharmD are in full agreement after conduction a survey on the topic. As reported in JACR, they found:

All 5 respondents pointed to the lack of intuitiveness of their systems as causing them inefficiencies and fatigue. Their concerns in this regard centered largely on their current workstations not easily presenting them with the full range of tools and options available, and variability among the different user interfaces of the workstations they used daily.

{snip}

Viewing our results qualitatively, there is a convergence of opinion among the respondents about the key shortcomings of their current PACS. The substance of what each radiologist told us was the same: flaws in design and IT connectivity diminish radiologists' productivity.

I could have told you that without conducting a study. Well, I guess you could say I have conducted a personal study over the past 20 years of using PACS in one form or another, and I certainly agree with their observations. As Andy Rooney put it:

People will generally accept facts as truth only if the facts agree with what they already believe.

My good friend Brad Levin has one of the finest resumes in the PACS business. I'm proud to say I've known him since the AMICAS days, and I'm grateful that he is still is willing to talk to me. Brad published this list of PACS grievances in response to the proposition that "Radiology has solved the problems of going digital." Ha! Anyone who believes that hasn't touched a PACS interface. Rooney's take would have been:

The 50-50-90 rule: Anytime you have a 50-50 chance of getting something right, there's a 90% probability you'll get it wrong.

In many ways, PACS makers got a lot of things right. But they got a lot wrong and continue to do so.  Brad's list, which I have abridged below, was gleaned from a survey he conducted. It reads a lot like my Laws of PACS:

Hanging protocols. Nearly every PACS has them, but how many work as expected? A huge number of systems I’ve encountered have flat‐out given up...

Timely access to priors.   Many organizations are still routing the same DICOM studies to multiple destinations because they don’t know ‘who’ is going to interpret the studies. It takes so long to move the DICOM, they can’t afford not to have the images at the right location...I’ve also run into systems that have multiple hospitals using the same vendor PACS, and yet they still do not have access to priors due to a variety of technical barriers.

Viewer overload. A multiplicity of viewers exist at most systems, especially those that have grown over the years. Viewers for the radiologists, for the clinicians, for access from the EMR, for access from CD/DVDs, for QA stations, etc. That’s 5 viewers...

Viewer capability. Radiologists and referring physicians are using viewers that were designed years ago to take on today’s challenges...

Won’t work. Does this sound familiar? “A prominent referring physician’s office just upgraded all of their PCs. They finally got rid of their old clunker systems, and they are now running the latest Windows 8 systems. They are literally on cloud nine, and we just told them our image viewer does not support the latest release from Microsoft.” You can also substitute, “We just upgraded our offices with new Apple iMacs.” This is bad customer service 101.

The reality is the vast majority of PACS in use today are woefully lagging behind their support of the latest operating systems, web browsers and platform support (e.g., Mac). It’s no wonder many referring physicians are frustrated with Imaging.

Advanced visualization. In 2011, KLAS reported that Radiology had not found an effective way to work 3D imaging into the workflow of the radiology department. I see this everywhere ...

...(I)t is common to see studies such as PET/CT and CTA only available at isolated workstations. If the radiologist is not at that specific station, they do not have access to the images. Far too frequently radiologists are forced to move to the images. That’s an archaic practice in today’s high‐tech, mobile world.

Speed of access. As mentioned, the majority of today’s diagnostic workstations and clinical viewers were originally designed a decade ago or more. When those old viewers were forced to support multi‐slice CT in the mid‐2000s, it took several years for viewer performance improvements to catch up. But the growth in multi‐slice studies has continued in terms of study size and number of slices. One prestigious system out West has a current benchmark that their viewer(s) need to be able to support rapid local and remote access to current + (multiple) prior studies totaling 8,000 slices. If viewers don’t support 2‐3 second access, they are no longer being considered...

Remote/At home access. The PACS revolution eliminated film, but an embarrassingly large number of institutions to this day do not provide radiologists the same level of access at home as they provide at the hospital or imaging center that they work at during the day. The legacy technology either is too expensive to support from home, or does not provide adequate speed/quality of access over consumer networks using VPN. As many institutions strive to take‐back‐the‐night, this problem needs to be solved.

Mobile access and image exchange. Despite the availability of mobility and image exchange solutions over the past several years, the use of these solutions is far too low in actual practice. My guess is hundreds of facilities are using mobility and image exchange solutions, when they should be in use at thousands of facilities.

Unsustainable workflow. I’ve seen each of these reading workflows at multiple settings, from coast to coast ‐‐‐ Swivel‐chair workflow: A radiology group reads for multiple entities, each with their own RIS and PACS. Today’s typically used solution is to have a dedicated workstation for each entity and literally have the radiologist move in the swivel‐chair, from one station to the next, to read the day’s studies...Literally a setup of workstation overload, to perform multi‐modality analyses, instead of reading off a single viewer.

Graphically, survey SAYS (in the tone of the late Richard Dawson):

Image courtesy siimcenter.org

If I were in the PACS business, I would hide my head in shame.

In the end, we are dealing with two intertwined problems, the PACS architecture and the graphic user interface, or GUI. Both are languishing somewhere in the late 20th century, and thus, so are we.

With respect to the GUI, Dr. Elliot Fishman, whom some have called the World's Best Radiologist, lays it on the line:

As I sit here at my PACS workstation, I see a long list of icons on the left, most of which I have neither ever used nor know what they do. Our newest 3D imaging system boasts a bevy of icons that are little more than symbols—possibly only recognizable by cavemen—and unexplainable motions for the right and left mouse button. It makes one wonder why things aren’t simpler, similar to what we see on an Apple iMac or MacBook, or iPad, or the user interface screen of Amazon.com.

The aforementioned are examples of technology used by millions and “customized for every one of them.” It seems that lessons learned there have never made it into the medical arena, let alone radiology. Why must my PACS screen look exactly like yours, especially when we recognize the inefficiency that comes with the lack of customization? How is it that Amazon remembers every purchase I ever made and makes suggestions for what I might want or need, while my PACS workstation acts every morning as if we’ve never met before? Why is it that evolutionary and revolutionary changes in Google and Facebook continually affect everyone and yet those changes never make it through to how we practice radiology?

More on this in a moment.

We need people who can actually do things. We have too many bosses and too few workers.

Andy Rooney

As an aside, some have suggested that IT-savvy departments assemble their own PACS from off-the-shelf components. To that, I can only say, "BWWWWAAAAAHAHAHAHAHA!" Good luck, folks. Not going to happen for the foreseeable future, at least not in my enterprise.

The world must be filled with unsuccessful musical careers like mine, and it's probably a good thing. We don't need a lot of bad musicians filling the air with unnecessary sounds. Some of the professionals are bad enough.

I'm not going to get too deep into the architecture discussion, as many of you could talk rings around me. There are a number of ways to skin this particular cat, and technology will provide the answer. What we know is that the old, distributed architecture from the 1980's no longer is satisfactory, and hasn't been for quite a while. The web-server model, more or less the de facto standard today, can't cut it anymore, as demonstrated by the various problems Brad outlined above. To some degree, the problem is bandwidth. 8000 images might be roughly 4 Gb of data, and if you're sitting in a Gigabit Ethernet environment, we're talking 4 second delivery. Lossless compression brings this well within Brad's tolerances. But this doesn't do much for the home or mobile environments. I just upgraded my U-verse home internet to 50 Mb/sec, and on AT&T's LTE, my iPhone can reach 80 Mb/second. Streaming and compression will help, since we aren't going to see gigabit speeds outside the institution until we get the next wave of bandwidth innovation (5G? 6G? Fiber to the home?).

The answer here is probably server-side rendering; don't mess with sending the data at all. But this is such a huge paradigm change, you don't see many PACS vendors doing it. Basically, the number-crunching gets done on Big Computer in the data center, cloud, Mars, wherever, and we only see the pitchurs. (Of course, the remote site has to have at least barely adequate bandwidth, 4Mbs or so, on both the uplink and downlink sides. Our IMPAX requires each command and mouse stroke to be transmitted back to the production server, and this has led to slowdowns even with gigabit ethernet.)

This goes hand-in-hand with the so-called zero-footprint viewer. You use your computer and browser to peer into the system, and none of the data ever is truly on your computer. This certainly helps with security concerns, and solves multiple problems, not the least of which is access on devices running something other than a particular older version of Windows that your particular PACS software demands for its particular fetish. To show you how far we haven't come, I remember the days when you could not access most PACS via the internet. Mitra, now part of Agfa, came up with one of the first ways to do so, an appended web-server that had to be grafted onto the PACS called the Web1000. Today, to get iPad access for our Merge PACS, we would have to get an appended zero-footprint viewer server called iConnect, which is too expensive to justify for that purpose alone.

Making duplicate copies and computer printouts of things no one wanted even one of in the first place is giving America a new sense of purpose.

The answer to Elliot's question of why things are as they are is rather simple.  We, the radiologists and technologists, the actual end-users of these products are in general, NOT the decision-makers on their purchase. More often than not, the IT department, that has little to no understanding of what we do and how we do it, chooses the PACS vendor based on how easy said vendor will make their lives, but not ours. This corporate mentality has to change. Elliot concluded:

We need to find a way to encourage those companies that are designing the future—like Apple, Google, Amazon and Facebook—to help us create our future. I think it is neces- sary not only for our survival but also if we want to continue to be innovators in patient care.

Or, at the very least, we need to figure out what those companies are doing right, and get the PACS vendors to implement it.

I'm a big Apple fan. Between me, Mrs. Dalai, Dolly, and Dalai, Jr., we have one iMac, two Macbook Pro's with Retina screen, one regular old Macbook Pro, three iPads, and four iPhones. Not counting the two old Macbooks and a dead iPod or two sitting in the closet.

I don't like food that's too carefully arranged; it makes me think that the chef is spending too much time arranging and not enough time cooking. If I wanted a picture I'd buy a painting.

Andy Rooney

What is the secret to Apple's iSuccess? Some have called this "The Humane Interface":

A key to Apple’s success is the company’s insistence on reducing options in the name of reducing complexity. Those who decry Apple customers as fanboys attack us and the company alike, saying that because Apple chooses to focus on simplicity, we and it must also be simple. That’s the wrong interpretation of the facts. Instead, Apple’s focus on simplicity isn’t about reducing choices to make computing idiot-proof; it’s about focusing on the important bits instead.

{snip}

It wasn’t the first iMac that came along and disrupted things. It wasn’t even Mac OS X. It was the iPod, and even then, not all at once.

{snip}

The iPod’s true advantage was that it was just easier to use. It had fewer buttons, looked nicer, synced with iTunes, and was the only music player at the time that could play songs from the iTunes Music Store...(Y)ou had to beat the entire experience, not just the device.

{snip}

Design is a series of decisions. Should it be this color or that color? What’s the first thing you see when you log in? What happens when the user clicks here?

Sometimes these questions are really hard to answer, and the easy solution is to make it a preference for the user to decide instead. But the best designers tend to view such options as admissions of failure. Where Apple differs from its competition isn’t in aesthetic beauty, it’s in the company’s ability and willingness to make decisions on behalf of its users.

{snip}

(T)he megahertz race is over, and it was won by the people who just wanted to check their email and surf the Web without having to think too hard about what they were doing.

While RIM was busy making BlackBerries that appealed to network administrators, the people who actually have to use the things were going out and buying iPhones. No surprise, then, that the next great leap forward in technology was the removal of the keyboard and mouse. What could be more human than touch?

Linux and its cousin Android win with hobbyists and technology enthusiasts by providing options for everything. Like software development itself, the use of an application becomes a flow-chart of possibilities. Where, then, is the line between configuration and programming?

Apple’s take is to remove complexity and make choices long before the user sees the product. For some, this feels like control is being taken away, and they accuse Apple of dumbing down their products, presumably giving us the old cliché that Apple products are for dumb people. For those of us who prefer technology with a human touch, the magic is in what we can accomplish. Our tools are extensions—not reflections—of ourselves.

{snip}

It turns out that the real secret to making computers usable is to make them disappear. Our humanity is finally catching up with our technology.

In these paragraphs is the key to the future of PACS. Very simply, I was right years ago when I drafted the Laws of PACS. I'm thinking specifically of the Fourth Law: "PACS should not get in your way." I can't say with certainty what a Zen/Steve Jobs inspired PACS GUI might look like, beyond simple, well, simplicity. PACS should anticipate the tools we need and provide them, hiding the other 100 tools and buttons that we don't need at the time. Displays should be fluid and adapt to the task at hand. Stuff like patient-demographics and lab results need to be unobtrusively available; basically, we need a transparent window into the EMR. 3D displays need to come up as part of a super hanging-protocol if you will. In essence, the darn thing needs to be intuitive, as we've said above. And trainable too, adapting on a case-by case basis to your needs.

Such easy concepts, so difficult to execute.

We're all proud of making little mistakes. It gives us the feeling we don't make any big ones.

So how do we get from here to there? One big impediment to progress was outlined above: those who buy the PACS aren't those who use the PACS. So should we go on strike until someone listens?

Let's make a statement to the airlines just to get their attention. We'll pick a week next year and we'll all agree not to go anywhere for seven days.

Andy Rooney

I really don't have a better idea. And besides:

I'm in a position of feeling secure enough so that I can say what I think is right and if so many people think it's wrong that I get fired, well, I've got enough to eat.

Thanks, Andy. We miss you.

Would You Buy A PACS From A Company That Can't Manage A Bulletin Board?

I'm feeling cranky, and I'm going to take it out on Agfa.

I've just received a barrage of emails from various PACS admins around the country stating that THEY have received a barrage of emails...from ME!

It seems that after about five (5) years of my not showing my face on the Agfa Healthcare Users Group, AHUG was kind enough to send "New Years Message" to everyone on their lists. Everyone. Including those of us who got tired of the rather cumbersome navigation and gave up on the site five years ago. Did I mention that I haven't been on the site for about five (5) years?

Now here's the problem. AHUG has my old Yahoo address. I stopped using it regularly because Yahoo has been a b*tch about passwords...every few days it was requesting a new password be created, probably due to a problem with iOS Mail (which I also stopped using). I keep the Yahoo address active because there are some places that still use it, rather than my newer Gmail address. So, I autoforward all the Yahoo mail to Gmail, and reply to the sender with a "vacation response" containing the new address.

When AHUG decided to raise my identity from the dead, its poorly designed listserver, or maybe just the poorly designed site itself, sent the entry to my Yahoo address. It never did make it to Gmail, probably diverted as SPAM, but the autoresponse DID get back to AHUG, AND TO EVERY SINGLE USER ON THE LIST!

Now many of the PACS admins who received this autoresponse, who should probably know better, responded to the autoresponse, which generated MORE autoresponses! And so the cascade propagated.

I finally found out about this when four of the victims emailed me at the Gmail address that was clearly outlined in...the autoresponse. I'm going to assume that these nice people entered the PACS realm via IT as they blamed ME for the problem!  "You need to turn off your forward to Gmail!!!" "You need to cut off the away message!!"  Yup. All my fault. Couldn't be faulty software from the vendor, could it?

I was able to reactivate the account, and guess what!?? There is no way to change one's email address OR to delete the account! How wonderful! It's up to Agfa to fix this little glitch and calm its angry users.

Oh, by the way, the same damn thing (or at least something similar) happened in 2007, although I wasn't the culprit then:

Dear APUG Members,

First and foremost, I want to personally apologize to you for inundation of emails you received yesterday morning and even more importantly any pain and disruption it may have caused you!

Second, the auto-notifications have been turned off for all the discussion threads except the Agfa Announcement Discussion Thread

The flurry of emails was spawned as a result of three auto email replies which our system was not able to trap.

Our system captures automatic email notifications based on the subject strings/headings and unfortunately we were not prepared to capture subject text which included the words “Maternity Leave”. In addition, we also appear to have a problem with an out of office subject text contained within parenthesis. And last but not least if the subject heading is blank the system would not trap this message either.

Now the system has been updated to capture at least the Maternity Leave message. In any event, to reiterate all auto email notifications have been turned off, except of course for the Agfa Announcements Disccussion Thread.

We are looking into ways of subscribing people to the appropriate discussion threads without the SPAM. In the meantime, if you are interested in receiving the threads please go into the relevant thread and subscribe yourself. This seems to be the bottleneck to getting the site to be more interactive.

If you have any personal comments, please do not reply to this email notification. Rather than posting your message to everyone using the Agfa Announcements discussion thread please just drop me an email or call me directly. I have provided my contact information below.

If you wish to be taken off from even this discussion thread, just simply click on the unsubscribe*** link found at the very bottom of this email message.

Sincerely,
A***
Global Marketing Manager – PACS

I'm a little worried about zillion dollar software investments when they're having trouble with a simple, though cumbersome, bulletin board...

Keyboard Lethargy

In looking at my dear blog, I see that I haven't posted in an entire month. (I even missed a scoop: Dr. Robert Taylor, formerly CEO of TeraRecon, is now vice president of global business development and technology innovation for Siemens' syngo imaging informatics business unit, according to AuntMinnie. Maybe he will be able to get Siemens PACS going properly.) I'm certain, well, I hope in a perverse way, that my readers are horribly disappointed in me. But did you call? Did you write? Did you check to see if I was still alive? Ugh...sorry, I was channeling my Jewish grandmother for a moment. There, I'm better now.

I'm sitting in a hotel room in a Big City in the Midwest, where my son had his colonoscopy this morning to monitor his Crohn's Disease. Thanks to God, it went well, and he looks good from that end. We fly back to our small town in the South tomorrow, weather willing. You see, we're caught in the Polar Vortex, and temps here are well below zero, where they will stay for several more days. We got a foot of snow last night, which nearly paralyzed this Big City that is used to such things.

Our current situation is a study in unexpected consequences. The original plan was for Mrs. Dalai and I to drive with Dalai, Jr. from the Deep South to the Big City, and stay in the Fancy Hotel, miles from the hospital. However, last week the Senior Dog started limping, and wouldn't play nicely with Auxiliary Dog. A trip to the vet with expensive radiographs revealed an expansile lytic lesion at the tip of what was once a dew-claw. So Mrs. Dalai and I divided our efforts: she is taking care of the convalescing dog following Thursday's surgery (the tumor was not malignant says the vet, but Senior Dog did have tremendous swelling of the paw which required healing by tertiary intention) and I got to fly to the Big City with the kid. By some stroke of genius, I decided to save some money by staying in the hotel attached to the Big Medical Center in the Big City. As it is connected by skywalks to the hospital, we haven't had to go outside at all in this miserable (but beautiful) weather, and Dalai, Jr. actually walked to and from the procedure. Tough kid. This has been his medical month from Hell. He caught mononucleosis (no comments) right before finals, then had his wisdom teeth out, then had a Remicade infusion, and now this insult to his dignity. But I think things are looking up, and I'm not referring to this morning.

But none of this explains my lethargy at the keyboard.

I can honestly tell you that I can't honestly tell you everything that has kept me away. Suffice it to say there has been some less than inspiring dialog with colleagues and with children that doesn't merit repeating, lest I embarrass someone, particularly myself. Children have a way of not listening when you see them going down some of the paths we wish we hadn't taken, and, well, I'll leave that one at that.

Professionally, I have decided to take the next step in my evolution. For the last year or so, I've been paying for other members of the group to take call for me. This has been satisfactory up until now, but for various reasons, it is time to formalize the arrangement. Thus, I have requested the group to allow me to go permanently off of call. Normally, this triggers a five-year clock with retirement at the end of that period, and a significant financial penalty. I've asked for a two-year clock with a less painful fee. We shall see how that request is received.

For various reasons, I won't go into the machinations that led me to this point, but again, suffice it to say that many things came together. Mrs. Dalai and I decided that it was worth the hit on our lifestyle to spend more time together (don't laugh!), and we realized that with Dolly about to finish medical school, we would be receiving a raise of sorts. I realize time with family is precious, something I wish I had grasped when my children were younger. This was made crystal clear today when we heard that a friend of Dolly's from home was in a terrible wreck a week ago and is now in a coma. Life is way too short to spend it all at work. There are several negative motivations as well that won't be discussed, but everything finally made sense. I see light at the end of the tunnel, but fortunately it isn't that blinding white light described by folks who have made it to the edge of death and back.

Once out from under the burden of the daily grind, I have some grandiose ideas of how to evolve into Dalai 2.0. I hope to continue writing about PACS and life in general, and perhaps to continue to assist my group and any others in need of PACS or Nuclear Medicine faux-expertise. I might possibly be available to PACS companies for my unique advice, which won't come cheap, well, not not real cheap, anyway. Maybe I can hook up with the PACSMan (NOT THAT WAY!!!) and together we'll terrorize the PACS world! There are a few other opportunities in this realm that may or may not pan out, but I'm open to exploring many different possibilities.

I plan to do charity work as well, and travel to the ends of the Earth as long as our health and funds hold out.

I'm ready to go! I just hope the rest of the world is ready for me!

Friday RSNA Postcards

Thursday RSNA Postcards

Today's RSNA Postcards

More RSNA from Dr. Sardonicus

My friend, Dr. Sardonicus, sends these postcards from RSNA:

Small Food

My friend, Dr. Sardonicus, has graciously offered to send in periodic missives from RSNA. Here is his first Postcard from Chicago: