There aren't too many pictures that come up when you search for "RIS", so how about a flourless chocolate cake instead? RIS-less, flourless, what's the difference?
This post may disturb my friend Mark, who recently left Amicas for Empiric Systems, the creators of a very nice web-based Radiology Information System, or RIS. I am going to tell you how I'm going to forgo purchasing his product for my independent PACS operation, and that means he won't be selling me one for a while. It's a great system, but I need to trim my costs where possible.
Speaking of Marks...some of you may know I tried to hire back a PACS guru named Mark M., who was driven out of town for various reasons by a certain IT empire. Fortunately for him, but unfortunately for me, he likes his new spot, and he couldn't be lured back to my place. But Fate always has something interesting up her sleeve. Our PA came to me one day and said, "I know this really great PACS guy, who might be interesting in your weird, I mean progressive ideas. He is thinking about moving, so why don't we get in touch with him?" What's his name? Mark S! Must be karma again. He came to look around, liked what he saw, and we now have our PACS guru. He is already hard at work creating our independent system, and I'll report back as we progress.
Anyway, back to RIS's or the lack thereof. To achieve the RIS-less RIS, you must first define what you need out of such a contraption. At the bare minimum, we need to attach demographics and reports to a study. Yes, a RIS can provide much more than that, but keep in mind, the clients for our little operation are mainly clinicians with scanners in their offices (DON'T even say it...), with relatively small volumes and internal billing and scheduling. Therefore, we can stick to the very basics, at least for now.
I have mentioned PACSGEAR in earlier posts, and I had the chance to meet some of their staff and play with their products at RSNA. They offer two products that solve my "RISsy"-fit, and later I'll tell you about a third that is really nice.
This illustrates the concept: You have a sheet of demographics, history, or whatever that you want the rad to have available with the scan. With the PACSGEAR PacsSCAN program, you just scan the piece of paper with a regular old TWAIN document scanner (they recommend a heavy-duty version rather than the $25 Best-Buy bargain), bring up 
the patient in question via the little dialogue window ("Lookup" will fetch the pertinent info from your PACS or RIS if you have one), and off you go. Just press SCAN and the document becomes yet another DICOM sequence in the designated exam. Couldn't be easier. Print2PACS does something similar, but instead of scanning a physical document, you quite literally print a DICOM image into your examination. With this little program, our transcriptionists can print the report straight into the system, where it can be viewed along with the rest of the examination. Print2PACS makes it possible to store other things like DEXA or cath reports, or even JPEG images if you have a need to do so. Now, this isn't a perfect solution. What you get on the viewing end is a picture of a report, and it can't be edited or minipulated. (I suppose you could play with its window and level, and magnify it if you wanted, but you can't change any of the words.) Still, it gets the report in front of the clinician, which is the goal.
The third product in the PACSGEAR suite is one that doesn't really contribute to the RIS idea, but it is great for our purposes none the less. PacsSCAN Film adds a film digitizer to the picture, if you will, and will scan yucchy old film into your shiny new PACS system. But it goes one step beyond just digitizing...it will divide out sheets of multiple images into understandable sequences that fit right in on the PACS workstation. No more big picture full of smaller images that you have to pan around to view. This is a great thing for those of us reading from sites who are still filming.
I have to add that there are free programs out there that do much of what we're talking about here, basically converting .TIFF or conventional print files to DICOM. I've played with some of them, and while they do actually work rather well (especially for being free), they are not as smooth and elegant as the PACSGEAR products. Therefore, PACSGEAR gets the Dalai Seal of Usability. I'm looking forward to being one of their customers.
THERE ARE TWO PARTS to the human dilemma. One is the belief that the end justifies the means. That push-button philosophy, that deliberate deafness to suffering, has become the monster in the war machine. The other is the betrayal of the human spirit: the assertion of dogma that closes the mind, and turns a nation, a civilisation, into a regiment of ghosts — obedient ghosts, or tortured ghosts.
It is said that science will dehumanise people and turn them into numbers. That is false, tragically false. Look for yourself. This is the concentration camp and crematorium at Auschwitz. This is where people were turned into numbers. Into this pond were flushed the ashes of some four million people. And that was not done by gas. It was done by arrogance. It was done by dogma. It was done by ignorance. When people believe that they have absolute knowledge, with no test in reality, this is how they behave. This is what men do when they aspire to the knowledge of gods.
Science is a very human form of knowledge. We are always at the brink of the known, we always feel forward for what is to be hoped. Every judgment in science stands on the edge of error, and is personal. Science is a tribute to what we can know although we are fallible. In the end the words were said by Oliver Cromwell: 'I beseech you, in the bowels of Christ, think it possible you may be mistaken.'
I owe it as a scientist to my friend Leo Szilard, I owe it as a human being to the many members of my family who died at Auschwitz, to stand here by the pond as a survivor and a witness. We have to cure ourselves of the itch for absolute knowledge and power. We have to close the distance between the push-button order and the human act. We have to touch people.
Jacob Bronowski
The Ascent of Man
BBC, 1973
With apologies to George Lucas, and anyone else who ever had anything to do with Star Wars, including those who watched the movie, not to mention PACS and IT personel around the world...
The thread got rather contentious, which seems to happen a lot on AuntMinnie. Even David Clunie weighed in on this; apparently he receives a very large number of non-DICOM disks from Amicas sites and it makes his life miserable. Dr. RW cited a case of something missed because someone had to compare a non-DICOM study on one machine to the DICOM study on their PACS workstation. (This is exactly why I think the Napster PACS idea has come of age.) Mr. Clunie actually advocated avoiding Amicas and others that don't burn DICOM CD-ROMs.
Given the other methods that exist to get the DICOM CD-ROM, I think it is a little drastic to tell people to avoid a PACS system on that criterion alone. Remember, never buy a PACS based on one particular bell or whistle (even a very important one), or you'll end up with a ScImage or ITL type product. Avoiding a system on the same basis will exclude some good companies. Still, I DO think Amicas and Philips need to get their DICOM-burning software finished yesterday.
For those CD's already out there, I wonder if there is a translation program that will convert an examination from Amicas or iSite (or for that matter Siemens proprietary ECAT PET) to regular ol' DICOM format? I know a few people that would gladly pay a reasonable amount for something like that. I have found a few pieces of software over the years that will do the conversion to some degree, although the process is rather painful and not worth it in the end. Once someone creates this, they may feel free to pay me a 10% royalty for the idea.
News Flash!!!
Andreas Knopke just posted this on the AM thread:
Thanks, Andreas! Great minds think alike, huh? Don't worry about my royalty, just make sure everyone knows about this!Hi Dalai,
We already contacted Stentor in order to get some information on their proprietory image format but without any luck. They answered with something like "DICOM will be supported soon". Amicas' JPEG2000 + XML template format will be supported soon by our DICOMReader ( free download at http://www.dicomreader.com) because it is quite easy to "dicomize" it.
Regards, Andreas
But Reuters' attempts to compete with Bloomberg led to financial disaster and a series of lawsuits. In 1989 the company hired a former Smith Barney executive, Stephen Levkoff, to devise a bonds analysis database to rival Bloomberg. But the product, released as Decision 2000, was regarded as a technological disaster and cost $10m after Levkoff sued.
Another lawsuit, from brokerage house Cantor Fitzgerald, followed over a failed joint venture through which Cantors would provide Reuters with a live feed of US Treasury securities prices.
Even worse was to follow with Reuters' next project, codenamed 'Armstrong', an ambitious attempt to correct what it had failed to achieve with Decision 2000 - fusing real-time market data with legacy information. Armstrong proved to be another huge disaster and cost the company some $20m.
In response, I saw the Observer many years ago. It was an attempt to hammer Reuters for its incompetence in financial markets other than foreign exchange. Reuters failed in two major deals with two industry experts: Cantor Fitzgerald (government bonds) and me (multicurrency analytic systems). In my case, they wanted to integrate D2000 functionality into ALL Reuter terminals –but with no royalty payments. The business landscape is littered with numerous other IP vendor lawsuits against Reuters for various material breaches of contracts, bad, faith and lack of fair dealing. Cantor Fitz and I had the wherewithal, strong legal position and balls to fight back. We won – more than you will make in a lifetime as a radiologist in private practice.
I didn't respond to the Observer nor will I now. I consider the Observer article libelous – incorrect and uninformed. D2000 was extremely successful. Clients in 30 countries were serviced by 6 redundant data centers via a failsafe global network. It significantly undercut the "Reuters Terminal (RT)" - a proprietary PC platform that delivered nothing but real time data that was only a small part of D2000.
Decision 2000, a highly viable multi-lingual Bloomberg competitor with operations in 30 countries, subsumed the RT functionality and offered more advanced real-time analytics than Bloomberg has today - in an industrial strength platform. D 2000 became a $250 million disaster for Reuters AFTER I sold it to them - they mistakenly did not understand the financial markets or the expertise necessary to compete. They hired 1000+ (semi-competent) people to attempt to do what I had done with 150. They bombed badly and attempted to blame me long after I left the company. If you can read, you should review the federal case that we brought against and books written by insiders at Reuters. D2000 comes out very well.
"...found that Siemens Syngo Suite offers the only fully integrated, industrial strength RIS/PACS solution in the market. The platform - Fujistu Siemens servers, Sun Solaris (UNIX), Oracle (db), EMC (storage) - is the only one in the industry capable of supporting multiple, fully redundant data centers with real-time database replication and synchronization. At the June 2005 SCAR meeting in Orlando, most vendors not only completely failed our platform requirements but scoffed at our requirements for a completely fail-safe, multi-data center integrated health care information environment. However, post-Katrina, the need should be obvious to all health care executives."
If bullet-proof, uncrashable hardware was the end-all to end-all, we would all still be using UNIX on Sun boxes. Somehow, Katrina or no, that has not been first and foremost in everyone's mind. Wintel boxes are considerably less expensive, and with off-site storage, you should be covered. The best Unix box hooked up to the best SAN becomes inoperative when immersed in water, last time I checked.
The Siemens Syngo/eSoft approach is very esoteric (read: strange) although it does work well once you get used to it. They have unified the appearance of their modality controls and workstations, and from a very brief peek at RSNA, their PACS uses the very same interface. That is a good thing to some extent, but how many rads are going back into the control room and running the CT scanner? I personally don't think this interface is the easiest or the most straight forward for PACS use. It has certainly been a long time in coming. I would be curious to hear from any rad who is using this product.
Hello Dalai Lama - You sound like a weak Siemens competitor. Your Wintel comments are extraordinarily naive - typical of the industry. Microsoft does not offer an industrial strength operating system for zero-downtime environments - particularly across data centers. Further, you obviously don't understand the concept of running multiple, fully redundant data centers with real time database replication....On the user interface issue, you may find it "strange" because you are accustomed to doing things a certain way. Loosen up - it’s very intuitive and flexible. Additionally, commonality of user interface across applications and modality is essential for training, cross-training, quality control, and leveraging personnel for operating efficiency. As a CEO, I would not make a purchase decision that did not offer all of the characteristics of the Siemens Syngo Suite, given its availability. Also, I wouldn’t hire a radiologist who couldn’t scan.
How many radiologists did you meet with to discuss their impressions of the viewer? How many hospitals did you visit using the product that you would be buying?Dr. Levkoff is obviously a very brilliant man, and has done a great deal research in PACS and healthcare informatics. Unfortunately, his wisdom has manifested itself into tunnel vision, and he has sandbaged himself into a particular corner. Even more sadly, he cannot tolerate the disagreement over his choice of, well, corners, and he has lashed out to the point of destroying his credibility, at least to me. He had much to contribute, but in trying to change the entire industry in one fell swoop, he lost his chance to do so meaningfully. RIP.
The Future of Medical Imaging - 2020’
By: Digital Doctor
Sat 31 Dec 2005
My Predictions for 2020!
Government Regulations
In the United States, we will face a healthcare CRISIS on or before 2017 due to a lack of funding for Medicare and Medicaid. As Medicare and Medicaid are the "insurers" for approximately 30% of all medical care in the United States, you can perhaps only imagine the potential for havoc. The United States CARE Act will be passed prior to 2012, which will mandate federal registration of radiologic technologists. PACS Systems Analyst (a radiographer with minimal certification in PACS), PACS Administrator and PACS Manager will become recognized growth opportunities for radiographers. Registration will be required as part of the CARE Act. Many clinicians will truly question the necessity of radiologists (but not for the first time) and a political struggle will ensue for the future of medical imaging. Ultimately, radiologists will win for several reasons despite the overwhelming anti-radiologist movement. Radiologists will put more weight behind the radiographer role as well so that the two professions will be inseparable to better support their own role.
Expansion of Services
Medical Imaging will, of course, become an even more integral component of healthcare as (in the United States) utilization will continue the trend of expansion of 7% every year. Medical Imaging will assume as much as 25% of total hospital revenue on average.
Expansion of Roles
The Radiology Practitioner (introduced in 2003) will become an essential role in the United States due to expanded utilization of services and a reduction in reimbursement. Physician Assistants have been assigned to Radiology Departments since least 1995, which I would argue fulfills a similar role, as both the Radiology Practitioner and Physician Assistant are "physician extenders." The Radiology Practitioner will require a Masters Degree and two years residency (in addition to four years practice and registration in a Medical Imaging specialty).
Technology
The "One Touch" scan will revolutionize technologist workflow. Technologists will be able to focus attention on patient care and post-processing. OLED monitors (displays) will be the predominant technology of the day; however, OLED will soon be replaced by 3D Holographic displays which will offer the first "true" 3-Dimensional views of the human form in medical imaging.
"Personalized Medicine" (the most overused medical "buzz" phrase of the current decade) will finally be a reality at about the same time as healthcare in the United States nears collapse. Driving "Personalized Medicine" will be the introduction of several new "multi-modality" scanners. An “Omni Scanner” will be introduced that is able to perform diagnostic radiographs, Computed Tomography, as well as Magnetic Resonance and Nuclear Medicine scans.
TRIP (Transforming the Radiology Interpretation Process) by SCAR will become an extended initiative. By 2020 radiologists will interact visually, verbally and tactilely with PACS (renamed Medical Imaging Informatics in 2008). The radiologist will don gloves that will act as a virtual keyboard, a mouse and a multimedia controller (think the "Shuttle Pro" by Contour Design) "all-in-one." PACS systems will offer, "Visual memory cues" (not CAD) that will act as mnemonic prompts for radiologists and clinicians to remember specific patients and abnormalities. PACS will track and respond the eye movements so that visual fixations will result in image zoom and pan or will activaate functions upon which the user has a visual fixation.
AN ENTIRELY NEW MODALITY WILL BE INTRODUCED which will assume much of the workload of Computed Radiography and Digital Radiography. The new modality will not utilize ionizing radiation as a means for imaging. The new modality that will (possibly) continue to be known as Digital Radiography will undergo the most dramatic changes, as "unlimited" radiographers will utilize equipment that is more similar to Computed Tomography than Computed or Digital Radiography. Radiography Equipment will become much more portable so that the "Radiography Suite" (not the portable machines of today) will be portable. Computed and Digital Radiography will often acquire tomographic images from which 3D images will be automatically constructed by the modality. Computed Tomography will "top off" at 2048 "slices" which will become the new "unbreakable barrier" for years to come. Computed Tomography will automatically generate any required MPR, MIPS and even 3D volumetric series.
Nuclear Medicine and Magnetic Resonance (and likely Computed Tomography to some degree) will be the true driving force of the "Personalized Medicine" trend. Nuclear Medicine, in particular, will lose the moniker "Unclear Medicine" as images will begin to resemble the image quality captured in the 256 "slice" Computed Tomography images of 2008.
Computer Aided Detection will become so ubiquitous that CAD will be a standard feature on every modality. Every modality will utilize CAD for nearly every conceivable procedure that will increase in-office utilization of Cardiologists and nearly every medical specialty group.
Structured Reporting will become a reality and will drive major changes to the workflow of radiologists. In fact, Structured Reporting will be hailed as the "saving grace" of Radiologists. The innovations related to Structured Reporting and CAD will so alter the job function of radiologists that the profession of radiologist will either disappear (not likely) or become more interventional (especially as radiation therapy and nuclear medicine take on many new roles) or radiologists will offer "value added interpretation" (very likely).
Educational Trends
In response to the CARE Act and technological innovations the minimum educational requirement for radiologic technologists will be an Associates Degree (two years post primary school). More offerings of advanced degrees will be available for technologists seeking to specialize. Magnetic Resonance will have been recognized as a "primary modality" by the ARRT before 2012.
Even more COOL stuff on the horizon in 2020
BEYOND SIMPLE IMAGE DATA...Radiologists will utilize tactile and auditory senses by donning a suit that will provide additional sensory data to perform diagnosis - this data will be derived from image data (or data collected during the scan). Surgeons and Interventionalists will be able to utilize this data to perform remote surgeries. WAVELET COMPRESSION utilized by nearly every PACS and modality will be replaced very soon with "Fractal Compression" which will finally compensate for the overwhelming data sets generated.
Here we have two companies who were not well-known (at least to me) until the past few years, but are now topping out the KLAS surveys. Their "current performance" screens on KLAS are a sea of green lights like I haven't seen in a while, and both are showing major upticks in their indicators since Fall, 2005. I took a long look at Intelerad's InteleViewer and Dynamic Imaging's IntegradWeb systems at RSNA. Both are impressive products, and to give away the punch-line, I give both the Dalai Stamp of Usability.
Superficially, InteleViewer and IntegradWeb are fairly similar. Both interfaces resemble Amicas LightBeam to some degree, although their worklists use flags and other indicators rather than the more pronounced color-changes we see with Amicas.
Let's deal with Intelerad first. I was given a disk with a limited, but still very functional viewer embedded, and I have included some clips below. (To my friends at Intelerad: please let me know if you don't want these online...) For those so inclined, Intelerad offers a free beta version of their full viewer if you agree to help test it. To sign up, click here. I'm going to do it myself, although I'm not sure how much time I can devote to the project.
Intelerad began as a company creating a backend PACS system using eFilm as their viewing client. Rather what Merge/eMed/Cedara has become today, I guess. They now have 300 installations, including many in Canada and Australia. This is a Canadian company, after all. Today, they use a Linux backend, and a Java applet for the client. The Intelerad VP assigned to "Dalai-duty" tells me that their architecture is distributed, and that the product is considered web-enabled. There is auto-routing and pre-fetching, both sounding more like the older approach to PACS database architecture that the unified web-based database I am used to seeing today. There is streaming of the image once selected to allow faster downloading.
The worklist reminded me somewhat of an Excel spreadsheet, rather spartan compared to the Amicas Rainbow, I mean RealTime Worklist, but still functional. Once in the viewer, you are presented with a toolbar having nicely-done, simple and clear 3D color icons.
The study is deployed into the usual viewports, i.e., frames in the window. Multiple patients can be selected and are accessed by right-clicking or from the Patient menu on the toolbar. The overall appearance belies some eFilm heritage. Thumbnail views ala Amicas are optional. A comparison/prior exam will have the date highlighted to clearly define it as a prior. Hanging protocols can be set up with great detail, but configuration requires a bit more work than the WYSIWYG approach. Monitors are detected and hanging protocols are deployed accordingly. All the needed tools are available, with simple orthogonal and more advanced MPR, and there is integration with Voxar or TeraRecon. Measurements work in context with the image being viewed, and the viewer remembers what you used last time. Scroll wheel will activate either "next image" or "cine" depending on the examination. There is a cute little indicator at the bottom right of the screen which displays the current assignments for the three mouse buttons.
Right-clicking brings up either a limited tool menu, or this more prodigious menu if you so choose:
I have been known to call this sort of thing right-click-o-rhea, and it's still somewhat overwhelming, but then I'm not at all certain where else to put these functions. At least the layout is clear. Note the small letters in Courier font that are clues to the hot-key equivalents.
As with Emageon, there is a tremendous degree of customization possible. In fact, there are "three ways to do everything." The configurations are based on modality and user login. You can have the machine always remember the last tool used, or always do thus-and-so in a given circumstance. Below are screen-shots from the CT configuration window including overlay construction and more general intereface controls. I didn't include a shot of the control panel for fonts and colors, also customizable to the nth degree.
There are remote administrator tools, and a well-done comment tool is found in the report viewer. Comments are time-stamped and indelible. There is a teaching file module.
Intelerad creates an online "virtual PACS" as a training and configuration tool before actually deploying the product.
Dynamic Imaging began life as a Canon dealer. Various customers asked them to create a Windows/Intel client, and so they did. DI had four goals in this endeavour:
DI has met these goals. Today, DI claims 100 sites with 300 installations (obviously differentiating between number of customers and the number of places they cover.) The latest iteration, IntegradWeb, looks somewhat similar to InteleViewer on first blush. Under the hood, however, it is totally web-based, although they note the use of a "core clustered architecture", which I assume is a server cluster of some sort. Upon sign-on, you are presented with the worklist page, and different worklists are tabbed at the top of the frame. As with Emageon, there are small flags to the left of the patient name indicating read-status, report status, dictated, etc. These flags are color-coded. The "search" function is a separate worklist tab, and it is very intuitive, using some boolean variations such as "CONTAINS", rather like the Impax 6.0 version.
The viewer itself leverages the windows of Windows to great advantage. Each open patient study is a separate collection of individual windows, not just panes within one window. This allows something I haven't seen before, the deployment of multiple windows of any size as part of a hanging protocol. DI used a knee MRI for an example of how this would benefit the reader: wide, short windows were used for meniscal display, and regular square panes were used for the rest of the study. You can set this up literally any way you can think of. Hanging protocols are similarly flexible; any window can be anywhere with any image. You can even set an MRI portal to display the sequence with a certain TR/TE range, bypassing the need to have the sequences labelled correctly (although I hope they are anyway.) The icons on the toolbar are larger and more elaborate 3D renditions.
Unlimited measurements are allowed, and the tools are very intuitive. The Cobb-angle tool is very nicely done, requiring that you simply draw two lines parallel to the vertebral end-plates in question. The spine-labelling tool has a first to my knowledge: it detects the interspaces and does the labelling at least semi-automatically. However, the sagittal labels do not yet propagate to the axial slices. There are fetal measurement tools and a built-in database of standard values, another first in user interfaces as far as I am aware.
There is a proprietary MPR program and images can be saved back to PACS. There is a "slab scroll" function that yields a thick-slab MPR in a clone window that tracks with the main window, most helpful for 1000(s) slice studies. DI has surrounded the Voxar 3D ActiveX controls (at least partially) with its own interface, yielding a good blend of the two. Linking between two CT's can be set to automatically occur (or not, for that matter), and can be based on relative position or bed position (or even image number if you want, although I don't know why you would). Only one prior can be displayed.
Window/level settings are set to cycle via the space-bar, and this actually works pretty well, at least as fast as using F-keys or number keys for selecting an individual setting. Navigation between patients is accomplished simply by clicking the tab on the taskbar, just like switching applications in Windows XP.
Monitors are automatically detected (both their number and whether or not they can display color) and changes can be made even on-the-fly, without rebooting.
Streaming plays a very important part in the viewer, and DI was confident that IntegradWeb would allow one to be able to read sooner than any other system given their "SmartLoading" approach. DICOM printing and DICOM CD creation can be performed from any location. The CD's include a DICOM-push application. Online administration is available from any web-connection.
Key images are well done, and can include any individual image or a saved 3D recon. There are three levels of notes available to facilitate interdepartmental or interdisciplinary communication. An email can be automatically sent to the clinician with links back to the image in the viewer. Web-access can be anonymized, and they showed me a live feed from a site in New Jersey that I could safely view with this accessory. Teaching file creation works with anonymization as well.
PET/CT can be accommodated by integration to the Mirada 7D program (although this was purchased by CTI which was in turn purchased by Siemens, and I don't know if this is still available). DI has a more limited proprietary fusion module. General Nuclear Medicine can be enhanced with MedImage.
IntegradWeb is VERY customizable, more so than I have seen elsewhere. It is so adjustable that you can relabel menu items and right-click options if you so choose. I could, if I were so inclined, relabel the window/level control as Bass and Treble, the ruler as "How Big IS It?" and the Save as "Terminate Patient". But of course, I would never even think of such a thing. Of course, everything else can be reconfigured as well, including hot keys and so forth. You don't even have to keep the space bar as the window/level cycler if you don't want to, but apparently most folks don't change this.
I'm sure I've missed a number of features of both Intelerad and Dynamic Imaging's offerings, and I would welcome their comments. Suffice it to say that both viewing clients are very nicely done, and I would consider each one Usable with a capital U. It is said that he who dies with the most toys wins, and I guess that means Dynamic Imaging's tour de force, IntegradWeb, would certainly be the winner here.
Stay tuned for the epilogue of this whole RSNA opus.
In reading over the Emageon post, I realize that it is next to impossible to do any of these products justice in the space of one short post. I will apologize for any omissions on any of these "mini"-reviews. I'll try to hit the highlights from my somewhat limited perspective.
The good people at BRIT were most anxious to have me over to their booth. Yassin, in particular was my contact, and made me feel very welcome. I was able to meet many of the BRIT engineers and execs.
I must confess that I did not get to see as much of the BRIT product as I would have liked. There is an entire RIS and workflow strategy that I just didn't have time to demo. They present an approach that "closes the exam loop":
Well, that's basically how most systems do it, I think, but when you have your own RIS incorporated, that may make the cycle run a little smoother.
BRIT calls most components "Workbenches"... you have your Capture Workbench, the Scanning Workbench, and most important for me, the Viewing Workbench. (The way things are going lately at my place, it might be more appropriate to call my station an eSweatshop or something like that, but I digress.) BRIT offers three versions of the Viewing Workbench, the Radiology Workbench for diagnosis, the Clinical Workbench for those other docs, and the Web Viewer for remote. All are similar, though they are indeed separate applications.
I spent most of my time looking over the Radiology Workbench. The "look and feel" of the GUI is significantly different than that of any other product I have seen, although I think I could get used to it quickly (it is nowhere near as esoteric as Siemens' Syngo interface.) The worklist layout is a little spartan, but still very functional, with black type on white background. The worklist is very flexible, and you can deploy different worklists to different monitors if you so choose. The worklist(s) update(s) dynamically in real time. BRIT uses what they affectionately call "Collaberative Rodent Technology": the worklist has little caricatures of mice as status indicators. If someone else is looking at a particular exam, the mouse pops on with red-colored sunglasses. There is a facility to place messages within the worklist, and one can reply directly to those messages, good for physician to tech communications, for example. If you choose an individual study off the worklist, you can drag it to the monitor where you want it to display, or alternatively to an icon representing that monitor. Alternatively, there is a Power Read mode which will pull the next study on the worklist in the background. Exams are tabbed at the bottom of each monitor, and prior studies are tabbed as well.
Once in the viewer application, there are large buttons off to the right side of the monitor. I noticed that the buttons were on the large side, and the icons within them were kind of small, but still clear. Button layout is customizable per logon ID and modality. Simple MPR is available, with a more advanced version to come later. Hanging protocols are set up in WYSIWYG fashion, and are saved by name.
There was much more, and I'm doing BRIT an injustice by not being more complete. However, the bottom line is this: although their approach to the interface is somewhat different than most, it is still very usable, hence earning the Dalai Stamp of Usability. (As I've mentioned, there are certain LARGE companies that can't earn that.)
Now, a discussion about BRIT would not be complete without mentioning this little guy over to the right.....
BRIT is the only major company using Linux for all operations, front and back-end. Why is that a big deal? Isn't Win-Tel the end-all-to-end-all in this venue? In a word, no. Despite some unpleasantness on an AuntMinnie.com thread, I am no big fan of Windows. It is not as stable as Linux, or its cousin UNIX, but it has taken over the market, I believe for purely economic reasons. (Consider Beta vs. VHS in the video world...Beta was better, but VHS was perceived to be cheaper, and guess who won that battle.) No one can convince me that Windows is more solid than Linux (or even as solid), and in fact, the BRIT team very proudly told me that some of their workstations out in the field have continued to run perfectly for years without rebooting. I have to reboot every Windows machine I own or use at least daily. Maybe BRIT is bucking the trend, but given the mission-critical nature of PACS, rock-solid stablilty is something that deserves a second (and a third) look. Rather than a liablilty, I think BRIT's use of Linux is a true asset. Hear that, Bill Gates?
Microsoft Small Business Center tells how to "Make it a politically correct holiday season: 7 tips".... absolutely serious article!
CNN reports on "Tiptoeing around 'Merry Christmas,' er, 'Happy Holidays'"
ABC News Original Report: "Calling Christmas by Its Name"
This is ridiculous, folks. I'm Jewish, and I guess I'm one of those who is supposed to be offended if someone wishes me "Merry Christmas". I wish someone had asked me about that, because nothing could be further from the truth. While I don't share the beliefs of my Christian friends, I certainly respect those views. It warms my heart to know that my friends want to share their joy at this season. I take the greeting in the loving spirit in which it is offered. No more, no less.
And so to all my readers, I wish you a very Merry Christmas, Happy Hanukkah, Happy Kwanzaa, and a Happy New Year. Sorry if I left anything out, but you get the idea.
Agfa doesn't work this way. You can do something similar with their "clone window" concept, that does link the windows together (which it should since it is the very same data), but doesn't let you link them to a prior. This is a serious lack in my book, and this is exactly the way the older Impax platforms function. I am left with the nagging sensation that Viewer 6.0 is much closer to Viewer 4.1/4.5/5.2 than I would have guessed.
Our demo was choreographed by Bob, Agfa's Senior Marketing Manager, and he did a very good job, I might add. He made one statement that I keep replaying in my mind: "We worked with 12 doctors on this, and they agreed it was perfect!" I can't get any two of my partners to agree that the sky is blue, let alone anything of more substance. I will make a little side-wager that those 12 docs had used mainly Agfa PACS for a long time. We all tend to become a little inbred, and happier with the familiar. That would explain the "perfect" designation of a product that does things in somewhat similar manner to the old way. This is a path to stasis. There are a lot of new ways of doing things that are work very well, and it is important to seek opinions of those who use the "other guys'" stuff as well as your own loyal customers. Now don't feel like I'm picking on you, guys, I've told this to Amicas and GE and everybody else who will listen.
Impax 6.0 is without question a significant improvement over its predecessors. Will it really become my favorite PACS? Likely not, but I will give it a fair shot, I promise. We have yet to see whether or not it will get in my way.......
Fuji Apple Photo Courtesy of New York Apple Association
It's easy to find an image for Fuji, but I had to search far and wide for something to go with Meditech. Here is a Russian blood pressure cuff, and I could stand to have my BP checked about now.
For over a year, I have complained to our powers-that-be about our Fuji CR. The images show poor contrast and cannot be adequately adjusted on my workstation. Many are just barely of diagnostic quality, and some don't even make the "barely" category.
As usual with this sort of thing, there is much finger-pointing. Fuji says their system works, but the Amicas PACS is the culprit. Amicas, of course, says just the opposite. Numerous posts on AuntMinnie.com indicate that there are settings within the CR that make it work better with Synapse; these have to be enabled (or disabled or whatever) for the CR to work with other vendors.
After a year of whining, I am fed-up, and I am really frightened by the possibility that I'm missing things due to the poor image quality. Therefore, I recently had a tantrum and declared that if this thing isn't fixed by the end of 2005, it's outta here. By that, I mean forklift removal and full refund. Enough is enough, guys. We have had much better luck with our Agfa CR over at the Agfa hospital. Could that be due to the fact that we have Agfa PACS over there? Could be, but they may get the chance to show how well their CR works with Amicas PACS in the near future. In the meantime, I would suggest that anyone considering the purchase of Fuji CR put that idea ON HOLD until I can tell you that our problem has been resolved.
Meditech gives me a different set of frustrations. The IT types at our Amicas/Meditech hospital decided in their infinate wisdom to purchase the Magic HIS/RIS instead of the client-server version. They felt the latter was not stable. Naturally, we were told about the purchase after all decisions were made; why would anyone want input from the people who will be using the product? (We actually do use the client-server flavor at a little suburban place, and it works just fine, thanks.) Magic is anything but. Basically, it is a port of their very old dumb-terminal software. Only the shortest reports can be seen on one (minature) screen, and it takes several key-strokes to view an entire report. Basically, sign-off time is tripled or quadrupled because of this antiquated approach. Trying to find an old report is an exercise in agony.
So, all I want for Christmas (or Hanukkah) is (to keep) my two front teeth, and to replace the Fuji CR and the Meditech Magic systems. Do I need to ask Santa for all this? At least I could get a candy-cane with that approach.
ADDENDUM: After having my tantrum to our imaging director this morning, I come to find that Fuji had already "fixed" the system last week. It seems that numerous settings were incorrect, including an interesting situation of the CR trying to send 14-bit data into an 8-bit PACS display. That's the good news. The bad news is that a very significant portion of the 200 or so studies I read over the weekend were still pretty awful. We would have tried to work on this more today, but it seems that Fuji won't let us have any of the manuals. Oh well.
NEW ADDENDUM, 12/21/05: Fuji has been slaving away on this problem, and the CR images are tremendously improved to the point that I can remove my "ban". I do have to admit that the prettiest images I have seen to date are from the combination of Agfa CR and GE Centricity PACS. See? I do give credit where credit is due...
Fuji still seems to harbor thoughts of blaming Amicas for the problems. I think that would be somewhat of a mistake. First, Amicas does not post-process the data, and secondly, we displayed a Fuji CR through an eFilm viewer, and it looked just as bad. Add this to the fact that Fuji was able to effect some improvement, and I must conclude that the problems lie with Fuji alone. Sorry, folks.
Real Software Not Available
