WARNING: Our Scanner May Not Work With Your PACS...or should that be "Our PACS May Not Work With Your Scanner?

On the heels of the prior private tag post comes some further information from GE, which provides paranoiacs like me more to worry about.

This is a known issue with the AGFA system in which the AGFA PACS does not support WW/WL > 13 bits. Per the DICOM standard the ww/wl values can as large as the image data. Per the HDMR2 DICOM and Annotation SRS (DOC0084074 rev 5) section 2.1.2 Smallest Image Pixel Value,Largest Image Pixel Value, MR image data is stored as 16 bits.

It seems that Agfa is only supporting 16 bit for a small number of modalities. The Impax developers are working on a solution to this problem. They are trying to work the fix into the next service pack or perhaps the next service update. I recommend that the you contact their AGFA representative regarding this issue. . .

Ummmm... Guys, this is a real problem, and I think both vendors really should have disclosed it. Unless perhaps this bit problem is more widespread than we know. I would like to know if any PACS out there can deal with 16-bit output from a scanner without modification. If so, please let me know which product can do so. If not, someone please tell me why the scanners' main output is in a form that the majority of the PACS systems cannot handle. And if Centricity (and IntegradWeb for that matter) can't deal with the 16-bit output, then this makes no sense at all.

Add as an aside the fact that every Barco monitor I've ever seen attached to a PACS system runs at 8 bits, or at least that's what the Windows Display Properties control says on these machines.

Frankly, I'm confused. And very, very concerned about what we are seeing or not seeing. I am disappointed in both vendors for not making this situation clear. While I think my group of radiologists is top notch, I find it difficult to believe that we are the first to have discovered the discrepancy.

So, who is at fault here? Is it Agfa for not being able to receive the full output from the GE MRI, or GE for sending data that the PACS cannot completely digest? Let's be democratic and blame both of them. And both need to work on the solution. Which I'm assured is in progress.

A Private Little (Tag) War

"Mugato" from the Star Trek Second Season episode, "A Private Little War"

Courtesy Paramount Pictures/CBS Television

OK, only PACS aficionados who are also Trekkies will get the reference, but I thought it was attention-grabbing.

We have recently upgraded our GE MRI, adding various bells, whistles, coils, software, and various and assundry other items. I myself have been scanned in this machine, and I can tell you that the new, improved version is louder than a freight train as heard from the track's perspective. However, the images are excellent. Well, I should say that the images as viewed on the MRI console are excellent, but once they make it to our Agfa PACS, they would rate as only "good". It seems there is much degredation in the display, and we have been asking about this for quite a while.

The fault appears to lie with DICOM, the communications protocol of digital imaging. Well, that's actually a mis-statement, as the real fault lies with the vendors and their use or misuse of the DICOM standard. In this case, the culprit is probably GE, although they aren't the only bad actors in this venue. I have also noted severe problems with Fuji CR in the past not displaying properly on an Amicas PACS. In both cases, the modality makers tried their best to indict the PACS for the situation. However, while the PACS does bear some responsibility, the lion's share of the blame probably goes back to the modality.

Now, you don't want a complete course in DICOM, and even if you did, I couldn't begin to do it justice. If you are truly interested, please consult David Clunie's website, http://www.dclunie.com/, for the most complete information possible. (God Himself consults David when He has a DICOM question.) For the purpose of this discussion, you need to know that a study, a group of images and associated data, is called an object, and it has a header, which is some alphanumerical data tacked onto it. Michael Gray, of Gray Consulting posted this link as an example of what the header looks like. The header contains "tags" which in turn have code for "attributes" And this is where the trouble starts. The even-numbered tags are Public, representing standard variables for PACS systems, archives, and modalities. Ah, but the odd numbered tags are Private, and therein lies the trouble.

There was a huge discussion on AuntMinnie.com, prompted by my article, "The Dalai's Laws of PACS" a few months ago, where many of the Great Ones of PACS, including David Clunie himself, Michael Gray, and of course Mike Cannavo, the One and Only PACSMan, as well as the phenomenal Digital Doctor, and several very, VERY wise folks hashed out the vagarities of vendor-neutral archives. The modalities were not really mentioned much, but as our experience reflects, they have this problem too.

It seems that the likely reason for our images degenerating to mugato-poop in their journey to PACS is the fact that modality vendors use these private tags to add various parameters that are not generally readable by a PACS from a different vendor! As described by Donald Peck, Ph.D., in a lecture for the American Association of Physics in Medicine,

. . .you can use them to display almost any tag as an annotation, also they include acquisition and processing parameters inside of the DICOM header. These processing parameters though are often stored in what’s called private tags, which are proprietary to the vendor and may or may not be visible inside of your PACS system.

This supposedly is a way to make you want to buy all your toys from the same company, but no one told the salespeople about this, or the service engineers for that matter. They subsequently flail around trying first to point fingers at the PACS involved, and when that doesn't work, they attempt to fix a problem that turns out to be intrinsic to their scanner. But it is the way it is. Does this interfere with the image enough to cause a miss? To answer that, we would have to compare each and every study as displayed on the MR console and on PACS, and that ain't going to happen. But we're still going to worry about it.

This situation dovetails into the larger discussion of proprietary fields/private tags in DICOM in general. Why are they even there? Michael Gray, on his website, describes the example of Presentation States and Key Image Notes as illustrative of the Proprietary Problem:

It has been at least four years since Presentation States and Key Image Notes were included in the DICOM standard, yet the majority of PACS vendors continue to treat these key work products as proprietary objects. The most consistent excuse is "There are many more features on our engineering schedule considered to be more important to our users."

I can almost believe that story, since I have found that most users are not aware of the implications of proprietary data objects. Since almost every PACS supports the creation and display of Presentation States and Key Image Notes, the fact that most PACS treat these as proprietary objects is lost on most buyers and eventual users. Provided that these objects are kept within a given PACS, there is no apparent negative to their being proprietary. The user may not experience a situation where the proprietary nature of these objects presents a problem.

The problem arises when the user of one of these proprietary PACS tries to forward study data to another Facility or Health System that is using a different PACS. Whether that other PACS is DICOM conformant or not, unless it is the same PACS, those presentation States and Key Image Notes cannot be transferred, accessed, or displayed. Physicians using the other PACS will not have the benefit of seeing exactly what the radiologist interpreting the study saw in the images or what he may have typed as a text message. The benefit of these "work products" is lost.

The real problem will manifest itself only after the user has decided to replace the proprietary PACS with the next PACS. Data migration services will typically migrate the study pixel data to the next PACS, but few of these services currently migrate any proprietary study-related data objects. To do so would require knowing where these objects were stored in the PACS, how to extract them and how to convert them to their DICOM counterparts. This extraction, conversion, migration is not being performed and as a result, those proprietary data objects are lost forever. The images are available for historical comparison in the next PACS, but none of the proprietary work products are available. Now imagine the implication of having to window and level all of these priors again, when they are recalled for viewing with the new images. Imagine not having the spine labels, and not having any other annotation or overlay graphics created when the prior was first interpreted. That's working without benefit of prior information, or a possible expenditure of time redoing all that work.

. . .Lack of DICOM conformance is a type of vendor lock. I believe that the PACS vendors still believe that anything that complicates moving to another vendor's PACS may persuade the organization to stay with the incumbent. It's time to make them pay for that strategy.

Amen. Sadly, it is next to impossible to find a scanner OR a PACS that doesn't dabble in this unfortunate practice. Maybe if we users started demanding such products, the vendors would provide them. OK, I'm demanding it. And so should you. Let's start a private, little war on Private Tags.

Addendum

Our GE rep (who is NOT pictured above, by the way) sent in these responses to our complaints. Our notes are in black, the GE responses are in green (of course!):

Issue #1:
"In my (Dalai's note--PACS IT expert) experience, GE as well as some other vendors, are notorious for placing key information in proprietary fields outside the DICOM standards. This creates a marketable advantage for the vendor to sell other related products in their product line."

When the original DICOM standard was developed for the MR image object, there were few fields defined. As MR has evolved these standard fields have become insufficient to contain the data necessary to annotate our images to the level we currently support. The enhanced MR image object has defined many more standard fields to better align the image object with current technology. At this time GE only supports the original MR image object. At this time no date has been set to support the new MR DICOM object. However, GE provides details on each of the private fields for our MR object in our DICOM conformance statement. When requested, additional details are provided on how the private data maps to annotation fields on the image. As far as selling related products, the only GE products which interpret MR private data fields is the CT system and the Advantage Windows. The GE PACS does not interpret private GE fields any better than it interprets competitors private data.

Issue #2:
"Why do the MRs on the GE scanner look so much better on the MR console than they do the Agfa PACS?"
In general I would expect a PACS viewer (which is designed specifically for displaying images) to have a better display then the MR scanner. I suspect that there is a calibration difference between the Agfa PACS monitor and the GE MR system monitor. I would suggest you take a representative image on the MR and set its window & level to optimum display on the scanner. Record the WW/WL values. Then send the image to the PACS and re-adjust for optimum viewing on that display station. Record the WW/WL values again. What are the differences? When adjusted for optimum display on each station, is the MR monitors image still better?

Well, the answer to Issue #1 is pretty clear, and makes sense to GE, I'm sure. It's easier to stick to an old standard and the software band-aides that have evolved over the years to deal with the limitations of the OLD standard, than to migrate to the new standard that would handle the problem. Maybe. I'm encouraged to know that Centricity wouldn't deal with this any better than any other PACS. Actually, I'm pretty discouraged. The implication is that the internal standards are available to the PACS vendors via the DICOM statement, and they should feel free to rewrite their viewing software to accommodate this, um, individuality of GE's private tags. I guess the PACS vendors could take a Microsoft Windows Plug-and-Play approach, gathering all parameters on all possible scanners to create a brute-force, comprehensive compilation that would let their PACS read all private tags of all vendors. Sounds pretty daunting to me. Why not just create a standard that all scanners could follow? Wait, we already have one.....

As for monitor calibration, I'm not buying that one. Why would the images from various CR's, sonograms, scintigrams, R&F rooms look OK, and the MR's not? I'm guessing that we are to adjust some sort of mapping of window and level settings between the scanner and the PACS, but that sounds sort of kludgy to me. Maybe DR's Catapult system is the answer here, wherein the technologist has to adjust the image within PACS for optimum viewing before sending it on to the docs. But frankly, this still sounds like finger-pointing, when the real problem is those pesky private tags.

It's still time for a private little war on Private Tags.

At Least He Has His Priorities Straight!

eBay seller clydekat is trying to sell off his 10,000 sets of Star Trek Lenticular Motion Cards. This amounts to about 40,000 of these trading cards. He is asking what is, I suppose, a reasonable price of $11,999.99. But, there appears to be a problem, or maybe an added bonus....If you examine the ad very closely, you will see in the subtitle, "MUST SELL WIFE"! He doesn't specify how much shipping is on the wife, though.

The real story is that "The wife is making me clear out the extra room for the baby, imagine that!" After this, I have a feeling clydekat will be cleared out himself.

Be careful how you word your eBay listings!

Centricity and Linux (and IntegradWeb)

Our Centricity site has been waiting to upgrade from version 2.x to 3.x for a while. We had an intermediate upgrade recently, but we're still in the 2.x's. The PACS administrator was just informed that (surprize!) the jump to 3.x will require new hardware, because the new back-end uses Linux.

This isn't a total shock, really, given the fact that GE uses Linux in other products, such as the Advantage Workstation (the beloved AW), as well as within the consoles of several scanners. Not only is Linux cheaper than Windows (they use the Red Hat flavor), but it is more robust as well. It is reasonable for them to do some back end migration to this platform, especially since at one time or another, there has been everything from Sun Unix to Mac OS bundled in there somewhere.

Ah, but here is the problem we face. At this point, we don't know how much this hardware upgrade is going to cost. AND, we aren't really all that sure how long the Centricity product will continue, given the recent acquisition of Dynamic Imaging and the incorporation of its IntegradWeb program. At some point, depending upon how much hardware (and software for that matter) the upgrade will require, the balance sheet tips in the favor of simply replacing the old Centricity 2.x with the new IntegradWeb. I'm hoping that migration of several years of data from on to the other won't be a big problem. If it is, there really might not be a reason to upgrade at all, except to keep the whiney radiologists happy. And eventually, there might not be a reason to migrate within the GE family altogether.

Anybody out there know any details about these upgrades and migrations? I suppose GE will tell us sooner or later.....

Is Speech Recognition a Kickback? Maybe....

In a post from last year, I asked this question on behalf of a reader. When posted on AuntMinnie.com as well, there was nothing but laughter. To repeat the original query,

Do you know if anyone has ever tried to construe the adoption of voice recognition technology as a kickback to the hospital in violation of federal antikickback statutes? It would seem to me that transcription services are traditionally provided for free by the hospital to hospital-based physicians (except of course the cardiologists and administrators don’t have to use it!) and that the cost of transcription is covered by the technical fee collected by the hospital. In essence we are providing free services to the hospital in return for a hospital contract. I wonder what the lawyers would say.

Well, writing in the current JACR, Richard Duszak Jr., M.D., restates the question, and comes to some disturbing conclusions. At best, this is a gray area, and at worst, it is indeed a kickback, subject to some rather strong penalties.

According to CMS,

“[N]o one involved with the processes of developing either the radiologist or physician fee schedule made a decision that would have specifically placed transcription costs in the [professional component payment]” [4]. And, even more definitively, “there is no question that costs incurred by the hospital for the transcription of interpretations are allowable operating costs for the purposes of intermediary payments” [5]. When hospitals are paid by Medicare intermediaries for the technical part of imaging services, historical documents indicate that they are unequivocally being paid for the costs of associated transcription services.

Keep in mind that

The federal antikickback statute makes it illegal to solicit, receive, offer, or pay any remuneration for referring a service for which payment is made by a federal health care program.

Because hospitals are reimbursed by Medicare for transcription expenses as part of their normal technical charges, they potentially run afoul of the antikickback law if they “double dip” and collect those same transcription costs from their radiologists, who necessarily receive referrals of Medicare patients from those hospitals. In such a scenario, the amount charged to radiologists for transcription costs could not possibly represent fair market value, because those transcription services are already being reimbursed by Medicare.

Now, enter Speech (OK, Voice) Recognition:

Depending on the specific circumstances of implementation, VR technology also creates antikickback concerns with regard to radiologists’ making in-kind payments to hospitals for transcription services. Even advocates of VR technology acknowledge that “it transfers a task to radiologists that previously was performed by transcriptionists” [11]: work for which Medicare is already paying the hospital. That transfer of “secretarial duties” comes at the very real cost of increased work time to radiologists [12].

If . . . radiologists are forced by a hospital, as a condition of maintaining their professional services contracts (and hence continuing Medicare referrals), to assume all the secretarial duties of now laid off hospital transcriptionists, jeopardy more likely exists.

This is called double-dipping, and it is a big no-no. So, keep this all in mind if you feel forced to accept SR in your practice.

I Miss Ronnie

I rarely dabble in politics here on the blog, although I might get into a fight or two on AuntMinnie.com's "Off Topic" forum. However, a friend forwarded me these quotes from the late President Ronald Reagan, and I have to share them with you. They are all-too pertinent in today's political quagmire, and they speak for themselves, requiring no interpretation from me.

"Here's my strategy on the Cold War: We win, they lose."

"The most terrifying words in the English language are: I'm from the government and I'm here to help."

"The trouble with our liberal friends is not that they're ignorant; it's just that they know so much that isn't so."

"Of the four wars in my lifetime, none came about because the U.S. was too strong."

"I have wondered at times about what the Ten Commandments would have looked like if Moses had run them through the U.S. Congress."

"The taxpayer: That's someone who works for the federal government but doesn't have to take the civil service examination."

"Government is like a baby: An alimentary canal with a big appetite at one end and no sense of responsibility at the other."

"The nearest thing to eternal life we will ever see on this earth is a government program."

"I've laid down the law, though, to everyone from now on about anything that happens: no matter what time it is, wake me, even if it's in the middle of a Cabinet meeting."

"It has been said that politics is the second oldest profession. I have learned that it bears a striking resemblance to the first."

"Government's view of the economy could be summed up in a few short phrases: If it moves, tax it. If it keeps moving, regulate it. And if it stops moving, subsidize it."

"Politics is not a bad profession. If you succeed, there are many rewards; if you disgrace yourself, you can always write a book."

"No arsenal, or no weapon in the arsenals of the world, is as formidable as the will and moral courage of free men and women."

"If we ever forget that we're one nation under God, then we will be a nation gone under."

1000 X-rays

I have got to get a Wii!

AuntMinnie.com reviewed a study published in the Annals of Emergency Medicine which I find rather disturbing. It seems that if you are so unfortunate as to experience trauma and fortunate enough to make it to a trauma center alive, you will be the likely recipient of a "pan-scan" of the head, neck, chest, abdomen, and pelvis. At our local trauma center, we call it a "man-scan" with no offense to the ladies, and it generally includes a scan or two of the extremities as well as regular old radiographs of all areas in question. There is a lot to be said for this approach, as the victim of polytrauma will most certainly have multiple injuries, and CT is very good at ferreting them out. The man-scans can be very tedious to read: "There are minimally displaced fractures of the 3rd, 4th, 7th, 9th,10th, and 12th ribs on the right and......"

But use of this powerful tool has its price, and that is in terms of radiation, as well as the final bill. it seems that the average trauma patient is exposed to radiation equivalent to 1,005 chest x-rays, which is enough to raise the individual's risk of developing a malignancy later in life. While the average person in the US receives a dose of about 3 millisieverts (mSv) from environmental sources (radon, cosmic rays, friends with glowing personalities, etc.), the star of the trauma imaging show receives an average dose of 40 mSv, and gets it all at once.

What to do? The study's author suggests:

Possible options for reducing radiation exposure may include ordering fewer repeated imaging studies, using lower dose radiological imaging techniques and using alternative imaging methods that do not use radiation, such as ultrasound and magnetic resonance imaging.

I think that there also has to be a little cerebral activity injected into the decision process. It is all too easy to order a shotgun battery of tests as a knee-jerk response to a trauma situation, without completely evaluating if some components are necessary. I realize that I'm not on the front line here, so to speak, and the folks that order the tests are. Still, I think they have to be made aware of the fact that the "man-scan" might not be quite as benign as we would like to think.

The ACVR

In my travels, I have run into a few lucky folks who have discovered long-lost relatives. This has never actually happened to me, but today I did have a somewhat similar experience. In looking for something else, I stumbled across the existence of the American College of Veterinary Radiology, the ACVR. Here we have an entire parallel universe, a completely new set of radiologists that work with other species! Truly our professional cousins.

There turns out to be a lot that I didn't know about this. There are dozens of veterinary residency programs, a three year program, and there is a written and an oral board for certification. Most important of all, there is even a Society of Veterinary Nuclear Medicine, but one has to have a password to get into their site.

Having once performed a bone-scan on a tree kangaroo, and an upper GI on a large bird, both from our local zoo, I feel definate kinship with this new-found branch of the radiology tree. I wonder if there is any reciprocal agreement for crossing over from one to the other....

The First PET/CT Workstation Shootout: Beam Me Up, Scotty! No Intelligent Life Here!

I've just returned from Las Vegas, having attended the Stanford University 2008 PET/CT Symposium. In my old age, I've decided that a good meeting teaches you some new things, but by and large reassures you that what you were already doing in day to day practice isn't too far below standard. This was a good meeting. There were numerous lectures by the luminaries of PET, as well as several case interpretation sessions, and what was (for me) the piece de resistance, the first-ever shootout between PET/CT workstations.

Of course, the second-most important part of the visit was a pilgrimage to the Star Trek Experience at the Las Vegas Hilton, which includes the Museum of the Future. The latter has changed a little, with the addition of props from the newest series, Enterprise, such as Captain Archer's uniform, communicators, and various other toys. My favorites, though, are still Dr. McCoy's medical kit and the tricorder patched into a network of vacuum tubes from the Original Series episode, "City on the Edge of Forever." The rides of the Experience have not changed at all, although I am sorry to report that the sound and video of Commander Riker on the Enterprise-D viewscreen in the Klingon Encounter have lost their synchronization. I took the "backstage" tour, and got to see how all of this works. We were all sworn to secrecy, but I can tell you that the riders don't actually go into space or the future. Darn.

There were a couple of photo ops that came with the tour package, so I took my turn in the command chair of the Enterprise-D. Sadly, the weapons were off-line, or some folks out there would be in real trouble.

The Borg are hanging around the Experience as well, and if you aren't careful, you might get assimilated, as I almost did:

Hmmmmmm...notice the green overtones. Could the BorG Eventually conquer Earth after all? Resistance is futile....

I also had the chance to see the comedian Carrot Top live at the Luxor. I caught his act here in the South at our State Fair, and he is absolutely hilarious. In Las Vegas, however, he can really let loose, and I haven't laughed so much in quite a while.

But on to the Shootout. This was a contest pitting four scanner manufacturers' workstations against each other. There were two players from GE, the Xeleris 2 Volumetrix, and the Advantage Windows Body Share 2. Siemens submitted the Syngo TrueD, and Philips brought its Brilliance platform. All were run by physicians experienced in their use, with the screens projected for the audience to see. All used dual-screens, although the Philips folks couldn't get the second monitor to project onto the overhead.

The audience was allowed to score each station's performance for three cases on the following criteria: ergonomics, speed, and display format, as well as an overall score. Sadly, these ratings were not collected, although the course director, Dr. Quon, told me that there might be an opportunity to enter them online at a later time. But perhaps more importantly, developers for GE and Siemens (I'm not sure about Philips) were present to see how their offspring fared (and perhaps to get a glimpse of the other guy's program.) I hope they paid close attention.

Each workstation was put through its paces with everyone watching. Here is a the script for one of the cases:

1. Open the PET/CT dated 5/2/07 and display all of the following simultaneously (or show as many as possible):

a. Coronal PET, PET/CT fusion, and CT

b. Transaxial PET, PET/CT fusion, and CT

c. Sagittal PET, PET/CT fusion, and CT

d. MIP PET

2. Threshold the MIP PET image appropriately.

3. Rotate the MIP image.

4. In the transaxial slices, start from the thymus and scroll inferiorly until reaching the stomach region.

5. Select and triangulate on the two lesions in the region of the fundus.

6. Enlarge the transaxial PET, PET/CT fusion, and CT images, and measure the maximum SUV of both lesions.

7. Window the PET/CT fusion image: go from all PET to all CT to demonstrate the presence of hypermetabolic gastric masses.

8. Scroll to the subtle focus in the periphery of the liver and measure the maximum SUV.

9. Window the CT image in an attempt to correlate the lesion.

10. Open the comparison PET/CT dated 9/5/07.

11. Select and triangulate on the lesion in the liver and display the focus on transaxial PET and PET/CT fusion.

12. Display the PET/CT from 5/2/07 and 9/5/07 simultaneously to compare the liver lesion side by side.

13. Window the 9/5/07 PET/CT fusion image to demonstrate the anatomical location of the liver focus.

14. Measure the maximum SUV of the liver focus on the 9/5/07 PET.

15. Window the 9/5/07 CT to best display the subtle liver lesion.

16. Scroll to the gastric lesions, window the CT and PET/CT fusion, and identify the site of the gastric lesions. Measure and compare the maximum SUV to the prior scan.

17. Display DICOM information and demographics.

This more or less simulates how one might approach a real case. It would be very tedious to describe the events in detail, and the winner is in the eye of the beholder. Each station had its pluses and minuses, and given the subjective nature of the criteria, I'll bet a $100 chip that everyone in the audience came away thinking that a different product was the winner. Frankly, I thought that all of the products were quite fast, although the Xeleris appeared to choke while loading the second and third cases. The AW and the Syngo TrueD both ran significantly faster than the versions I use. (I guess it's time to hit up the powers that be for some upgrades!) As far as Ergonomics and Display go, this is almost purely a subjective choice. I thought the TrueD was the winner overall, followed closely by the Philips Brilliance. The GE (fraternal) twins were powerful, but I don't think their controls are particularly intuitive. The other two were a little better on this. Creating a custom display by yourself was said to be easy on the Brilliance (although it wasn't demonstrated). I know that doing this on the AW is difficult, and it is pretty much impossible on the older Siemens eSoft. I don't know about the TrueD's capabilities here. I haven't a clue about the Xeleris.

The sad fact to me is that none of these stations are as easy to use as they should be. Of the four, I would prefer the Siemens TrueD, acknowledging the fact that it has some esoteric controls that one must master. But somebody needs to do better.

Dr. Quon does plan to include some of the other non-scanner vendors in next year's shootout, such as MIM, TeraRecon, Voxar, and so on. You have to ask why few, if any, customers buy, say, a TrueD for a Philips scanner, or an AW for a Siemens scanner. One usually just takes what comes with. But I think the best option for PET/CT viewing might well come from the PACS vendors. At RSNA, I saw some preliminary versions of PET/CT reading modules from Intelerad, Agfa, Dynamic Imaging (GE!), and Amicas. I know ScImage has one as well, and I'm sure there are others. From my brief peek, I think that at least some of these could do the same tasks as outlined in the shootout script, and do them in a more intuitive and rapid manner than we are seeing with the high-horsepower stations.

Eventually, there will probably be some narrowing of the spectrum between the PACS workstation and the high-level imaging workstation such as those above, with thin-clients filling in the gaps. But PET/CT doesn't really require quite the level of processing we see in some 3D renderings of the beating heart, and I suspect we will see more and more PACS programs that can handle it readily, and as well (or better) than the big ol' workstation.

In the meantime, Live Long and Prosper! (Which is difficult to do in Las Vegas for more than a few days).

How Do You Like My Bodacious Tatas?

I guess nothing is sacred anymore. I have despised Ford Motor Company ever since it made the decision not to recall the exploding Pintos because it was cheaper to pay awards in wrongful-death lawsuits. I was very disappointed to see the results of Ford's buying spree of luxury nameplates; Ford presently owns Jaguar, Land Rover, and Volvo. But now, Ford will sell the first two to India's Tata Group, although this will be more of a partnership than a complete sale.

Tata is probably going to be the world's largest car manufacturer. It is actually a very large operation:

The Tata Group is one of India's oldest, largest and most respected business conglomerates. The Group's businesses are spread over seven business sectors. It comprises 98 companies and operates in six continents. It employs some 2,89,500 people and collectively has a shareholder base of over 2.9 million and market capitalisation of $66.9 billion as on February 21, 2008.

While the British (automotive) Crown Jewels are certainly a nice acquisition, Tata's greatest achievement is probably going to be the introduction of the Nano, a US$2500 "people's car":

There is a much larger draw for a US$2,500 mini-car than a US$75,000 luxury SUV. Nothing like covering both ends of the market.

I'm still stuck on Japanese quality, having been very pleased with my Lexuses and Toyotas for the past 20+ years. It will be interesting to see what Tata does with its new toys. So, if anyone out there wants to keep us updated on this topic, please feel free to send in photos of your bodacious Tatas. Thank you.

Stacks of Tiles

I like some degree of flexibility in my PACS display, but I like it simple. This has been a very difficult concept to convey to Agfa in the process of my occasionally-welcome attempts to help with Impax 6.x development. (I do have to tell you that Impax has been behaving quite a bit better these days, with crashes occuring only very rarely.) I have had a really hard time convincing them that any series should be deployable in any viewport. In other words, if I want to put the same CT series on the screen in 10 places, that should be possible. This idea just hasn't yet penetrated. The only way to do anything like this now is to create a "clone window", which can be set up to display multiple instances of the same series. However, I cannot link a "regular" series to one in the clone window, and there are some glitches in the implementation of window and level adjustments, rendering the clones limited at best.

Why is this important to me? An article that I rediscovered recently from the American Journal of Roentgenology by Drs. Kim and Lee, et. al., gives one possible answer. These radiologists from the Department of Radiology of Seoul National University looked at scans of hepatocellular carcinoma in two different modes. First, they used the old "tile" mode, showing a dozen slices from the scan on screen at once. Frankly, nobody does it this way anymore. Secondly, they used "multisynchronized stack" mode to view the multiphasic dynamic CT. While they didn't include any pictures in the article, I'm assuming the stack display looked something like this:

The key here is that you have multiple phases (with different series) of the same study, synchronized to the same level. A dynamic study of this type means that the patient was scanned as IV contrast was injected, and then at several fixed delay times thereafter. Thus, if the reader does stumble upon a lesion, he/she can see how the contrast material enters and exits the lesion, which yields a better depiction of the contents of the mass. With this display, you have all phases of the study up at the same time, and synchronization allows you to scroll through the study and view the lesion on all of the phases at once. This is much easier than trying to view "tiles" of all the series, and even better than viewing one stacked series at a time.

The flexible display lends itself to other approaches. I like to view abdominal and chest studies in this 4-up configuration with soft-tissue, bone, and lung windows, as well as the scout, all on-screen at once.

I do the same thing with head CT's, adding in a "blood" and a very narrow windowed viewport to aid in detecting subtle CVA's.

I guess the point of all this is that every rad reads just a little bit differently (although no one uses tile-mode much anymore). For my 30 rads, I need something that will adapt to our various ways of doing things. Many, if not most, other systems have the any-series-any-viewport approach these days. Most can actually handle the linked scrolling of the images, although our older installation of Centricity slows down markedly when windows are linked. Agfa still has its own version...send in the clone windows! Maybe we'll see the "any viewport" thing in Impax 7.x?

A New Cellphone Accessory

Now here's a good idea... I should probably patent this, as I came up with it all by myself, but since a search revealed that others have mentioned it (but not actually patented it or manufactured it), I won't bother. I'd just like to see someone actually make this thing.

We've all seen folks wandering around with Bluetooth headsets jammed in their ears, seemingly talking into space. I own one myself, but rarely use it because I can't stand to have something on my ear for more than a few minutes at a time.

But for those so inclined, I have invented (via paste-up, anyway) the Bluetooth headset/camera. Just what everyone needs! Note the camera lens grafted onto the headset's anterior tip. The concept here is that the camera points in the direction of your head (OK, not necessarily your gaze, but...) and lets you photograph or video whatever you are looking at. I think the bandwidth of Bluetooth is sufficient to handle this application, and otherwise it should work like any other cell-phone camera. Yes, it would add bulk to the headset, and drain the battery faster, but that's minor compared to the incredible convenience this will offer.

Do I have any takers?

Promiscous Blogs Contribute To Science!

When you think about it, this blog, and blogging in general, represents something totally revolutionary in the history of information. I can sit here in front of my computer, post some occasionally-good ideas, and publish them to the world. Literally! I have had hits from all over the globe, from Russia, China, Vietnam, Israel, Dubai, and many others. (For some reason, the plurality of overseas hits seem to come from Belgium and Canada.) The power of the individual to reach anyone else in the world has never been so great.

But a blog is not a static, isolated thing. It changes (when the blogger gets around to it), other people leave comments, and perhaps most importantly, other blogs or websites can be linked to mine. This is a property unique to the internet, allowing instant access to the thoughts of others within the body of your own writings.

Allison McCook, writing on the blog portion of the magazine The Scientist, quotes writer Clive Thompson as calling blogging "highly promiscuous" for this reason.

It's a basic concept. Thompson -- a surprisingly dapper (for a writer), well-coiffed, quick-talking presenter -- explained that he constantly feeds his blog, collisiondetection.net, because blogging is "highly promiscuous" -- meaning, you blog and link to another blog, then that person links to you in a future post, and so on. You find out who's linked to you (technorati.com ), check them out, and see other blogs by like-minded people, who might think about something you'd never considered before.

This leads to the concept of "crowdsourcing", "The idea is to use the internet to get large numbers of people to help with a task. They may do it for money — usually not much — or out of interest or simply because it's fun."

So, let's put this into practice. I get something upwards of 200 hits on this site per day. Not a lot, but still an amazing number to me. But only rarely, perhaps three or four times per week, will someone comment back, either by e-mail or through the comment field on the blog itself. So, I ask you to do your part for science. Post comments. Link to my blog. Ask questions. Help my blog become more promiscuous. Bet that got your attention!

SpaceNavigator...a tool for SpaceCadets and maybe PACS?

I can find inspiration anywhere, it seems. This morning I was perusing the Buy.com website, looking for bargains, when I stumbled upon this entry:

Is working in 3D frustrating? Feel like you can't get the model in the right orientation or move the world to the right location? If only you could put your hand straight into the display and directly interact with your 3D design. 3Dconnexion SpaceNavigator lets you come as close to that experience as you can get without actually putting your hand in the display. Push, pull, tilt or twist the SpaceNavigator's controller cap to interact with your 3D world or model with ease. SpaceNavigator PE supports over 100 popular 3D apps including Google Earth, Microsoft Virtual Earth, SolidWorks, Autodesk Inventor and lots more. Work in 3D as it was meant to be. SpaceNavigator PE is meant for non-commercial use and includes web based support.

Well, most of us do find working with 3D frustrating, as a regular ol' mouse is geared for 2D control. There are various kludges that give us the third dimension, but in general, they aren't very intuitive. You may remember my attempts to make a jog-shuttle device, the ShuttlePro2, work with the Amicas/Voxar 3D software. I really couldn't get it going properly. But keep in mind, Darth Vader's Codpiece was designed mainly for flipping video frames. It does work well for MPR viewing, but not so great for volume rendered images. It just doesn't have a control for the third dimension!

The SpaceNavigator does have a Z-axis control, solving this deficiency:

Pressure sensing technology allows the controller cap to become a virtual extension of you. Push, pull, twist or tilt the cap a fraction of inch to simultaneously pan, zoom and rotate 3D imagery. Increase pressure to go fast or decrease pressure to make intricate adjustments. . . The key advantage of a SpaceNavigator over a mouse and keyboard is the ease of performing intricate adjustments to camera views and models with out repeatedly stopping to change directions, zoom, or rotate models. With a SpaceNavigator you can do all three at once.

Click here for a video of the device in operation.

I guess we've gone from Darth Vader's codpiece to an excised BMW iDrive.

The SpaceNavigator is made by 3DConnexion, a division of Logitech. It lists for $59.99, but Buy.com sells it for $39.99. Having spent more than this on the jog-shuttle, I'm a little hesitant to invest more. But this one is pretty tempting...

eRad PACS

Mark Twain once received a telegram from his publisher stating:

NEED TWO-PAGE SHORT STORY TWO DAYS.

Twain responded,

NO CAN DO TWO PAGES TWO DAYS. CAN DO THIRTY PAGES TWO DAYS. NEED THIRTY DAYS TO DO TWO PAGES.

In the same vein, Dorothy Parker, an American poet and writer once said to then-Vice President Calvin Coolidge, "Mr. Coolidge, I've made a bet against a fellow who said it was impossible to get more than two words out of you." His famous reply: "You lose." (Ms. Parker stated upon learning of Coolidge's death many years later, "How can they tell?")

Those of you who have followed my attempts at writing over the years know that I am far from the Calvin Coolidge of blogging; I can yammer on and on for pages, and sometimes not say very much in the process. However, when it comes to PACS, I think Mr. Coolidge would have agreed with my minimalist philosophy, probably best outlined in my old post, Feature Fatigue and Lego PACS. There is such a thing as too many words, too many adjustments, and too many features, even if they are all relevant, useful, and powerful. And to pervert the spirit of Mark Twain somewhat, it is far more difficult to produce something with fewer features than a product with lots of them.

The folks from eRad gave me the keys to a web-demo, and then made the trip down to my average little town in the South from their average little town in the South to do a proper demonstration. In spite of my long lead-up, this is a powerful program with a bright future. However, you can guess where we're going with this in the end.

eRad's mission statement unifies one's view of their approach:

The Mission of eRad® is to unify diagnostic imaging processes and operations by:

• Applying unique technology which will present patient images, diagnostic reports and medical records to Physicians, Technologists and Clinicians from a single unified data base.
• Delivering images and information both error free and with high availability across a unified infrastructure.
• Enhancing patient care and reducing costs through improved immediate and long-term access to unified imaging information.
• Improving productivity through unified workflow.
• Delivering high value, scalable, cost effective unified diagnostic imaging solutions.

We invite you to look carefully at our product, its features and functions. This web site presents much of what a prospective user or institution may need to understand our solutions. In addition to a detailed description of the eRAD PACS® product line, you will find descriptions of the hardware components we use, demonstrations of our product, profiles of our staff and much, much more.

We recognize that a web site is no substitute for an informed account executive or service representative and invite you to contact us at any time by telephone or e-mail to open a dialog with eRAD. We are eager to assist you and look forward to the opportunity to do so.

Actually, these are lofty, admirable, and ultimately achievable goals. This is certainly in stark contrast to some companies out there with a mission statement of "Sure it works, sort of..."

One thing eRad can unify is an enterprise, or even a collection of disparate PACS systems. Uniting a (mostly) homogeneous enterprise shouldn't be that hard, but it certainly can be. eRad's approach. . .

is similar to most, with a server at each site feeding into the central server. Others call the peripheral computers spoke servers, and the effect is the same. At least they don't call for a separate computer for each scanner, like some systems are wont to do.

Trying to tie several different PACS together is a larger pain in the neck (or lower), but eRad has a better plan for this than most:

This is the sort of thing the VA has done with ScImage. Basically, it involves grafting their system over "legacy PACS" such as GE, Siemens, Sectra, and Agfa. This would really come in handy in an environment such as ours where our nighttime readers have to contend with two worklists from our Agfa system (even though it's one PACS, the two hospital worklists resident cannot be, well, united), one unified list from the Amicas dual hospital system, and others coming in on the group-owned Amicas. One single worklist would be a lifesaver. Of course, we would then have to come up with a way for the dictations to be routed to their proper site and so on. I'm not sure that one has been solved as yet. Still, the fact that eRad recognizes the need for such an umbrella is certainly important.

For me as a radiologist, the business-end of a PACS is its user interface. The web-demo as well as the live session gave me a good glimpse into eRad's GUI. I'm not going to do the features justice, but I'll try to give you a feel of what we have. Keep in mind that there are a lot of nice features. A LOT of them. Here is a screen-capture of their worklist:

and here is a snapshot of their viewer:

Clicking on the pictures above will expand them, and this is necessary to see what I'm going to talk about.

The worklist is customizable, and sortable on any column head. There is an indicator as to whether a study is locked, and there are various controls for batch reading, demographic editing, and for creating custom filters. ANY part of the DICOM header can be made a part of the worklist and subsequently a filter or search:

If one paid for PACS by the number of GUI features, eRad would be very expensive indeed. Here are just the extra modules that can be added when you first download the program:

These add some significant higher-level visualization to the package. Look at the viewer itself. The first thing that strikes me is the sheer number of buttons. The layout can be changed, by dragging the bars as you might with Microsoft Word. There are separate buttons for the major permutations of image and series layout. Most everyone else does this with popup menus and only one or two buttons. Many of the remaining functions have separate buttons as well. Notice that the buttons take up a lot of real estate that might otherwise go to the image viewports themselves.

There are good implementations of triangulation, linking, etc., and the ever-important mark-as-read-go-to-the-next-study button. When you click said button, there are various options as to how to leave the study status, or this can be determined from preset instruction. Window and level can be set from presets, slider controls, or the usual up/down/left/right drag. The series tray has a little indicator that tells if you have viewed all images. You don't want to miss the lesion on the last slice, now do you? There are separate buttons to reset image info, window/level, zoom, etc. There is a very nice report view that allows importing of key images. There is a pretty good spine-labelling module.

When going through the demo, I hinted at my discomfort with the multiple buttons and controls. My friends from eRad reassured me that there is a default configuration supplied out of the box that will get most rads up and running. But if you want to get in and change things, there is a way to do that. Oh, boy, is there a way to do that... Here are just a few of the 14 tabbed control panels for customization:

Oh, and the right-click menu brings up something like this:

This is where I have to say, "Whoa!" There is really a tremendous amount of power here, and in some respects, there is too much power. I have called this approach to a GUI the "Lego PACS", because of the high level of customization. As I've said before, this is to some degree a term of endearment, as Lego was my absolute favorite toy as a child, and it is still hard to resist when I go past a toy store or especially the Lego Store at the Mall of America. But I still prefer a simple, clean streamlined interface. Yes, the eRad default might give me that, but then there is the temptation that is hard to resist to go in and "tweak". OK, that's personal problem, and not eRad's fault, but still. . .

This is a program with great potential, one to watch closely. I think personally that the GUI needs a little smoothing and seasoning, but it is certainly usable. eRad has addressed a number of issues that are close to my heart, and some that the "big boys" haven't even solved as yet. I will expect to see great things from them in the future. In the meantime, if you ask me to say three words about eRad, I would say, "Pretty good."

Microsoft Enters PACS Game

Microsoft has been dabbling in the Healthcare IT space, and the fruits of their labor (and acquisitions) will debut at HIMSS later this month. The press release notes" The package is called Amalga, which to me is all too close to the word "amalgam," the mercury-containing metal that used to be used in dental fillings.

Microsoft Amalga: The new version of the product formerly known as Azyxxi, Amalga is part of a new software category called Unified Intelligence Systems that allows hospital enterprises to unlock the power of all their data sitting in isolated clinical, financial and administrative systems. Without replacing current systems, it offers an innovative way to capture, consolidate, store, access and quickly present data in meaningful ways for use by clinicians and executives of leading-edge institutions. Amalga is designed for hospitals and health systems that have invested in a diverse set of IT solutions.

Microsoft Amalga Hospital Information System (HIS): The new version of the product previously named Hospital 2000, Amalga HIS is a state-of-the-art, fully integrated hospital information system designed for developing and emerging markets. Amalga HIS is built around an electronic medical record (EMR) with complete patient and bed management, laboratory, pharmacy, radiology information system and picture archiving and communication system (RIS/PACS), pathology, financial accounting, materials management, and human resource systems.

Microsoft Amalga RIS/PACS: The new version of the product formerly known as GCS Amalga is now available as a stand-alone system as well as an integrated component of Amalga HIS. The integrated architecture means that a radiologist can use a single application to manipulate and study images and access the patient medical record. The workstation interface is optimized for radiologist workflow, including support for predefined templates, an intuitive report editor and voice recognition capabilities.

Of course, I'm more interested in the PACS product. The Microsoft Amalga website emphasizes the interconnectivity of the Amalga software:

Most companies don’t integrate their PACS and RIS software, translating into a forced fit between the systems. This often imposes the manual matching of studies between the PACS and RIS.

The Integration of Microsoft Amalga RIS/PACS provides a powerful, truly seamless system that can deliver quick, high-quality data to any department, which, in turn, can help hospitals increase patient turnaround time and enhance the patient experience. Integration also improves data integrity between PACS and RIS, can reduce transcription errors and duplication of data entry, and optimizes report turnaround. The system fully supports paperless, integrated workflows and facilitates easy access to patient medical information and order, scheduling, and study information.

The radiologist workstation is designed to optimize radiologist workflow. This unified system provides access not only to standard image manipulation tools, but also to the patient Electronic Medical Record (EMR), without requiring the radiologist to log on to external systems. Available information includes all previous laboratory and radiology results, the patient’s medication profile, and clinical notes. In addition, all historical studies are stored online rather than archived, which means historical films can be reviewed anytime, as needed, helping providers to improve their patient care.

The "key benefits" are mostly what you would expect:

• Automatic order management integrated from EMR and RIS.
• Automatic scanning and attachment of hard copies to study orders.
• Image manipulation tools include 3-D cursor location.
  Multiple language support provides patient demographic and screen label data in any Unicode language.
• Integrated database ensures patient medical information is accessible directly from the PACS.
• Template-driven options include reporting and voice recognition.
• Intuitive Report Editor accepts written or dictated reporting.
• Preference for radiologist worklist studies are customizable.
• Instant Study assignment to radiologist at time of ordering.
• Warning system provides real-time notifications to prevent radiologists from reporting a study that is being reported by another radiologist.
• Online Historical studies make historical studies available for quick retrieval, regardless of study age.
• Unlimited Study revisions save any or all key images, window-level settings, and image annotations.
• CD creation for PACS studies, Reports, and Electronic Medical Record. Options include DICOM and JPEG images, reports, and all or selected portions of a patient's EMR.

Frankly, this doesn't sound that much different than most modern web-based systems, at least those with online priors.

Microsoft, like some other big companies that come to mind, sometimes innovates and creates its own product, but often will simply buy the expertise and the software lock, stock and barrel. Such is the case here. Amalga started life as Azyxxi, which according to the Wikipedia, was "is a unified health enterprise platform designed to retrieve and display patient information from many sources, including scanned documents, electrocardiograms, X-rays, MRI scans and other medical imaging procedures, lab results, dictated reports of surgery, as well as patient demographics and contact information. It was developed by doctors and researchers at the Washington Hospital Center emergency department in 1996, and in 2006 it was acquired by the Microsoft Health Solutions Group, as part of a plan to enter the fast-growing market for health care information technology." Washington Hospital is part of the MedStar Health system.

As for the RIS/PACS module, this has been borrowed/purchased/liberated (and expanded) from

GC RRITS SDN BHD (GCR), is a Malaysian Company, which provide integrated information technology solutions to the healthcare industry. The business is built around its core product, Hospital 2000, was developed and will continue to develop locally, based upon a proven international standards.

The RIS/PACS module of Hospital 2000 is called....drum roll, please..... Amalga! Here is a link to the full brochure, and here are some screenshots:

Interesting look. No doubt Microsoft will add its own touch to the interface. But how well does it work? How will it be marketed? I guess we'll have to wait and see. Anyone want to send in a report from HIMSS?

Addendum:

Based on Aunt Minnie discussions, the RIS/PACS and other parts of the program may have been written by Global Care Solutions from Bangkok in cooperation with Bumrungrad Hospital. GCR may therefore be GCS's Malaysian reseller. However, in the statement above, which is no longer on the GCR website, they refer to local development, and local for a Malaysian company probably means Malaysia rather than Thailand.

The GCS website (http://www.hospital2000.com) now resolves to the Microsoft Amalga website.

In the end, it probably doesn't matter to anyone. Microsoft needed software in this space and found a reasonably good, and presumably reasonably priced product. Let's hope they learn the lesson from GE and avoid running it into the ground.

Letters Of Warning

The fellow that wants to sell us a Hawkeye so bad he can taste it sent out a press release the other day to just about everyone in my state that has anything to do with Nuclear Medicine. Except for me, of course. I've since seen the same release at a dozen other sites, including AuntMinnie, and it's probably common knowledge by now. No doubt its viral spread has been assisted just a little bit, so I'm not reporting anything new here. Within the press release is a link to the FDA that shows a copy of a letter to Siemens noting a software problem with PET/CT's installed prior to July, 2006. I won't quote the whole thing, but in essence there have been 4 complaints about the computer pulling the wrong PET to go with the wrong CT. Siemens fixed the problem, but didn't do proper risk analysis and according to the letter didn't actually issue a software patch. The letter goes on to say that Siemens has significant problems with their complaint process, and so on. The letter used the term "adulterated" which means that Siemens isn't completely conforming with with the "Current Good Manufacturing Practice (CGMP) requirements of the Quality System (QS) regulation found at Title 21, Code of Federal Regulations, Part 820 (21 CFR 820)." That means that they haven't addressed completely the concerns in the remainder of the letter.

Now, I won't tell you that this isn't serious, but we do have a Siemens PET/CT that was installed January, 2005, and we have not had the problem described. Frankly, it would be very obvious if the wrong PET image was trying to mate with the CT (get your minds out of the gutter!) as the activity in the various hypermetabolic organs would not match. We just haven't had this happen. (I found a reference to a SPECT/CT with a similar problem.)

The press release noted a second letter to Siemens within the past month (actually it was more accurately the prior two months) concerning their use of some marketing hype about the vascular software on some of the Siemens/Accuson ultrasound scanners, the Arterial Health Package, or AHP. It sees that Siemens didn't bother to obtrain marketing approval or clearance for the AHP, just the scanners themselves. So, selling the scanner with the AHP is illegal, and the scanners are "misbranded" and "adulterated".

And Siemens is working on fixing these problems ASAP. According to AuntMinnie:

A Siemens spokesperson said the company is working to comply with the requests in the letter.

"Siemens formally responded to the FDA to inform them of corrective actions to address the issues," said Tom Schaffner, Siemens Medical Solutions manager of media relations, in an e-mail to AuntMinnie.com. "Most of these actions have already occurred, and some necessary software updates are currently being tested that will be applied as soon as possible. With its warning letter, the FDA is now requesting detailed documentation of these corrective actions."

It is said that those who live in glass houses shouldn't throw stones, and that maxim is true here as well. It seems that my favorite larGE company has had some wrist-slaps as well. And in fact, they too received two letters, although these were just under nine months apart, much less embarassing than receiving them six weeks apart. I wonder why our caring salesperson has never sent us press releases about these particular letters of warning.

The letter from November 16, 2007, concerned a malfunction with an R&F room. Specifically, "(d)uring testing in both rooms on September 27, 2007, x-ray production was possible when the primary protective barrier was not in position to intercept the x-ray beam as required by 21 CFR 1020.32(a)." I could find no response as yet. At least the machine wasn't adulterated. The second letter of warning is from February 22, 2007, and had to do with a problem with MRI coils and breast biopsy plates. It seems that some of these were indeed "adulterated" in that they did not conform to the Current Good Manufacturing Practice, etc., etc. The biopsy plate sterilization process wasn't validated, although there was an adequate response to the FDA on this. There were coils shipped without verification and validation. There was identification of "soldering problems" as part of manufacturing errors, but inadequate documentation of how this was to be corrected. There was also an inadequate complaint mechanism.

No doubt these problems are fixed or being fixed as well.

Personally, I'm going to monitor the FDA website more closely. Press releases and word of mouth from the sales staff might not be adequate to inform us of the foibles of our vendors. But I'm sure glad that some are ready willing and able to keep us informed. . . about their competition, anyway.

Dalai Wins The American Spirit Award!

I received this fax today, and I got all excited. On the cover sheet, it was noted that "this fax and the attached documents are official documents of the Republican Party, and are confidential, and are intended solely for the individual named above." Which would be me!

The attached document said:

Dear Dalai:

I've just received word that based on your support of the Republican Party, you have been selected by the National Republican Senatorial Committee to receive the American Spirit Award. The American Spirit Award is a high honor -- the highest, in fact, that the NRSC can bestow upon an individual. This high honor has been endowed upon our nation's and our world's greatest defenders of liberty, economic freedom and military strength, including President Ronald Reagan and General Norman Schwarzkopf. I am thrilled that you have been selected and it is my sincerest hope that you will accept this honor....

Sincerely,

Senator John Ensign (Dalai's Note: (R) Nevada)

Chairman

National Republican Senatorial Committee

Now, that's what I'm talking about! I've finally been recognized for my selfless fight against certain large corporations, and blog-boredom. And I've voted Republican all my life.

But wait. There's a problem. Some quick Googling reveals something disturbing. Dozens of other folks reported receiving the same fax over the past several weeks and months. When they call in to claim their "award" they receive a high-pressure sales pitch to join up with NRSC at ever higher levels, for thousands of dollars, although for many, the price went down when they demurred. Sadly, this is nothing but a scam, designed to separate the mark from his money.

I don't know if Senator Ensign realizes that his name is being used in this manner, and I call upon the Senator to stop this low-class fund-raising tactic immediately. Who does he think he is, Hillary? I've actually e-mailed him with this request, but have yet to hear back.

Obviously, I'm not the only one to have this honor "endowed" upon him. There were several citations of the "award" being given to Democrats who never have voted Republican in their lives. The saddest story of all comes from Glasgow, Kentucky, where a poor fellow named David Thomas actually believed the hype, and so did his local paper, the Glasgow Daily Times:

Local wins mystery honor

Thomas still uncertain what American Spirit Award is

By BRAD DICKERSON Glasgow Daily Times

David Thomas was notified via fax that he was to receive a major award, yet it took some convincing before he accepted it as the truth.

The owner of Glasgow’s D&D Construction and Concrete received the correspondence last week from the office of Nevada Sen. John Ensign, chairman of the National Republican Senatorial Committee (NRSC), saying he was selected to receive the 2007 American Spirit Award.

Others who have been recognized with this honor were President Ronald Reagan, Prime Minister Margaret Thatcher and General Norman Schwarzkopf, the faxed notification stated.

“To be honest, I looked at one of my men and I said, ‘Somebody at work is really yanking my chain,’” Thomas said about his initial reaction. “We really didn’t know what it was. What we began to do is we began to call and we began to try to figure out what it was that we got.”

Thomas said he placed phone calls to representatives in both Frankfort and Washington D.C., to determine if the award was legitimate, which, he acknowledged, was.

“I was leery that it was probably someone just wanting money,” Thomas said. “I pretty much made them convince me of who they were. We ended up getting a number to the White House and we ended up figuring out that we had been given an award.”

Attempts to contact officials were unreturned, although operators answering calls referred to the office as that of the NRSC. Thomas believes someone wrote a letter and nominated him for the award, although he is unsure who it could have been or if he’ll ever know.

“What did I do to get this award?” he said.

After receiving confirmation that he was being recognized, Thomas tried to find out just what he would receive. That question, he said, is still a mystery.

“What the award is for, I don’t know right now,” he said. “I won’t know until I get there. They just needed to know if I would accept it.”

Thomas said that what he does know is he will be meeting President George Bush in March to get the honor. He added that he will also be sitting on a business advisory council.

Send me a postcard from the meeting, David. I think I'll have to pass.

As a reasonably staunch Republican, I am disheartened by this whole thing. My Democratic friends will laugh, but I think they have a few bad actors in their camp, too.