Two Hundred Thousand Hits!

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

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

SCRU-Verse

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

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

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

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

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

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

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

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

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

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

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

Hear that, Nahtanoj???

Reagan Was Right Again

Hooked Again

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

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

DoctorDalai.com "Noteworthy"!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Doctor Dalai and the Demo

Dalai's First Law

PACS IS the Radiology department. 

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

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

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

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

ADDENDUM:

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

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

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

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

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

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

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

The Doctor Dalai Show Revisits The iPad For Radiology

Meeting in Chicago

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Inca Trails and Tribulations

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

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

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

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

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

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

Please Stand By...

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

The Dalai's Meet Karl Rove

Through the generosity of a friend who had extra tickets, Mrs. Dalai and I had the honor of attending the Republican Party's Silver Elephant Dinner here in our fair Southern State a few months ago.  The keynote speaker was Karl Rove, the "Architect" of the Bush Administration, and as you see, we got to shake his hand and have our photo made with him.  Yes, it's a shocking picture; I almost never wear a suit!  I can just about guarantee we were the only two Jewish folks in the room. 

You can read the report of the speech here, but I can tell you that Mr. Rove is a captivating speaker, with a very humble but powerful style that shows the strength beneath the surface.  A very worthwhile evening, the boneless chicken Marriott nonwithstanding.

I can hear the aneurysms blowing in the brains of my Liberal friends about now.

Broke PACS Mountain

Bare Naked Calendar

I'm sure anyone in the PACS business is familiar with monitor manufacturer EIZO.  But I'll bet you have never seen their pin-up calendar, which I stumbled upon today.  Above is an example from http://www.coloribus.com/adsarchive/commercials/eizo/, where more are to be found, although they are not downloadable without an expensive subscription.

But wait... From the Butter Advertising Company in Germany that actually created this promotion, comes the whole year's worth of bony beauties!




When these ladies take it off, they take it ALL off. Pretty good stuff, no matter where you're from. Look at those clavicles on Miss July!


I clearly need to get out more. . .

The Blue-Footed Boobie Is Back!

Yes, their feet really are that color!

I'm back, but I caught a cold in Peru, and I've got a lot of call coming up.  Thus, I'll have to keep you waiting for a few more days for the report from South America.  I did make it to Machu Picchu, but just for two hours. . . Stay tuned for the story of the wildest ride of my life!

Australian Whistleblowers, Take Heart!

I'm gathering that there is about as much worry over who tattled to me and the Crikey site about Western Australia's PACS problems as there is with the troubles themselves.  I'm probably being quite generous with that assessment.  I thought those who are feeling heat from various places, deservedly or not, might want to hear about another whistleblower elsewhere in Australia.

From ABC News (which seems to be a different operation than our Disney-owned ABC News here in the States), comes the story of nuclear reactor operator David Reid: 

Mr Reid has been employed by the Australian Nuclear Science and Technology Organisation (ANSTO) at the south Sydney facility for the past 28 years.

He was suspended indefinitely a year ago, accused of bullying.

He maintains it was an attempt to stop him from discussing safety issues at the radiopharmaceutical production facility, ARI.

He had been raising his concerns as the staff-elected health and safety officer. He took his job seriously, telling the ABC, "If you don't follow the safety procedures and investigate the accidents, somebody is going to pay the ultimate price one day."

In August 2008, a worker at the ARI facility dropped a vial of highly radioactive material in a containment cell, which went unreported for several hours.

"We started investigating and the more we investigated the more we couldn't understand because it was such a massive dose," Mr Reid said.

"None of our instruments could measure it - it was way off scale. We cleaned up everything and we still couldn't get the dose down."

Mr Reid said one worker received a substantial dose of radiation, mainly to his groin.

......

Vindication does not happen often, but yesterday the head of Australia's Lucas Heights nuclear facility said a whistleblower was "absolutely correct" to raise serious safety concerns at the site.

The comments from ANSTO chief Dr Adrian Paterson contrast with the treatment that 55-year-old reactor operator David Reid has received at the hands of management over the past 12 months.

But Mr Reid remains suspended. ANSTO advised the Senate inquiry that Mr Reid was currently working on an agreed return-to-work program but had been offered an assignment with the organisation's decommissioning team when he completed the program..

I expect this story will have a happy ending for Mr. Reid, although possibly not for the fellow with the irradiated groin. 

We in the healthcare business have the goal of taking care of our patients.  Everything we do is directed toward that end.  When a piece of equipment, or a system, or a process, or whatever, impedes that goal, it needs to be dealt with properly.  Those involved need the freedom to verbalize their observations, without fear of retribution.  My sources of information for the "Blunder Down Under" right now aren't feeling too comfortable, and that is very sad indeed.  (I think most of them would rather experience radiation to the groin than let it be known that they spoke to me.)  There should be no punitive measures taken toward them or any other "whistleblowers" who are attempting to improve a bad situation, especially when people's very lives are involved.

Information is trickling in from WA, and I can report a little progress, but not much.  The Bluescreen of Death has stopped appearing, and there are far fewer random errors that crash IMPAX during a case.  (We certainly had our share of that here.)  However, loading of CT series can be impossible, with lags of 15 minutes and more mentioned.  It is taking the radiologists several extra hours every day to get through the workload.  Improvement?  Yes, but there is a long way to go. 

Agfa, step up to the plate and fix this.  You got our system running as well as it can, and I have faith that you can do this for my friends Down Under as well.

Apparently, I've been accused of being on the payroll of other PACS companies, which is definitely not the case.  As I've said before, whatever love I have or don't have for a product is based on the fact that I use it.  That's a little harder to dismiss, isn't it?

And, since it has been said that the articles on this topic are full of inaccuracies, I invite all affected parties to contribute to correcting the mistakes.  I will gladly publish any statement sent to me from Agfa, the WA Department of Health, or any other interested and affected party.  If I need to set the record straight, I am very glad to do so.

Fair Dinkum.

Doctor Dalai Is Not Available Right Now, Please Leave A Message...

I've been a little busy lately, which is my way of saying I haven't gotten around to blogging anything for a while.  My daughter graduated from college last week, and I've been working straight through this past weekend.  Thus, there has been little time for amusement.  To top it off, the Dalai family is shortly headed out to points south, and IF I can find internet service (doubtful) I might post from a wonderful exotic location somewhat removed from my usual stomping grounds.

Messages from points VERY far South, Western Australia, indicate some minimal movement on PACS problems.  I hope to have a full report eventually.  I'm still on the schedule for RANZCR in October, assuming I don't get stopped at the airport and turned away for my seditious activities in patient care.  What a story that would make!  One point I need to make:  I am NOT in the employ of ANY PACS company.  None.  Whatever antipathy I have toward certain larGE and AGraFAting companies is borne of my daily use of their products.  Period. 

I am scheduled to travel to Chicago soon to meet with the brass at Merge Healthcare, and a full report will follow.  My rendition of THE CALL from Merge seems to have disturbed some of my readers, and they are assuming I have "drunk the Kool-Aide".  Again, nothing could be further from the truth.  I am certainly willing to be fair, and listen to what Merge has to say, and I will relay that back to you.  Rest assured, as a physician, a radiologist, my duties are first and foremost to my patients, and not to any company.  I will be carefully monitoring the way in which our system is serviced and upgraded.  If Merge fulfills their promises in this regard, and especially if they don't, you will be the first to know.  I can only hope and expect (and to avoid the wrath of my partners who spent a lot of money on an AMICAS installation, I can also pray) that Merge will come through, maybe even with flying colors.

As the Governator says, "I'll be back..."  Be good in the meantime.

The Gospel of the Call According to Mike

Dalai's note:  As I noted, Mike Cannavo, the One and Only PACSMan, was in on the call with Merge as well.  Here is his take:  

As the Dalai indicated “The Call” was interesting both in its timing and content. After hearing what was said, though, I felt like the kid who finally realizes there in no Easter Bunny or Santa Claus- you sorta knew all along what was going on but now had to face the realization that your hunch was right all along. Interestingly, the reverence shown for “Michael” (a.k.a. Mr.. Ferro) was nothing short of what would be given to the Pope or others held in esteem by the Roman Catholic Italian community. I was waiting for his ring to be kissed and him being addressed as the Holy Father or Godfather, but I guess that’s what happens when you are part of the core team that helped his former company be sold for $300M- the line between man and Superman tends to blur.  Pulling off this deal as well some might indeed call him Superman- he earned my respect just pulling the deal off however he managed to do it- but in the end he puts his pants on in the morning just like I do. Honestly though, most days I work from home in gym shorts and a tee shirt while he gets dressed up so I guess that’s what differentiates his role in the business world from mine- that and a few million per year in salary and other perks. Minor details…

Initially the Dalai and I were told that not just Kurt and Nancy would be on the call but Paul Merrild, Merge’s new (and AMICAS’ old) Executive VP of Marketing, Justin Dearborn, Merge’s CEO, and perhaps a few others who were invited  as well. I guess we either didn’t rate highly enough or they were too busy to deal with lowlife’s like us, but either way it was just a cozy chat among the four of us without the big(ger) Kahuna’s listening in . (Side note: Merge also needs to get with Yahoo Finance because Nancy is still listed with her old title as are many of the “old” players). 

It doesn’t take much for the Dalai to get excited, being a married man of 25+ years or so, but after seven years of being divorced and dating way too many women with ambitious- or as I prefer to view it, grandiose- plans I’m a lot more skeptical of anyone with plans like those Merge outlined for the company. Let’s pick out my engagement ring after the second date. Umm…let’s not and say we did.  Certainly keeping everything and merging it into one product would be the best of all worlds and makes sense, but keeping the company alive and financially viable until this is actually done will be an incredible challenge, especially given both companies lack of positive cash flow and the significantly increased debt load.  Also keep in mind after two extensions Merge still only sold <92% of the available stock so….

I’m not sure I completely agree with Dalai that Merge was brought back from death’s door. Yes, the stock did hit the $0.20 range after being investigated by the SEC among others (from a high of $28.00 or so) but after nearly three years the patient still has quite a bit of rehab to go before they can be discharged, especially since it the stock still languishes in the low to mid $2.00 range since the sale to AMICAS went through (it’s in the mid $2.30’s as I write this).

Much of what was in “the call” outlined for us makes sense for a bigger company  but it remains to be seen if it makes sense for a company the size of Merge, even the “new” Merge. AMICAS could have taken the Emageon VNA components and done something with then but they elected not to. For that matter Emageon could have done the same themselves and elected not to. I’m not sure what Merge suddenly sees in this market except that the world is suddenly getting into it. It seems like the VNA and cloud market is averaging one new competitor every other week and already has at least two dozen providers vying for a piece of this pie. Now Merge it seems like is going to play in this marketplace too.

That is one of my biggest concerns- what exactly is Merge offering as a company? They already play in radiology, cardiology, and orthopedics markets and now with AMICAS they will enter into the healthcare IT market with VNA’s, financial, clinical trials, EMPI, perioperative, and many other areas. The vision expressed on the call was for Merge to either dominate the independent marketplace or compete with the bigger IT shops (all that is missing is a HIS), but neither makes much sense unless you believe that is part of Merge’s future. I’ll get to that in a bit.

Putting everything together in a single package is an admirable task but not nearly as easy to do as it sounds. As this strategy was being outlined to the Dalai and I all I could think about was that famous bus song the Hokey Pokey…

You put your right foot in,
You put your right foot out,
You put your right foot in
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

Of course you continue with your left foot, right hand, left hand, right shoulder, left shoulder, right hip, left hip and then your whole self in. One part at a time then you put it all together and jump in completely. That’s how Merge seems to address putting everything together- one part at a time- until their “whole self” was in .Maybe it was just my ADHD acting up but that’s all I could think about as they talked Of course instead of the Hokey Pokey I could have been thinking 99 Bottles of Beer on the Wall but I won’t go there.

I wouldn’t compare Merge to GE in any way, shape or form and while Merge may be a software company they lost a lot of good AMICAS software developers as well as sales people and others. I’m sure they will find all the engineers they need at “Bhopal Bob’s Developers and More” (BBDAM) but it still kinda sucks the way the guys were let go. Yes, they were offered a package after the fact, but it’s all about trust…and software engineers are very much like women- some may forgive but they NEVER EVER forget so in a situation like that it’s best to move on. Tiger, please take note…The logic of teamwork is also great when they are a team but with technology the way it is and everyone at Merge now Skyping, Webcasting and connecting remotely in various ways, all the engineers would have had to do is put on their orange ties, turn on the camera and voila- instant meeting! But alas, no sense crying over spilled milk. The kitties have no doubt lapped it up elsewhere which is a huge loss for Merge.

I’m also not sure I would compare what happened to AMICAS with Ben and Jerry’s getting bought up by Breyers (which happens to be owned by Unilever and makes everything from Lipton tea to Dove soap). Dalai, have you had Breyers lately? Yuck. Adding insult to injury they shrank their half gallon to 1.5 quarts and hoped no one noticed since they kept the price the same. Give me a full half gallon of Blue Bell, Ben and Jerrys, Haagen Dazs or even Publix Premium over Breyers any day. But alas, I digress.

Merge is the little engine that could that showed it can…at least in terms of pulling off the deal. My take on it is that the company has a much bigger vision of the future than what we are seeing and that AMICAS is merely a stepping stone.

The move of both companies to Chicago defied logic (why incur two expenses when one suffices?) but when you look at the long term picture it makes sense.

• Mr. Ferro’s mentor on this deal was Glen Tullman who has been Allscripts CEO since 1997.
• Merge also just added Jeff Surges, President of U.S. Sales for Allscripts Healthcare Solutions, Inc. to their Board of Directors.
• Allscripts is based in Chicago. Merge just moved the headquarters to Chicago.
• Allscripts currently offers clinical and healthcare solutions that address nearly every area EXCEPT those that Merge currently offers.
• Lastly, Allscripts has dipped their toe in the PACS marketplace a few times already without any real success but still retains a keen interest in this market.

I found this comment from 5/13 Merge press release very interesting- "Jeff joins a group of business leaders who have worked hard on behalf of Merge with no cash compensation, and who have each personally invested in the company through common stock purchases." Re-read that again-“….business leaders who have worked hard on behalf of Merge… who have each personally invested in the company through common stock purchases.”(emphasis added). So these “business leaders” (plural), also have skin in the game…and when you have skin in the game the rules usually change. That’s MY money you are playing with, not just investors.

You connect the dots and come up with your own conclusions…I’m not saying anything other than it’s mere speculation but…since Merrick Ventures (Mr. Ferro’s company) now owns 36% of the common stock, 24% of the preferred (non-voting) stock and they seem to be getting a lot closer with a certain $3B IT company somebody stands poised to get very, very rich in the near term if all goes well. It ain’t me- and I seriously doubt it’s the Dalai either.

So the Dalai was right. It’s a very different company for sure. But if Merge can deliver on the vision as expressed everyone will be in pretty good shape, especially the PACS marketplace. Only time will tell.