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A Note To GE PACS Service

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Image courtesy GEHealthcare.co.uk

Gentlemen:

I don't believe I've had the opportunity to meet any of you, but I am one of the radiologists who provide imaging interpretation at a site using GE PACS. I have some familiarity with PACS in general as well, and so I wanted to touch base with you on the issues we are having with the Universal Viewer. I was very disappointed to learn that GE would not have someone on site today; we had rearranged the schedule so I could be here to work with you. Since that is the case, I wanted to outline some of the difficulties we are facing with the new UV software in lieu of a personal meeting,   While UV represents a significant improvement over the old Centricity PACS/RA-600, we have encountered several problems with the software, some with severe enough impact upon patient care that we must request a patch on an emergency basis.

The most serious problem we face is the inability to save annotations (measurements, etc.) placed on an image. In the clinical oncology setting, it is absolutely critical that we have the ability to follow a lesion from scan to scan, and if the measurements are not preserved, the lesion on a comparison study must be remeasured, taking additional time and leading to possible inaccuracies.

An equally serious defect leads to one or more slices of a CT series simply dropping out, leaving a blank screen within the viewport showing only the text "0% loaded". Closing and reopening the study may reveal the missing slice, but usually this requires multiple attempts and sometimes causes other slices to disappear. Clearly, we cannot interpret what we cannot see.

At least one of us is experiencing intermittent zooming of slices when scrolling through a CT series. This is an unnecessary distraction at best which could lead to inability to visualize structures beyond the aberrant field of view.

On at least one occasion, and probably several others, a prior study does not appear to have been properly retrieved. I believe the most glaring case has been submitted to GE. The report from the prior study (multiple priors in this particular case) refer to images that are not present. Is there some reslicing taking place on the stored prior exams, particularly if they were performed on the old CT's which have since been replaced?

There are other lesser but still annoying and potentially dangerous glitches in UV. Scrolling though the prior report with the mouse wheel is disabled once the user clicks back into a viewport. The report can still be scrolled with the left mouse button using the cursor to drag the side-bar control. The Navigator window is hidden initially by the exam information window. To retrieve it, we must press "N" twice. I suspect both of these are state problems stemming from the use of Internet Explorer intermixed with your ActiveX viewer. Perhaps this legacy from Dynamic Imaging isn't playing well with the newer code?

We had high hopes of using UV for reading PET/CT scans. As it stands today, this cannot be done. Synchronization is not possible (at least on some patients) between the PET and a prior CT only exam. Perhaps this could be fixed with a new hanging protocol, but I haven't been able to make this work consistently. We are unable to get SUV readings, without which we cannot interpret a PET exam. In addition, the fusion function does not work correctly. Proper PET/CT fusion requires an "alpha" control which varies the contribution of the PET and the CT slice to the fused image. The only control you have on the fusion pane is for PET intensity, and this does not yield a usable image. This is properly executed on our old Advantage Workstation, and I would refer you to this display to see how fusion should work.

Finally, the search function of the worklist perpetuates the rather annoying requirement that ONLY GE has insisted upon for years and years, the placement of a space after the comma when searching for a patient by name. Yours is the only software out there that does not simply parse the input for the comma. Yes, it's a minor thing, but for those of us who have to bounce back and forth between multiple PACS systems, this uniqueness is really not appreciated.

I should add that the new Zero Footprint Viewer does work much better than the old Centricity Web client, which was truly one of the worst pieces of PACS software ever created. I had anticipated being able to utilize the full UV client remotely; I had thought it to be a zero-footprint product itself rather than an ActiveX app. I assume UV could be used remotely, but apparently our site is not allowing it to be distributed beyond the DMZ as we are doing elsewhere with Merge and Agfa clients. But that's another topic for another day.

The problems above that affect the display of the images, particularly the image drop-out and the inability to save annotations, represent impediments to patient care. I would urge GE to patch these as quickly as possible.

Thank you.

Sincerely,


DD

"Overcoming 10 Barriers To Happiness As A Radiologist"

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Dalai's note:  There has been considerable discussion on AuntMinnie.com in recent years as to the level of happiness (or lack thereof) among radiologists. Flounce, a frequent contributor to the forums, has authored this piece for AuntMinnie, and I believe his recipe is applicable to most everyone, not just radiologists.

May 26, 2015 -- Much has been written in the Forums on AuntMinnie.com about why radiologists are unhappy. Increasing volume. Cuts in reimbursement. Busier days. Difficult job market.
These trends all have some truth and are largely outside the control of any individual radiologist. There is no question that radiologists are less happy now than in the past. But I find that dwelling on things outside of our control is disempowering and leads to self-pity.
We do have a choice of what jobs we pursue. Discussions of what a "good job" is tend to focus on income, vacation, and work volume.
When I ponder what a "good job" means to me, the above three factors are not the first things that come to mind, though they are important (especially moderate work volume). Rather, I think about the things that are most important to my happiness.
I consider a good job in radiology one that allows you to achieve a reasonable degree of satisfaction in all of the following categories, where high marks in one category cannot compensate for a deficiency in another:
  • Satisfaction in your daily work life and level of morale
  • Satisfaction in your professional and career development, be it clinical, administrative, research, or whatever combination
  • Satisfaction in the relationships you develop at work, be it with fellow radiologists, technologists, clinicians, or even the nice lady who takes my trash every morning
  • Satisfaction in your health and general sense of well-being
  • Satisfaction in your family or home life
  • Satisfaction in your ability to cultivate and develop your interests outside of medicine, be it a hobby or something else
  • Satisfaction in your current material needs
  • Satisfaction in your ability to plan for your future needs
Yet a number of obstacles stand in the way of achieving happiness in radiology. While I'm no psychiatrist, here's my take on what they are:
  1. Overemphasis on salary and vacation in the job hunt, instead of focusing on job quality, people quality, and group work culture. The latter will determine your happiness more than the former.
  2. Unrealistic expectations of the type of material lifestyle you can afford, i.e., trying to match the homes, cars, and vacations of most other physicians -- and the resulting anxiety when the numbers don't add up. This forces you to work overtime to pay the mortgage on a house and leases on cars that you can't afford.
  3. The assumption that work must be painful, and therefore you should maximize productivity at work to maximize partner vacation time, which is when you hope to truly "live." When your work is reasonable and somewhat enjoyable, you don't feel a dire need for vacation.
  4. Not trying to cultivate your enjoyment of radiology. It's what we do with much of our time; liking it should be a priority.
  5. Not having a specific plan for professional/career growth, whether this means becoming a more knowledgeable radiologist, a better clinician, a radiology group/hospital leader, an accomplished author, etc.
  6. Failure to invest in relationships at work. The greatest secret to making friends is to be willing to show your friendship first, whether with a smile, a compliment, or treating someone to coffee or a meal. These small investments will be repaid to you in spades and will bring you more happiness than that black BMW M5 or Tesla. Ask me how I know. (Yes, I sold it.)
  7. Failure to give priority -- and protected time -- to other things in life. Buying the spouse flowers on the way back from work every few weeks; lunch with aging parents; flying a kite on Sunday mornings with your son: These should be recurring events on your calendar in the same way that partner meetings or radiation safety meetings are, and nothing should be allowed to squeeze these "small" things out of your schedule. Give them the priority you know they deserve.
  8. Seeking pleasure in owning/acquiring rather than doing/experiencing. It's more enjoyable to spend $800 to take a one-week bicycle mechanic's course -- and spend more time riding a basic road bike -- than to spend $4,000 more to get the high-end, carbon-frame road bike and expensive components that will just collect dust in the garage. Make art, don't collect it.
  9. Forgetting to maintain the most valuable piece of machinery you own: you. If you had a Ferrari, you would baby it and make sure everything is oiled and maintained. Your person -- i.e., your body and mind -- is the most valuable piece of operational machinery you have. It can generate a ton of income over the next 30 years. It can bring much joy and benefit to those around you, especially your patients. Maintaining your own wellness is not a luxury, it's a necessity. That refers to getting enough sleep; being in good physical shape; and being of sound mind, unperturbed by unnecessary stressors, with plenty of reserve capacity to deal with whatever challenges arise each day.
  10. Fear of poverty. Why someone who makes $200,000 a year -- or more -- should fear poverty is beyond me. Nothing is guaranteed in life except death and taxes, so, sure, you could be Warren Buffett and somehow end up on the street. But fearing it is something else. Dangers are outside you, but the fear is in your head. Live within your means, enjoy things that do not break your budget, plan for the future, and remind yourself that you make a choice every day to go to work: You are not a slave to your bills, nor will you become homeless if you decide today that you want to walk away from a bad job situation. And no, you do not need $1 million saved up in cash to walk away from a bad job. Compared with other humans on this planet, you are relatively powerful and capable, and there is no reason to disempower yourself in your head, such that you feel locked into anything.
Finally, a few parting thoughts ...
Keep the money in your hand -- to do things with -- and not in your heart. Don't worry, there is enough.
Be passionate about whatever you are doing. Life is too short just to go through the motions. If you must do it, then fully own it and take pride in it.

If you can't go to where you love, then find ways to love where you are.

Universal PACS Progress

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I will take only the most minimal credit, but GE is addressing our Universal Viewer PACS issues. From a GE VIP:

(GE) has escalated your top 3 issues for assistance in resolution. I was out of the office last week, but will be meeting this afternoon with our Leadership Team for needs in our zone and I have added your site to the agenda. This will ensure that GE Leadership is fully aware of the need and issues at your site.

I have also forwarded the tickets to a manager of the Customer Center asking for a dedicated resource to be assigned to all of your open tickets that either you or the GE team have opened on your behalf. I expect to have this update this afternoon.

. . . I will work to remove any roadblocks to getting your issues reviewed and updates to you and your team as soon as possible.

The top red issues identified on your tracker that I will attack first are listed below, if any others are more critical or just as critical let me know so I can keep the appropriate focus on your most important issue resolutions first and then we will continue working through the list.
  • Pet Fusion Hanging protocols not displaying properly. SUV values are not reliable. Images not displaying correctly in g/ml.
  • Measurements not saving on Image.
  • CT Series slices dropping out.. Viewer on shows the message 0% Loaded.
Thank you and please reach out to me directly if you have any concerns.

I am very grateful for this response. I don't expect immediate miracles, but this is progress, folks.

So far, though, much local effort has been directed toward figuring out why the timestamp on our notes reads one hour later than every system and workstation clock. I suggested that there might be some Time Zone setting buried in the PACS backend, but I don't think my credibility is adequate to participate in the process.

A correction/addition...the UV PET/CT fusion does not work correctly. It was not DESIGNED correctly. Please see my previous post.

In the meantime, we are all very meticulously dictating all measurements and the number of the slice on which the lesion is found. I suppose that is good etiquette regardless of the annotation malfunction. And I may have a solution to the slice disappearance; I have found that if I don't start scrolling until the entire display has loaded, in other words, when things stop moving, more often than not all slices are present and accounted for. I'm guessing there is some faulty code somewhere that allows the impatient radiologist to interrupt the loading of the scan data. I do believe IMPAX had a similar glitch years ago. Perhaps GE could buy Agfa, and create Universally Agile IMPAX, therein solving the problem.

I can't believe I just said that...

The Amoral Revolution In Western Values & Its Impact On Israel

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Dalai's Note: The writer of this piece was Commander of the British Forces in Afghanistan. The following text is Col. Kemp’s address delivered at the Begin-Sadat Center for Strategic Studies on May 19, 2015. This version was published on Aish.com. I think this is a VERY important article.
As an officer cadet at Sandhurst in 1977, I studied the wars and campaigns of the Israel-Palestine conflict in great depth, learning lessons in leadership, tactics and strategy from the always victorious operations of the IDF.
Years before that, in my school playground, girls always shopped and boys played war. Normally it was British and Germans or cowboys and Indians. For a time in 1967 it became Israelis and Arabs. After a few weeks, however, it reverted to the usual antagonists because nobody seemed to want to play on the Arab side.
I gather a similar recruitment problem exists today in the playgrounds of England with the Taliban side short of troops.
At 8, I was a little young for the serious study of military science beyond the playground, but later, as a 14-year-old schoolboy, I remember one day during the Yom Kippur War, my form master, a young chap just out of teacher training, came into the classroom with an arm full of newspapers.
He said that normal lessons would stop as there was a ‘real war’ starting and that this was really exciting so we should study it. Every day, we followed the events, wrote stories of our own, and learnt the geography. My father was unamused when all of the articles about the war had been cut out before he could get his hands on his breakfast-time paper. We were quite disappointed when it finished quickly and we had to resume normal lessons.
Why am I telling you all this?
It was all about the good fighting the bad and the good were expected to win. It was very simple even to a 14-year-old.
Even as late as 1973, Israel was still widely seen as the good guys and the Arabs were the bad. Sympathy was with Israel because they were being picked on and bullied. There was little consideration of the ‘legitimacy’ of Israel; it was taken for granted.
In 1967, the capture and occupation of East Jerusalem, which of course we commemorated on Sunday as Jerusalem Day, and of Judea and Samaria were accepted as a legitimate act of self-defense.
This was not true just for those of us still at school and in the fledgling days of a military career. This was the general view of British people, and of many in the West, obviously with plenty of exceptions.
Back then, in the 60s and 70s, young minds were still being shaped by traditional views of good and evil. The Valiant comic, read by most schoolboys, was all about heroic Tommies beating the treacherous Nazis or the fanatical Japanese. War films on the whole told the same stories, and without the graphic violence of today.
We had The Longest Day, The Guns of Navarone and Zulu. The BBC was neutral, and if anything supported the values of the country that paid for it. On the whole, like other UK news services of the day, it sought to convey events from the Middle East and everywhere else free of a political agenda, left or right.
In general, popular culture still reflected the long accepted beliefs and principles of a Christian society. All of this shaped the views of the majority of people.
We live in a very different world today. In 40 years the general opinion of Israelis and their Arab foes has been reversed.
Israel’s stance is unchanged from 1948. A desire for the survival of the Jewish national homeland, at peace with its neighbours.
What has changed? Some say the situation is different. But this is not the case. Fundamentally the situation remains the same. Israel’s stance is unchanged from 1948. A desire for the survival of the Jewish national homeland, at peace with its neighbours.
All that has changed about this has been that Israel has made repeated costly concessions, including giving up land, for peace. Concessions which have not been reciprocated by the Palestinians, but instead exploited at the grave expense of Israel. Concessions which have not been acknowledged or remembered by the international community, who, like the Palestinians, simply and uncompromisingly demand more and more and more and more.
Nor have the Arabs fundamentally changed. We have of course peace treaties with Egypt and Jordan. And the growing threats from Iran and from expanding Sunni jihadism may be leading to some temporary and below the radar mutual cooperation from parts of the Arab world.
But the underlying perspective and agenda, especially among the Palestinians, is the same as it was in the 1920s, 1930s and 1940s. Rejection of Jewish communities in the land of Israel. The destruction of the Jewish State.
Some of the basic dynamics have altered. Before, organized, uniformed and relatively disciplined and conventional Arab armies fought under their national flag. Today the armies have been replaced by terrorist gangsters and black-cloaked jihadists. Conventional war has been replaced by terrorist attacks. Battles fought between tanks and infantry in remote deserts have been replaced by battles fought in densely populated civilian areas and behind the protection of human shields.
In my view if such events as the Gaza conflict last summer were played out in the 1960s and 70s, the support for Israel in the West would have been greater than it was even then. The savage and murderous actions of the Palestinians are far more shocking today.
So I again ask the question, what has changed? And the answer is: The morality and values of the West. They have been transformed almost beyond recognition.
As public opinion in the West in the 60s and 70s was influenced by popular culture, so it is today. Throughout most of the West, certainly in Europe, Judeo-Christian principles, honesty, family values, respect for the state, honour and loyalty have all been eroded, often beyond recognition.
Negative values, such as the acceptance of betrayal, duplicity and deceit, have flourished. Defining values including patriotism and religious faith have been undermined.
We have gone from the heroic Tommies of the Valiant comic to the promotion of the criminal underworld in Grand Theft Auto. From Guns of Navarone to the naked violence of Terminator 3.
The 80s ushered in the insidious campaign of political correctness and moral relativity that has over the last 30 years gripped and taken over so much of our society.
Balanced, level-headed, impartial reporting in our media has been replaced by sensationalism as the purpose of mass media has swung from informing, educating and edifying to making money – and only too often to making the news rather than just reporting it. These negative and destructive values are being promoted constantly in the media.
The values and morality of the average person in the West have changed dramatically since the 70s. The new values often have more in common with Israel’s enemies than with Israel itself.
We all know but rarely have the courage to say, that hypocrisy, duplicity, betrayal and sensationalism are the four cornerstones of violent radical Islam as so often demonstrated to us on our TV screens by Hamas and the Islamic State.
It is impossible to avoid a connection between the shift in public opinion on Israel and the change in Western morality.
How has the new morality impacted on public opinion and perception?
The shift in the way war is presented has complicated the issue. War is no longer the good guy fighting the bad with the good expected to win. Political correctness encourages individuals to say what they think is seen as acceptable and will not offend the majority, rather than what they actually believe. This perpetuates itself and can lead to wholly unacceptable beliefs being outwardly and widely accepted and becoming the received wisdom. The destruction of defining values mean that people will now accept physical acts that would before have been utterly abhorrent to them.
The media destruction and character assassination of strong, outspoken leaders has led to the rise of the ‘grey man’. Political leaders are often seen as weak and gutless and will not stake their reputations on making bold, uncompromising, principled statements or decisions. Instead they frequently take the safer middle ground.  The population tends to take on the mannerisms of their leaders also becoming ‘grey’.
Sensationalism and the graphic depiction of violence has made the population increasingly immune to the horrors of violent atrocities such as public beheadings, massacre, kidnap, execution, torture and forcing your own people to die as human shields. These acts are now less likely to swing public opinion towards the ‘good guys’.
The glorious fight for a noble cause inspired by Judeo-Christian values and beliefs and fought with honor and dignity, the like of which has preoccupied generations of British soldiers before me is now, regrettably, a thing of the past.
So many of these extraordinary changes have been influenced and even driven through by a media, especially broadcast media, especially television, that has to a very large extent been taken over and subverted by those with a moral relativism heightened by an abhorrence for the traditional Judeo-Christian values of the West and a desire to promote as superior the values of other cultures in a form of all-pervading post-Colonial guilt.
The target is Western values themselves; most often represented by the United States, the most powerful country in the world. But Israel has increasingly become a proxy for the United States. For three reasons.
Firstly, the US President and the US Government is at present left wing and liberal and thus harder for left-wing liberals to attack. Second, Israel is smaller and more easily bullied and impacted by corrosive media sniping than is a superpower. Third, Israel can be portrayed as a Western colonial outpost in a rightfully Arab world.
These three things are underpinned by a pervasive and increasing anti-Semitism which intensifies the obsession with Israel and its portrayal as a true evil to be attacked at every possible opportunity.
This contrasts with the post-Colonial guilt I mentioned, combined also with a frequent desire to appease violent Islam and promote its cause and values as being superior to our own and certainly to Israel’s.
Any anti-Islam comment or perspective cannot be tolerated, while anti-Jewish, anti-Zionist and anti-Israel perspectives are all acceptable and encouraged.
In turn these double-standards are reinforced by the grey man syndrome, the corrosive political correctness that I mentioned, under which the majority feel obliged to support Israel’s enemies, and oppose Israel, and feel nervous about not doing so.
History has proven time and again that Arab nations cannot defeat Israel on the field of battle, and this will always be the case. That is of course why the Palestinians have chosen to use terrorist methods to attack the civilian population rather than conventional military forces to attack Israel’s army. It is why Hamas fires missiles at Israel and digs attack tunnels.
These measures, like other terrorist attacks against the Israeli population are not designed to damage or defeat Israel because they cannot and their perpetrators know they cannot.
They are designed for two different purposes. The lesser purpose is to demonstrate to their own population and their supporters that they are fighting for them against an existential threat – the last bankrupt recourse of all troubled regimes.
They use human shields in the hope that Israel will attack and kill their people.
But the far greater purpose is to provoke the inevitable and unavoidable Israeli reaction.  Hamas and the other Palestinian terror groups don’t use human shields in the hope that Israel will refrain from attacking their rocket launchers, weapons dumps, command centers, terrorist bases or tunnel entrances. They use human shields in the hope that Israel will attack and kill their people.
They do this for one purpose: to gain the global condemnation of the State of Israel.
Their particular target is the media, which they know will magnify and intensify their message to the world and force national governments, the UN, human rights groups and other international organizations to bring down unbearable pressure onto Israel.
This can only work of course if the media and these global organizations are willing to be subverted by their message. Willing to see them as the victims and Israel as the demons.
Fatah and the Palestinian Authority have a similar strategy. Their violence is of a different nature. Incentivizing terror by paying terrorists and the families of terrorists killed or imprisoned for attacking Israelis. By inciting anti-Israel hatred through speeches, newspapers, broadcast media, school textbooks and school teachers.
Not only does this entrench anti-Israel feeling that will prevent the acceptance of a two-state solution or any form of peace and future cooperation with Israel, but it also has the effect of inciting violence against Israeli troops and Israeli civilians who live in Judea and Samaria, including rioting, stone-throwing, ramming, battering, stabbing and murder.
Again the aim of this is to provoke an unavoidable reaction in order to attract global condemnation of Israel and bring unbearable pressure onto the Jewish State.
The next stage for the Palestinian leadership of course is to exploit anti-Israel pressure through the United Nations, the International Criminal Court, the European Union, the universities, businesses, trade organizations and now even FIFA.
The goal of all this activity is to undermine the Jewish State but the primary strategy is executed through a conspiracy with a compliant and complicit media. It is the media that brings pressure onto government leaders and heads of international organizations, compelling them to act in their weakness and with their values undermined.
Many of course need little persuasion but even here the media provides them with the excuse, the motive and the cover. It was strongly biased media reports alleging Israeli atrocities against Palestinians that either forced or allowed leaders like the US President, the British Foreign Secretary, the French Prime Minister and the UN Secretary General to demand that Israel did more to protect innocent civilians in Gaza during the fighting last summer.
Never mentioning, suggesting or even hinting at what more they can do. Never acknowledging the context for the action. Never condemning Hamas for the actual war crimes of using civilian locations as military facilities, compelling citizens to remain, and failing in their legal duty to evacuate civilians from a military area.
It is the media, the agents of moral relativism, the tools of the Palestinian leadership that are Israel’s enemies in this conflict today. They can win over not just Western leaders but the public who are imbued with the new morality.
The media should of course get at the truth, and they should fearlessly expose wrongdoing and criminality from wherever it comes. While remaining even-handed, Western media should remain mindful of, and to an extent reflect, the values of the society that supports them, funds them and depends upon them.
And of course it is in the changing nature of these values at much of the problem lies as I have explained. It is not the role of the media, especially publicly-funded media, to undermine the values of their society. It is not the role of the media to turn a blind eye to wrong-doing, corruption, law-breaking and immorality of one side, while exaggerating, falsifying, distorting and over-emphasizing allegations of wrong-doing against the other.
In many cases, the major media organizations have moved from reporting the conflict to being active protagonists.
But in the Israeli-Palestinian conflict this is, with a few exceptions, exactly what they do. In many cases, the major media organizations have moved from reporting the conflict to being active protagonists.
Josef Stalin once famously asked: ‘How many divisions has the Pope?’ The term ‘press corps’ in relation to Israel has assumed a military meaning that was not previously intended. Like Stalin, we might ask: ‘How many corps has the press?’
The answer is that the effectiveness of the press in the Israeli-Palestine conflict, on the side of Israel’s enemies, is immense, probably immeasurable. When the media distort and mislead, when they turn a blind eye, when they paint a false picture, they must be considered culpable for the consequences.
For the violence that is provoked, especially in this region, when they falsely report massacres, intentional targeting of babies, war crimes. For the anti-Semitism, including violent anti-Semitic attacks, and the terrorism around the world that their false prospectus inspires.
They must share culpability for the consequences that follow when political leaders and human rights groups respond to the pressure that their distorted reporting piles on. For the legitimacy that their reports give to political factions around the world that are opposed to Israel. For encouraging terror tactics, war crimes, crimes against humanity and the use of human shields by blaming Israel for the deaths of civilians, rather than the terror groups who are actually responsible.
I am sure most of you could recount many examples of exactly what I am talking about from your own personal knowledge and experiences in some cases. I will give you just a couple of recent examples from my personal experience.
I had just finished an interview on the conflict in Afghanistan in the studios of a major international broadcaster in London. I left the studio and was accosted in the corridor by the network’s prominent Middle East correspondent, who said ‘I want to speak to you about what you say about Israel’.
I said ‘I wasn’t talking about Israel but about Afghanistan’. He said, ‘No but I want to speak to you about what you do say about Israel’. ‘What is it?’ I asked, expecting the worst. ‘I agree with every word you say,’ he said. ‘Then why don’t you say it?’ ‘Because if I did I’d be fired!’ he responded.
I was in Israel for the duration of the conflict last summer. I was probably in a better position to understand what was happening than any other non-Israeli Western military analyst. Yet despite many offers to British, European and American networks I was not asked to do a single interview with the exception of Fox News in the US.
Why? Because I am a regular contributor of analysis to most of these networks on defence, security, terrorism and intelligence. They portray me as a reliable and trusted commentator. But they know that my perspective on Israel is objective and therefore contradicts their own political agendas. They cannot undermine me and therefore they simply do not give me air time on this issue.
I have been accused of supporting genocide and being an apologist for war crimes.  But in reality I have spent much of my life trying to prevent terrorist violence and attacks against innocent civilians and have often risked my own life to do so. I have been involved in peace-keeping operations and have physically intervened in situations where ethnic cleansing has been threatened.
In social media I have been the subject of sustained assaults by particularly virulent anti-Israel networks that I shall not name as I do not wish to give them the benefit of any publicity. I have had my words willfully distorted and falsified in the social media, even as recently as last night.
In universities I have been the subject of demonstrations that have sought to silence me. Most recently in the University of Sydney last month.
I have been subjected to virulent anti-Semitic hatred and threats. I have been placed on a terrorist death list.
I have been publicly accused of corruption and being in the pay of the Zionist entity. I have been deliberately denied business opportunities. I have been subjected to virulent anti-Semitic hatred and threats. I have been placed on a terrorist death list.
Why is this? It is not because I speak out against the moral bankruptcy, corruption, incitement to terrorism or oppression of the Palestinian Authority; or the murder, brutality and terrorist violence of Hamas, Hizballah or the Palestinian Islamic Jihad. I have spoken out at least as much against Al Qaida, the Taliban, the Iranian regime, the IRGC and many other sponsors of terror and terrorist groups without anything like this level of attempted intimidation.
It is for one reason, and that is because I fail to falsely condemn Israel in circumstances where to even be neutral on the subject is itself a crime in the eyes of so many. It is because I have gone further, and used my military experience and my objective view to explain and defend Israel’s legitimate military actions.
Of course in the eyes of many in this region this is already heinous in and of itself. But it is only heinous in the Western world because of the distortions of the media that amplifies the message and helps mobilize a public that it has persuaded to reject traditional values and adopt a new politically-correct moral relativity.
How do we fight this new form of political warfare where so much of the media is the enemy?
As with all battles we must conduct both defensive and offensive operations. The defense in this case of course revolves around doing what we can to ensure that the truth is made known. Both the truth about Israel’s enemies and how they act; and the truth about Israel and how its forces operate.
This must of course be the truth, I am not suggesting false propaganda. I include in this truth, open admissions when errors and wrong-doing take place, including and especially when innocent people die as a consequence.
This is one of the many things that separate us out from our enemies who so often refuse to tell or report the truth.
The offence in this form of political warfare is in exposing the bias, distortions, and untruth of the media. This is much more difficult but it is vital. As in all forms of war, the best form of defense is attack. Without effective offensive action our defensive work will succeed much less and can never produce decisive results.
Some good and vital work is already being done by a range of groups. But their effects remain limited. This campaign has had much tactical success and needs to continue and if possible to intensify. But so far there has been no real strategic impact. Nothing that has forced major media networks to fundamentally re-think their anti-Israel agenda.
Of course strategic effect requires strategic assets. And by strategic assets I mean the combination of significant funds, concerted and sustained will and large-scale, thoroughly planned and carefully-focused effort. The challenge is of course immense, and as with any battle, there is no guarantee of success.
As for myself I have gone through the transmutation from Infantry officer to fighter in this new form of political warfare.
The danger that Israel faces and that the media projects extends far beyond Israel, and threatens us all.
Much of my fight, as was recognized yesterday in the honour graciously and generously bestowed upon me here at Bar-Ilan University, is a fight for Israel. The warm support, encouragement and friendship of this great seat of learning will help to sustain me and to renew my vigor in this fight for Israel and for freedom that I shall never give up.
But to fight for Israel on the international media stage is also to fight for the values of democracy, freedom of speech and expression, and civilized social values everywhere. All of the principles and virtues that once made Britain great.
Make no mistake. This afternoon I have spoken about Israel’s fight. But the danger that Israel faces and that the media projects extends far beyond Israel, and threatens us all.
We should never forget the words of Pastor Martin Niemoller: “When they came for the Jews I did not speak out – because I was not a Jew. Then they came for me – and there was no-one left to speak for me.”
Israel’s fight is the Western world’s fight. Upon Israel’s survival depends the survival of Western civilization.
Do you agree or disagree with Col. Kemp’s analysis? Let us know what you think in the comment section below.
Col. Kemp’s 40 minute address can be viewed here.


Krauthammer: "Why Doctors Quit" Hint: EMR's have something to do with it...

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I'm a fan of conservative commentator Charles Krauthammer. If you read his column in the Washington Post, you might know that he is a physician by training, although he hasn't practiced in quite a while.

Krauthammer's recent column discusses some of the factors that have driven physicians away from actually practicing medicine. It should come as no surprise that EMR's are near the top of the list of troubles.
In general, my classmates felt fulfilled by family, friends and the considerable achievements of their professional lives. But there was an undercurrent of deep disappointment, almost demoralization, with what medical practice had become.

The complaint was not financial but vocational — an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to “provider.”

As one of them wrote, “My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else.” By which he meant “a never-ending attack on the profession from government, insurance companies, and lawyers . . . progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces nothing more than “billing and legal documents” — and degraded medicine.

How did this happen? I've personally advocated for EHR, RHIO's, Universal ID's, etc., since the early days of this blog. What went wrong?

Krauthammer continues:
And for what? The newly elected Barack Obama told the nation in 2009 that “it just won’t save billions of dollars” — $77 billion a year, promised the administration — “and thousands of jobs, it will save lives.” He then threw a cool $27 billion at going paperless by 2015.

It’s 2015 and what have we achieved? The $27 billion is gone, of course. The $77 billion in savings became a joke. Indeed, reported the Health and Human Services inspector general in 2014, “EHR technology can make it easier to commit fraud,” as in Medicare fraud, the copy-and-paste function allowing the instant filling of vast data fields, facilitating billing inflation.

That’s just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity . . . Then there is the toll on doctors’ time and patient care. One study in the American Journal of Emergency Medicine found that emergency-room doctors spend 43 percent of their time entering electronic records information, 28 percent with patients. Another study found that family-practice physicians spend on average 48 minutes a day just entering clinical data.
The devil is in the details, in this case the implementation of the details. EMR should have been a boon to physicians and patients alike. No more duplicated tests or doubly-irradiating patients for a repeat CT. No matter where you go, your information should be easily retrieved, yes? Sadly, no. And all because of good intentions, well, we hope the intentions were good, gone bad:
The geniuses who rammed this through undoubtedly thought they were rationalizing health care. After all, banking went electronic. Why not medicine?

Because banks deal with nothing but data. They don’t listen to your heart or examine your groin. Clicking boxes on an endless electronic form turns the patient into a data machine and cancels out the subtlety of a doctor’s unique feel and judgment.
Yes, I'm from the government and I'm here to help you . . . So why is the federal effort a failure?
Because liberals in a hurry refuse to trust the self-interested wisdom of individual practitioners, who were already adopting EHR on their own, but gradually, organically, as the technology became ripe and the costs tolerable. Instead, Washington picked a date out of a hat and decreed: Digital by 2015.
And so, here we are today:
As with other such arbitrary arrogance, the results are not pretty. EHR is health care’s Solyndra. Many, no doubt, feasted nicely on the $27 billion, but the rest is waste: money squandered, patients neglected, good physicians demoralized.

Like my old classmates who signed up for patient care — which they still love — and now do data entry.
Although I have supported the concept of EMR, and particularly image sharing (ala lifeIMAGE), I have also said at least once a week for the past 10 years on this blog that poor software design is an impediment to actually enacting and using these things, EMR, PACS, RIS, etc. We are reminded on a daily, really an hourly, basis that these programs don't work as they should. They have NEVER worked as they should.

We radiologists tolerated the imperfect software because even a VERY imperfect viewer was a huge advance over film. As the late, great Douglas Adams said of the products of the fictional Sirius Cybernetics Corporation in the Hitchhiker's Guide series:
It is very easy to be blinded to the essential uselessness of them by the sense of achievement you get from getting them to work at all. . .In other words - and this is the rock solid principle on which the whole of the Corporation's Galaxy-wide success is founded - their fundamental design flaws are completely hidden by their superficial design flaws.
I'm sure Mr. Adams wasn't thinking of any Epically LarGE companies when he wrote that piece. But this is where we are. We physicians, radiologists particularly, have accepted utterly unusable software in the name of progress. Programs and equipment that should make our job of promoting the health of our patients easier instead get in the way of doing so. EHR's that should streamline the day-to-day practice of medicine do anything but.

Why?

Why???

WHY?????

In no small part, it is because the software is spec'ed, designed, created, bought and sold primarily by IT folks. And now, of course, the government is stepping in to "help". Those who actually USE the damn things are left out in the cold. And then these same wretches are blamed when patient care is negatively impacted.

This paradigm has to change. But it won't in my working lifetime. Or that of the hundreds and thousands of physicians who are bailing out.

Progress. Forward. Hope and Change. Just keep saying that to yourself when you have intractable pain and there aren't any doctors left to help you.

Alone In A Conference Call

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Today marks my first direct, spoken communication with GE discussing the problems we have had with Universal Viewer. I wish I could report some progress. I wish I could...

As Mrs. Dalai will tell you with great relish and regret (and those aren't easy traits to combine), I am not very good at reproducing conversations. But I'll give you the gist of it.

The call was led by someone most interested in the PET/CT problems. She wanted to understand our workflow, but after a few moments, it became clear that understanding was not likely. Contrary to assumptions on the other end, our older AW workstation does NOT save measurements on the AW server which we don't have. It took 10 minutes to get that across. To be fair, our UV still doesn't save measurements either, and it only took about 1 minute to get that across. Now, we do understand HOW to measure SUV's with UV. (At first, we weren't getting accurate readings, but our new mentor did prompt me to try it again, and SUVmax at least does yield the same number as our AW.) Even though our apps people should have told us how to measure SUV's and make hanging protocols and use the restroom all by ourselves, said our new friend, she would be glad to run us through these things on the WebX once more.

"OK," said I, "that's wonderful. But you do realize we can't read PET/CT on this viewer, yes? Because the fusion pane DOESN'T WORK! A fusion window needs to have an alpha control that varies the contribution of the PET and the CT. We don't have that. The fusion images are unreadable, and unusable, and thus so is the UV itself for PET/CT viewing!"

Oh, yes, we've heard that from other sites. We're working on adding the alpha function. All that IS available in the AW Suite if you didn't know. (We did know...when UV was demo'ed, we were shown AW functionality and I think we somehow thought it was to be included.) In the meantime, what else could we show you about UV?

I pressed on, adding more and more irritation to my voice. I started to wonder if the WebX had disconnected me somehow, as I began to feel quite alone in my own little world where my PACS doesn't work. You would think I could Imagine something better than that.

In my reverie, I reviewed some of our pressing problems beyond having to use the old AW to read PET/CT. Such as images showing up as "0% Loaded" when scrolling through a CT. Such as our annotations not saving. Such as annotations from old studies not showing up. Which is just wonderful for oncologic imaging wherein we measure lesions and determine if they are larger or (hopefully) smaller than they were last time. It helps to actually HAVE those measurements for comparison, otherwise we are doomed to remeasure and remeasure and remeasure. Yes, we are diligent about reporting the slice number and the measurement, but this is a little ridiculous in the 21st Century flagship PACS product of the largest healthcare company in the universe. It teeters on requiring reporting to the FDA. But I'll let someone above my meager pay-grade make that call.

But if I were in the market to buy a PACS, well...

Operator? I think I've been disconnected....

ADDENDUM...

A ray of hope!

We've discovered, somewhat accidentally, on our own, with no help from the mother ship, that the annotations ARE saved...most of the time...within Presentation States. IF you know they're there. Next step: getting the presentation state to present automatically.

That's progress, folks!

GEe Whiz...Waiting For Godot Metadata

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Two steps forward, one step backward. The story of my life with Universal Viewer. The phrase above is what was displayed when I tried to view the PET images from a comparison PET/CT. I never thought I would appreciate the old Advantage Workstation but like an old Chevy pickup truck, it still does the job when the shiny new Maserati is in the shop, which happens more often than not. (No, I don't have a Mas, but a friend once did, and he always had to have someone follow him in case it broke down.)

We have made some progress, as I alluded to in the last post. It seems that our measurements and markups were being saved after all, but hidden in what I'm going to call a non-standard application of the Presentation State. It seems that they are ONLY saved in a presentation state. Whether this is actually the GSPS (Grayscale Softcopy Presentation State) or something else, I'm not certain.

The key to getting this far was discovered by the chief tech at the GE site, and one of my bosses (former partners) who isn't all that into software. My colleague was subsequently awarded Level Four Status by the techs as he had discovered something Level Four Technical at GE had not, that the measurements were being saved somewhere. I'm not really sure just how he found this but I was able to take it from there.

The secret lies buried in a sub-sub menu, "Done Options", a drop-down from the exit button:


Here, we find several very important check-boxes:



Now, some of these don't seem to work. Clearly, we must be doing something wrong in that we can't designate key images, and so they don't save, check-box or not. For the longest time, we did not have the "Load Presentation State on Startup" checked, and since measurements are saved in the Presentation State, this seems to explain why we weren't seeing them. We've been live with UV for almost two months and no one at GE knew this software well enough to tell us how to make this work. I'll be waiting on my check in the mail.

I'm thinking we are still not configured at all correctly. I cannot believe that measurements and such are ONLY saved in the Presentation State. UV would be the ONLY PACS out there to do so as far as I'm aware. But I guess the developers used their imagination.

But I have only just begun to whine.

So far, I cannot import CD's into the system directly via UV. The mechanism seems to be there, but it doesn't work. To be fair, the Centricity backend spat back or distorted the images of a significant number of outside disks, studies which AMICAS/Merge PACS would handle with aplomb, and even AGFA IMPAX would open nicely. This has made my life miserable, as the outside disks have to be loaded by ME and not preloaded by the staff in downtime. They must be viewed with their native software (although I usually crack them with Merge instead) and I have to compare across different machines. Really poor patient-care, boys and girls. Most every other PACS can do better. We paid extra for this?

Hanging protocols work oddly, but then this is nothing new from Centricity 3.x. Sometimes my standard protocol will display the proper CT series. Sometimes it will show the Smart-Prep single image instead. Sometimes the image will be windowed as I set it, and sometimes not.

The zooming issue seems to relate to field-of-view as saved in the Presentation State, which can be fixed by pressing the "1" key that rezooms all images to the same degree. But we shouldn't have to do that, should we?

I could go on...

I have to take a moment to trash the IDX Centricity RIS-IC. When it works, it works OK. But periodically we get the following set of nag messages when we attempt to sign EVERY SINGLE report:




We have similar problems when using Centricity RIS-IC via Citrix. And every single time we open PACS (via Internet Explorer), we get a nag about its certificate being invalid. It has been said this is due to local site problems rather than something intrinsic, but I'm not sure that is the case and frankly I'm not sure I care whose fault it is at this point.

This is the most advanced system from the biggest name in the business? Seriously?

I'll wait for Godot.

Universal Cobbling

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I've received a number of comments about the state of our Universally Disappointing Viewer. Here are some of the best:

As for the UV, thanks for the details on your experience thus far. I assure you that lots of GE customers are watching. As you know, GE has sunset PACS-IW.

The underpinnings of the UV are a Frankenstein PACS -  the UV is a "deconstructed" viewer built on the bones of multiple GE products cobbled together.  The UV can be deconstructed into the following parts - PACS-IW, RA1000, AW Server, IDI (for mammo), Centricity Clinical Archive and streaming from RTI (RealTimeImaging acquired via IDX in 2005). Pieces and parts cobbled together over the past decade largely through separate acquisitions that can be traced back to last century, the earliest from Applicare and Siemens/Loral.

The way GE runs their development, if each piece of the puzzle is not at the exact build of the other, it won't work. Keeping that in synchrony for the life of the product(s) will constantly be an issue.

Outside of the product itself, GE is a shadow of the PACS company they once were, having reorganized so many times and letting go so many expert staff.

This is a GE product and will take a while for it to stabilize. It has been over 2.5 years (I think) since they announced UV. Add on how many years they were working on it prior to launch, and well, that's too long considering the instability you are seeing.

But it's GE.
As it turns out, GE is proud (at least they say they are proud) of this heritage:

Legacy Products

Founded by Thomas Edison in 1878 as the Edison Electric Co., GE is recognized worldwide for excellence, innovation and imagination for numerous products and services spanning a wide breadth of industries. 
GE Healthcare IT is comprised heritage companies including IDX, Marquette Medical Systems, Millbrook, iPath, Innomed, Lockheed Martin Medical/LORAL, MedicaLogic, Dynamic Imaging, Medplexus and many others.
Company NameAcquired DateKey Product Legacy Names and New Names
Lockheed Martin Medical/LORAL1997(now Centricity PACS)
Innomed1997(now Centricity RIS-I - Europe/Asia)
Marquette Medical Systems1998QS (from QMI purchased by Marquette in 1995) (now Centricity Perinatal)
Applicare1999(now Centricity PACS [RA600/CA1000/EA])
Sabri2000(now Centricity EMR - Europe & EOL)
Micro Medical2000(now Centricity CVIS)
Systems Engineering Consultants2000(now Centricity Acute Care - EOL)
Per-Se RIS2001(now Centricity RIS - EOL)
ProAct Medical2001(now Centricity CIS)
CIS HQ2002
iPath2002ORMIS (now Centricity Perioperative Manager)
SEC (now Centricity Perioperative Anesthesia)
BDM2002(now Centricity Pharmacy)
MedicaLogic Logician2002Centricity Physician Office EMR (now Centricity EMR)
Millbrook2002Centricity Physician Office Practice Management (now combined with Centricity EMR as Centricity Practice Solution)
TripleG2003(now Centricity Lab)
IDX Systems Corporation2006IDX Flowcast (now Centricity Business)
IDX Groupcast (now Centricity Group Management)
IDX Carecast (now Centricity Enterprise)
IDX Patient Online (now Centricity Patient Online)
IDX Referring Practice Online (now Centricity Referring Practice Online)
IDX eCommerce Services (now Centricity EDI Services)
IDX Web Framework (now Centricity Web Framework)
IDX Imagecast (now Centricity RIS-IC)
Dynamic Imaging2007IntegradWeb PACS (now Centricity PACS-IW)
Integrad RIS/PACS (now Centricity RIS/PACS-IW)
MedPlexus2010MedPlexus EHR, MedPlexusPractice Management, MedPlexus Revenue Cycle Management and MedPlexus BSP Solution (now Centricity Advance)

Do patients really value interaction with radiologists?To Tell Or Not To Tell?

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Dalai's Note: This is compilation of my thoughts as posted to AuntMinnie.com on the topic of  discussing results with patients. It is cross-published as a Front Page article there today! I'm listed under the category of "Imaging Leaders" which tells me the field is in real trouble...
Merriam-Webster defines "value" as follows:
  • The amount of money that something is worth: the price or cost of something
  • Something that can be bought for a low or fair price
  • Usefulness or importance
I find this intuitive, really. The value of something is what it is worth. However, is that something worth the same to me as it is to you? And if I give you something of value, does that make me valuable to you? And what is the value of value?
Under the new healthcare paradigm that's emerging under government-mandated accountable care organizations (ACOs) and the like, healthcare dollars will be divided among member physicians based on the "value" they provide. More accurately, there will be extra money on the table if savings and benchmarks are achieved, and there will be penalties if costs exceed expectations.
As the minority faction at the distribution table, radiologists might just be in trouble. If we try to act as imaging gatekeepers and restrict useless examinations, we'll be told we killed grandma by cutting her access to imaging. Don't laugh -- this is exactly what has been said in the past by those who favor unlimited physician-owned imaging. On the other hand, if we allow unfettered access to imaging, costs skyrocket and the fingers once again point in our direction.
I personally think ACOs and the other "risk" programs are simply clever ways to separate physicians from their hard-earned pay, but not all agree.
A brave new world
To justify and even secure our place in this brave new world, radiologists are being commanded to prove our value, and we are told that our future revenue may depend on this rather nebulous concept. Our leadership has implied that we have to be more visible to patients, that we must make it clear we are "part of the team." Then the patients will finally understand the important role we play, which will somehow translate into a stronger position for us at King ACO's round table.
Having become even more cantankerous in my old age and semiretirement, I view this as little more than a desperate Hail Mary and a naive, knee-jerk response to the coming economic pressures of the (Un)Affordable Care Act. We are being asked to jump up on tables and shout, "We're doctors, too!"
But in its panicky zeal over potential loss of revenue, our illustrious leadership has forgotten something: We are not clinicians. We radiologists are, indeed, doctors, and we are the experts in imaging, but we are not in charge of the patient's care. This is well-illustrated by the concept of reporting our results directly to the patient.
In the June 2015 issue of the Journal of the American College of Radiology, Cabarrus et al presented the results of a patient survey on this topic. They found to no one's surprise that patients preferred to hear the results of imaging exams from the physician who ordered them. I would urge everyone to read the entire report, but in essence, the majority of patients surveyed "appear to prefer the current model of results delivery, in which ordering physicians provide results."
And this makes perfect sense. The usual course of events established decades ago is that results are communicated to the physician who ordered the study, and he or she then discusses them with the patient. There are only two reasons to force this responsibility onto the radiologist, and neither is a good one.
The first excuse is time. Or rather patience. Or rather the lack of patience. You can safely assume that an important, life-threatening result -- a "the patient will die in the next five minutes" type of result -- will be communicated as quickly as possible to the ordering doc. There have been hundreds and thousands of lawsuits on the issue that ensure this will happen.
But a noncritical finding, and even a flat-negative report, generally winds its way to the clinician over a longer time frame. To be fair, in some shops, this could take quite a while: Allow several days for the report to be typed, proofed, and signed, and however long it takes for snail-mail to deliver it to the physician, who then must read it and either call the result or meet with the patient. The entire process could take more than a week, although with our current electronic state of affairs, the nonemergency report should be available to the physician within a few hours of its rendering. Many impatient patients simply don't want to wait. They want the result now. Not next week, not tomorrow, but now.
Patients must remember that I, as a radiologist, cannot pluck them off the street and perform a radiographic examination. In the vast majority of cases, their physician, be it their own internist or an emergency room doc, must order the study. That physician has an established doctor-patient relationship, and knows at least something about the patient and his or her medical history.
When a study comes through on my PACS, I could come running out of the reading room; seek out the patient; act like I'm his or her new best friend, playing a warm, fuzzy Marcus Welby (a TV doc from way back, sort of the opposite of House); and discuss the results of the test. Instant gratification! If you knew me personally, you would realize that I really am a warm, fuzzy, caring kind of guy.
But when those radiographs come though on my PACS screen, I don't know anything about the patient other than the two- or three-word history the physician has lowered himself to give me. If I should happen to have a functioning electronic medical record (a contradiction in terms), I might be able to get some lab values and maybe some additional history. But ... I still don't know the patients like the clinical doctors do. I haven't talked to them, I haven't touched them, and I haven't examined them. So would I be doing them a favor by indulging the itch for an immediate answer?
If I give out instant reports, I place myself between patients and their own physicians. I can tell them what I see, and what they tell me might even enhance my interpretation of the images. But I can't do anything else for them. I am not their doctor. I cannot prescribe drugs to cure the pneumonia I've found, I cannot place a cast on a broken big toe, and I cannot say which surgeon or oncologist to see or what procedure to undergo should I (heaven forbid!) find a cancer.
What happens if in my rush to keep a patient from waiting too long, I miss something on the image, only to discover it later? (Or much later?) And what if a patient is, shall we say, a bit unstable mentally, and he or she totally decompensates in my office after receiving bad news? (I've had this happen to me, by the way.) In the end, my attempt to be kind by humoring a patient's need to know right bloody now may cause more harm than good. And the survey says patients would rather have their own docs do this anyway.
Why the push for 'value'?
So, given that it seems to be a bad idea for radiologists to deliver reports directly to patients, why would our illustrious leadership push us to do so? The answer is value, or rather, the perception (or perversion) of value. Cabarrus and colleagues write:
In an era of value-focused care, some authors have called on radiologists to increase their direct communication with patients in an effort to improve visibility and create value. Improved visibility helps radiologists demonstrate the value they already currently provide. Additional "value" through direct communication could result from a reduced number of intermediary communication errors, decreased delays in patient management, reduced patient stress and anxiety, and improved patient adherence to follow-up recommendations.
Communication errors? Reduced stress and anxiety? How about when the patient hears only every other word I say, and nothing past the word "cancer"? All we've managed to do in that scenario is scare them and then throw them out in the cold until their clinician can see them. The only "value" this practice will create is whatever one might place on the insertion of our faces into the patient's experience. In other words, it is another facet of the pitiful, plaintive cry, "We're doctors, too!"
In discussing this topic with colleagues on the AuntMinnie.com Forums, I have been saddened to find many whose "reality" is that the ACO model is here to stay, and they had better do everything our leadership says to do to secure one's place at the table. What we have here, folks, is a collection of milquetoast millennial physicians who find themselves overwhelmed by the changes around them, changes made by people with no interest in anything other than slashing payments. Changes made by those who think they are smarter than doctors and often have a grudge against them. Changes that pit physician against physician -- and particularly clinician against radiologist.
Many of the mostly younger posters are so frightened of losing their revenue that they are pushing each other out of the way in order to cheer at the front of the crowd when the naked emperor walks by. To be blunt, we all know this "value" thing, this business of pretending to be a clinician, is a crock. But because this is the new "reality," the rubes play along and chastise those who are willing to call it what it is, hoping the new masters notice their loyalty. And even worse, some have declared that they will only talk to patients if they are paid extra to do so. I hope they sleep well at night.
My solution probably comes too late: Avoid joining anything resembling an ACO. You see, we radiologists do add value -- with every single exam. Even a normal chest radiograph adds value, but it isn't "sexy" and doesn't increase our self-aggrandizement.
Most of us do a very good job in the imaging venue. Could we do better? Of course. We could and should have better and tighter communications with our referring clinicians, and we really do try to do this. We could and should do our best to confirm that the patient is receiving the correct exam (even though many ordering clinicians don't want to hear that the exam they ordered won't answer their question, nor do they want to hear that the question is wrong in the first place).
And we can and should talk to the patients, and let them know -- quietly and with dignity -- that we are indeed doctors. We are part of the team whose one and only goal is to make them better.
I, for one, will talk to patients at any time about their exam, provided their clinician is present or at least aware that the conversation will take place and knows what I will say. But I am not going to step in and pretend to be the patient's doctor when that is definitely not my role. That adds absolutely no value at all.
In addition to regular posts in the AuntMinnie.com PACS Community Forums, Dr. Dalai also maintains a blog at www.doctordalai.com. His observations and opinions are entirely his own.

Belgian Rhapsody

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Dalai's Note...Since IMPAX has decided to quit working this afternoon, I'm left with time on my hands, and we all know what the Devil does with idle hands...So please enjoy this repost from 2009. I wish I could say that was the last time we had a PACS outage, but my creativity can only be stretched so far.... 
 
 
Is PACS online today-
Is that just fantasy?
Still caught in downtime
With no functionality-
Open your files
Look up from the dials and see
I’m just a poor rad, trying to get through the day
‘Cause PACS is easy come easy go
Why it glitches, I don’t know
Any way the circuits blow doesn’t really matter to me
To me…..

Mama, just read a scan
Had a CT of the head
Clicked it off, now PACS is dead
Mama, it had just come up
But now I’ve gone and crashed it all again
Mama, Oooo, ooo ee ooo
Didn’t mean to make it die
If it’s not online again this time tomorrow
Back to film, Back to film, as if PACS doesn’t matter

Too late, my PACS won’t scroll
Couldn’t label any spine
Lovely software past its prime
Goodbye to my worklist, it won’t update now
Gotta reboot yet again and hope it works
Mama, Ooo Ooo Ooo Ooo,
I can’t have it die
I wish sometimes I wasn’t a rad at all

I see a little problem getting back online
Waterloo, Waterloo, Can you make the damn PACS work?
Shorting out and sparking, keeping me remarking: OY!
Mike Cannavo, Mike Cannavo
Mike Cannavo, Mike Cannavo
Mike Cannavo make it work, oh make it work Ooo, Oooo,Ooo
But I’m just a poor rad and my PACS hates me-
He’s just a poor rad from a bad residency
Spare him the joy from this monstrosity
Easy on easy off, will you let me work
Just fix it! No we will not make it work-Make it work!
Just fix it! We will not let you work-let it work!
Just fix it! We will not let you work-let me work!
Will not let you work-let me work
Will not let you work-let me work
No,no,no,no,no,no,no,no
Mama mia, mama mia, mama mia let it work
The Psycho ward has a nice cell set aside for me, for me, for ME!
So you think you can patch me and tell me I’m fine
So you think that an upgrade will keep me online
Oh, baby, can’t do this to me baby
Just gotta hang on, just gotta stay online right here
Nothing ever matters
Anyone can see
Nothing ever matters-nothing really matters for me
Any way the circuits blow….

Medical Bill: Mystery donor picked up $150G tab for 2010 Clinton speech

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Dalai's note:  What happens in Vegas stays on the Internet it seems. I wrote about Bill Clinton's speech at RSNA, 2010 back in (surprise) 2010, and it was discovered only recently by Fox News. The anonymous donor who paid for Bill's rambling wreck remains anonymous, and in fact, there seems to be no record of the donation at all. Hmmmmmm....

Medical Bill: Mystery donor picked up $150G tab for 2010 Clinton speech

Published July 10, 2015


It was a big coup when a nonprofit medical trade group landed Bill Clinton as a speaker at its 2010 annual conference in Chicago -- so big that some members wondered how the former president was being paid.
Not to worry, members of the Radiological Society of North America were told: An anonymous donor footed his bill.
The $150,000 fee was a mere fraction of the $48 million Clinton took in from 215 speeches between 2009 and 2013, while his wife was secretary of state. Who paid Clinton and why they thought it was a fair bargain may never be known — but government watchdogs say it is a prime example of how elusive accounting can be for the ex-president's eye-popping earnings.
It was clear, however, that the husband of America's top diplomat was not chosen for his medical expertise.
“I think this is interesting that you would ask me to come and speak today to a group of people from all over the world, and everyone of you knows more about the subject than I do,” Clinton said at the beginning of his 45-minute address to an audience of 4,250.
Dr. Sam Friedman, a radiologist from Columbia, SC., said at first he was “peeved” when he heard Clinton was paid $150,000 for the “rambling” speech, during which Clinton took several “gratuitous shots” at Republicans and blamed U.S. doctors for many of the healthcare problems in third world countries. When he and like-minded members made their objections known to the organization, they were told the fee was paid by an “anonymous” donor. 
Radiological Society of North America spokesman Marijo Millette told FoxNews.com the group “strives to provide compelling speakers that will satisfy the educational needs and special interests of a diverse audience.”
Millette would not comment on Friedman's claim, which was also reported by trade media, but said Clinton's fee and travel expenses were paid to the Harry Walker Agency, which represents Clinton. The organization’s 990 forms, filed with the Internal Revenue Service and required to maintain its 501(c)3 status, do not list any payment to Clinton or his representative. Neither the executive director nor three executive board members contacted by FoxNews.com would divulge who paid Clinton's fee.
Matthew Whitaker, executive director of the Foundation for Accountability & Civic Trust, a Washington-based, non-partisan campaign and ethics watchdog group, said the anonymous donation “opens up a Pandora’s box of questions including who funded this speech and what their motivations were.”
“This issue has to be resolved," Whitaker told FoxNews.com. "There has to be an answer as to who gave the money. “It has the smell of someone trying to move money through an organization to curry favor with the former president. It also calls into question almost every speech Bill Clinton has made and who the ultimate funder is.”
Neither Clinton's representatives at Harry Walker nor at the Clinton Foundation responded to a request for the name of the mystery sponsor. It was not clear if other speeches by Clinton were similarly funded by anonymous third parties.
Tom Fitton, president of Judicial Watch, a Washington D.C.-based government watchdog foundation, said much of the $48 million Bill Clinton made from 215 speeches during the time Hillary Clinton was Secretary of State went to the Clintons' personal coffers, not to the foundation. Federal disclosure forms filed by Hillary Clinton for 2010 record her husband’s compensation as $150,000 from the Oak Brook, Ill.-based group, but critics say the lack of transparency about where the money really came from raises serious questions.  
“Bill and Hillary Clinton are married, so under the law, paying him for a speech is like giving money directly to her – to the Secretary of State,” Fitton said. “I cannot think of a comparable ‘pay to play’ scandal.”
Clinton gave 542 speeches around the world between 2001 and 2013, earning $104.9 million, and delivered another 53 speeches between January 2014 and May 2015, earning an additional $13.5 million, according to reports by Fox News and the Washington Post. The former president's speaking fees have ranged from $28,100 for a 2001 talk at the London School of Economics to $750,000 for a 2011 appearance at an event for Swedish communications company Ericsson.
While Clinton's knowledge of world events and charm as a raconteur is well-documented, critics doubt the sky-high fees are doled out by anonymous parties for sheer entertainment value.

"These donors don't cut checks because they want to hear a brief speech," said Sean Davis, co- founder of The Federalist, a conservative online magazine. "They do it to gain access or favors from the Clintons. The Clintons owe voters a clear explanation of who is funneling them this money and why.”

Pointing Fingers At Meetings

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PACS is complicated. Really complicated. Really, REALLY complicated.

So when something goes wrong, there is a lot of investigation that needs to be done, and occasionally, there will be a lot of 'splainin' to do. And here and there, people point fingers at the perceived source of the trouble. Sometimes they are right, sometimes they aren't.

As you might guess, one of our systems is having a problem, and we aren't getting to the bottom of it. And there is some finger pointing. As we are in the midst of working it through, but we do not yet know what's wrong, I won't name the name of any entity, person, nation, President, planet, or vendor involved. You may feel free to guess, but I'm not telling. Wild horses couldn't drag the information out of me. And I hate horses. Well, I hate riding horses, which is close enough.

So. Just the facts, Ma'am.

The PACS in question has never operated quite perfectly. You might say that none of them do, and I would have to agree. But this one has had a few operational issues, including occasional complete outages, which fortunately are few and far between. And you might say all of them do that, and I would have to agree.

But the system in question has always had some little glitches I don't see from our other sites. In particular, we have noticed over the years that scrolling of large data-sets can be painfully slow. Surprisingly, turning off annotations will speed things up considerably. No one has been able to explain this adequately, although some have suggested that it is due to this particular architecture having to communicate back to the mother ship server for every command and mouse stroke and click. Could be. Also, SOME of us, and not all of us, experience very slow searches, worklist refreshes, and so on. This bad behavior has been attributed to bad individual user profiles, and rebuilding them may or may not cure the problem. And it has also been said that because some of us keep multiple worklists active, and all of those worklists have to have a little chat with the server upon each refresh, we are the ones slowing down our own workstations. Blame the victim. Love it. But it might still be true.

We've been putting along like this for several years. I've complained, others have complained, things are looked into, things are tweaked, and sometimes we see some improvement. I do have to say the system has been usable, even with the glitches, except on those occasions when it dies completely, and then it isn't very usable at all. In the meantime, I'm informed that we are about the last site in this quadrant of the galaxy on our particular version of the product. Fits like an old shoe, I guess. We need an update, although no one is certain that will solve any of our problems.

Unfortunately, over the past month or so we have been seeing a definite deterioration in function. Things load slightly more slowly, then a bit slower still, and in some areas, including an ED and a remote site on the network, the speed drop has reached the point that the stations are inoperable. But here's a little clue for you electronic Sherlocks out there: Stations accessing PACS via the Internet, outside the Enterprise, demonstrate adequate speed. We get better service from a home station on a 50M Time-Warner home connection that the gigabit Ethernet inside the hospital. Hmmmmm. Aside from the network connection, the only other difference between a station within the network and outside is that our main reading stations have digital voice (NOT speech-recognition) software integrated, although the ED stations do NOT.

To me, this all points to a network problem, possibly/probably compounded by the way this particular PACS architecture works with the network topology.

Now here's where we get into trouble. It seems that IT and the vendor have been working on the problem for a month or more. And they have come up with nothing. Well, I've been talking with folks on all sides of this, and that's not quite true.

The vendor has run tests from sample workstations at multiple sites, and lo and behold, the site with the most trouble has significantly slower transmission speeds back to the gateway than the site with less trouble. I'm leaving out a lot of detail, but that's the gist of it. Sounds like the answer, yes? No. IT has run tests on the network, and the report is that everything is perfect, nothing wrong, nothing to see here, move along. And so the finger points to the vendor.

The vendor, for its part, is bringing in everyone who knows anything about how the thing works, and promises to do everything possible to get to the bottom of the bottoming out.

And that, dear readers, is where we sit today. All sides are supposedly working furiously on the problem. I think (I hope) they all realize the mission-criticality of what it is they are fixing. Remember Dalai's First Law:  PACS IS the Radiology Department. Right now, our beloved department is impaired. I personally don't care whether this is the fault of the software vendor, the hardware vendor, IT, or if the janitor slopped a wet mop on a server. Our system is absolutely vital for patient care, and we cannot begin to tolerate anything less than 100% function. And we cannot tolerate anything less than 100% cooperation to get us back to 100% function.

I have had the good fortune of creating an international speaking career based on some of the foolishness I've seen over the years on every side of the PACS equation, and that includes ridiculous behavior on the part of vendors, IT types, and yes, even radiologists. As a crotchety, cantankerous, semi-retired curmudgeon, I can say with confidence that with most PACS problems, all parties have some degree of guilt. It is really bad when one side digs in its heels and declares: "it's not my problem!" But there is something even worse: MEETINGS!  Many folks out there, often but not exclusively IT types who have come up through the IT bureaucracy and not via Radiology, know of one and only one way to handle a situation: We need to have a MEETING! Thus time and resources are wasted trying to get the Important People in the same room at the same time so they can all explain why something isn't their fault, and agree on the time of the next meeting. Yes, I know that's how things are done, but in my experience, it's more how things don't get done. My very favorite example comes from my early days of dabbling in PACS, now over 20 years ago. I was sitting beside the one and only PACS administrator, a good friend of mine, while an IT person was droning on and on about how thus and so wouldn't work, how it couldn't possibly work, and how they should all meet again in a month to discuss why it was a bad idea. My friend whispered in my ear, "I did it and it works just fine!"

No doubt I've stepped on a few toes with this little rant. I mean no disrespect, and I dearly value the friendships I have made throughout the years among IT folks and vendors alike. But I have very little tolerance for things that get in the way of patient care. A failing PACS is right up there. Let's not add squabbling and finger-pointing to my sh*t list.

Besides, if I should disappear tomorrow, you all might have to deal with some of my former partners (now my bosses) instead, such as the fellow for whom Dalai's Twelfth Law was written:


At least I speak the IT language. Which might not be all that appreciated in the end.

Nothin' New

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I wish I had something new to report on our current PACS issues. Sadly, I do not.

The Team of Experts from the Vendor, including the fellow who probably knows the software best of anyone in the entire world and beyond has been working feverishly. Things have been tweaked, caches have been cleaned, cookies have been baked, red heifers have been sacrificed, and the moon has been howled at.

Nothin' new. Bupkis. We don't seem to be getting anywhere. What hasn't been done to my knowledge is taking a workstation (or laptop) straight to the data center and plugging in right into the server. That might provide a hint as to what part the network and hardware might play in this little fiasco. Of course, the fact that the darn thing works near-perfectly (relatively speaking) when accessed from a regular old home broadband connection might be another clue. Yes, Colonel Mustard did it with a candlestick in the parlor. But hey, a clue is a clue!

When there's some news, I'll let you all know. But don't hold your collective breath.

Time For Hope And Change

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From one of my former partners, now bosses, who is taking back the night this week:
The situation with PACS is completely unacceptable. As you can see it is 5:55 AM and the system has been "down for three hours. My phone will not stop ringing with upset doctors that they have non reads and can't get images. ER can't hear my voice clips. I am rendering interpretations on monitors in the modalities on studies such as deer vs moped and attempted murder buckshot to the face cases. The problem is more than just my obvious legal exposure, but there is a notion somehow this is the radiologist fault, like we exert some control over this.

There was an ugly incident a couple of days ago with me and a PACS administrator in the reading room when I was told the problem was fixed and I had an issue. The next confrontation I fear will result in me saying something I will truly regret and this is my last warning email. Its time to go up the ladder and make changes.
And from the guy on the early evening shift:

PACS started the inexorable slow decline at about 9pm last night, with the usual >30 sec between studies, lack of initial response to mouse input resulting in cursor catastrophe when the machine finally caught up, and...a new one for me...the mouse cursor got stuck at the bottom of far right screen number 5...it took me forever just to find the cursor.

Is it unreasonable to institute a "no further imaging" point where, at our discretion, all imaging is halted until PACS resumes normal function? Otherwise, as stated above, we are liable for studies we cannot interpret per ACR guidelines, as the images are locked in a radiology purgatory. Continuing to scan patients and send them to this purgatory does absolutely no one any good at all. It only leads to the clinician unrest and anger our partner fought for us all last night/this morning.
This sounds eerily familiar...

Remember the Blunder Down Under?

To this day, five years later, my friends in Perth and elsewhere in Western Australia tell me their Agfa system still doesn't work properly. Now you see why Agfa has been very hesitant to share information with me!

It is quite possible this cannot be fixed. Agfa's PACS architecture is extremely complex, to the point that their own experts may not know what's going wrong with the system. Add to that a very clear reluctance on the part of our IT department to consider a network problem even in the face of clear evidence.

We are now backed in a corner. We cannot allow this to degenerate into another Western Australia debacle. For what it's worth, here are my suggestions:

First, someone needs to take a laptop to the data center and plug it straight into the server. If the PACS client works properly, we will know something about how the network is or isn't affecting performance. (Which we already know since different sites have different speed issues, and we get the best performance when connecting over the internet, but there are those who need proof...)

Secondly, given the crashes, it is clear that the problems go beyond the network, although I still think the network plays a significant part. Even if it isn't included in the contract (which I would like to peruse), the vendor needs to perform the next major update AT NO CHARGE given the current impairment to patient care we are experiencing.

Third, it is time to strongly consider moving to another vendor, this time using a Vendor Neutral Archive (VNA) which allows for easier migration in the future. I don't know the exact figures of how many exams and how much data we have stored over 20 years of PACS experience, but it would be a VERY major undertaking. Still, the switch to a VNA is something I strongly recommend even if we stay with Agfa. Keep in mind, migration from the old database could literally take years.

I haven't had hands-on experience with all of the vendors out there, but of course that doesn't stop me from having an opinion. While not everyone likes Merge/AMICAS, and they have had their problems at the hospital using it (although our group's system has had very, very few over the years), it has a much simpler architecture, built around a regular old web-server (Windows Server if you're interested), and as such it can handle a tremendous amount of traffic. I personally like the client (which I had a small hand in designing). The newer versions use a VNA database.

McKesson gets good reviews from the rads that use it, and in fact one of my bosses/former partners has had a very positive experience with it. McKesson was excluded from the 2003 PACS upgrade search because at the time, IT was phasing out other McKesson products for reasons known only to IT and would not consider any new McKesson product. Sectra out of Sweden has its fans and a fairly large US presence. Intelerad has a product similar to Merge/AMICAS that is certainly worth considering.

TeraRecon and a smaller advanced visualization company called Visage have something they call "deconstructed PACS" which overlays the existing database and provides another client interface. You still need your own VNA and other supporting components.

My short list ends there.

Based on our experience with GE's Universal Disappointment, and some insider knowledge, I would not even bother with them. Fuji continues to have many weird client problems, and locked-down software for which changes take years. Philips rebrands the web-based system once called Stentor. It is the last of the major programs that can't burn a DICOM CD readable by another PACS. People either love it or hate it. Siemens' latest PACS offering, syngoPlaza, hasn't taken off to any significant degree. There are a dozen more small PACS offerings out there that I would never recommend at all, let alone for an enterprise the size of ours.

For the very short term, IF our system cannot be brought under control, it will be necessary to do some form of overlay. From limited exposure at the last RSNA, the deconstructed PACS concept would work, BUT there are missing pieces such as the inability to generate a worklist, which requires another product. Years ago, an older version of AMICAS was used at Mass General as an overlay for their older (version 4.x) IMPAX to provide web-based access. With the proper interface engines, I think Merge could create an overlay to our database with full functionality. I think so, anyway.

It is validating, though sad, to have Dalai's First Law proven correct again and again:

PACS IS the radiology department.


No Rush....


Perhaps This Is The Problem?

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“A Japanese company and a North American company decided to have a canoe race on the St. Lawrence River. Both teams practiced long and hard to reach their peak performance before the race.

On the big day, the Japanese won by a mile. The North Americans, very discouraged and depressed, decided to investigate the reason for the crushing defeat.

A management team made up of senior management was formed to investigate and recommend appropriate action. Their conclusion was the Japanese had 8 people rowing and 1 person steering, while the North American team had 8 people steering and 1 person rowing. So, North American management hired a consulting company and paid them a large amount of money for a second opinion.

They advised that too many people were steering the boat, while not enough people were rowing.

To prevent another loss to the Japanese, the rowing team’s management structure was totally reorganized to 4 steering supervisors, 3 area steering superintendents and 1 assistant superintendent steering manager. They also implemented a new performance system that would give the 1 person rowing the boat greater incentive to work harder.

It was called the”Rowing Team Quality First Program“, with meetings, dinners and free pens for the rower. There was discussion of getting new paddles, canoes and other equipment, extra vacation days for practices, and bonuses.

The next year the Japanese won by two miles. Humiliated, the North American management laid off the rower for poor performance, halted development of a new canoe, sold the paddles, and canceled all capital investments in new equipment. The money saved was distributed to the Senior Executives as bonuses and the next year’s racing team was outsourced to India.”

...from various sources around the internet

We're Not There Yet

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GE might think I've given up on bashing their flagship Universal Disappointment. Sorry, but I've just put that on hold while struggling with Agfa at the other site. More on that in a moment.

I can tell you that some of our Universal problems have been solved, mostly anyway. We figured out that the disappearing measurements were there all the time; we had applied them to a cloned window, and there they stayed, not applying to the original dataset. Who knew? But our other maladies go untreated.

The PET displays still don't work right, and we've heard nothing about the future of this promised function. The Navigator window still hides when we need it. The leveraging of Windows and Internet Explorer to show patient lists and so on needs some more leveraging. But the worst of the errors remains with us:


THIS is what we see when scrolling to the fourth or fifth slice on almost every CT. It will go away...after closing and reopening the scan three or four or five times. Isn't failing to show scan data a really bad problem? Ironically, this is a problem we had with the original Centricity 2.x install twelve years ago at the same site. What a comfort it is to know that some things never change.

On the Agfa side, things are slowly improving. VERY, VERY slowly. Today, I was able to work at a barely-adequate speed from our remote site. Until the client started crashing repeatedly. In the middle of reading a scan. Fortunately, the digital voice (NOT SR!!!) program stayed up, making it a little easier to retrieve the lost exam. But this isn't the way things are supposed to work. I'm told that there were many "maintenance problems" that needed addressing. Why they weren't addressed before the radiologists had a collective meltdown I can't say.

So, we carry on. Dealing with all this PACS grief will inspire all involved to do better, to view not only gently, but wisely, and make judicious choices in hardware, software, maintenance agreements, etc.

Sorry. Just Kidding. We continue with business as usual.

IBM BUYS MERGE!!!"Merge! Come Here! Watson Needs You!!

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NEWS FLASH!!!

I just received the notice (as did several thousand others) from Dustin Dearborn, Merge CEO, that IBM has purchased Merge, and will incorporate it into the IBM Watson Health Unit. Here is the press release:

Chicago, IL, 06 Aug 2015

Armonk, NY and CHICAGO -- [August 6, 2015]: IBM (NYSE: IBM) today announced that Watson will gain the ability to “see” by bringing together Watson’s advanced image analytics and cognitive capabilities with data and images obtained from Merge Healthcare Incorporated’s (NASDAQ: MRGE) medical imaging management platform. IBM plans to acquire Merge, a leading provider of medical image handling and processing, interoperability and clinical systems designed to advance healthcare quality and efficiency, in an effort to unlock the value of medical images to help physicians make better patient care decisions.

Merge’s technology platforms are used at more than 7,500 U.S. healthcare sites, as well as most of the world’s leading clinical research institutes and pharmaceutical firms to manage a growing body of medical images. The vision is that these organizations could use the Watson Health Cloud to surface new insights from a consolidated, patient-centric view of current and historical images, electronic health records, data from wearable devices and other related medical data, in a HIPAA-enabled environment.

Under terms of the transaction, Merge shareholders would receive $7.13 per share in cash, for a total transaction value of $1 billion. The closing of the transaction is subject to regulatory review, Merge shareholder approval, and other customary closing conditions, and is anticipated to occur later this year. It is IBM’s third major health-related acquisition – and the largest – since launching its Watson Health unit in April, following Phytel (population health) and Explorys (cloud based healthcare intelligence).

“As a proven leader in delivering healthcare solutions for over 20 years, Merge is a tremendous addition to the Watson Health platform. Healthcare will be one of IBM’s biggest growth areas over the next 10 years, which is why we are making a major investment to drive industry transformation and to facilitate a higher quality of care,” said John Kelly, senior vice president, IBM Research and Solutions Portfolio. “Watson’s powerful cognitive and analytic capabilities, coupled with those from Merge and our other major strategic acquisitions, position IBM to partner with healthcare providers, research institutions, biomedical companies, insurers and other organizations committed to changing the very nature of health and healthcare in the 21st century. Giving Watson ‘eyes’ on medical images unlocks entirely new possibilities for the industry.”

Teaching Watson to “See” Medical Images
The planned acquisition bolsters IBM’s strategy to add rich image analytics with deep learning to the Watson Health platform – in effect, advancing Watson beyond natural language and giving it the ability to “see.” Medical images are by far the largest and fastest-growing data source in the healthcare industry and perhaps the world – IBM researchers estimate that they account for at least 90% of all medical data today – but they also present challenges that need to be addressed:

The volume of medical images can be overwhelming to even the most sophisticated specialists – radiologists in some hospital emergency rooms are presented with as many as 100,000 images a day.

Tools to help clinicians extract insights from medical images remain very limited, requiring most analysis to be done manually.

At a time when the most powerful insights come at the intersection of diverse data sets (medical records, lab tests, genomics, etc.), medical images remain largely disconnected from mainstream health information.

IBM plans to leverage the Watson Health Cloud to analyze and cross-reference medical images against a deep trove of lab results, electronic health records, genomic tests, clinical studies and other health-related data sources, already representing 315 billion data points and 90 million unique records. Merge’s clients could compare new medical images with a patient’s image history as well as populations of similar patients to detect changes and anomalies. Insights generated by Watson could then help healthcare providers in fields including radiology, cardiology, orthopedics and ophthalmology to pursue more personalized approaches to diagnosis, treatment and monitoring of patients.

Cutting-edge image analytics projects underway in IBM Research’s global labs suggest additional areas where progress can be made. They include teaching Watson to filter clinical and diagnostic imaging information to help clinicians identify anomalies and form recommendations, which could help reduce physician viewing loads and increase physician effectiveness.

“As Watson evolves, we are tackling more complex and meaningful problems by constantly evaluating bigger and more challenging data sets,” Kelly said. “Medical images are some of the most complicated data sets imaginable, and there is perhaps no more important area in which researchers can apply machine learning and cognitive computing. That’s the real promise of cognitive computing and its artificial intelligence components – helping to make us healthier and to improve the quality of our lives.”

Watson Health and Merge Capabilities Will Benefit Researchers, Clinicians and Individuals

IBM’s Watson Health unit plans to bring together Merge’s product and solution offerings with existing expertise in cognitive computing, population health, and cloud-based healthcare intelligence offerings to:

Offer researchers insights to aid clinical trial design, monitoring and evaluation;

Help clinicians to efficiently identify options for the diagnosis, treatment and monitoring a broad array of health conditions such as cancer, stroke and heart disease;
Enable providers and payers to integrate and optimize patient engagement in alignment with meaningful use and value-based care guidelines;

Support researchers and healthcare professionals as they advance the emerging discipline of population health, which aims to optimize an individual’s care by identifying trends in large numbers of people with similar health status.

“Merge is widely recognized for delivering market leading imaging workflow and electronic data capture solutions,” said Justin Dearborn, chief executive officer, Merge. “Today’s announcement is an exciting step forward for our employees and clients. Becoming a part of IBM will allow us to expand our global scale and deliver added value and insight to our clients through Watson’s advanced analytic and cognitive computing capabilities.”

“Combining Merge’s leading medical imaging solutions with the world-class machine learning and analytics capabilities of IBM’s Watson Health is the future of healthcare technology,” said Michael W. Ferro, Jr., Merge’s chairman. “Merge’s leading technology and proven expertise represent a unique combination of assets that will deliver unparalleled value to Watson Health clients. Together, we will unlock unprecedented new opportunities to improve patient diagnostics and deliver enhanced care.”

Interesting. Justin goes on to add a personal note:

We are very pleased to share some exciting news with you. Earlier today we announced that we have entered into a definitive agreement under which IBM will acquire Merge Healthcare. Through this transaction, Merge will become part of the IBM Watson Health unit. The plan is for the Merge management team to remain in place following closing. You may read the full press release here, but allow me to take this opportunity to tell you about the news directly and what it means for you.

Combining our strengths as a leader in healthcare imaging with IBM’s powerful Watson Health Cloud cognitive and analytic capabilities will enable us to expand the reach and effectiveness of our solutions. The vision is that healthcare organizations could use the Watson Health Cloud to surface new insights from a consolidated, patient-centric view of current and historical images, electronic health records, data from wearable devices and other related medical data, in a HIPAA-enabled environment.

Additionally, we expect to benefit from the ample resources IBM can offer to support the continued growth and development of our business. In short, as a result of this transaction, Merge products will only become better and you will benefit from continued innovation to support your medical imaging needs.

I want to assure you that you can continue to expect the same level of service that you have come to rely on from Merge. Importantly, IBM will continue to support the Merge platform, and will continue to honor all existing contracts and agreements.

While we are very excited about today’s news, this announcement is just the first step in the process. The transaction is subject to regulatory review and shareholder approval. Until the transaction closes, which we expect will be later this year, we will remain an independent company, and it is business as usual. We remain focused, as we always have, on execution and results, and will continue to deliver the innovation and support that you have come to expect from us.

We’ll stay in touch as future developments take place, and we look forward to continuing to serve you.

Please do not hesitate to contact your Merge account manager with any questions.

What does this mean for us end users? Probably not much difference in service for the immediate future. But this does boost Merge significantly, now putting it up there with the other "big companies". Moreover, IBM does not have the previous stake that those others have with existing PACS software, etc., that has to be taken into consideration when moving forward.

This will prove interesting. I do recall Mike Ferro declaring that Merge would become the premier HIT company, and would eventually be worth $1 Billion. Looks like they made it.

Of course, now we have to worry that Watson will put us out of our jobs, but I'm not expecting that to happen for quite a while.

I wonder when Apple will take the plunge into the HIT pool. Between you and me, I was hoping Apple would be the suitor...

And We're STILL Not There Yet

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Despite rosy, glowingly positive reports from IT and Agfa, implying that all is well and the rads are once again fat and happy, we continue to have difficulties.

This morning, my poor, suffering bosses (formerly partners) who were on Saturday call report this amusing scenario:

Now at hospital for over one hour. Still unable to read studies. Worklist now opens in the upper left screen about the size of a postage stamp. I am able to expand it to the size of the screen. Worklist however does NOT open studies to be viewed; in another words, we see no images, just a worklist. And I have done the usual reboot four times on four different computers.

You'll be glad to know that this glitch, which affected all three guys on call, was finally fixed by bouncing all three production servers. How long that will keep things going, I haven't a clue. 

To be fair, much has improved, with speed improvements at most sites. I find I no longer have to turn off annotations to scroll through a CT series, which is huge. But we are clearly not out of the electronic woods as yet.

I am told that the improvements have come because of various maintenance procedures, cleaning out this, redoing that, etc., etc.  You might ask, why weren't these things done before the radiologists started acting out? That, dear reader, is a VERY good question...

Error Message

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I'm just waiting for this to happen...




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