Reading Rooms

November 15, 2015, 1:36 pm

≫ Next: Code Name: AvicennaThe Future In Progress

Back before most people could even spell PACS, we read from film, and nothing but film, and our offices reflect that legacy. This is the plan of one of our hospital reading room suites from 1990, still in use today:

The plan consists of eight similarly-sized offices, with X-ray view boxes on one wall, built-in shelves and a big wooden desk. The room hanging off the edge is the restroom, if you couldn't tell. Today, four of these offices have hospital PACS workstations, with one of these also having a PACS station for our PACS, and another having a Nuclear Medicine workstation. Another only houses our PACS computer. Two of the remaining offices have no workstation, and the third is used by one of our administrative assistants.

The computers are scattered in a haphazard manner. Some sit on the old wooden desks, some sit on (sort of) ergonomic tables. Some sit on the old built-in mini-desks.

Aesthetically, the offices are, well, not very aesthetic. We have dark carpet, beige walls, and white ceiling tiles. And whatever chairs happened to find their way in there, from an old leather and wood extravaganza bought for me 25 years ago, to several Herman Miller Aeron Office Chairs. There are bright fluorescent lights on the ceiling, and maybe a lamp here and there for more subdued illumination.

There is a lot of room for improvement, which will eventually happen. To be prepared if the department wins the lottery, I've been looking into the office suite I would like to have should cost be no object. (Well, if cost were no object we would all be on vacation in the Caribbean, but you know what I mean.)

Eliot Siegel, M.D., Chief of Imaging at the Veterans Affairs (VA) Maryland Healthcare System in Baltimore, has done extensive research into the ergonomics and design of radiology reading spaces:

Through trial and error, Dr. Siegel and colleagues discovered that redesigning the entire reading room is vastly more effective than simply adding computerized workstations to the previous film-based environment. Initially a single, unpartitioned space, the Baltimore VA reading room now features areas where radiologists can work independently and others where they can collaborate when necessary.

“In a digital environment where we are interacting with computer workstations, it is really critical to rethink the entire design of the room in terms of lighting, sound, temperature and other elements,” Dr. Siegel said. “Some factors that were less important in a film-based environment become extraordinarily important in this new digital environment.”

One of those factors is lighting. Back in the days of film, the light-boxes were the most important occupant of the room. Turn out the lights, turn on the box, flick the film onto the clip (I became far more adept at making the film lodge in the holder by flicking it with my ring finger from a foot away than I ever was at actually interpreting the images...)

(L)ighting is a key to improving the overall radiology work environment in a digital workspace. Because overhead fluorescent lighting cannot be adjusted for brightness and often flickers and causes glare, Dr. Siegel switched to indirect, incandescent lighting which helped reduce physician eye strain. In addition, using a blue light behind the workstations decreases radiologists’ stress level while increasing visual acuity, the team discovered.

“It is a very calming and relaxing environment,” Dr. Siegel said. “In fact, it is so relaxing we’ve had clinicians and visitors say that they would love to take a quick nap in the low-stress environment.”

And Dr. Siegel reminds us to keep ambient noise in mind:

If a facility can make only one change, Dr. Siegel recommends implementing a sound-masking system. At the Baltimore VA, the system emits a constant sound at a frequency close to human speech, which helps minimize noise distractions from the lobby and MR imaging scanner, both which are immediately adjacent to the reading room. Although the ideal reading room includes sound-proofed walls to eliminate ambient noise, the sound-masking system is a more affordable option.

“We found that just using the sound-masking system, which costs about $500 for an approximately 500-square-foot room, can significantly decrease distractions associated with noise in and outside the room,” Dr. Siegel said. “In our experience it has been effective, and it can even increase the accuracy of the speech-recognition systems being used now.”

And we mustn't forget that radiologists breathe:

Because controlling temperature and ventilation is also critical and can impact productivity, the facility’s new reading rooms have a subset of workstations equipped with individual controls for each user, Dr. Siegel said.

“Many of us work in environments where the air doesn’t move much and gets stale,” Dr. Siegel said. “Nobody would drive a car where they didn’t have air blowing or couldn’t control the temperature, but how many radiologists will sit in a room for 8 or 10 hours without being able to easily adjust the temperature or ventilation?”

These factors influence radiologist comfort, and help to minimize workplace injuries and complaints. Hey, if my thumb hurts, I can't trigger the microphone and so I'll have to go home on disability. Let's do what we can to prevent this.

Extensive work on workstation environments had been performed at Cornell, and Dr. Siegel applies the lessons in a humorous manner in this video:

Using Dr. Siegel's VA reading room sketch

and the concept of an "Imaging Interpretation Theatre" as seen in THIS paper from Hugine, et. al.,

as a starting point, I used my HGTV planning software (really!) to revamp our current space:

I'm childish enough to be thrilled with the ability to "walk through" this imaginary space I've created!

I've toned down the "theatre" to a small conference area, and I've made the reading areas a little too office-like in this first attempt, but much can change when (and if) we actually get into design mode. Personally, I like the idea of a "pod" as seen in Hugine's article,

but I don't see that happening in our neck of the woods.

Going through the Cornell checklist tell me this will be a tedious project, but well worth the effort.

By the way, we do NOT plan to have a glass door on the bathroom. There's nothing to see in there but plumbing...

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Code Name: AvicennaThe Future In Progress

December 3, 2015, 6:20 pm

≫ Next: Exhibits At An Exhibition: Siemens Press Conference

≪ Previous: Reading Rooms

One of my Radiology professors back in residency, a very wise man, had a saying: "The more dogmatic you get, the more likely you will be wrong."

In the medical business, there is a tie for the three most important little words: "I was wrong," competes nicely with "I don't know." (If you were wondering, the four scariest words in the radiological lexicon are: "You read a scan...")

The Future has a way of sneaking up on us, and occasionally biting us on the behind. In my youth, I thought for example, that age 50 was a long way off. Now I'm well into that decade of life, and the 60's are looming. As Steve Miller put it, "Time keeps on slippin', slippin', slipping', into the Future..."

All this leads us to the fact that I was dead wrong about something futuristic, something I thought we wouldn't see until many years from now. Something I saw this week at RSNA at the Merge booth. I was quite adamant that it would not be possible for a computer to read scans and such for at least 5-10 years. What I saw proves me wrong, or at least indicates that being dogmatic led me down the wrong path yet again. I was blindsided by a Work In Progress titled "Code Name: Avicenna", a peek into the future at some very disruptive technology (I use that term with all due respect and awe) brought about by the new consortium between Merge, now a wholly-owned subsidiary of IBM, and IBM Watson Health.

Let us speak a moment about Avicenna, whom I'm assuming is the inspiration behind the Code Name: Avicenna project. Since you are reading my blog, you are of course quite intelligent and well-educated, and thus you have probably heard of Avicenna. I, however, had not, so I turned to the Wiki:

Avicenna (c. 980 – June 1037) was a Persian polymath who is regarded as one of the most significant thinkers and writers of the Islamic Golden Age. Of the 450 works he is known to have written, around 240 have survived, including 150 on philosophy and 40 on medicine.

His most famous works are The Book of Healing– a philosophical and scientific encyclopedia, and The Canon of Medicine– a medical encyclopedia, which became a standard medical text at many medieval universities and remained in use as late as 1650.

Besides philosophy and medicine, Avicenna's corpus includes writings on astronomy, alchemy, geography and geology, psychology, Islamic theology, logic, mathematics, physics and poetry.

Image courtesy StatusMind.com

Pretty amazing guy. Now personally, I would have gone with "Code Name: Maimonides", after Moses Maimonides, an equally famous physician of the middle ages, or at least with his acronymed nickname Rambam (for "Rabbeinu Moshe Ben Maimon"). But then this isn't my project, is it?

The choice of the code name for this Watson-based process clearly tells us where we are going; Watson is learning medicine, and doing so at a very young age, as did Avicenna who became a physician in his teens.

IBM Watson, image courtesy IBM.com

Everyone has heard of IBM's Watson. Watson thinks, or at least simulates it nicely:

We produce over 25 quintillion bytes of data everyday and 80% of it is unstructured. Therefore, it’s invisible to current technology. IBM Watson is a cognitive system that can understand that data, learn from it and reason through it. That’s how industries as diverse as healthcare, retail, banking and travel are using Watson to reshape their industries. Watson is designed to take data in all its forms—including unstructured—and understand it, reason through it and learn from it. In a sense, Watson can think. When Watson thinks with you, you can outthink.

I cannot proceed without mentioning the old joke about the movie 2001: A Space Odyssey. The rogue self-aware computer, "HAL 9000" was supposedly a joke on IBM, the acronym being one letter off, yes? Arthur C. Clarke (or was it Stanley Kubrick?) denied this, claiming that HAL stood for Heuristic ALgorithm, and in fact IBM did help considerably with the movie details.

And this brings us to IBM's acquisition of Merge, which I blogged about when it was announced. It has since been finalized:

IBM itself whet our appetite for what was and is to come on the Watson Health website:

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 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.

I can't quite shake the thought of HAL, I mean Watson, watching us, but in a good way:

While it is just a Work In Progress, Code Name: Avicenna presents the first steps in realizing the unified goals of teaching Watson to see radiologic images (among others) and putting that, ummm, knowledge to good use for our patients. And you can see it in action today. Here is Merge's description of the demonstration, i.e., Code Name: Avicenna...

Merge PACS™ workstation viewer and IBM Watson Health – a vision for how to help radiologists with clinical decision making

Radiologists and cardiologists today have to view large amounts of imaging data relatively quickly leading to eye fatigue. Further, they may have limited access to clinical information relying mostly on their visual interpretation of imaging studies for their diagnostic decisions. In this demo, we present a futuristic workstation for radiologists where their normal viewing of imaging studies is augmented with clinical and imaging summaries to help their clinical decision-making. This technology could assist by running in the background to collect relevant clinical, textual and imaging patient data from electronic health records systems. It could then analyze multimodal content to detect anomalies and summarize the patient record, collecting relevant information pertinent to a chief complaint. The results of anomaly detection would then be fed into a reasoning engine which uses evidence from both patient-independent clinical knowledge and large-scale patient-driven similar patient statistics to arrive at potential differential diagnosis to help radiologists’ clinical decision making. Compact clinical summaries, along with the findings from imaging studies, would be available both for simultaneous viewing and export as a DICOM SR report.

The demo will show our vision of this futuristic technology using the Merge PACS™ workstation. The radiologist will open an exam from the Universal Worklist (UWL). When the exam is opened, both the PACS viewer and the IBM Watson Health work in progress will be launched in separate monitors to show respective content. The ultimate output from the tool in the form of a pre-populated radiology report will then be presented to the radiologist to review and consider in making his or her decisions.

DISCLAIMER: The capability demonstrated here is for DEMONSTRATION PURPOSES ONLY. The capability is in the research and development phase and is not available for any use, commercial or non-commercial. Any statements and claims related to the capability are aspirational only. The case study in this demonstration is a hypothetical case study using fictitious medical information and do not represent an actual medical case. The results contained in this demonstration were obtained in a controlled environment and represent a vision of possible future technology. The demo will show our vision of this futuristic technology using the Merge PACS™ workstation.

The punch-line to Code Name: Avicenna is quite simple. IT WORKS (something typical of Merge products, but sadly not for others in the same industry). A case was presented to Watson consisting of history, physical findings, lab values, and a CT. Well, it was a CT-pulmonary arteriogram, so Watson had a little clue there. The demonstration progressed to show Watson's integration of the data into a cloud-display of likely diagnoses. He, OK, it, proceeded to analyze the CT, showing outlines of ~~his~~ its regions of interest. And Watson found the majority of the emboli on the very positive sample scan. Watson's ROI's matched those of the training radiologist quite well. And it then displayed dozens of priors from its memory with similar findings. The most likely differential became "pulmonary embolism", which was of course correct.

As an aside, many have wondered just how Watson acquires the images upon which he it trained. I had asked this question of the Merge execs early on, but they weren't ready to answer until now. Basically, the scans are collected with secondary use rights, to which the institutions providing them must agree. The images and reports and other data are anonymized, so there is no privacy problem. To date, several Big Name operations have signed on to this effort, including many you might have heard of. (I'm not supposed to name names as yet, but I, for one, was quite impressed with the players so far.) I'll be glad to sign mine over, too. There simply is no downside to doing so. There are 30 BILLION images in Merge's iConnect cloud service already. That should keep Watson busy for a millisecond or two, once they are allowed to be, shall we say, assimilated?

Now you might say that Computer Aided Diagnosis is already here. You would be missing the point. CAD doesn't learn. Watson, being a cognitive computer, learns. It learns the way I learned to read CT's. Hopefully it will read them better than I do. Think of it this way... I went to college to learn the chemistry and physics (and for me, engineering and computer science) needed to understand higher concepts. I went on to medical school to learn how the body is put together with all that chemistry and physiology and stuff. I learned where the pulmonary arteries were, and what happens if a clot gets lodged in one. In radiology residency, I learned how it looks on a scan if that happens. (Well, to be fair, the scanners weren't fast enough for CTPA grams back then, and so we learned the concept with conventional arteriography, but you get the idea.)

One physician was overheard saying something like, "Bah. My first-year residents could get that one." Yes...A COMPUTER can match the achievement of a human that has gone through college and medical school. Let this sink in. Code Word: Avicenna shows us THAT A COMPUTER IN THE EARLIEST STAGES OF LEARNING HOW TO READ COMPLEX IMAGING STUDIES CAN MATCH A FIRST-YEAR RADIOLOGY RESIDENT.

This, people, is the epitome of disruptive technology. This is a sea-change in how radiology will manifest in the future. The implications here are staggering. To me, this is MUCH more important and noteworthy than an extra Tesla on a magnet (although a Tesla in my garage would be most appreciated) or an extra hundred slices on a CT. Code Name: Avicenna represents the most important development in our field in a very, very long time. This is a fundamental change in the way we do things. It assists the radiologist, allowing him/her to perform at the highest possible level, but does not replace us. Not for the foreseeable future, anyway.

I was right on that one, at least.

I have seen the future, and its Code Name is Avicenna. Seriously. Trust me, I'm a doctor! But if you don't believe me, just ask Watson.

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Exhibits At An Exhibition: Siemens Press Conference

December 5, 2015, 11:59 am

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≪ Previous: Code Name: AvicennaThe Future In Progress

"Pictures at an Exhibition" Courtesy

I'm back from a rather brief trip to Chicago and RSNA. I had two days to see stuff and get some edumacation, as we say down here in the South, and I tried to make the most of it.

Educationally, I used my limited time to concentrate on PET and thyroid/parathyroid imaging. I come out reassured that we are doing things correctly. I'm still a little confused as to the best application of SPECT/CT to parathyroid imaging, so I'll probably be doing some experimentation when we finally get the darn thing sometime early next year. One presentation claimed better accuracy with good old pin-hole/planar imaging than with SPECT/CT. We'll see.

I began my 48-hour RSNA marathon early Monday at the Siemens Press Conference. Somehow, Siemens still thinks I'm some sort of journalist, which speaks more toward my friendship with people who decide such things than their better judgement. Not to worry, though, the room was filled with real reporters from real publications, who will properly convey the things correspondents are supposed to write. But you might want to question their judgement: some of them said they were readers of this blog, or at least familiar with me, and if I were them I probably wouldn't admit it. One VERY wise lady from a VERY respected publication did note the iconoclastic tone I generally manifest, proving that she really does read this. Thanks, Ms. C.P.!! I'm going to tattle, though. Some of the reporters were on their laptops doing things other than paying attention to the presentations, and one reporter who used to work for Siemens asked some very long and barely comprehensible questions at the end. Which were answered quite throughly.

Having been a regular attendee at the Siemens event, I was surprised this year to see new faces. In years past, Dr. Hermann Requardt, (PhD in Physics!) CEO of Siemens Healthcare, presided over the meeting, with Dr. Gregory Sorensen, (Neuroradiologist) CEO of Siemens Healthcare North America, in the supporting role. They are no longer with us, at least no longer visible, having been replaced respectively by Dr. Bernd Montag, also a physicist, and David Pacitti, recently of Abbott Labs. Requardt is now on the board of Bruker, Inc., and is the new Chairman of the Board of SuperSonic Imagine; Sorenson was removed just in October. HMMMMMM.... Perhaps their vision didn't match the current trends, but I can't say I heard anything much different than last year in that regard. Back in February, Siemens announced the change of CEO's. Joe Kaeser, President and CEO of Siemens AG, said: “Mr. Requardt and the managers and employees of Healthcare can be quite proud of their highly successful work together over the past years. I have the greatest respect for Mr. Requardt’s decision to make way for a generation change. We are now setting up Healthcare as a separately managed business within Siemens in order to pave the way for an equally successful future in a highly dynamic market and innovation- driven environment. This is now the task of Bernd Montag, Michael Reitermann and Michael Sen. They will have the full support of the Managing Board and their direct partner, Board member Siegfried Russwurm, who worked in the company’s former Medical Engineering and Medical Solutions units for ten years.”

I could report chapter and verse of what was said, but I'll leave that to the real reporters. What I will convey is my impression as the only physician in the room. (At last year I was one of two along with Dr. Sorensen.)

Technologically, there was a smattering of this new or upgraded scanner or that, the standard stuff. Dr. Montag announced 510K approval of Siemens CT scanners for lung screening programs, and the new "teamplay" software for data transparency and availability (acknowledging the ubiquity of tablets in the healthcare environment). The new HELX touch-control ultrasound scanners should reduce operator variance thorough streamlined user interface. It's supposed to be easy for inter operative use by surgeons. Thanks, Siemens. We also note the advanced robotic and even 3D capability of the new MultiTom Rax X-ray room. Good incremental improvements, all. No mention of PACS, advanced visualization, etc.

The main message I got from the hour-long session is that Siemens understands the changes in healthcare, both here and pending, and wants to help physicians navigate them successfully, "Enabling Healthcare Providers Worldwide" in their words. The flip-side is that Siemens is invested in these changes, assumes they will come, and is resigned to the fact that they ARE coming. The transformation process to the new reality has three components:

Consolidation of Providers
Industrialization--Dr. Montag: "Medicine is not an art anymore. It must be managed like a company in a controlled fashion." How sad.
Managing Health--i.e., the transition from fee-for-service to value models

The process supposedly is inexorable, like the Law of Gravity.

Diagnostics, particularly imaging are pillars of healthcare, and have been almost from the beginning. In fact, Roentgen himself was an early Siemens customer, and the company archives contain a letter of complaint from the man himself, noting the rather high equipment costs. Some things never change. Indeed, Siemens has been in on quite a few innovations in medical imaging, PET, PET/CT, PET/MRI, dual-source CT, etc.

Dr. Montag tells us that "90% of medical decisions are based on technologies in the Siemens portfolio." This, I think, is a little misleading. We could say that 95% of the world is lit by technology in the GE portfolio, the remaining 5% still using fire, but that really doesn't get us anywhere. I might have phrased it differently, but we get it.

Further examples were given of how Siemens can and will holistically improve health care, radiation therapy guidance, laboratory productivity, and triaging patients. Siemens will help us with standardization, consulting, and a world-wide network geared to mastering the digital transformation, leading to better outcomes at lower costs.

In the end, 10% of the costs of healthcare relate to diagnosis, and our value thus depends on early diagnosis which could reduce the price of the remaining 90%. That's a better definition of value than I've heard to this point.

Still, I'm personally not as convinced as the good folks at Siemens that this value thing is permanent. Much will depend on the upcoming elections among other things. But I do understand the need to conform to the environment in which they wish to sell their wares. No doubt if fee-for-service comes back, Siemens will exercise its flexibility once again, and pivot back to whatever worked in the old days. Like selling scanners to doctors' offices. Just like GE. Still, if your going to scan, you might as well have the best scanner.

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Exhibits At An Exhibition: PACS, HYPOTHETICALLY-Speaking

December 6, 2015, 8:32 am

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≪ Previous: Exhibits At An Exhibition: Siemens Press Conference

Having little time at this year's RSNA, I was able to only briefly stop in to see friends at the Visage and lifeIMAGE booths. Both products show nice incremental improvements. Visage offers deconstructed PACS, with better collation of prior studies in this incarnation. It is a viable alternative to a full-fledged PACS, IF your IT folks can handle the concept. Big IF for some. Again, there is no worklist option included; "That would make us a PACS company!" So what's wrong with that?

lifeIMAGE continues to progress, now with even better connectivity. See this nice summary from Imaging Technology News for details. Many PACS vendors offer some form of image sharing in competition with lI, but the latter does it better. I've said it before and I'll say it again: NOT using an image-sharing system is MALPRACTICE. Period. If you never believe anything else I write, believe that.

I have stated elsewhere that if I were to need a new PACS, my list would be short, based on experience, discussion, research, gestalt, instinct, hubris, and maybe a little luck: Merge, McKesson, Intelerad, and Sectra. Unfortunately, I only had time to visit the first two.

In addition to the Code Name: Avicenna project, Merge offers the latest version of PACS, Merge 7.1, to be released in the Spring of 2016. This latest descendant of the venerable AMICAS PACS (Version 3.7 is still in use at Mass General!) includes a number of tidbits gleaned from Emageon and DR, the systems Merge has assimilated over the years. The major improvement concerns the worklist, which can be used in composite mode, with up to 10 separate worklists operating on-screen at once. And unlike a certain system we know and love, this has no IMPAXT upon the speed of the client. Rules for the next study to be read can be specified so the most appropriate (and urgent) study is the next one to be read. (The next iteration, still a Work In Progress, will further assign studies based on RVU, subspecialty, etc, and should truly be Universal across the enterprise.)

My Merge-based IT people will be pleased to know that user-management is now templated, allowing quicker assignments of permissions and so forth. And the slippery menu-driven preferences is now on a single pop-up window. There is user-level XML integration which could, for example, be used to keep windows open or closed after completing dictation.

There is a new Macro Manager that will combine multiple repetitive actions. There is advanced breast-tomosynthesis with slab-viewing and position markers, as well as PET/CT fusion.

From DR comes embedded dictation with Speech Recognition (which I won't use!), and further improvements on an already excellent hanging protocol functionality. I'm excited to say that there will no longer be the same degree of dependence on series labels (which I cannot get the techs to standardize for love, money, or prolonged tantrums); one can specify, for example, what T2 means on an MRI from Scanner Vendors X, Y, and Z, and then key a hanging protocol to show all the T2 images. You get the idea.

I proposed the HYPOTHETICAL scenario of a failing Big-Iron PACS and asked what Merge could do in such a HYPOTHETICAL situation. HYPOTHETICALLY speaking, Merge could either provide an overlay to the database of the HYPOTHETICALLY failing PACS, assuming that component retained its integrity. Alternatively, Merge could move in as the primary PACS in such a HYPOTHETICAL situation, using DICOM Q/R to retrieve priors in the near term while migrating the entire database in the background. Fairly standard, although the ability to front for a failing system might not be as facile with the other vendors. Should the users of the HYPOTHETICALLY impaired PACS have a Merge PACS somewhere, that existing system could perhaps be used as a secondary server. Also, it would be easier to create a unified worklist for all the PACS in an enterprise if they happened to be from Merge. Food for thought.

McKesson is one of those rare PACS for which we hear minimal if any complaints, even fewer than for Merge and the others. No doubt there are some cranky rads out there who could find something wrong with it, but they are a minority indeed. McKesson PACS is now known as McKesson Radiology, a regression from the old Horizon moniker. The company has a much greater presence in my home state than I knew; they might actually have the majority of PACS here, or at least a significant pleurality.

McKesson is also proud of its hanging protocols, although the emphasis in the demonstration seemed to be on the fact that once they are set up, one wouldn't need to change them. But drag-and-drop and scripting is available for those who want to tweak things. As with Merge, they are not based on series descriptors. If your mouse wheel can tilt to either side, this motion can shift sequential hanging protocols.

There is a nice embedded advanced imaging module that does "~80%" of what one gets with an external TeraRecon, most everything but vessel fly-through. It even has lesion tracking. Tomosynthesis and PET/CT viewers are fully integrated.

Add-on modules include "Imaging Fellow" which can open RIS/EMR data, and is supposed to be able to open "any other exam from any accessible database." This would allow for data mining if you were so inclined.

PeerVue was purchased by McKesson years ago and is now called Conserus. (I would have gone a different direction...sounds too much like Cons 'R Us.) This critical-result software sends texts and emails and other reminders about things that need to be seen NOW.

The "Intelligent Worklist" allows prioritization by rules as we saw with Merge PACS (although the AMICAS/Merge worklist continues to have by far the best visual clues.) This module will monitor foreign PACS, allowing a sort of unified worklist, but still launches the foreign PACS client. I think it is capable of opening the study in your McKesson PACS if you have one, but I wasn't completely clear on that one.

A collaborative tool allows instant pinging of a colleague, referrer, etc, to get them to view a study. Right now, this spawns a second viewer program, not the main PACS viewer itself. This is to be incorporated into the main viewer eventually.

For those who work from or view from home, the main client can be used, although a VPN is required. It was unknown as to whether SSL would suffice.

When asked the HYPOTHETICAL question about the HYPOTHETICAL scenario in which a HYPOTHETICAL PACS needed replacing, the McKesson folks offered up similar solutions. The Intelligent Worklist could probably access the HYPOTHETICALLY failing PACS, as long as one had McKesson for the actual reads. Of course, they would be willing to migrate the old database in such a HYPOTHETICAL situation, and McKesson has in-house capability to do so.

With the observations now documented, I shall now stray into opinion territory. Emphasis on opinion. Or really just me babbling on.

I have no clue at this point in time if I might be involved in any HYPOTHETICAL PACS replacements. I suppose I would suggest sending RFP's to the four companies mentioned above if that HYPOTHETICAL ever occurred. My good friend Mike Cannavo, the One and Only PACSman, has some very wise and mildly cynical ideas about RFP's. Adding in my own sarcasm, basically the IT folks don't know the questions to ask on an RFP but think they do. I have just one very easy question: "Does the damn thing WORK?" Vendors will of course respond in the affirmative, but this really requires a far more complex answer with quite a few nuances and shades of gray. Perhaps the better question would be: "Does the damn thing work the way I want/need it to work?" I would love to hear the response to that one.

Mike noted an uptick in the number of vendors offering PACS and PACS-related wares at this RSNA:

So what was new? There are more PACS vendors for sure. I would venture to say that at least 70% of the vendors at RSNA 2015 had something PACS or PACS-related. It's just a matter of time before former PACSman award winner Ernie's Welding and Fabricating becomes Ernie's Pipes and PACS.

Even though we have had some market consolidation with high-profile mergers and acquisitions, for every one vendor that gets gobbled up, it seems like four new vendors appear. How many of the newbies will be here next year is anyone's guess, but if history repeats itself and 10% remain, it's a lot.

The problem is, even though some might have an innovative feature here and there, these tiny vendors probably won't be around in a few years, and many that are maintain their viability because their products are cheap (in price, but probably quality as well) and they appeal to small operations being run by those who don't understand what it is they are buying.

Ironically, the Powers That Be at one of our places blackballed AMICAS years ago because a consulting company (someone you hire and pay $50,000 to tell you what you already think you know) told them it was "too small" and would likely be acquired. Well, they were half-right. IBM now owns Merge, which owns AMICAS, but instead of quashing it, ala GE, the acquisition has strengthened the company and the product. GE assimilated DynamicImaging, among others, cannibalizing its PACS components into the Universal Disappointment. DI no longer exists in any form. Merge, however, is still alive, being billed as "an IBM company". AMICAS PACS lives on, and continues to grow. My friends from Emageon and DR Systems might roll their eyes a bit, but at least the best of their PACS components live on within Merge PACS, and credit is given to the predecessors as is due. I'm good with that.

McKesson Radiology is in many ways at the other end of the spectrum, being one of the last Big-Iron companies. Their product list contains hundreds of entries, and PACS is far from the largest offering. Still, there is a lot to be said for having a HUGE presence in the health-care marketplace, and to have a product with relatively few complaints. (However, I probably don't even have to say that simply buying from a huGE company doesn't guarantee a quality product.) Supposedly the rule at McK is that a call to the support center MUST be answered within 3 rings. I can't vouch for what happens after that. Many have said McKesson's architecture is a generation behind, and that there are too many different clients for different purposes, but I didn't discuss that with them at this point.

I have had very nice chats with Sectra and Intelerad folks over the years. In fact, Sectra invited me to come to their headquarters in Sweden, but I could only go in July, and Sweden apparently closes for vacation that month. My contact at Sectra has since left for a different company, as folks in this business are wont to do. I do keep in touch with some good friends at Intelerad as well. It is of note that both companies demurred somewhat as to what could be accomplished when given bits and pieces of the HYPOTHETICAL failing-PACS situation.

I'm in my eleventh year of blogging about PACS, and the more things change, the more they stay the same. What worked before still works and works better, and what didn't work still doesn't work, and may even be worse. (And the attitude of IT doesn't seem to be much different at all.) Some companies listen better than others, and some even listen to the right people, the end-users of their wares, and not just the people with the checkbook.

Remember Dalai's First Law of PACS: PACS IS the radiology department. It has to work. And not just HYPOTHETICALLY.

↧

Frasier

December 18, 2015, 12:52 pm

≫ Next: The Demonstration

≪ Previous: Exhibits At An Exhibition: PACS, HYPOTHETICALLY-Speaking

Hey, Dad!

What, Frasier?

There isn't a lot of time, Dad, and there's a lot to say. The vet will be here pretty soon, you know.

Vet?

Yeah, Dad. I'm almost 17 years old, damn old for a Jack Russell Terrier, and I'm not doing so hot. I know you see it when you look at me.

Yeah, Fras. I know. I had hoped you didn't understand.

I put on that dumb face so you won't worry about me. But it's OK, Dad. Really. I'm ready. I can barely breathe, I can't eat, I can't stand up anymore. I'm not having a very good day, and I'm tired. Really, really tired. It's time. We all know it.

I'm sorry, Frasier. We don't want to let go of you. You aren't hurting, are you?

Nah. Just uncomfortable. But this whole dying thing is darn undignified, you know? Why you humans keep yourselves going when you've reached this state is beyond me. If you really loved your loved ones like you love me, you would let them go in peace. Personally, I'm looking forward to it.

Frasier...

Cut it out, Dad. No tears, please. OK, maybe a few if you must. I know you and Mom and the kids (and even that little devil dog Sophie) love me. It's been a damn good life. I don't have any regrets and you shouldn't either. Really. Loved our walks, loved sleeping in the bed with you, licking your pillow (even when you yelled at me for it). I really liked the frozen yogurt on my birthday, and the occasional McDonald's cheeseburger and fries. It's all good. It really was.

You are a very good boy Frasier...

Yeah, I tried my best. At least you never played that stupid human game of "Who's a Good Boy?" I can rest knowing that I was.

Will we see you again?

Ha. That's the Big Question, isn't it? Wish I could tell you. Jewish law is kinda vague on that. Supposedly, there are 5 kinds of souls. Animals have the most basic version, the life-force. That goes back to G-d. Humans have all 5, and they say go to a different part of Heaven.

I hate to disagree with you and the Rabbis, Frasier, but I'm pretty convinced you have a human soul, too.

Hope you're right, Dad. I've always thought so, but I'm just a dog. If so, we will meet again. But even if not, I'll be back with G-d which is a fair trade-off, don't you think?

We love you Fras... Godspeed.

Love you too, Dad. Don't forget me, but don't grieve too much. I'll be fine. I promise. And you will too.

↧

The Demonstration

January 7, 2016, 7:09 am

≫ Next: RAD-AID

≪ Previous: Frasier

Image courtesy of Dilbert.com

Hi, everyone. I see we have some folks here from Administration, and from IT, and even five or six radiologists. That's great. I was sent here by your EMR vendor to give you a look at the new RIS add-on, DoctorThingy. It's a nice piece of software that can be used in either RIS-driven or PACS-driven mode. We could probably run it both ways, but we don't recommend doing that. Why? Well, you might have some trouble synchronizing worklists, and some exams might just get read twice. We don't want that to happen, do we? So let's see how this looks.

Your overhead projector will only work in landscape mode, but we recommend using portrait mode. No, we can't turn the projector sideways, it's bolted to the ceiling, isn't it? Maybe you could all tip your heads to the left? No, no, I'm just kidding. But keep in mind that you would normally see this wonderful informational window stacked on your portrait monitor with another window below it. Of course, you could get one of those nice Barco 12 MegaPixel monitors and have room for lots of windows! Or you might need a fifth or a sixth monitor for our window, and your old PACS text window and your PowerScribe window. Oh, you don't have that yet? Oops.

Our early implementations of the DoctorThingy were PACS-driven. That's probably because no one had invented RIS-driven workflow back then. But now most of our sites go RIS-driven. That means we replace your PACS worklist with our page that includes your worklists. And it will show you how many reports you have to sign, and let you do that without opening another app, and we know you hate opening other apps! When you select a patient, it shows everything you have in the EMR about him. Oh, yes, you can have as many worklists active as you wish. No, that won't bog down your page. Your PACS can't handle that? Well, that's a good reason to go RIS-driven, isn't it? Ha ha. Anyway, our RIS when teamed with DoctorThingy replaces your worklist completely. You can make any kind of worklist you want, using any criteria you can think of. What's that? You want just to search for a individual patient? Easy peasy! Here is the search window. You can search by name, date of birth, ID, and AARP number. Really? You want to search by modality? Or you want to go back and review the MRI's you've read in the last week? Hmmmmm. The DoctorThingy search window won't do that. Never has. But don't worry. If you minimize DoctorThingy and open CollosusSearch, you can find just about anything...like maybe all the patients with a certain astrological sign who had defagrams in months that contain the letter "R". Isn't that worth opening up another app to see? Oh. Forget what I said before about opening another program.

What's that? You need voice clips on the ER exams? Well, DoctorThingy 1.2.11.3 had voice-clips. You know, saving them as .WAV files and all. But we dropped that. No, we have no plans to put it back. Well, OK, I'll ask. You have voice-clips in your PACS viewer? That might work. If you can get to your PACS viewer text page. Oh, silly me, it will be hidden by the DoctorThingy window. But if you have a proper portrait monitor, you could still arrange things so you could see it after all. I think.

Oh, you want to know about workflow with your PACS? Oh, yes, we've integrated at another site to the same PACS. Yes, ONE other site. You'll be the second. But we really appreciate your help with beta-testing the system! Yes, the existing installation is in Nome, Alaska. Nome. N-O-M-E. Shall we go for a site visit? You all go on ahead, I'll meet you there in July. Since I haven't been there, I really don't know just exactly how this will work with your PACS. But it's really really powerful. Great software.

I know you guys want some kind of demo program you can play with. Sorry, but this nice demo you are seeing on the screen is straight from our HQ inside the NORAD mountain. It's only for the demonstrators like me. No, you can't have access to it. But your site already has the code. What? It isn't online yet? Well, once it is, you can probably play with it, if IT can set up a test environment for you. That shouldn't take too long, right? No more than a month or so. Because I'm told this project won't go live until April Fools Day, and that's almost three months from now! That's certainly enough time for you to iron out any and all difficulties presented by this wonderful software. IT people, do you know how it works? Are you all ready to get it going? Oh, well, you'll figure it out.

So don't worry! Just because you are being forced to use this untested integration of new software without adequate prep time which will completely upend the way you do your job shouldn't bother you! It will all work out. It always does. Just look at how well your PACS runs! On second thought...

If there are no further questions...

↧

RAD-AID

January 8, 2016, 8:36 am

≫ Next: Reporting In

≪ Previous: The Demonstration

If you didn't know, I'm semi-retired, working only 26 weeks of the year. That would be half of the year for those uncomfortable with mathematics. The ultimate plan is to do this for another 12-18 months (one to one and one half years if you need the conversion factor) and then goodbye to the joys of private practice.

Of course, my ultimate plan lacks some ultimate planning. Being relatively young, and in relatively good health, I've got to do something with all that free time beyond writing blog posts few read, and lurking around Facebook and AuntMinnie.com.

A friend knew people who were going to create a flying hospital within an old 747 some airline was going to donate to them. I found this a fascinating concept, and I was forwarding suggestions as to which scanners and PACS and so on might be critical for such a project. Sadly, this has yet to get off the ground, so to speak.

A Merge Healthcare newsletter, however, revealed their partnership with RAD-AID, a world-wide Radiology project that IS active, and in fact has done quite a lot of good already in many far flung places.

Chicago, IL, 10 Sep 2015

Merge Healthcare (NASDAQ: MRGE) today announced a new global collaboration with the nonprofit organization, RAD-AID International, (US Registered 501c3) to bring vital radiology and health information technologies to medically underserved and poor regions of the world. The collaboration—RAD-AID Merge International Imaging Informatics Initiative (RMI4)—leverages Merge’s leadership in radiology information technologies with RAD-AID’s global health outreach network, including 3,500 volunteers, 14 country-outreach programs, 33 university-based chapters and affiliation with the United Nations’ World Health Organization (WHO).

WHO reports that nearly half the world has little or no radiology services. Moreover, most of these low and middle-income countries have no access to health information technologies, such as Picture Archiving and Communication Systems (PACS), Electronic Health Records (EHR), Radiology Information Systems (RIS), Hospital Information Systems and other life-saving health informatics platforms for storing, retrieving and interpreting patient data. In collaboration with Merge’s charitable contributions of software, technical resources and expertise in radiology image-management, RAD-AID will implement these health information technologies at the nonprofit’s partnered international sites along with RAD-AID’s ongoing delivery of clinical education, on-site training and radiology assistance to comprehensively support poor and resource-limited countries.

“This collaboration between RAD-AID and Merge represents a major step forward in bridging charitable outreach and health technologies for the mission of improving global health,” said Dan Mollura, chief executive officer, RAD-AID International.

Serving as an important foundation for this collaboration, RAD-AID has designed and deployed its Radiology-Readiness AssessmentTM tool since 2008, to assess, plan and deliver radiology in poor and medically underserved regions. Over the last seven years, these RAD-AID Radiology-Readiness Assessments confirmed the near-complete absence of health information technology in low- and middle-income countries. To begin addressing this significant health care disparity, RAD-AID and Merge developed RMI4. As a resource for carrying out this initiative, RAD-AID recently enhanced the Radiology-Readiness tool to include PACS-Readiness, a data analytics tool for specifically planning international deployment of PACS in facilities having little or no prior experience with imaging platforms.

“Merge takes corporate social responsibility very seriously and is excited to partner with RAD-AID to bring radiology and health information technologies to medically underserved and resource-limited countries across the globe,” said Justin Dearborn, chief executive officer, Merge Healthcare.

The collaboration envisions the creation of a constructive, educational and supportive roadmap for medical imaging facilities and health institutions in underserved regions of the world to adopt radiology imaging informatics systems.

Now THIS is what I'm talking about. Here's a chance to deploy the software I appreciate most in areas where it will do a tremendous amount of good. And maybe I could share some of my meager radiology expertise as well. (Ironically, when I first contacted RAD-AID, I was asked if I knew how to implement the dcm4chee open-source system, which I don't, but perhaps I won't have to learn it after all...)

RAD-AID itself is an interesting operation.

RAD-AID began in 2008 to answer this need for more radiology and imaging technology in the resource-limited regions and communities of the world. The organization began as a few people at Johns Hopkins, and has grown to include more than 3,500 contributors from 200 countries, 45,000 web visitors per year, 33 chapter organizations, and on-site programs in more than 14 countries.

RAD-AID’s mission is to increase and improve radiology resources in the developing and impoverished countries of the world. Radiology is a part of nearly every segment of health care, including pediatrics, obstetrics, medicine and surgery, making the absence of radiology a critical piece of global health disparity.

The organization sends teams to dozens of countries, and truly has a positive impact upon health care. I've been in touch in particular with the team working in Ghana, and there was even an immediate opportunity to go there which I can't at the moment.

But the need is great, and we all can help.

Go to RAD-AID.org, and consider volunteering. Even if you can't volunteer at the moment, please consider a donation, either to the Ghana project HERE, or to RAD-AID in general (popup link on their homepage).

This is a worthy cause, one which should be close to the hearts of those in the imaging business.

See you in Ghana! (Or maybe Nepal, or maybe...)

↧

Reporting In

January 25, 2016, 10:40 am

≫ Next: The Measure Of A Company

≪ Previous: RAD-AID

A few weeks ago, I received this message from one of the top Merge execs (emphasis mine):

Notification of Enhanced FDA Reporting Methodology

Dear Valued Customer,

As part of our commitment to ensure compliance and driven by our objective to deliver high-quality medical devices, we want to inform you of a change in our quality management processes to provide greater transparency to our customers and raise the bar on delivering quality in the medical device industry. I also want to take this opportunity to reiterate Merge Healthcare's commitment to implementing corrective actions to ensure compliance with the Federal Food, Drug, and Cosmetic Act and all regulatory requirements. Merge's executive management team takes the FDA’s observations seriously, and we have been fully cooperating with the FDA to resolve any questions or concerns expressed by the FDA.

Merge Healthcare has enhanced its FDA reporting methodology to report to the FDA product corrections and removals including those that may be classified by the FDA as Class III recalls. For clarity, Class III recalls signify the lowest potential risk situations, representing minimal impact to patient care. In this context 'recall' can be a form of communication and should not be interpreted as always requiring an update to a product. This change in policy will also increase transparency and notification to the FDA of Corrections and Removals associated with our medical devices. As a result, it is very possible that you will see an increased number of reported events on the FDA website. You will also see an increased number of messages from us, explaining the details around the event and any required action that may need to be taken.

So what does this mean to you? It means that we will continue to provide timely and comprehensive communication and information about the use of our products and overall product quality. It also means we will continue to deliver solutions you can trust and that help you provide the best patient care possible. And lastly, it means we will continue to provide world class support of those solutions and provide the opportunity for you to take advantage of our latest product advancements.

Merge Healthcare intends to advance the delivery of quality, patient-centric solutions in healthcare. We thank you for your continued partnership with Merge Healthcare and look forward to continuing to serve you for your current and future needs.

If you have any questions or would like to discuss this matter further, please feel free to reach out to me at your convenience.

I am gratified to read this; it is an upstanding and even courageous stance.

Software, being written by human beings, always contains some mistake or glitch or something. The PACS created by Merge, and its predecessor AMICAS, are no exceptions. THIS LINK takes you to the 11 complaints I could find about Merge PACS. THIS LINK shows a few more, older complaints when AMICAS ran things.

By the way, MAUDE in the list of problems stands for: "Manufacturer and User Facility Device Experience". I guess that could be positive or negative.

Having a problem? Your government is here to help you. Search for it at:

http://www.fda.gov/default.htm

↧

The Measure Of A Company

February 6, 2016, 10:23 am

≫ Next: Hostage Data

≪ Previous: Reporting In

The measure of a man cannot be whether he ever makes mistakes, because he will make mistakes. It's what he does in response to his mistakes. The same is true of companies. We have to apologize, we have to fix the problem, and we have to learn from our mistakes.

Wil Shipley

Software, being written by humans (until Watson gets the hang of it, I suppose) is going to contain errors. When the program has something to do with the medical field, those glitches could cause devastating effects.

Now being human as well, and having made my share of mistakes in interpreting images over the years, I'm not really trying to throw stones at the software folks. But when a glitch is found, there are ways to deal with it, and ways NOT to deal with it.

The latter is easy to recognize. Say one has a shiny new PACS system that skips CT slices intermittently. Telling the customer that it's an issue with the code, and the next fix will come roughly a year after the software went online is probably NOT the best approach. Having a PACS that sometimes doesn't inform the user that there are prior issues, and spending lots and lots of time backpedalling and outlining how the issue was bounced back and forth and back again within the corporate structure is definitely NOT how I want things handled.

So how should our friends in the medical software market do their mea culpa's? An excellent question. Here is how Merge Healthcare did it with two recent letters to their customers.

These two notices arrived January 27, 2016:

URGENT: MEDICAL DEVICE RECALL
Recall #2016-012
January 27, 2016
Dear Radiology Manager or PACS Administrator,
This is to inform you of a product recall involving:
Product:
Merge PACS™ V6.0.2.0 MR2 and earlier. We shipped these products May 2006 through June 2010, or earlier from Amicas.
Issue:
This recall has been initiated due to an issue in which the patient name in the Halo title bar may not update to match the name on displayed images due to the JAVA running out of memory.
Potential Harm:
Use of this product may result in a mismatch of the displayed patient name on the Halo title bar and the displayed images.
Product Containment:
A software update has been released which adds a warning message to the user interface for the user to close some viewers whenever the Java memory usage size exceeds 97%. The use of Merge PACS does not need to be discontinued.
Instructions:
An upgrade for Merge PACS is available for this issue. Call Merge Customer Service at (REDACTED) to schedule the upgrade.
If you decide to decline this maintenance release, please complete (REDACTED)

Please ensure that all users of the product are provided with this notification. Your assistance is appreciated and necessary to prevent patient harm.
If you may have further distributed this product, please identify your customers and notify them at once of this product recall. Your notification to your customers may be enhanced by including a copy of this recall notification letter.
Merge Healthcare is committed to improve efficiencies and enhancing the quality of healthcare worldwide. If you have any additional questions, call Merge Customer Service (REDACTED)
This recall is being made with knowledge of the Food and Drug Administration.

And...

URGENT: MEDICAL DEVICE RECALL
Recall #2016-012
January 27, 2016
Dear Radiology Manager or PACS Administrator,
This is to inform you of a product recall involving:
Product:
Merge PACS™ V6.0.2.0 MR2 and earlier. We shipped these products May 2006 through June 2010, or earlier from Amicas.
Issue:
This recall has been initiated due to an issue in which the patient name in the Halo title bar may not update to match the name on displayed images due to the JAVA running out of memory.
Potential Harm:
Use of this product may result in a mismatch of the displayed patient name on the Halo title bar and the displayed images.
Product Containment:
A software update has been released which adds a warning message to the user interface for the user to close some viewers whenever the Java memory usage size exceeds 97%. The use of Merge PACS does not need to be discontinued.
Instructions:
An upgrade for Merge PACS is available for this issue. Call Merge Customer Service at (REDACTED) to schedule the upgrade. Reference this recall #2016-012.
If you decide to decline this maintenance release, please (REDACTED)

Please ensure that all users of the product are provided with this notification. Your assistance is appreciated and necessary to prevent patient harm.
If you may have further distributed this product, please identify your customers and notify them at once of this product recall. Your notification to your customers may be enhanced by including a copy of this recall notification letter.
Merge Healthcare is committed to improve efficiencies and enhancing the quality of healthcare worldwide. If you have any additional questions, call Merge Customer Service at (REDACTED)
This recall is being made with knowledge of the Food and Drug Administration.

You get my drift. Face up to the glitches, let the customers who haven't yet found them know they exist, and FIX them. Sounds like a plan. A plan other vendors need to follow a bit more religiously.

↧

Hostage Data

February 18, 2016, 6:05 am

≫ Next: Brother, Can You Spare A Dime ($0.10 CAD) For A PET?

≪ Previous: The Measure Of A Company

I was first alerted to the situation by my friend Stacey, who directed me to the story on the Daily Kos. I tend to avoid that site like the plague, but I had to read this story. Fortunately, the author, "Medical Quack", has the information on his own blog, and the story has since been picked up by many other news outlets, including Fox.

Here are the facts from Medical Quack:

A Southern California hospital was a victim of a cyber attack, interfering with day-to-day operations, the hospital's president and CEO said.

Staff at Hollywood Presbyterian Medical Center began noticing "significant IT issues and declared an internal emergency" on Friday, said hospital President and CEO Allen Stefanek.

A doctor who did not want to be identified said the system was hacked and was being held for ransom.

There is no information that any patient or employee information was compromised, but the hospital called in computer forensics experts, and the FBI and the LAPD to investigate.

The hospital's emergency room have been sporadically impacted since Friday, Stefanek said.

The unnamed doctor said that departments are communicating by jammed fax lines because they have no email and that medical office staff does not have access to email.

9000 bitcoins is the price demanded to give the hospital back the “key” codes to open the system back up. 911 patients are being diverted to other hospitals.

The hospital seems to be keeping it pretty quiet and I guess really what else can they do as paper back up files come out as they always do in times when the EHR goes down.

This disruption is raising havoc with getting access to all the patient information needed at times. Radiation and Oncology has been shut down and they are not allowed to turn on their computers.

The Daily Kos quoted all this directly, but revealed the EMR vendor in the title of the piece:

Hollywood Presbyterian Medical Center McKesson EHR Hacked And Hospital Data Being Held for Ransom..

If you prefer a little less innuendo and speculation, here's the FoxNews version:

A Los Angeles hospital paid a ransom of nearly $17,000 in bitcoins to hackers who infiltrated and disabled its computer network because paying was in the best interest of the hospital and most efficient way to solve the problem, the medical center’s chief executive said Wednesday.

Hollywood Presbyterian Medical Center CEO Allen Stefanek said the hackers demanded a ransom of 40 bitcoins, currently worth $16,664. The FBI is investigating the attack, which began on Feb. 5.

Authorities said this kind of attack is called “ransomware,” where hackers encrypt a computer network’s data to hold it “hostage,” providing a digital decryption key to unlock it for a price.

"The quickest and most efficient way to restore our systems and administrative functions was to pay the ransom and obtain the decryption key," Stefanek said. "In the best interest of restoring normal operations, we did this."

This implications of this sad situation are staggering. Some little twerps, most likely operating from outside of the United States, brought a hospital to its knees, forcing it to pay a ransom to continue operations (and surgeries too, we assume.) I'll bet this has happened before, but hasn't been reported by the IT and IT Security folks affected. I'd be embarrassed too. That the little miscreant involved settled for "only" $17,000 in untraceable Bitcoins suggests that he is but a lowly amateur. And that is even more frightening. If some high-school kid in an Internet cafe can do this, what could government-backed (and you know which governments I mean) hackers accomplish? What could ISIS-owned hackers do to us?

Everything we associate with daily life is hooked into the Internet somehow. Communications, entertainment, health-care, power plants, missile launchers...pretty much everything. Now I'm a firm believer in individuals, companies, enterprises, etc., taking reasonable precautions against hackers. Cybersecurity is big business and rightly so. But the relatively minor incident in California is a HUGE wake-up call, not that we really need it. Hacking our infrastructure via the 'Net is a huge national security issue. We are in just as much danger from the hackers as we are from the crazy kid in North Korea with the bad haircut and shiny new intercontinental ballistic missiles. With a few key-strokes, a hospital was taken down (proving Dalai's First Law in the process: PACS IS the Radiology Department). With a few more, a nuclear power plant could shut down. Or melt down. That's no exaggeration.

We the People need to be protected from this sort of thing, and it is our government's job to do so. Yes, they are trying, half-heartedly, without adequate time, money, or effort, to fight against a hidden enemy. I've been told by execs from phone companies that the telemarketers hacking and spoofing their systems have better software and better technology than we do. If they can bollux our phones, if we can't defend our communications networks, we're sunk.

Our administration, in its infinite wisdom, will be turning over control of the Internet to the UN. Great. Most governments of Third World nations, not to mention quite a few Second World countries, ISIS, and other nice folks, either ignore illegal Internet activity, or actively encourage and participate in it. And there are no consequences from us. Zero.

How to solve this? Somehow we have to let our "friends" overseas know that we won't tolerate this anymore. Do we have to sever the Internet backbones? I hope not but unless the rest of the world will police their own vermin, we will have to do it for them, or at least isolate ourselves from the infection. There need to be sanctions, fines, treaty revocations, and I don't know what else to put a stop to this.

As for home-grown United States-based hackers, we have to institute some VERY severe punishments. Up to and including capital punishment for anyone whose illicit activity leads to the death of innocents. And we have to have a moon-shot level program to boost our technology to surpass that of the criminals.

I'm mad as Hell about this. Our government has failed to protect its citizens, and that has to change.

NOW.

↧

Brother, Can You Spare A Dime ($0.10 CAD) For A PET?

February 20, 2016, 5:18 am

≫ Next: My New Workstation

≪ Previous: Hostage Data

The Canadian healthcare system has been touted as the most wonderful thing since sliced bread, the epitome of the Single-Payer model, the Way It Should Be Done, the ultimate, logical manifestation of where we are headed. The Affordable Obama Care Act is, of course, just a brief bus-stop on the highway to Canada.

But wait just a moment, eh? All is not perfect in the land of the frozen. How many Americans (or Saudis or potentates of various small nations) go to Canada for esoteric, life-saving surgery? Conversely, how many Canadians cross the border (no wall as yet) for their care? (Answer: Depending on the source and the year, upwards of 50,000.) Yes, drugs are cheaper Up North, because the Canadian government artificially caps the prices, forcing us hosers in the U.S. to pay the difference.

It seems that some procedures might require a wait. A long wait. In fact, wait times are so much a part of the Canadian healthcare culture that there are official websites devoted to telling our Canuck friends just how long they'll have to wait. Here's the link from the Ontario Ministry of Health and Long Term Care, for example.

If you should happen to check Diagnostic Scans, you'll be able to chose CT or MRI. Let's pick MRI, and then select a nice town in Ontario called Sudbury, which yields:

Diagnostic Scans
Magnetic Resonance Imaging (MRI)| Target:28 days
[Oct-Nov-Dec15]

View shortest wait times in the province for this service

Hospital Name	Location	Wait time (days)
Provincial Wait Time (9 out of 10 patients complete their procedures in this time)		101
Hôpital régional de Sudbury Regional Hospital	Sudbury	83
Northeast Mental Health Centre	Sudbury	NR/NS

Can you imagine the b*tching and moaning you would hear if you told an American he/she would have to wait over three months for an MRI? Yanks get upset if they can't get their scan the day it's ordered.

The site above doesn't mention PET/CT scans, and there's a reason for that. There are 12 (give or take) PET/CT scanners in all of Ontario, and utilization is, well, a bit different than we see here in the States:

The volume and percentage of PET/CT scanning across the province in 2013 remained steady in relation to the previous year (Figures 2 and 3). The number of completed oncology-related PET/CT scans per million population increased from 510 in 2011 to 671 in 2013, which may be a result of an increase in the population of the province and of rising cancer incidence rates (Figure 2). The increase also might be attributed to some head and neck cancers becoming part of the insured indications for PET/CT scans in April 2012.

That would be just under 700 PET/CT scans per million, yes? In the US, that figure is 5,000 per million population. In fact, here is a breakdown of scanner distribution and utilization in some of my favorite countries, although some of the numbers are a little older:

Which brings us to the PET/CT status of Sudbury, Ontario, which is either heartbreaking or heartwarming, depending on your point of view. It seems that the citizens of Sudbury themselves have been asked to pay for the regional scanner themselves. The following quotes are all from the Canadian Broadcast Company (CBC):

Sudburians have spent years trying to raise millions of dollars to buy its hospital a PET scanner. A Positron Emission Tomography (PET) machine uses a type of sugar to detect cancer, cardiac issues and even dementia.

The Ministry of Health and Long-Term Care has told the city it's up to residents to raise the money needed to buy the region's first machine, which is estimated to cost as much as $5 million dollars.

The machines are cheaper than that, but you have to have a shielded room in which to put them, and a great deal of additional infrastructure, so the price is probably not far off the mark. Or the CAD. But this sure sounds unusual. Making the patients pay for the scanner? I knew this sounded familiar, and in fact, another Ontario hospital, Seaforth Community in East Huron, had to hold a radiothon to pay for its PACS in 2007. Again, the money just isn't there for a critical service. Well, we assume the money just isn't there, eh?

A Sudbury doctor says his community's struggle to get an important piece of cancer detection equipment is another example of the provincial government's attempt to block the technology...

The Ministry of Health and Long-Term Care has told the city it's up to residents to raise the money needed to buy the region's first machine, which is estimated to cost as much as $5 million dollars.

Dr. Dave Webster says asking the community to foot 100 per cent of the bill is a way for the ministry to purposefully slow down the introduction of PET technology across Ontario.

"It's quite simple. They don't want to pay for it," he said.

Webster, a nuclear medicine doctor who has fought for decades to bring more PET scans to the province, said the machine can accurately detect cancers that MRI and CT scans cannot.

"You have patients that would have survived their cancer had they had a PET scan at an appropriate time," he said. "And similarly, there are people that are told therapy is not possible and the PET scan shows they are."

"People in Ontario are more likely to die simply because they will not have access to what has simply been the standard of care on following up with cancer patients for more than a decade," he said.

Windsor doctor Kevin Tracey was a founding member of a ministry-backed committee set up more than 15 years ago to bring PET technology to Ontario.

He said he resigned in protest because the government was purposefully slowing down access to the scan.

"Basically, we're holding the number of patients down that need scans done. I'm sure there's monetary reasons why that's done," he said.

Tracey said Ontario is doing fewer PET scans than just about anywhere in the western world.

Ontario performs 11,000 PET scans per year, according to Cancer Care Ontario, while Quebec performs nearly four times that number, more than 40,000 scans annually, with a much smaller population.

There is a very personal facet to this particular PET tale:

(The decision to fund PET operations) was an early Christmas present for the family of Sam Bruno, a man who spent the final years of his life trying to bring a PET scanner to Sudbury...

Since his death five years ago, Bruno's family has spent years raising money for a PET scanner in Sudbury — and on Tuesday were one big step closer to realizing their dream.

The province has agreed to spend $1.6 million each year to operate the machine.

The community needs to raise $2 million more to make it a reality. A total of $1 million has been raised so far.

Hoskins said he hopes his ministry's funding commitment will be a shot in the arm to fundraising efforts.

Having a PET scanner in Sudbury to service northeastern Ontario patients means people like Bruno will no longer have to travel to Toronto for tests.

You might think Sudbury is too small for a PET/CT. You would be wrong. Sudbury has over 160,000 citizens, not much smaller than my little town in the Deep South. And we have three PET/CT's here. Sudbury has an-otherwise state-of-the-art oncology facility, lacking only PET/CT.

"We should have had it a long time ago," said Wayne Tonelli, co-founder and president of the Miners for Cancer charity. "We have a world-class facility here in Sudbury with our cancer centre. Let's get some world-class equipment here."

I'm assuming the "Miners for Cancer" actually favor a cure for cancer.

Editorial time. Forgive the somewhat jingoistic language to follow.

The healthcare here in the United States is good. Really, really good. People who can afford to do so come HERE to be diagnosed and treated. Those who can afford to come HERE do NOT go to Canada. Or Germany. Or Switzerland. Or Sweden. Or India. Or Anywhere Else. I'm not saying I contribute much, if anything, to it, but the best medicine in the world is practiced in the United States. Now I don't think our system is perfect, and I have called for massive reforms, dumping Obamacare, Medicare, Medicaid, and revamping the whole thing including a huge revision of the laws governing the Third-Party Payers, our beloved insurance companies. Ours is a dysfunctional system and it has to be revised. But even with its blemishes, ours produces some of the best medicine in the world.

And yet, in our inexorable march toward Socialism, led by demagogues who would have us trade everything that makes America America for "free stuff", American health care stands to be crippled in the process of making it "free". And by the way, nothing is "free". Someone has to pay for the "free stuff".

We need to look at the case of Sudbury's PET/CT and understand the implications. There isn't enough money in Ontario to provide "free" PET/CT for Sudbury, and in fact, funds for this life-saving technology are limited province-wide. Thus, the fine people of Sudbury will have to fund the purchase themselves. That they are willing to do so to help their fellow citizens is the heartwarming part of this story. The heartbreaking aspect is that they have to do so. I see this as a huge crack in the perfect facade of Canada's single payer system. It FAILED the people of Sudbury. And it fails the people of Ontario, and indeed all of Canada by limiting resources and thus rationing their care.

In response to my East Huron Radiothon post of 2007, a (probably former) reader commented:

As a personal friend, and former patient of Dr. (mentioned in article), I need to comment!

Our healthcare is NOT free, but our taxes allow us wonderful healthcare, and an above-average level of access to all kinds of medical tests etc. What we need, we get. It's easy to stand in the U.S. and throw stones, but around here (Southern Ontario) we decide how many kids to have by deciding how many kids we WANT to have, rather than by how many our insurance (or lack thereof) will pay for! We take our kids to the doctor when they NEED to go, not when we have enough money to pay a co-pay!

My son was special-needs...yes, born at Seaforth Hospital. He received first-rate care, with swift and appropriate transport to Children's Hospital. On day 3, I heard a PCCU nurse say of my son "Well, there's a million dollar boy!", meaning his cost of care had already topped the million dollar mark. Had my husband and I NOT lived in Canada, our grandchildren would still be paying off the cost of that hospital stay...let alone the other numerous hospital stays our son had through his life.

We don't have a problem donating for good causes...we're neighbours. That's what good neighbours, and good citizens do.

It's hard to argue with this statement, but read it again. Maybe twice more. "What we need, we get." Sounds a little bit too close to "From Each According to Their Abilities, to Each According to Their Needs". But then maybe I'm biased.

The profit motive has brought an overabundance of expensive CT, MRI, and PET/CT scanners to the United States, with the inherent likelihood of over utilization. Contrast this to the neighbourly situation in Ontario which requires the citizens themselves to raise money for life-saving technology that the government, even using the generously given tax-dollars (CAD) cannot provide. Better to over-utilize, or better that ". . .(p)eople in Ontario are more likely to die simply because they will not have access to what has simply been the standard of care on following up with cancer patients for more than a decade..."? You tell me.

"Free stuff" can have a very high price-tag.

↧

My New Workstation

February 21, 2016, 6:46 pm

≫ Next: Merge CEO Leaves To Run Tribune Publishing

≪ Previous: Brother, Can You Spare A Dime ($0.10 CAD) For A PET?

I sit on my backside most of the day, staring at a workstation monitor. At some sites, I have the Herman Miller Aeron chair, which is OK, but there has to be a better way to sit and think and interpret, and whatever else it is I do all day.

And here it is:

The Altwork Company has come up with a better way, a "new way to work," the Altwork Station. Look at the pictures and watch the video, and I think you'll agree, it has got to be better than what most of us do now.

This next step in workspace evolution is fairly reasonable as such things go...

As an early adopter, you’ll be one of the first people on Earth to have a workstation that works with you.

The list price for an Altwork Station is $5,900, but for our early adopters, we’re offering significant discounts.

Our early discount program will provide a forum for you to get to know us, and for us to get to know you as we build, deliver, and support a workstation that will change the relationship between you and your work.

There are two options for Altwork early-adopter discount customers:

Buy Now – $4,900 or $3,900

Signature Altwork Station – $4,900 includes:

Lock-in early adopter discount of $1,000
Choose from 10 custom upholstery colors, 3 frame colors, 4 desk and accent colors
Engraved commemorative plate with unique serial number
Priority manufacturing and shipping (you’ll be the first on your block)
Limited quantity available
Price does not include shipping

Altwork Station – $3,900 includes:

Lock-in early adopter discount of $2,000
Choose from 2 pre-configured color palettes
Priority manufacturing and shipping (you’ll be the second coolest kid on your block after Signature series, which is still pretty cool)
Limited quantity available
Price does not include shipping

I think I could do without the Signature Version. On second thought, why not go all the way?

I think my backside is worth it!

↧

Merge CEO Leaves To Run Tribune Publishing

February 24, 2016, 12:10 pm

≫ Next: Cinders, EHRs, and Other Disappointments

≪ Previous: My New Workstation

Is it me? Is it something I said?

I keep having to break in new CEO's at Merge Healthcare, and AMICAS before that.

Back in the AMICAS days, I apparently chased out Hamid Tabatabaie. Then Peter McClennen. Then Steve Kahane. Then Merge came on board, and I thought I had a keeper with Justin Dearborn. But alas, he too has seen the light.

I'm kidding, of course, about me having much of anything to do with anything at Merge, but it is true that Justin Dearborn is leaving Merge to become the CEO of Tribune Publishing. From the Chicago Tribune, one of the papers TP manages, comes this article, dateline yesterday:

Three weeks after welcoming Michael Ferro as the largest shareholder and nonexecutive chairman of Tribune Publishing, Jack Griffin is out as CEO.

Griffin, who has guided Tribune Publishing since its August 2014 spinoff, has been replaced by technology executive and longtime Ferro associate Justin Dearborn, the Chicago-based newspaper company confirmed Tuesday.

Dearborn, 46, had been CEO of Merge Healthcare, a Ferro-controlled medical technology company that was acquired by IBM in October.

"Although this is a different medium than my last technology company, it has the same challenge on how to create the highest value for our content," Dearborn said in the news release.

Michael Ferro, as my readers know, bought the scraps of Merge years ago, and then purchased AMICAS to give the reborn company a working PACS.

Tribune Publishing owns the Chicago Tribune, Los Angeles Times and other major newspapers. When Ferro's acquisition was announced, Griffin called Ferro "a tremendous admirer of our brands at the Tribune … so it's a winning combination for our company."

{snip}

Dearborn, who has no media experience, takes the helm of the legacy newspaper company as it struggles to reverse years of industrywide revenue declines and transition to a digital-first medium. He has a long track record with Ferro, the two having worked together on Internet software company Click Commerce, investment firm Merrick Ventures and most recently Merge Healthcare, a Chicago-based medical software company that was sold to IBM for about $1 billion, including the assumption of nearly $198 million in debt, according to Dealogic.

In June 2008, Merrick Ventures bought a controlling stake in Merge, which had been reeling from an earlier accounting fraud scandal, for $20 million, including a $15 million loan. Dearborn was installed as Merge CEO the following month.

Although Merge didn't turn a yearly profit under Ferro's and Dearborn's leadership, the development of an artificial intelligence initiative to analyze medical diagnostic records caught IBM's eye last year, leading to the sale of the company.

Merrick's 23.5 percent stake in Merge was valued at nearly $190 million in the IBM transaction.

Congratulations to Mr. Dearborn. He is incredibly capable, and I'm sure Tribune will thrive under his leadership. Perhaps with his connections, we will see Watson trained to read the various newspapers and provide commentary. That would be about the only column I would pay to read.

In the meantime, I'm waiting to find out something very important to us customers...Who will take the helm at Merge?

↧

Cinders, EHRs, and Other Disappointments

March 6, 2016, 5:46 pm

≫ Next: Lingering Frustration And Bad Design

≪ Previous: Merge CEO Leaves To Run Tribune Publishing

I admit to being addicted to new technology. I love gadgets of all shapes, sizes, and sadly, prices. If there's some technological toy out there I'm missing, let me know and I'll run right out and buy it.

The crowd-funded sites, Kickstarter and Indiegogo, are the perfect trap for ~~suckers~~ people like me. Here, we find a plethora of inventions that one just has to have, requiring only a small investment for a piece of the future. Dangerous places, these.

Sometimes, the invention is so outlandish that it doesn't get funding, but some creations are so tempting and apparently within the realm of possibility that the rubes like me line up to part with their hard-earned cash. I've fortunately only gone down the tubes once, that on a pre-Apple Watch smartwatch wherein the inventor collected funds but never actually made a working copy of his invention. Fortunately, I didn't lose much on that one.

A more frustrating situation arises when the invention sort-of works but doesn't really. Such was my experience with Cinder, a screen protector for the iPhone 6 series.

The enticing property of the Cinder that made me dump a perfectly good Rhino-Shield was the curve...curved edges, that is, as you can sort of make out in the picture above. And why do we need this? Just ask Cupert, the makers of Cinder:

We created CINDER - the picture-perfect, seemingly invisible, ultra-thin glass screen protector with a form-fitting, edge-to-edge wrapped screen design, providing the ultimate user experience.

Unlike dull and ordinary flat screen protectors, CINDER beautifully combines flawless form with practical functionality in a precision-fitted, curved glass screen protector with specially-developed nanotech adhesive to ensure easy installation and reusability.

{snip}

Engineered to be the most elite, user-sensitive screen safeguarding accessory, CINDER protects your iPhone 6 or iPhone 6s at the highest possible level without compromising design or functionality. Real curved glass edges seamlessly wrap around the iPhone 6 and 6s Series screen - no gaps or hard edges to chip. Just impeccably beautiful, iPhone-flattering protection that’s practically invisible.

Nice idea, but for the majority of users, per Amazon.com reviews, the Cinder just didn't work. It was not washable as claimed, it was very fragile, often breaking when installed, and it was not made from Corning Gorilla Glass as had first been claimed. For me, the problem was that it did not snugly fit around the glass of the screen, and thus, it was dislodged by the iPhone's protective case, and you MUST use a case to cocoon your iPhone should it fall to the floor. When I informed Cupert that every single case I tried knocked their stupid Cinder off the screen, they simply said, "Try another case." No refund, no nothing. So instead of the damnable Cinder, my iPhone now sports a Thule case with built-in screen protector, and I'm pleased with it. But I now have about $100 of unusable protectors and cases sitting in my drawer, thanks to my infatuation with a concept that just wasn't properly produced.

There are probably a million other similar product design missteps like the Cinder. Even Big Companies like Fiat-Chrysler can go down the tubes on a foolish idea. Take something as mundane as a gear-shift lever:

Image courtesy FoxNews.com

You would think it hard to bung that up, but you would be wrong. From FoxNews:

Electronic gear shifters on some newer Fiat Chrysler SUVs and cars are so confusing that drivers have exited the vehicles with the engines running and while they are still in gear, causing crashes and serious injuries, U.S. safety investigators have determined...

Agency tests found that operating the center console shift lever "is not intuitive and provides poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection," investigators wrote in the documents. They upgraded the probe to an engineering analysis, which is a step closer to a recall. NHTSA will continue to gather information and seek a recall if necessary, a spokesman said...

In the vehicles, drivers pull the shift lever forward or backward to select gears and the shifter doesn't move along a track like in most cars. A light shows which gear is selected, but to get from Drive to Park, drivers must push the lever forward three times. The gearshift does not have notches that match up with the gear you want to shift into, and it moves back to a centered position after the driver picks a gear.

And so it is with EHR's. These gargantuan and hideously expensive systems have great potential to improve health care, but unless they are well-made, and programmed for success, they can do just the opposite. And they do.

I hope you are already a fan of ZDoggMD, a physician-rapper (much funnier than a physician-blogger). ZDogg has encapsulated the frustrations with today's EHR's in this painfully hilarious video:

You will find the lyrics and background information on ZDogg's website.

His bottom line is this:

Simply put, the Tower of Babel of existing EHRs may not ever talk to one another, but they do share one thing: they come between us and our patients. Staring at a screen to click boxes and satisfy quality measures while figuring out the seventeenth digit for an ICD-10 code—this nonsense robs us of precious time and attention that should be spent on and with patients. I would never advocate going back to paper. Ever. But we need to demand technology that binds us closer to those we care for, technology that lets doctors be doctors. And nurses, and RTs, and case managers, and dietitians, and scrub techs—[insert crucial care team member here].

Which is what I've been saying for YEARS about PACS. The damn things work just enough to justify their existence, barely. They are clearly designed by people who do NOT understand our workflow, and they get between us and our patients, or their images, anyway. This is not how it should be. So why are EHR's so hard to use? Easy. Poor design, poor testing, and no real incentive to change.

As with PACS, EHR's are sold not to the end-users, but to the IT department and the CTO/CIO, who probably have absolutely no idea how it should work. Their criteria will be some combination of the following:

Which product is cheapest?
Which product is most expensive? (If it costs more it must be better!)
Which is the Big Name Company that everyone thinks you have to have?
Which company will do the maintenance and let IT off the hook?

Notice that having the thing actually work in the hands of those who use it is not on the list.

A comment on ZDogg's page from someone who claims to work for THE Big Name in the EHR business is quite revealing:

People wonder, "why aren't EHRs designed with providers in mind?" I've worked at Epic and can tell you why not:
Physicians were on staff, but hard to reach. They were technophiles and barely practicing as others mentioned.
It really is a billing platform with some patient stuff tacked on. Everything useful you see is probably a workaround and one level away from not working at all.
Quality Assurance (manual testers) are supposed to be a surrogate for users, as there is no beta testing. They are intentionally hired without CS background and maintained as laymen with a very lite, monkey-see-monkey-do training. However if they are not lickety-split quick to master the software, they are fired. Quality Assurance ends up being more like Self-Reassurance.
There is absolutely no testing of interoperability. There is however plenty of testing for the several convoluted ways of sharing data between Epic servers.

And in fact, interoperability is another HUGE bugaboo with EHR's. As ZDogg rapped, er, said in the video, "Bought the new software, and though we use it here, I can’t use it over there, different systems everywhere!" In fact, Epic has been charged with overtly blocking data from other systems. Rather ominously, the original piece from ihealthbeat.org has been taken down, or at least yields a 404 error. But what happens in Vegas stays on the internet, and so the cached version is still accessible:

Thursday, November 5, 2015

Connecticut reportedly has launched an investigation into several hospital networks and Epic Systems over their information sharing practices after a state law (S 811) took effect last month, prohibiting the use of electronic health records to block the flow of health data, Politico reports.

Background on Law

The law, which was passed in June and took effect Oct. 1, makes information blocking an unfair trade practice and subjects violators to penalties. According to Politico, the law based its definition of information blocking on the one used in the Office of the National Coordinator for Health IT's April information blocking report.

In addition, the law aims to slow the rate of health care network consolidation.

State Investigating Complaints

According to Politico, the Connecticut Attorney General's Office is reportedly investigating complaints under the law, including those against Epic and health systems in the state (Allen, Politico, 10/30).

The investigation stems from independent medical groups' allegations that hospital networks are using EHRs to dictate patient referrals and bring patients back to their networks (Walsh, CMIO, 11/3).

Critics allege that Epic -- which holds more than 50% of the state's hospital EHR market -- is unfairly collaborating with certain health networks against smaller physician practices.

For example, state Sen. Len Fasano (R), who co-sponsored the new law, said he heard anecdotes about physicians struggling to access patient information recorded at large hospitals, in particular Yale-New Haven Health System.

He said, "It was impossible for them to gain access to a patient's full medical record unless they were associated with the hospital," adding, "Independent doctors cannot properly care for their patients if they are denied access to full medical histories."

Meanwhile, state Senate President Martin Looney (D) said Epic was being used "as both a coercive tool to shut out nonparticipating practices and, in some cases, force them to be sold to larger health care networks."

Epic's Response

Epic spokesperson Eric Helsher said the vendor is not responsible for creating the conditions that led to such complaints, noting that the health care landscape is changing.

He said, "Physicians are aligning with health systems to reduce costs and improve patient outcomes," adding, "Epic enables this alignment by providing deep integration around a single patient record, a robust patient portal to increase patient engagement, and population health management and analytics tools that drive coordinated care" (Politico, 10/30).

So...Epic admits no responsibility although it created a proprietary system in a space that should be trying to integrate. Heck, even the majority of dysfunctional PACS can talk to each other, at least to some degree. Epic's stance is tantamount to Apple saying that from now on, an iPhone can only call other iPhones, but why would you want to communicate with a filthy, stinkin' Android anyway? Not cool, and at least in Connecticut, not legal.

And this unbelievable combination of hubris, arrogance, and indifference to the real needs of the patients, let alone those of us striving to take care of them, sets a rather nasty tone for the future.

I have said repeatedly on this blog and elsewhere for the past eleven years that PACS is a critical, life-saving creation. Dalai's First Law, in fact, states that PACS IS the Radiology Department. And as it is used today, the EHR the patient's entire record, and his connection to healthcare. Nothing happens in an electrified hospital that doesn't pass through the EHR. If it works, great. If it fails, people die. You might recall the little Ebola episode in Dallas from 18 months ago, and the Epic Fail that contributed to the near-disaster. (I say "near" because "only" one person died that time.) What I said then is still true:

Do you sense a familiar refrain? (Lawyers please note...THIS IS ALL MY VERY OWN HUMBLE OPINION, as is every other word that I have ever written or ever will write, unless quoted from someone else, and worth every cent my dear readers paid for it.) Once again, here in the Health Care Field of Dreams, we have badly written, badly designed software, created with minimal input from those who have to use it, selected and then implemented by IT types who also don't have to use it and don't understand enough about those who do to get it done right. This has to stop. Right. Bloody. Now. Hit CNTL-ALT-Delete and start over.

With Epic and the government having their hands deep inside each others' panties, we may well be stuck with these unusable systems for the foreseeable future. (And as an aside, if you deconstruct the Meaningful Use rewards and penalties, doctors are being bribed to buy EHR's that have the certified and confirmed ability to transmit data to Washington, D.C., so again, we won't expect the government to do anything about anything.) But, the demise of Mr. Duncan, and no doubt dozens if not hundreds more that he inadvertently infected between his two ER visits may level the playing field.

It is clear that Epic's epic Dallas fail (which might not really be totally attributable to Epic per se, but rather to the way the product was set up in the field, not passing that one lil' bitty critical entry to where it should go), contributed to Mr. Duncan's being released when he should have been locked up in the local version of Wildfire. It is possible, just barely possible, that this tragic episode will awaken the public to the dangers inherent in the IT-controlled medical software industry and its acronymbysmal spawn, EHR's, CPOE's, and the occasional unruly PACS. Get enough people upset about this, and they will call their congressmen, and more importantly their lawyers. (I would submit that more gets done by class-action suit in this country than by Congress.)

I realize that replacing these huge legacy systems which were outdated before they were even conceived would cost somewhere in the trillions of dollars, and so I'm not holding my breath that this will ever happen. But maybe a few million and billion dollar suits and fines would get the attention of the Epics, the Cerners, McKessons, and all the others who create these nightmares. Or maybe, just maybe, the execs will read this, and the other rebellious propaganda we are starting to see online, and realize that they are causing damage rather than progress, and be inspired to turn it all around. I'm a staunch believer in the electronic record, PACS, computers, iPhones, Apple Watches, and anything else technical. This is the future, without question. But it has to be done right, and so far that hasn't happened.

And don't underestimate the power of the individuals. Go to ZDogg's site, letdoctorsbedoctors.com, and express your opinion about EHR's. It's a start.

This sorry state of medical software cannot go on. The time has come to fix it. Now.

↧

Lingering Frustration And Bad Design

March 27, 2016, 6:39 am

≫ Next: PACS Tidbits

≪ Previous: Cinders, EHRs, and Other Disappointments

Mrs. Dalai loves HGTV, and so I end up watching it quite a bit. I think I've even become somewhat of a house connoisseur after all this time.

So let's look at a house, pictured above. Wouldn't you love to live in this house? It's a great house! 4 bedrooms, 3 bathrooms, gourmet kitchen with granite countertops, stainless steel appliances, the whole nine yards! The house contains every gadget you could possibly want.

But there's a problem. The house was designed by someone who lives in a cave and doesn't drive a car. It is part of, well, a rental community, owned by an absentee landlord who will never set foot in the neighborhood, living in a corner office suite in some skyscraper somewhere. Can you see what's wrong? Hopefully, you did before you moved in. Because once you're in, it's too late.

My metaphor might be a bit stretched, but I think it is clear nonetheless. It is all too easy to design something wrong when you don't know anything about those who will use your product, and when the end-users aren't even the targets of your sales pitch.

So it is with PACS and EMR's, and so I've been saying here and elsewhere for a very long time. But it seems that with the greater penetration (government-mandated or not) of EMR's has come a deeper understanding and acknowledgement of just how flawed they are from the user's standpoint, the only one that counts.

This graphic from Gomerblog nicely outlines the problem:

And I will shout about the problem as loudly as I can:

THE PEOPLE THAT CREATE THESE PRODUCTS AND THE PEOPLE THAT BUY THESE PRODUCTS ARE NOT THE PEOPLE THAT USE THEM!!!

Moreover, there seems to be very little interest in correcting this.

But wait, the world is beginning to feel our pain, and attention is coming from a very unlikely source: the government! Read this article, "Frustrations linger around electronic health records and user-centered design" in Healthcare IT News, and be encouraged. At least some in relatively high places seems to get it:

In a provocative prime-time speech, meanwhile, Acting CMS Administrator Andy Slavitt threw down the gauntlet: "I'm certainly not bashful about what we need to do better, and I'm not going to be bashful here, even in the face of some very good reasons for optimism, about ways we need to take our game up across the board.”

The health IT industry has done very well in the years since the HITECH Act, said Slavitt. "But we're still at the stage where technology often hurts rather than helps physicians providing better care."

Wow. Someone from the government is here to help us! He actually said out loud what I've been saying for years. These poorly-written, outlandishly expensive software extravaganzas can HURT patients. Yowza!

Mr. Slavitt, my new governmental hero, continues my, I mean his, rant:

To bolster his case, he rattled off a series of actual quotes from frustrated clinicians. One complained that in his EHR, "to order aspirin takes eight clicks; to order full-strength aspirin takes 16." 

Slavitt said CMS is newly committed to taking a "user-centered approach to designing policy." He asked vendors to do the same, with a similar spirit of empathy: "Step back and look at what you don't think is working, and make it better."

This, from CMS? Someone pinch me...

Perhaps the additional attention comes from the fact that more and more physicians have become disgusted with the status quo:

That dissatisfaction is getting worse, not better. A study published this summer by the American Medical Association and the American College of Physicians found that physicians are more frustrated with EHRs than they were five years ago.

Forty-two percent of respondents said their EHR system’s ability to improve efficiency was "difficult or very difficult." Some 72 percent said the same about its ability to decrease workload.

We saw similar feedback in Healthcare IT News' first-ever EHR Satisfaction Survey this past fall. In addition to numerical scores, we also asked for anecdotal feedback from more than 400 people who took the poll. Opinions such as "not very intuitive,""cumbersome" and "too many clicks" cropped up over and over again.

So what's the problem? As usual, that can be stated with two little letters: I and T. The article continues:

In his landmark book, The Design of Everyday Things, Don Norman, director of The Design Lab at University of California San Diego wrote:

"The reasons for the deficiencies in human-machine interaction are numerous. Some come from the limitations of today's technology. Some come from self-imposed restrictions by the designers, often to hold down cost. But most of the problems come from a complete lack of understanding of the design principles necessary for effective human-machine interaction. Why this deficiency? Because much of the design is done by engineers who are experts in technology but limited in their understanding of people."

Of course, in healthcare IT there are other challenges. EHR vendors would probably love to have all their products look as sleek and intuitive as the latest iOS release. But they also have to ensure they check all the boxes to comply with certification criteria from the Office of the National Coordinator – all 560 detailed pages of the 2015 Edition.

"I know some people inside big EMR companies who want to do excellent design, but in an organization that's owned by IT, it's difficult for even a design advocate to have their voice heard and affect the process," Amy Cueva, co-founder of the design-centric Health Experience Refactored conference, told Healthcare IT News in 2013.

I have been saying this in reference to PACS for much of my career, and it applies equally to the superset of EHR's. Let me emphasize these very important statements:

Why this deficiency? Because much of the design is done by engineers who are experts in technology but limited in their understanding of people.

(B)ut in an organization that's owned by IT, it's difficult for even a design advocate to have their voice heard and affect the process...

There is some light at the end of the tunnel, but...

That's changing, thankfully, as more and more efforts are being made industry-wide to make EHRs easier to use and perhaps a bit better-looking. One of those ONC certification criteria, after all, is that vendors employ a user-centered design process when developing their tools, and report the results of usability testing.

A study published this past November in the Journal of the American Medical Informatics Association took a look at UCD processes at 11 unnamed vendors, seeking to understand the challenges and opportunities for better design practices.

"Our analysis demonstrates a diverse range of vendors’ UCD practices that fall into 3 categories: well-developed UCD, basic UCD, and misconceptions of UCD," wrote researchers from MedStar Health's National Center for Human Factors in Healthcare, noting that the latter category might refer, say, to the mistaken belief that responding to end-users' requests and complaints qualifies as user-centered design..."

But we aren't there yet...

Dishearteningly, the researchers found some respondents still didn't see the business case for investing in UCD processes. It even found that some smaller EHR vendors didn't even have any usability experts on their staff.

And this is the bottom line. As with PACS, in most places, IT controls every facet of the EHR. Software wonks create these jumbled messes while insulated from the actual users. IT folks buy the stuff while equally removed from the wants and needs of those who have to use it. It needs to be reiterated...physicians use EHR's (and PACS) to take care of patients. What a concept. Healthcare IT is used for HEALTHCARE! This isn't some app for your iPhone that won't hurt anyone if it fails or if it isn't usable. This is life and death, people. That's not an exaggeration. It has to work and work well. And today, it doesn't. It gets between physician and patient, impairing instead of facilitating that sacred relationship.

We just aren't there, yet. But maybe someday...

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PACS Tidbits

March 30, 2016, 12:04 pm

≫ Next: Apple EHR "The Narrative Of Your Life"

≪ Previous: Lingering Frustration And Bad Design

New stuff in PACS seems to be overwhelmed somewhat by the Trump-like stampede of EHR data. Still, I've got a couple of items which might interest my loyal readers, all four of you.

Let us start with GE. Our Universal ~~Disappointment~~ Viewer should be updated to the next version sometime in the next few weeks. For those who haven't heard, our current UV has a number of problems, not the least of which involves not displaying one or more slices from a CT series when scrolling through. Fortunately, we do see a blacked-out pane with the phrase "0% loaded..." to let us know that we might be missing something. That is a major step up from our earliest go-round with Centricity 2.x years ago, which would skip images and not be kind enough to tell us it had done so.

As it stands, the "0%" thing happens on nine out of ten CT's, forcing us to close and reopen the exam, sometimes three or four or five times.

So...let's run some numbers. It adds 30 seconds to the exam each time we have to go through the close-and-reopen cycles. The busy site has maybe 40 CT patients per day (I'm underestimating), and for simplicity's (not Centricity's) sake, let us say they operate 5 days per week, and 50 weeks per year. That would be 10,000 patient-exams per year. So that's 9,000 exams that need to be reopened, wasting 4,500 minutes or 75 hours wasted for this year of Universal joy. At $200/hour (EXTREMELY reasonable rate), that would be $15,000 blown because of this poor coding.

I am hereby submitting a bill for this amount, $15,000.00, to General Electric for our professional services and time lost. I would urge all other departments experiencing this sad software error to do the same.

GE, please contact me for the address to send the check. I'll let everyone know when it arrives. Or if it doesn't.

While we are waiting on the check that's certainly in the mail by now, let us turn our attention to Agfa. You haven't heard much from me about our situation there, and you won't for a while. But in my search for an image-sharing solution (I still favor lifeIMAGE for this purpose) I stumbled across the fact that Agfa has an offering in that realm. Which has been deployed exactly never. I've learned not to beta (or alpha) test when patients are involved, thank you. Also, I'm hearing that Agfa plans to standardize and unify all of its installations onto one uniform platform. I'll assume this platform will be Agility, but I have no confirmation of that as yet. Good luck.

Onward and upward. Apparently Fuji has released Version 5.0 of Synapse PACS, and in an article on ImagingBiz.com, (which was sponsored by Fuji and written by Fuji USA V.P.'s), it was the "hit" of RSNA 2015. I must have missed that somehow, perhaps because I rarely wander over to the Fuji booth. But the Veeps do make the new version sound quite intriguing.

Our latest Synapse PACS has beefed-up archival and worklist/workflow-engine capabilities—from unique sharing features to EHR interoperability tools to workflow-optimizing options that take integration beyond the enterprise, into the cloud and, from there, wherever collaboration is happening—or should be happening.

In a nutshell, the need today is for a diagnostic-level PACS workstation that extends through the PACS to any desktop that a PACS might touch. That’s why the Fujifilm team came up with the Synapse 5 PACS viewer. It’s designed to help users keep up with the changes that have already taken place and, more importantly, to help them stay out ahead of what comes next.

Nice to hear this from the company that has the reputation of taking years to update things.

When I first saw Synapse in action in the early 2000's, I was told that the local group had insisted on three-second transmission times for any study. Of course, it turns out that the group itself figured out how to accomplish this without help from Fuji. But speed is indeed an important factor today:

Going into the Synapse 5 PACS design phase, our team knew the only way to achieve sub-second image access while also virtually caching large datasets and enabling reads from wherever, whenever—including with 3D—was to approach server-rendering technology in a whole new way. That’s why we came up with not just a new viewer but a next-generation viewing application, one combining architecture changes as well as technology advancements.

With the new Synapse 5 technology, there’s no client at the desktop, and the image rendering occurs on the server. This allows the technology to be far less dependent on the viewer side, and it allows users to simply log in and choose their interface as well as their screen—Explorer or Firefox or Chrome, desktop or smartphone or tablet—or work with any combination of preferences.

Yup. Server-side rendering and a zero footprint client. Nothing novel, but Fuji is the first of the big-iron companies to implement this on this scale. I think it's a good idea if done right.

One of our favorite aspects of Synapse 5 PACS is its brilliant simplicity. Like most cutting-edge websites and more than a few apps, it uses HTML5 and was largely inspired by what you’ve seen in the world of e-commerce. It’s got a user-friendly, intuitive GUI, with high performance, limitless scale and strong security.

Can you say "Hyperbole?" I knew you could.

Here’s another reason we were so busy answering questions at RSNA 2015: As “disruptive” a technology as Synapse 5 is, it’s barely a disruption at all for existing customers. It’s not a forklift of a database or a migration or a platform change. It’s just an upgrade to our current Synapse 4 platform. Current Synapse users will be able to light up an entirely new viewer that will work off of the existing database they already have.

An upgrade? Definitely. I'll bet money it is a HARDWARE upgrade, requiring a new server (or more likely many servers) added to the back end. I could be wrong.

We haven’t forgotten to take what we’ve heard from radiologists and apply it. That means, among many other things, that our new viewer makes it easy to look at a screen for eight hours a day. We’ve thought through ergonomic implications, right down to details like minimizing wrist strain, and we’ve geared everything toward greater efficiency and productivity.

Oh, still my beating heart! Someone cares about us poor rads? That would be nice...

But now a thinly-veiled slap at our competitors...

There’s been a lot of talk lately about “deconstructing PACS” in order to free it from silo-ed systems. Customers want fast image viewing, diagnostic integrity, flexible worklist, integrated 3D, platform independence and information lifecycle management. Legacy PACS does not perform all of these functions well, which is why Synapse 5 is so different.

Synapse 5 PACS inherently does what PACS deconstructors would do if they could: It helps transform healthcare organizations as they enhance collaboration and optimize workflows across the enterprise.

I'm not seeing anything that says Visage and TeraRecon can't do all that, too. In fact, Fuji's non-deconstructed PACS sure sounds a lot like Visage's deconstructed PACS. But I'm sure there are differences.

Remind me to stop by Fuji's booth next RSNA. If I'm still in the business, that is.

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Apple EHR "The Narrative Of Your Life"

March 31, 2016, 9:00 pm

≫ Next: Gomerblog On EHR's...

≪ Previous: PACS Tidbits

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Gomerblog On EHR's...

April 13, 2016, 5:35 am

≫ Next: Siemens Health-Imagineers

≪ Previous: Apple EHR "The Narrative Of Your Life"

Gotta love Gomerblog. In fact, I urge all of you to subscribe for a dose of medical humor far more sophisticated than what I provide here.

Today's entry follows upon the heels of the wishful thinking April Fools' Day post. (I do have it on good authority that Apple really IS working on medical software, but my source would have had to kill me had he elaborated.)

The dirty little secret seems to be that the EHR programmers didn't know their software would be used on real, live patients! Wow...

From Gomerblog:

EMR Developers Shocked to Learn How Their Software is Actually Used
By Gomerblog Team on Apr 12, 2016 07:00 pm
Several developers of widely-used electronic medical record (EMR) software were invited out of their cubicles last week for a much-hyped tour of the real-world health care system.
A volunteer team of medical office managers showed the visiting programmers around inpatient hospital wards and outpatient clinics yesterday, carefully coordinating the visits so the programmers could witness physicians in the full swing of patient care. Seeing their products being used in actual clinical settings for the first time, the general response of the developers was shock.
“Wait, wait, wait,” said Bingo “Bozz” Murdoch, developer of MediQuickChart Systems. “They’re actually using our software to, like, keep track of real patient records,” he noted. “And they’re trying to enter the data real-time.”
Murdoch simply shakes his head when asked about the many levels of inputs and multiple levels of exhaustive drop-down menus. “You just can’t get all of medicine into a dropdown menu,” he said incredulously. “It would just be impossible. That’s why we just picked a handful of interesting diagnoses and codes to include in the system. These systems were never meant to be comprehensive.”
EMR software has long been a source of headache and delay for physicians and associated health personnel alike. Along the way, many have wondered what the heck the developers were thinking.
“Why would you list 63 different ophthalmology exam findings on this drop down menu, and yet require us to free-text ‘enlarged tonsils’ every single time? It’s supposed to be a primary care EMR, for gosh sakes,” said Dr. Goodforyou, a physician who was noted to be running 90 minutes behind at the time of the interview. “Ever since moving to electronic medical records,” he added, “my charting has bitten the big one.”
Patients and physicians have also been critical of the need for computers in the exam rooms, complaining that the screens introduce a barrier to personal communication.
“It’s like talking to my teenager,” complained patient Mandy Mayhow, when asked about her impression of EMRs. “I feel like the doctor isn’t even there any more. I’m just talking to the back of a screen.”
Dr. Goodforyou was no longer available to respond to Mayhow’s comment. His office manager, however, noted that he probably feels the same way.
Again, the software developers were at a loss. “We were never asked to consider doctor-patient interaction or clinic flow in our product development,” said Murdoch. “We thought the goal was simply to try to maximize required visit documentation. It was all supposed to be a game.”

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Siemens Health-Imagineers

May 6, 2016, 6:25 am

≫ Next: YUVGE Disappointment

≪ Previous: Gomerblog On EHR's...

From Siemens comes this press-release:

Today Siemens Healthcare unveiled its new brand name Siemens Healthineers. The new brand underlines Siemens Healthcare's pioneering spirit and its engineering expertise in the healthcare industry. It is unique and bold and best describes the Healthcare organization and its people – the people accompanying, serving and inspiring customers – the people behind outstanding products and solutions.

"We have an exceptional track record of engineering and scientific excellence and are consistently at the forefront of developing innovative clinical solutions that enable providers to offer efficient, high quality patient care. Going forward as Siemens Healthineers, we will leverage this expertise to provide a wider range of customized clinical solutions that support our customers business holistically. We are confident in our capability to become their inspiring partner on our customers' journey to success", explained Bernd Montag, CEO of the company. "Our new brand is a bold signal for our ambition and expresses our identity as a people company – 45,000 employees worldwide who are passionate about empowering healthcare providers to optimally serve their patients."

As part of its Vision 2020 strategy Siemens AG announced nearly two years ago that its healthcare business would be separately managed as a company within the company with a new organizational setup. Siemens Healthineers will continue to strengthen its leading portfolio across the medical imaging and laboratory diagnostics business while adding new offerings such as managed services, consulting and digital services as well as further technologies in the growing market for therapeutic and molecular diagnostics.

The name of the legal entities will remain unchanged.

I heard about this new moniker a few days ago, from a friend high up in the Siemens hierarchy. It took me a moment to place the term, and then I realized why it sounded familiar...From the Disney Imaginations website:

About Imagineering

Walt Disney Imagineering is the unique, creative force behind Walt Disney Parks and Resorts that dreams up, designs and builds all Disney theme parks, resorts, attractions, cruise ships, real estate developments, and regional entertainment venues worldwide. Imagineering’s unique strength comes from the dynamic global team of creative and technical professionals building on the Disney legacy of storytelling to pioneer new forms of entertainment through technical innovation and creativity.

The name “Imagineering” combines imagination with engineering. Building upon the legacy of Walt Disney, Imagineers bring art and science together to turn fantasy into reality and dreams into magic.

I really think this is an incredible way to view healthcare software, although maybe a little difficult to roll off the tongue. Still, I predicted a cooperative effort of this sort way back in 2008...

It's far better than someone else's motto..."ImaGinE It Works..."

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YUVGE Disappointment

May 9, 2016, 7:39 am

≫ Next: Life Is Short, Play Hard...Anton Yelchin, The "New" Chekov, Dies At 27

≪ Previous: Siemens Health-Imagineers

Our Universal Disappointment has been updated to the latest and greatest, Version 6.x. I should have been more wary, as a certain other Version 6.x has led to a lot of Pain And Constant Suffering. But no, I was optimistic. After a YEAR of having to reopen examinations four and five times to make all the images load, lo and behold, the New and Improved Universal Disappointment did indeed fix the problem. And even more exciting to us, it seemed to be more generous about showing saved measurements as well. We thought we were back in business.

Now, that's not to say that UV6 fixed everything. We still have windows covering over windows, and the measurement tool and the scrolling tool do not play nicely together. We could have lived for another year with that, if we really had to. But, no, we had to find another, far worse problem.

Last week, the second week of UV6 deployment, things started drifting downhill. We would get an occasional presentation state error when loading old PET's for comparison. No big deal. But today, things took a nose-dive. We can no longer load ANYTHING, new or old. We get these rather cryptic messages instead:

Someone want to tell me WHO the F... Dakota might be? Are we talking about Dakota Fanning? What would she have to do with my PACS? North Dakota? South Dakota? Is that where GE keeps its cloud? Must be raining up there.

We are dead in the water, once again proving Dalai's First Law: PACS IS the Radiology Department. No PACS, no exams, no patient care.

GE, you should be ashamed. You made us wait a YEAR for this update that fixed a "coding problem" that should have been fixed 51 weeks ago with a minor hotfix. NOW you deploy a faulty upgrade that has taken us down completely? Really? Don't you boys and girls ever even test your software before unleashing it on the masses?

GE took a fantastic product, Dynamic Imaging's IntegradWeb, and ran it into the ground. I can promise this particular site will NEVER purchase anything from GE again, and if anyone asks me in my waning years about GE products, I won't have much nice to say.

UV now earns the dreaded Dalai Do Not Buy designation. No surprise.

ADDENDUM...

We're back up. The problem was "a setting got changed that made the system look in the wrong places for things." Perhaps it was checking Fargo and not Rapid City.

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