PACS-aholic

A New Beginning (after the end)

2010-08-05T13:08:00.000-07:00

PACSman: I was doing a Google search for songs that have the lyrics “All Good Things Must Come to an End” in them and only two songs came up from people I never heard of — a country singer named Joe Nichols who has a song titled, “All Good Things” and Nelly Furtado’s “All Good Things (come to an end).”

My sons and I don’t live in Texas, so Joe Nichols isn’t exactly a household name here, even though I have one friend who does live in Texas and knows the lyrics to every yippee-kai-yeah song known to man — those “I Want a Beer as Cold as My Ex-Wife’s Heart” genre-type songs. I also have another good friend who has a horse farm here with ten horses, five of her own, who should know all these songs but, thankfully, has a much more balanced and well rounded musical taste than my Texas friend…But Nelly?

“God, Dad you never heard of Nelly Furtado? You embarrass me sometimes.” OK, so what else is new?….

Then I broadened my search to just the words “The End” and got to a few groups I had heard of, although most of the songs weren’t always familiar. These included The Doors and Black Eyed Peas, both with songs titled, “The End” (although BEP I know more for the controversies they cause than their music — people after my own heart), U2, Norah Jones (the romantic still in me lives), Linkin Park and 2PAC (heard of them, don’t listen to their music, though, although anyone who has PAC in his name can’t be all that bad), Traveling Wilburys, Breaking Benjamin and Smashing Pumpkins, and a few others.

I stopped at Boyz II Men to listen to their tearjerker song, “End of the Road” that I haven’t heard in years. I am a sucker for intricate a capella harmonies and these guys have it for sure…until my manhood was called into question by my sons as I sang along with Wanya, Nathan, and Shawn “… Although we’ve come to the end of the road. Still I can’t let you go. It’s unnatural, you belong to me, I belong to you….”

“God, you are sooooooooo gay dad!!!” OK so I’m gay and an embarrassment, while they invoked God’s name twice no less. Have I missed anything? I should have stuck with David Bowie’s “Changes” instead…”Time may change me. But I can't trace time”…

If you’ve read PACS-aholic with any regularity over the past several years, you have realized that Cristen and I had an interaction between us that was just like a married couple. Most times we loved each other — okay, we liked each other. Sometimes we hated each other, sometimes we did things without the other person knowing or even liking what we were doing and we never made whoopee, either. In the end, though, we still respected each other in the morning, even before that first morning cuppa Joe. So when Cristen unexpectedly elected to move beyond the great white world of publishing, it left me with a chasm to fill the size of the Grand Canyon relating to the PACS-aholic blog. Do I keep the blog or….

The answer was easy. I am not the PACS-aholic nor was Cristen. We together were the PACS-aholics, and so since there is no official “we” any more, Joe and Nelly both sang it right “….all good things must come to an end.”

And so it will right here, right now – with apologies to Jesus Jones as well. (Fuji used the band’s “Right Here, Right Now” song as its CR theme several years back, when John Strauss was the head of marketing there and Fuji allowed John’s creativity to flow unimpeded. He unquestionably had some of the best marketing ideas I’ve ever seen in this industry.)

Know though that just as God shuts one door, another one opens. Instead of watching what I say and how I say it, lest I offend a potential group as I have done more than once, requiring me to “set the record straight,” I have elected to start my own blog — The PACSMan Pontificates. You can visit it here — http://thepacsmanpontificates.blogspot.com/.

I’m going to try to have at least 4-5 blog posts up per week — not as many as Dr. Grumpy does by any means (one of the funniest blogs I’ve read in ages by the way, http://drgrumpyinthehouse.blogspot.com/). But probably close to the amount of postings my good friend the Dalai does (http://doctordalai.blogspot.com/) when he is in his blogging mood and doesn’t have to work for a living, which lately has been more often than we both like it. Dalai is also helping me get this blog in order, so please be patient with us both. It, like me, is a work-in-progress.

The blog will be 80% about my life and 20% about PACS, or as I promote it, “The trials and tribulations of a middle-aged PACS consultant, father and garage sale junkie as he engages in his never-ending search for sanity in an insane world.” I’ve been having a lot of fun doing my own thing over the past few decades in the PACS arena and for the past nine years as a single dad to two teen sons. Many people who have read my private musings have said I should share it — and so I will. Should be interesting to see where it goes.

As for Cristen, we’re still friends — and always will be — that is, until she gets “involved” with someone and forgets her true friends, which happens all too often with women. That said, though I don’t think that will happen any time soon. She’s not quite as cynical as I am — hell, no one on this planet is. But she’s been on the Love Train often enough to know it’s not nearly as much fun as riding the El late at night like Tom Cruise and Rebecca de Mornay did in the movie Risky Business either. ”Joel, have you ever….” Someone cue Tangerine Dream please….”My name is Joel Goodson. I deal in human fulfillment. I grossed over eight thousand dollars in one night. Time of your life, huh kid?”

So, bookmark the site http://thepacsmanpontificates.blogspot.com/ and get ready for the ride of your life! Topical? Of course! Informed? I wouldn’t have it any other way! Opinionated? Moi? Please, bite your tongue! Censored? Nope. Irreverent? Well cointenly!! Politically correct? Well cointenly not!!

So this isn’t goodbye but rather “until we meet again,” which I’m sure we will. I’ll still be involved with ITN by being on its Advisory Board, doing the PACS, RIS and CR charts and maybe even a new category this year on storage options, which will include VNAs, Clouds, MSPs and others, if I can convince the new leadership to do this.

So I leave you with the immortal words from Risky Business, when Joel is being interviewed by the recruiter for his Princeton admission in the middle of his “party.” It reminds me so much of the times we had here on PACS-aholic and how it will be even more so on my own as well…

Recruiter: “Your stats are very respectable. You’ve done some solid work here. But it’s not quite Ivy League now is it?”

Joel puts his hand on the recruiter’s knee and says, “You know Bill, there’s one thing I’ve learned in all my years. Sometimes you gotta say what the…. Make your move.”

Cruise lights a cigarette.

Recruiter: “I beg your pardon?”

Lana: “So how we doing?”

Joel: “Looks like University of Illinois!!!!”

A li’l up-tempo music by Prince – D.M.S.R., if you please, as the curtain slowly closes on the PACS-aholics. I’m making my move to The PACSMan Pontificates…. Hope to see you all there!!

NOTE: The ITN staff expresses its thanks to the PACSman, aka Michael Cannavo, founder and President of IMC, for sharing his opinions and insights with the PACS-aholic world for the past few years. We look forward to reading more from him in his new blog, The PACSMan Pontificates. http://thepacsmanpontificates.blogspot.com/

Is Cloud Computing Annoying?

2010-05-26T14:11:00.000-07:00

Ms. PACS: Has anyone seen him? The PACSman I mean. I filed a missing person's report, posted his face on a milk carton, but still no sign of him.

Of course, he must be moonlighting on some other blog. I don't mind being cheated on, as long as you're honest about it (oxymoron?).

Well the only thing more frustrating about him running off with another blogger is the pretentious attitude of IT "geeks" (they love to be called that) when you talk to them about cloud computing. They act like you are so behind the times, or just a moron, because cloud computing has been around for awhile. Didn't you know?

Even when you say you realize Amazon, Google and Facebook, which you've been using for years now, are clouds (because someone recently tipped you off), you're still scoffed at. But for you PACS admins, what business are you in anyway? This is health care. It's always been a decade behind the consumer curve when it comes to IT. Blame it on incentives; compared to consumer markets, there is less in health care.

Let's face it, much of the PACS user interface is a rip off of Adobe Photoshop anyway. How's that for being an early adopter?

Besides, cloud computing may be yesterday's news amongst IT geeks, but it is still relatively new to PACS and even advanced visualization for medical imaging. Ergo, it is relevant in radiology today. And should be in radiation oncology where image volumes are going through the roof. But who knows when the RT image management systems will catch on. And when it does in 2020...it will be relevant too. So lose the attitude.

Speaking of lost, have you seen the PACSman?

What about cloud economics. The adoption of cloud-based architecture is assured if it benefits hospitals financially. This makes it very relevant.

A cloud environment enables ubiquitous access to programs, reduces the dependence on the users’ bandwidth and computer power and eliminates the danger of obsolescence.
This may be a scary step, but it would enable hospitals to share infrastructure with systems linked together. This would reduce cost, plus force interoperability, which is still lacking today.

Another benefit, you don't have to pay up-front costs for apps if it offers pay-per-use pricing. You don't have to upgrade your PC. You don't have to upgrade your hardware or networks.

If you don't like a vendor, you can easily switch - once there are enough cloud-based apps to choose from in health care. Another bonus is there is less of a threat of obsolescence because data centers and on-site technology can be continuously maintained and upgraded. That also removes barriers for vendors, allowing for more start-up Web services and more competition, which tends to favor the end-user.

It kicks in speed too. The cloud leverages available bandwidth and local computing power to optimize performance and speed. So now radiologist may be able to work faster and process more of those exams. That's what radiologists want - to be able to read more exams and make up for reimbursement cuts. Or is that the administrators' agenda?

Let's look to the cloud icons, and trend setters in IT. The Google's App Engine will let you run whatever program you want - as long as you specify it in a limited version of Python and use Google's database. I can run everyday programs like Word and Excel on Google and store it all right there. But you can't save your document to a folder, and you can't start a new document in a folder. That's REALLY annoying. We suspect Google is trying to rid users of the concept of folders. But then how do you organize things? Through search? What if I can't remember the name of the doc? SOL?

Sorry to be annoying, but cloud computing is not just trendy, it is relevant in health care and will change how you use your PACS - it will now be a service you access online. Talk about disruptive technology - I guess that's annoying too.

Top 10…or 19 PACS Problems

2010-05-11T09:40:00.001-07:00

PACSman: I love how I’m given a list of the "Top 10 PACS Issues" to comment on, and it’s 19 items long. Mars and Venus says it all, if it wasn’t a list drawn up by a guy. Although, maybe Ms. PACS translated it into 19, adding her own stuff that isn’t in bold, which makes more sense. Who knows.

Here are the Top 10 PACS Issues, according to Richard (Skip) L. Kennedy, MSc, CIIP; Kaiser Permanente Medical Group, Sacramento, that will be discussed at the SIIM 2010 educational session on Thursday, June 3, 2010 in the "Practical Imaging Informatics Learning Track.”

Top Ten PACS Problems

“It doesn’t go through…” Part 1: Network layer issues
“It doesn’t go through…” Part 2: DICOM layer issues
“It doesn’t do what I want/need/expect…”:
-Managing user expectations and user education
-Vendor feature requests and customizations
“It’s really slow…”:
-Performance management
-Scaling issues
“That can’t be right…”: Data QA management
“Everybody wants on board now…”: Imaging content outside of Radiology (Cardiology, Dermatology, etc.)
“You didn’t tell us about…”: User community communications and change management
“We need to get a new…”:
-PACS-to-PACS migration issues
-PACS hardware refresh issues
“We need to know…”: Dashboards and reporting issues with PACS
“What to do when the lights are out…”:
-Availability and uptime
-Downtime processes and procedures
-Disaster recovery

About 3/4 of the items on the list are technical issues. For the most part, those are a piece of cake to deal with. While they may not be solvable right away, they are solvable nonetheless. The other issues aren’t so easy.

My #1 is managing user expectations and user education. Will PACS solve every problem you have and meet every need? No. Will there be no downtime? No. Will it…the list goes on and on, and the answer typically remains the same - No. It’s even worse when you are replacing a PACS, expecting the new one to do things the old one didn’t do while you use the same RFP and get the same answers from the same vendors and expect the outcome to be different. Isn’t that the classical definition of insanity?

My #2 would be creating a vendor neutral system or at least incorporating a vendor neutral archive (VNA). Despite 20 years of standards development, the vast majority of systems out there can still be considered proprietary or closed systems, each having at least one component from the database structure to the archive that locks in the end user. That is just plain sad. Vendors say they support a standard - all images are in a DICOM Part X format, for example, then they throw on a proprietary compression algorithm that only they provide. So much for an open system .

My #3 would be making sure the system is designed right. That didn’t even make the list. When you buy a PACS you buy what the vendor says is the solution based on your needs. The question remains: did you adequately outline ALL of your needs and did their solution meet it? This is easily addressed contractually, but few people include the proper contract language to address this.

My #4 would be…..well, you get the gist of it…problems are just masked opportunities for improvement. If you address #1, everything else is a piece of cake, but it’s like marriage - you never know what you are in for until you are in it so…Maybe that’s my #4. Once you make a decision to implement a PACS vendor, accept what you have and make the best of it. You are going to have it for a while, and getting out of it isn’t easy or cheap either. The upside of a PACS is that you get to choose a new one every 5-7 years without penalty. If life were only that simple

Splain Me Some More Ricky

2010-04-16T10:54:00.000-07:00

PACSman: I love how women like Ms. PACS bait me by putting things up on a blog, then tell me about it after the fact once it’s up, as a comment in an e-mail in a “by the way” fashion. This must be her way of playing the Wicked Witch of the West, “I’ll get you my pretty and your little dog too ah ha ha ha ha …..” only her version of it is closer to “I’ll get you (to post something up on here one way or the other) my pretty (PACSMan)…” Once again, using her feminine wiles, she has succeeded…although if she keeps this up I’ll have my little dog Elvis (not Toto) hump her leg, then pee on her bookshelves too…although she might actually enjoy the former (laugh).

Yes, Ms P., I have been following the Merge/AMICAS story closely, and a lot of what is going on has me completely stumped. That said, I am not an investor in either company - my objectivity in this market would suffer if I invested in either of these PACS companies. One look at the past six months is enough to make any investor cry, although Merge stock has rebounded $0.50 in the past two weeks - although why is anyone’s guess.

Now we come to the good stuff.

On April 2, Merge completed a private placement of preferred and common stock totaling $41.75 million, which is specified for use in funding a portion of the proposed acquisition of AMICAS. The merger agreement contains a commitment from Merge to provide $40 million in preferred equity to the acquisition. This private placement will satisfy that commitment and is scheduled to close prior to the close of the tender offer to AMICAS shareholders.

Merge entered this securities purchase agreement with 14 institutional and other accredited investors, pursuant to which Merge will issue an aggregate of 41,750 shares of Series A Non-Voting Preferred Stock and 7,515,000 shares of common stock for a total purchase price of $41.75 million, before fees and expenses.

Now here is what I don’t understand. 99.45% of the $40M in stock issued is common stock, while only 0.55% is preferred. So what’s the big deal? A couple of days later Merge then announced its intent to offer $200 million aggregate principal amount of senior secured notes due 2015, which will be used to fund a portion of the proposed acquisition of AMICAS. The notes will be senior obligations of Merge and will be guaranteed on a senior basis by all of Merge’s domestic restricted subsidiaries.

Now what am I missing here? Fourteen investors said: “Yup we are in!!” and get 7.5M shares of common stock with no guarantees attached to it whatsoever. Four days later, Merge announces its intent to offer $200 million aggregate principal amount of senior secured notes due 2015, “guaranteed on a senior basis by all of Merge’s domestic restricted subsidiaries.” So if I read this right, the $200 million comes with guarantees, while almost all the $40 million comes with nada since it is “common stock.”

I have many friends in the industry that have been issued common stock before as employees, as have I, so that is my only frame of reference. Some have even been former e-Med employees (now part of Merge coincidentally). They worked hard and long for many years in the hope that once their company was sold they would finally get their just reward. And they did, right in the ……This isn’t just e-Med folks who have had this happen to them, I can give you a list of at least half a dozen companies where the rich got richer (a.k.a. management and investors), and those who truly made the company what it was were left to squeal like a pig Deliverance-style….

So what happened? Once all the preferred stock was paid the old Italian proverb that goes “Con nulla non si fa nulla” got put into play. Translated this means “Of nothing comes nothing.” And that is what they got. Top management and investors got theirs, but what of the people who made these companies what they were? Niente….nothing…They couldn’t even use the stock as TP, which they needed after the “good lovin” they just got by the companies they sacrificed their lives, marriages, and families for, all in the hopes of achieving the Great American Dream called financial freedom. They had common stock - just like the 7.5M shares that were issued on the 4th are…..

I hope I am wrong here, but….it sure seems to me like someone needs to be kissed. Would these 14 investors have ponied up and laid $40M on the bar knowing $200M in guaranteed stock would be offered a few days later? You’ll just have to ask them. But I bet a few are as confused as I am, if not outright pi$$d off. I know I would be, assuming my assumptions are right that is.

The other interesting thing (to me, at any rate) is with the $40M “the securities to be issued in the private placement have not been registered under the Securities Act of 1933, as amended (the Securities Act) or any state securities laws and may not be offered or sold in the United States absent registration with the Securities and Exchange Commission (SEC) or an applicable exemption from the registration requirements of the Securities Act. Merge has agreed to file a registration statement with the SEC covering the resale of the common stock issued in the private placement, provided however, that pursuant to the terms of the securities purchase agreement the investors shall be restricted from transferring the shares acquired in the private placement without the prior consent of Merge (other than to an affiliate) until the earlier of the first anniversary of their issuance or the occurrence of a “change of control” as defined in the securities purchase agreement.”

And the $200M? “The notes and the related guarantees will be offered in the United States to qualified institutional buyers pursuant to Rule 144A under the Securities Act of 1933, as amended (the Securities Act), and outside the United States pursuant to Regulation S under the Securities Act. The notes and the related guarantees have not been registered under the Securities Act and may not be offered or sold in the United States absent registration or an applicable exemption from the registration requirements.”

One seems to be registered, the other isn’t. Now again I’m way out of my comfort zone here and have no idea what the difference nor can I explain it, but I’m not putting more than $250K of my hard earned money per bank account lest the FDIC not insure it. The same probably holds true here. Gimme a guarantee any day… Of course the FDIC will probably go bankrupt anyway, but at least I can say I’ve been prudent in trying…

Now, if Merge has already obtained $200 million of bridge financing from Morgan Stanley and has also started a cash tender offer for all of the outstanding shares of AMICAS, has been extended to 5:00 p.m., New York City, New York time, on Friday, April 23, 2010, unless further extended, why then do they need all this money? That’s sorta like your wife asking you to wear a condom five years after you had a vasectomy - and she is on birth control to boot…Someone please ‘splain me that to me, Ricky, too…

I’m not sure I buy the statement made that “The successful acquisition of AMICAS will enable Merge to acquire one of its main competitors and widen its customer base. This will in turn expand the company’s top line.” Merge and AMICAS competed in very few accounts in both the PACS and RIS arena over the past five years – a few handfuls per year at best that I know of if that - so who is coming up with a blanket statement like this is anyone’s guess. That is like me putting up my profile on Millionaire Match in the hopes of finding my very own gold digger once I hit my first million later this year (provided the FDIC doesn’t go belly up that is).

That same report said the following: “In the past, Merge has been paralyzed by several issues like a dwindling cash balance, management turnover, accounting miscues and litigations. The real turnaround started in the second quarter of 2008 when the company received the much-needed cash infusion of $20 million from Merrick RIS LLC in May 2008.” Real turnaround? You mean from $0.26 to over $2.00? Oh yeah, my bad again. But how soon some people forget the past:

Now let’s be fair and show the same time period they are referring to

Wait!! Does that not show $4 a share in June 2009? Then a $3 a share in 2010? Below $2.00 a share in March 2010? Maybe jumping back up to over $2.50 is the turnaround they are referring to here but in my book this is more of Mr. Toad’s Wild Ride or a trip in the Tower of Terror at Disney than anything else. Turnaround? Look closer...

Income Statement:

View: Annual Data | Quarterly Data
All numbers in thousands
PERIOD ENDING 31-Dec-09 31-Dec-08 31-Dec-07
Total Revenue 66,841 56,735 59,572
Cost of Revenue 19,377 20,072 29,348
-------
Gross Profit 47,464 36,663 30,224

Operating Expenses
Research Development 10,689 13,240 21,065
Selling General and
Administrative 22,208 29,774 48,057
Non Recurring 2,838 11,816 124,131
Others 2,766 3,530 8,209

Total Operating
Expenses 38,501 58,360 201,462

Operating Income or Loss 8,963 (21,697) (171,238)
Income from Continuing Operations
Total Other Income/Expenses Net (6,097) (296) (481)
Earnings Before Interest And Taxes 2,866 (21,993) (171,719)
Interest Expense 2,716 1,750 89
Income Before Tax 150 (23,743) (171,808)
Income Tax Expense (135) (60) (240)
Minority Interest - - -

Net Income From Continuing Ops 285 (23,683) (171,568)

Non-recurring Events
Discontinued Operations - - -
Extraordinary Items - - -
Effect Of Accounting Changes - - -
Other Items - - -

Net Income 285 (23,683) (171,568)
Preferred Stock And Other Adjustments - - -

Net Income Applicable To Common Shares $285 ($23,683) ($171,568)

Um…. to me this looks like they still lost over $23.6M in 2008. I guess compared with losing $171M this is a turnaround for sure…but that’s like comparing me to John Holmes (God rest his perverted soul).

This year Merge made $285K (K is the symbol for thousand for those economically challenged) on almost $67M in revenue - although they would have made more if they didn’t lose over $2M in the 4th quarter. To me that’s hardly worth getting out of bed for…Now let me say that given the softness of the imaging marketplace ANY profit is commendable - you go Merge, especially since big boys could have used some Viagra this year their sales were so soft - but I’d feel a lot more comfortable if Merge made their profit on actual SALES rather than through a $20M (that’s million) reduction on operating expenses. Still a profit is a profit so…

Now I hear a lot about longs and shorts, and I’m not talking about anything other than Merge’s 2008 10K I found this:

Common Stock Market Prices:

2009 4th Quarter       3rd Quarter          2nd Quarter      1st Quarter
High $4.25     $4.78                         $4.48                    $1.84
Low     $2.93                  $2.98        $1.25 $1.07

2008
High    $1.75                  $1.60                          $1.37                   $1.26
Low     $0.26                  $0.60                          $0.26                   $0.33

And this:
COMPARISON OF THE 5 YEAR CUMULATIVE TOTAL RETURNS
FOR THE FIVE YEAR PERIOD ENDED DECEMBER 31, 2009

Now for those who have a hard time interpreting what this means, $100 invested
in Merge would bring you a $15 ROI today…Of course that is triple what it brought in 2007 and, yes, nearly as much in the turnaround year 2008 as well so again we have a turnabout…so to speak…

Index

Date                    Merge Healthcare Inc.    Nasdaq Computer Index    Russell 2000 Index
                              (Nasdaq: MRGE)       (^IXCO)                       (^RUT)
12/31/2004     $100                                  $100                                   $100
12/30/2005            $113                                   $103                                    $103
12/29/2006              $29 $109    $121
12/31/2007                $5                                   $133    $118
12/31/2008                $6 $71    $77
12/31/2009             $15                                    $121                                     $96

So what’s going to happen?

Merge has a very very sharp, financially savvy management team that understands the financial marketplace. They are some of the best of the best from the finance world and know how to turn a profit. That, no doubt, is what they will do.

So here are the PACSMan’s predictions. A few months after the sale goes through (assuming it does go through, that is), the boys up top will get out their Ginsu knives and slice and dice both companies to maximize the investment and show a decent ROI to the investors. They will keep what the products and services they feel they can grow and profit from and ditch the rest. And if a few (or more than a few) people happen to get hurt along the way, well that’s called collateral damage. “It” happens and no one, especially not the investors, give a rat’s…..It’s all about the buck.

Now the burning question - will AMICAS PACS survive? I sure hope so. It’s a great product with even better potential - the best in the entire Merge/AMICAS portfolio.

What about the other products in the line, including the ones that have the strongest OEM relationships i.e. Cedera, Camtronics, and eFilm? That remains to be seen… I’d put money that there are a few buyers lined up for some of these products already. Don’t ask me who, though, cuz I’m not saying, but I have some very strong hunches.

In my hometown this week, we experienced nothing short of a miracle. A mere two miles from my house an 11-year-old girl who was lost in dense woods filled with snakes and alligators got rescued. Very near the 96-hour point where a search and rescue operation becomes a recovery operation, a volunteer from her former church, who really shouldn’t have been in there looking for her, found her - bug bitten and dehydrated, but very much alive… Everyone I know shed a tear or two. I have kids as well and know how it feels to not be able to find your child. When my “baby” Matt, who will be 17 on Friday, was age two he was “lost” for a whole 30 minutes, very well hidden in our house. During the time from when we called 911 until he was found, we had five sheriff’s deputies inside and out plus a chopper overhead looking for him. God bless these people. I can’t even fathom going for four days now knowing how or where our child is except being lost somewhere out there.

Yet the girl, her rescuer, and her parents all quoted a single bible verse that sustained them, Proverbs 3:5 “Trust in the Lord with all your heart and lean not on your own understanding.”

I put my trust in Him always and sincerely hope that the trust I have in Merge management to do the right thing for both its and AMICAS’ people, and not just the investors, is not displaced…

Only time will tell…stay tuned…

Merge/Amicas Deal: Place Your Bets

2010-04-14T15:45:00.000-07:00

Ms. PACS: It's time to place your bets ladies and gentlemen.

The odds were in favor of Merge pulling off a $248 million acquisition of Amicas when it issued a statement guaranteeing it could back the offer. Morgan Stanley even put its good name behind the deal. But let's face it, this Merge/Amicas merger keeps dragging out...although it has provided hours of fun for the PACSman...and its getting a bit messy.

According to the PACSman, "They raised $40M from 14 investors on the 2nd then came out with another $200M offering on the 6th." This would prompt anyone to wonder if their loan from Morgan Stanley has fallen through. Or are there some existing conditions in the loan, forcing Merge to raise capital from other investors?

They say, never let them see you sweat, but it's pretty hard not to in a pickle like this one. So, if you don't mind a little sweat, and want to enjoy this as much as the PACSman does, then let's play a favorite game of mine, Texas Holdem Poker.

Get ready to place your bets.

Lets look to an impartial party, Moody's Investors Service. Moody's recently demoted its rating of Merge Healthcare Inc. slightly to a B2 corporate family rating. Why did Moody's drop it five notches below its previous investment grade? Risk. Moody's said, in a nice way, it was due to "Merge's small scale, integration risk, and risk that it could continue to pursue growth through acquisitions are behind the rating."

Place your bets...

But there was a tone of optimism. Moody's said, "We believe, however, that if the Amicas acquisition is well-executed, there could be substantial opportunity for cost synergies..."

Place your bets...

"...And the combined company to generate strong free cash flow. Another beam of hope.

Place your bets...

But Merge is a "relatively niche player" in an industry dominated by large imaging equipment vendors and IT companies.

Place your bets...

Plus, it relies heavily on radiology.

Place your bets...

In the meantime, while the company figures out how to diversify its consumer base, the $35 million to $40 million it will get following the acquisition's close will provide "adequate cash" over the next year. Whew.

Place your bets...

Wait, one more thing, it’s lacking a “revolving credit facility,” which apparently could lead to the depletion of its cash reserves.

Now, show your cards

And you wonder what really happens on Wall Street.

Beware of Ninjas

2010-04-06T11:36:00.000-07:00

Ms. PACS: It seems like everyone wants to be a black belt these days. Just go to Ballys Total Fitness, all you need to have is a bank account and a pulse to move up in the ranks.

And while the ‘fitness’ business has sadly denigrated the art and the term black belt, business management has upgraded it to guru status -- as a rank for experts in Lean Six Sigma management methodology.

I get it, it’s sounds more Ninja than just a boring old MBA. And now it is being adopted in PACS. Yes, radiologists can qualify for Ninja status too.

One of the big adopters of Six Sigma is applying its industrial methodology to radiology workflow. The company is spearheading a study to improve radiology productivity by finding where they can enhance PACS. I know about this because I included it an article in ITN’s April issue: Best Practices in Radiology Workflow.

The goal of the project is “to understand the exact work efforts of a radiologist and make changes to products/solutions to take the wasted effort away through better software and/or configuration.” The company enlisted its team of Lean Six Sigma Black Belts (LSSBB) to watch radiologist, actually timing them with a stop watch, to analyze the workflow process. The plan is to then apply industrial engineering techniques combined with Lean Six Sigma methodology to the radiology workflow. Finally, the Black Belts’ is to find opportunities to reduce wait time, excessive mouse clicks, redundant actions, and repetitious movements. The idea is to help radiologists make a leap to increased efficiency - Hiyaa!

I like the theory, but would karate chop my boss if he stood over me with a stop watch.

But there is a colony of Power Rangers out there in the making. The other day, this guy who runs a marketing company called Power…something asked on a certain networking site: “How can the Radiology industry use Lean Six Sigma? I am looking to market my LSSBB to a greater extent. Any suggestions?”
There were suggestions. One that stood out was: “The January 2010 issue Vol 65, Iss 1 of the ACR bulletin may be a good place to start.”

I googled and i found: “Get your black belt in ACR MRI accreditation.” So the ACR has Ninjas too. In fact, a number of different organizations in the U.S., Canada and the UK are applying Lean/Six Sigma concepts to help improve efficiency, utilization, productivity, cost containment, etc. Between decreasing reimbursement rates, increasing imaging volumes, shortage of radiologists, etc. there is certainly growing interest in finding new ways to streamline and improve the delivery of imaging.

According to another Radrounds participant: "While there is a lot of info on the web about Radiology process improvement, key performance indicators (KPIs), etc – there seems to be a technical gap in terms of how people are able to analyze results/performance." He said he is working on a new solution to take data from any source, combine it into useful perspectives, and help organizations to improve workflow, reduce costs, increase utilization, patient volumes, etc.

Those are some useful tips, but is it just more pseudo black belt speak?

One thing is for sure: everyone thinks it’s cool to be a “black belt.” And, every field has one - whether it's radiology, the music industry, or its the originator of Lean Management itself -- Toyota -- but look how that turned out. The term “black belt” is a business buzzword. What the heck, Ballys Total Fitness runs a “black belt” mill.

For those who actually want to know, the real black belt is only the very beginning stage of becoming a master in either karate or tae kwon do or judo. It takes many, many years to move up the ranks and to understand it. That leaves just a few real Ninjas in the world - those who understand the real meaning of the belt (that does not include Yoda). So shhh...keep the secret. Kamsamida.

I wonder how long it will take to get a black belt in PACS? Anyone know?

PACS Divorce Rate Spikes!

2010-03-11T09:01:00.000-08:00

PACSman: So why aren’t second PACS purchases flawless? One only needs to look at marriage and divorce statistics to understand. It is pretty much agreed by most experts that first marriages end in divorce about 40 to 50 percent of the time. The PACS “divorce rate” is much higher than that.

What surprises me is that the divorce rate increases with second marriages to 60 percent and more, while third marriages end in divorce at least 70 percent of the time. Does that mean third generation PACS are more doomed than second?
One would think that an individual who has gone through a marriage and divorce would have “learned his (or her) lesson” and will, therefore, not repeat the mistakes of the past. Alas, this is often not the case. Those who marry to fulfill certain needs, but are not prepared to give in return, usually marry with the same intent the next time around.
The same holds true with PACS. The second or replacement PACS becomes nothing more than a walk down a precipice, a courtship leading to fresh disaster, only because it involves a new partner.

Avoid Disaster
So how do you avoid the disaster? Make a list of what you liked and didn’t like with your first PACS. Evaluate your new PACS partner not just by the freshness they bring to the relationship but by how well they performed during the time you were together.
In doing the detailed evaluation and assessment, it is important to understand that while newer systems might perform better – after all it does run on newer hardware and is one of the primary reasons why you are upgrading – you have to also ask if the better performance helps you or hinders you? That may sound contradictory, but sometimes faster and cheaper isn’t always what you need, especially if you lose a feature you really used before.
Look at the company’s track record in delivering what they promised relative to software updates and upgrades. Did they meet the promised delivery dates? Did it work right the first time? Did it include everything that they said it would or merely provided a fraction of what they said?

Get the Top 10 Considerations for PACS Replacement here and read the complete article in the April issue of Imaging Technology News

AMICAS Opts for the Bigger Diamond

2010-03-06T13:01:00.000-08:00

Ms PACS: I'm sure you've heard the expression: "A woman has the right to change her mind." That's just how we women explain our whimsical nature or, simply, our indifference when blowing someone off. Fact is, it's good to have options. Besides, who can resist the ego-trip of having several suitors making you offers. Sure, you probably know the one you're going to say yes to, the one who offers the biggest diamond ring, but you keep the other ones on the back burner, just in case.

On March 5, 2010, Merge had the pleasure of announcing: "AMICAS Agrees to Merge Acquisition Offer for $248 Million." Actually, it sounds like the release came from AMICAS. But whichever, the deal was sealed after AMICAS wavered between an initial offer from Thoma Bravo for $5.35 per share, and an offer from Merge for $6.05 per share, and entered into a definitive merger agreement (the “Merge Acquisition Agreement”) in which Merge will acquire all of the outstanding shares of AMICAS for $6.05 per share in cash, or an aggregate of $248 million.

As you all know, AMICAS had rejected Merge's offer of $6.05 per share and urged shareholders to support a rival offer of $5.35 per share, or $217 million, from Thoma Bravo, which AMICAS had agreed to in Dec. But on Monday AMICAS said it considered the Merge offer superior.

Finally, the Board of Directors of AMICAS unanimously voted to terminate its previous deal with Thoma Bravo and to enter into the "Merge Acquisition Agreement." Merge pulled the old "get her a bigger diamond and she'll say yes" trick - 13 percent bigger - and it worked.

Together, AMICAS and Merge aim to become "a leading global healthcare IT provider" with a combined portfolio of solutions for cardiology radiology, management solutions for IDN’s, OEM solutions for pharmaceutical, biotechnology, medical devices....yada yada yada.

Now, everyone's asking, just like with Branjolina (Brad and Anjolina), will it last?

PACSMan: I believe the words for that are gold digger...And now you know why I am a confirmed batchelor....Thanks, but no thanks...

Merge's Bid for AMICAS - Gordon Gecko Style

2010-03-02T04:18:00.000-08:00

Ms. PACS: You've heard it before. From 1831, when he lost his job to 1858 when he was again defeated in a run for U.S. Senate, Abraham Lincoln experienced 12 major career setbacks. Finally, in 1860, he went on to become one of the most renowned U.S. presidents.

Why do you care? It just goes to show we can all pull ourselves up by our bootstraps, get back on our feet and take another jab at whatever our obsession may be. In Gordon Gecko’s case, it would have been heading back to Wall Street or to a small island country to do some offshore banking once sprung from jail – lets hope Maddoff never gets out. For Lincoln, it was running for political office. For Mike Tyson, it took converting to a Muslim to get out of jail, and more recently appearing in The Hangover to win back respectability, kind of. Or what about Ford? The company is touting the all-new 2012 Ford Focus as the comeback kid. Their pitch is: "it's one of the greatest automotive comeback stories in a long time. After too many indifferent refreshes it's finally, and awesomely, everything enthusiasts have been begging Ford to build." Don't hold your breath.

For Merge, it’s about acquiring a leader in PACS to become a larger player in the U.S. market. Merge widely OEMs internationally, but needs to regain its footing in the national market...to become another comeback kid.

So, is your gripe, PACSman, really over fears that Merge is digging itself too deep into debt? Or do you have a special infinity for AMICAS, and the fact that its brand name will no longer be stamped on the packaging chokes you up? Does AMICAS mean quality PACS to you? That's great for Merge if it does because they are probably going to own it. Or is this a sentimental thing – AMICAS represents an impressive start-up that kind of makes you proud? I'm sure they planned to sell from day one. Even when the company rejected Merge's offer of $6.05 per share and urged shareholders to support a rival offer of $5.35 per share, it took no more than a good nap over the weekend to wake up and smell the offer. I bet the AMICAS' CEO is about as sentimental about selling AMICAS as Marshall Fields, a real historic landmark, which brought me warm fuzzies as a kid, sitting under the six-story Christmas Tree, as it did for many Chicagoans who loved Frango Mints. But what did their Board Members really care about when Macy’s made them an offer (especially if Fields was on the road to bankruptcy)? Or what about the historic Empire State Building? All they cared about was the green. As you reminded us, PACSman, green and greed is good. And we Chicagoans adjusted – albeit begrudgingly.

So, turn up the 70's Steve Miller classic, “Go on take the money and run.” Just remember, the delinquent, p*& smokin' couple taking off to Mexico successfully romanticized greed, as did Pretty Woman - she was after the bucks. Gecko - many a man would love to be him - and Maddoff - he just makes you sick.

Remember, it’s all "in good faith." Despite Merge upping the ante 13% to $6.05 to make Thoma Bravo's $5.35 offer look, well, meager in comparison, AMICAS is giving Thoma Bravo another chance at bat. BusinessWeek reported on Monday: On Monday Amicas said it considered the Merge offer superior. Amicas said it will offer to negotiate "in good faith" with Thoma Bravo through March 8 under the terms of their agreement. Amicas' board of directors authorized ending the Thoma Bravo deal if the Merge offer is still superior after negotiations.

Who knows, maybe Thoma Bravo can rally before March 8 when its deal with AMICAS turns into a pumpkin. Even then, who doesn’t love pumpkin pie? Yummy☺

PACSman: Back when I was in my early 30’s, single, and living la vida loca I had these grandiose ideas of making a few investments, riding out the market for few years-buy low, sell high- and voila, the good life comes my way in the form of a lot of money. I’d be retired and enjoying life before age 50... Now that I’m over 50 I’m working more and making less now than ever before and what I get to “invest” is in a glass jar in the corner of my room- loose change- my “vacation fund”. Of course two kids, one ex-wife, a mortgage from hell and various other setbacks haven’t helped any but that’s just the American way.

Around the same time as I held onto my dreams the movie “Wall Street” came out. The movie starred Michael Douglas as Gordon Gecko, an extremely successful (but ruthless and greedy) broker who takes a young and naïve Bud Fox (Charlie Sheen) under his wing and explains his philosophy that Greed is Good despite it being one of the seven deadly sins. Taking the advice and working closely with Gekko, Fox soon finds himself swept into a world of "yuppies", shady business deals, the "good life", fast money, and fast women; something which is at odds with his family including his estranged father and the blue-collared way Fox was brought up. It’s all about “bagging the elephant”- getting a shot at the big-money brokers and learning how to make the big bucks.

I’ve been watching this “Wall Street scenario” develop with Merge Healthcare’s recent offer to buy AMICAS. At first I was majorly pi$$ed off at AMICAS - how can you let theses guys even make an offer when you have one on the table already?- but then I realized that they have effectively been rendered impotent by rules that are meant to protect the AMICAS stockholders. It’s all about getting the most return on investment. Does that protect the company? No. Truth be known, it could lead to its demise. But as Bruce Hornsby once sang “That’s just the way it is...some things will never change.”

Allowing a company that has a net worth of $137M (and dropping- as of this writing) to go in debt up to its ears spending $250M to buy another company is could be seen as obscene or just the American way…Listen to Gecko address the stockholders at Teldar Paper in the movie Wall Street:

Teldar Paper, Mr. Cromwell, Teldar Paper has 33 different vice presidents each earning over 200 thousand dollars a year. Now, I have spent the last two months analyzing what all these guys do, and I still can't figure it out. One thing I do know is that our paper company lost 110 million dollars last year, and I'll bet that half of that was spent in all the paperwork going back and forth between all these vice presidents. The new law of evolution in corporate America seems to be survival of the unfittest. Well, in my book you either do it right or you get eliminated. In the last seven deals that I've been involved with, there were 2.5 million stockholders who have made a pretax profit of 12 billion dollars. Thank you. I am not a destroyer of companies. I am a liberator of them! The point is, ladies and gentleman, that greed, for lack of a better word, is good. Greed is right, greed works. Greed clarifies, cuts through, and captures the essence of the evolutionary spirit. Greed, in all of its forms; greed for life, for money, for love, knowledge has marked the upward surge of mankind. And greed, you mark my words, will not only save Teldar Paper, but that other malfunctioning corporation called the USA. Thank you very much.

Sound familiar? It could be just about any company...

So who is greedy here? Merge? Not really - they are just playing the game and doing it exceptionally well at that. Kudos to Merge here. At 7:50 a.m. Monday the headlines came across the PR Newswire “AMICAS Board of Directors Determines Updated Proposal From Merge Healthcare Is a Superior Proposal” (Sigh).

So it’s all over except the fat lady singing. Now Thoma Bravo has the right to make a counteroffer but will they? There is a lot of room between the $5.35 they offered and $6.05 Merge has offered - 13% to be exact. Yet the smart money who own AMICAS stock have already cashed their stocks, taking the $5.85, $5.90, and as of this writing $5.99 being offered for their shares of AMICAS in the event that the deal with Merge somehow falls through or Morgan Stanley finally wakes up. After all, what’s a nickel or dime in the grand scheme of things- and it sure beats the hell out of $5.35...

So for all intents and purposes, unless Thoma Bravo ponies up to the bar and matches the Merge offer AMICAS will now be a part of Merge.. Can that happen? Yes. Will it happen? Who knows. Unless it does though AMICAS, or at least AMICAS as we now know it, is gone. My friend the Dalai invited me up to Columbia to sit Shiva with him and I just may go. Not only do friends need to be with friends in times like these, but his wife Jane is an incredible cook and wonderful person as well and I love being with them both.
Am I mad at AMICAS? I was before but I also understand that this is pretty much out of their control, so apologies to those in management who had to endure what may have seemed as my misguided anger. It’s just that Sam and I both stuck our necks out to here trying to save a company that we both felt was worth saving yet not realizing that the lamb had already been brought to the table as the sacrificial offering. The Dalai even made a post in AMICAS’ Yahoo Finance message board titled “Don’t Do It’ yet the first responses back pretty much summed it all up. “One way to keep your patients from SUFFERING would be for Thomas Bravo to match MERGE's offer. Yes, this is all about money. As I mentioned before I could care less who buys this company!” The next post was equally adamant “Who ever pays the most will win the day. Now if Bravo was a publicly traded company and offered in share, there may be some consideration for future growth etc. but none of that is a factor here.. Bravo better up the bid or they lose the company.. As simple as that..”

Yet one more quote from the movie Wall Street - “The main thing about money, Bud, is that it makes you do things you don't want to do.” I’m not Jewish, but like the Dalai he and I might both smear some blood on our door posts hoping whatever wrath God (or the stockholders) take on the company after this deal is done spares both our souls...

If I were Morgan Stanley I’d also do a lot better due diligence than they obviously have. Last time I checked $200M wasn’t peanuts although the feds have bailed out the banks before so I have no doubt they will again - using our money, of course. It, too, is the American way...

So what's the big deal with a company in the PACS marketplace buying AMICAS? All we need to do is listen to the words of George Santayana who said “Those who cannot remember the past are condemned to repeat it.” Look to the past as to what can- and probably will- go wrong here…So much can go wrong- and so few companies are prepared to deal with it, especially a company the size (and income) of Merge. And while sales were up in a down industry the past two quarters the company still managed to lose $3M. They are no alone either as everyone in this industry is struggling by introducing one solution….after another…and another is not the answer in my book.….So Morgan Stanley- please cover your tails and call me. The first hour is free and with $200M on the line how can you afford not to call?

Merge investors also stand to lose as well but then maybe that’s why Merge stock has tanked from $2.46 on February 22nd to under $2.00 today. Memories of May 12, 2008 aren’t that long ago and this is a move that redefines risky for any company in this market…In a way it’s a shame too because Merge has had a Phoenix-like revival of late. It will probably never get anywhere close to the $26.00 days it enjoyed just four short years ago, but $2.00 is much better that $0.29 too. And despite my having issues with those at the top in the past who seemed to lookout for themselves more than the company - not with those who work there or those in control today- I do love rooting for the underdog, something Merge has been the past few years. I also honestly never thought Merge would make it this long but they had a great PR and marketing team behind them pumping them up every chance they got. They played it perfectly and still are. Unfortunately this play may indeed be their undoing. Only time will tell.

Santayana also said “Injustice in this world is not something comparative; the wrong is deep, clear, and absolute in each private fate.” This just seems so wrong, but how can something so wrong happen? Maybe it’s time for me to re-read Rabbi Kushner’s book “When Bad Things Happen to Good People” or balance it out from the Christian perspective with Dr James Dobson’s (Holding onto your faith even) “When God Doesn’t Make Sense”. There has to be an answer somewhere.

Three years after Wall Street came out another movie premiered that has become one of my all time favorites even though it’s sappy as all get out. It, too, featured a ruthless businessman who specializes in taking over companies and then selling them off piece by piece. The guy meets a gal who has a rather unusual occupation yet refuse to compromise her values. Edward Louis, played by Richard Gere, said it best to Vivian, played by Julia Roberts “You and I are such similar creatures Vivian. We both screw people for money.“. In the end it is Vivian who wins out by holding fast to her dream. “I want the fairy tale”, she says, and in the process changes Edward from a man who was about to dismantle and sell off yet another company piece by piece as he had done in the past to a man who is shown another way of being - taking time off and enjoying life - and working. He wants to create things rather than just making money. “Mr. Lewis and I are going to build ships together, great big ships.” Gere tells Philips, one of Edward’s handlers. Of course Philips, who is ONLY in this for the money, goes ballistic on both Edward and then later Vivian for the impact she had on him, leading to his ultimate demise with Edward.

Contrary to what the AMICAS stockholders might think or feel there is more to this deal than just money. Thousands of AMICAS users are going to be impacted as well. The same can be said for Merge users. The same can be said for the entire PACS industry. Think this completely through. Please. Think.

In my opinion, and this is just my opinion, the deal with Bravo would have allowed AMICAS to mature as a company and made the company more money in the long run, getting it out of the public eye and allowing it to focus where it needs to focus. The problem is, when one PACS company acquires another, it may just exacerbate any problems AMICAS has today. It’s not just about the buck. It’s about so much more...

So the vote happens on the March 4th. I hope I am contacted before then by Morgan Stanly, by both AMICAS and Merge investors, by someone, anyone who wants to know just what they are in store for. But in the absence of that the Dalai and I can both hold our heads up high saying that we tried.

Wall Street had another good quote that is something that everyone involved in this deal needs to think about - "Man stares into the abyss, and there's nothing staring back at him. That's when man finds his character. And that's what keeps him out of the abyss." We’ll see where everyone’s true character is at the end of this week...

Digital Imaging Delivers Modern Medicine to the Third World

2010-02-23T16:32:00.000-08:00

Ms. PACS: I want to share a very special experience and a huge trend in PACS and radiology - delivering modern medicine to developing countries. Just how do you go about doing it? Well, sometimes a primary care physician can show a radiologist the way. In this case it was Dr. Jeffrey Heck, Founder and Executive Director of Shoulder to Shoulder, a non-profit charitable organization, and Professor of Family Medicine at the University of North Carolina.

Before opening the doors of a new medical clinic in a remote region of Honduras, Dr. Jeffrey E. Heck, founder of the sponsoring NGO Shoulder to Shoulder said, “It’s important to offer the same services here as if it were a clinic in the United States.”

Dr. Heck’s vision became a reality when he installed a suite of digital radiology and telemedicine equipment in a clinic serving a resource-poor community of 30,000 plus inhabitants. To drive home the message that Web-based medicine could revolutionize a healthcare system like the one in Honduras, which allocates just $12 per person annually, where patients walk several hours to receive medical treatment, and where digital imaging is virtually non-existent, Dr. Heck arranged a live demonstration. The guest of honor was Honduran Minister of Health Arturo Bendaña.

Once the Minister’s helicopter landed and Bendaña set foot in the new clinic, Honduras took its first step toward delivering modern medical care to its predominantly rural population. The crowd of locals cheered on the Minister who was escorted into the clinic to tour the room labeled Rayos-X/Ultrasonido. Read the Full Story or support Shoulder to Shoulder

PACS Drives the Image Exchange

2010-02-12T14:30:00.000-08:00

Ms. PACS: "This was the year that imaging exchange went mainstream at the show,” said Elliot Menschik, M.D., Ph.D., who sits on the IT Infrastructure and Radiology planning committees of Integrating the Healthcare Enterprise (IHE) International and has served as a member of the SSS-U study section at the NIH Center for Scientific Review.

Cross-enterprise document sharing (XDS-I) is the profile for medical image exchange that the U.S. Health Information Technology Standards Panel (HITSP) has adopted. The profile was also presented at “The Document Sharing Focus” at RSNA 2009 IHE Demonstration.

To understand the critical role PACS plays in driving the medical imaging exchange, Imaging Technology News asked Elliot Menschik, M.D., Ph.D, who sits on the IT Infrastructure and Radiology planning committees of Integrating the Healthcare Enterprise (IHE) International and has served as a member of the SSS-U study section at the NIH Center for Scientific Review.

Why is XDS-I the most appropriate profile for a medical imaging exchange?

Dr. Menschik: For vendor-neutral exchange among disparate facilities/organizations, there is no interoperability alternative to XDS-I. DICOM alone is insufficient to manage issues such as multiple patient identities and federated, peer-to-peer publishing, discovery and exchange.

At the RSNA 2009 IHE Demonstration, PACS showed the benefits of driving images to the EHR and enabling provider and patient access to radiology images and reports. How is this beneficial to referring physicians?

Dr. Menschik: Referring physicians today struggle with either, one, managing a flood of inbound CD-ROMs or, two, logging into multiple Web-based PACS portals. The CD problem is particularly acute among surgical subspecialties - inbound CDs often don't run on the local PCs, when they do each one has a different viewer that is unfamiiar to the doc, and importing images off the disc is time-consuming and inefficient even when it can be accomplished (some CDs do not even store in DICOM). From the perspective of operational efficiency, referring physicians have much to gain from network-based access to outside images, whether in a patient's personal health record or a direct network connection to the imaging provider.

ITN: Do you think that PACS and radiology is driving the image exchange?

Dr. Menschik: For years, the radiology community has largely sat out of the health information exchange revolution despite having led healthcare for decades with novel applications of IT. This now seems to be changing...

Read the Full Article in the March issue of www.ITNonline.net

Setting the Record Straight

2010-02-07T14:28:00.000-08:00

PACSman: It took about three to four days before the calls started coming. “We aren’t very pleased with Mr. Cannavo’s comments about us.” The calls started and the plotting began. You- get the wooden stake. You- find the right mallet. And you- find a hit man who can do a job on the Anti-Christ here. And through it all, including the inevitable call from Ms. P. asking me what she should tell those asking questions about this posting, all I could think about was that silly early 80’s movie Stripes. You know the one, with Bill Murray, Harold Ramis, John Candy, et.al. and that memorable scene between Psycho and Sgt. Hulka.

Psycho: The name's Francis Soyer, but everybody calls me Psycho. Any of you guys call me Francis, and I'll kill you.
Leon: Ooooooh.
Psycho: You just made the list, buddy. And I don't like nobody touching my stuff. So just keep your meat-hooks off. If I catch any of you guys in my stuff, I'll kill you. Also, I don't like nobody touching me. Now, any of you homos touch me, and I'll kill you.
Sergeant Hulka: Lighten up, Francis.

So to those who see me as the Anti-Christ because I dare make suggestions about (OMG! Gasp!!)change I offer these three words - “Lighten up, Francis.”

Before I submitted what I wrote I read, re-read and re-read my reread to make sure I put as positive a spin on things as I could. This is a blog site and not a journal page. So why the uproar? Got me, but if I were a betting man I would say that people are just way too sensitive about ANY press that isn’t Pollyanna sugar-coated positive.

The powers that be need to go back a re-read this blog posting again. Sure I talked about numbers and how most focus on quantity over quality (which when you get to be my age is not an important feature) and said “Most shows promote quantity over quantity. Why they do this is anyone’s guess because it is simply wrong. As one vendor told me: “I’d rather have 10 qualified leads that 1,000 whom I have to educate from the start.” Is saying that certain trade shows don’t market themselves properly considered wrong? Mea culpa then…but I did say how you need to market instead and even cited an example from a vendor friend of mine (and yes, I do have a few remaining in this industry). I also ended this on a positive note as well: “For the most part the RSNA has proven to be a very good show for most PACS vendors despite the costs and numbers game being played.” Maybe had I said “all” instead of “most” it would have gone over better. Ya think?

This isn’t the first time I’ve given HIMSS a spanking for ignoring PACS and won’t be the last either. Frankly I’m at a loss on how radiology can get HIMSS’ attention. If I thought that putting the leadership of HIMSS through a session with Mistress Margo in the Dungeon of Doom with her black whip and high heeled boots would do it, I’d pop for the expense, but somehow that doesn’t seem like the answer - or maybe it is. All I know is while several PACS companies have discussed not going to HIMSS or at least scaling back their presence, few are willing to take that chance because at HIMSS they can actually get the IT managers’ attention. Why? Read again..."The dynamics of the PACS decision making has significantly changed in the past few years. Where radiology departments once stood apart from other clinical systems and with them the way decisions surrounding the vendor of choice were made, now nearly half (and in some cases more) of the final decision on the PACS vendor of choice falls to the IT department. And where does IT go to gets its information? Largely from HIMSS...". Now just being at HIMSS and getting IT managers’ attention are two entirely separate animals, but as Woody Alan once said, “80% of success is just showing up.” I’m sure even the most challenged marketing departments can figure out how to make up the remaining 20%, but if not, give me a call and I’ll show you how. And for the record, I did give HIMSS a pat on the back while I was kicking them in the a$$ as well, saying "Why not bring the trade show to the end user just as HIMSS is doing with its virtual conferences and expos?"

SIIM. What does the PACSMan possibly know about SIIM? Besides being one of the original members of SCAR way back when and active in it for several years back when Sam Dwyer (God bless his soul) and Ron Schilling and others were involved, absolutely nothing (laugh).

Now let’s set the record straight - I like SIIM, I like the members in SIIM, and SIIM is the pre-eminent PACS organization in this market and I said as much too. SIIM has also made several strides in the past year to make its annual show a lot more end-user and vendor-friendly which I applaud. These include having 11 hours of unopposed time in the Exhibit Hall (not having this was a biggie with vendors in previous years), new roundtable discussions (which our illustrious Ms P was invited to be a part of), private demo rooms, a networking lounge and much more.

I never said that any of these shows sucked or wouldn’t survive. Never. The closest I came to implying or inferring there would even be change necessary was my comment "The question is not so much will trade shows survive but in what form and function?" Read it as it was intended. Yes, trade shows WILL survive but they need to adapt to these changing times. And unlike many who simply bitch about a problem without offering a solution, I offered several possible solutions as well. Read back. Those were obviously my thoughts and perspectives and people don’t have to agree with them. Truth be known some don't (but many do). That said the last time I checked there was just my mug and Miss P’s on the masthead and no one else’s. Anyone is free to express their feelings on in the comment section- it's open to all- or if you feel strongly enough make a post on your own web site. I'll visit it if I hear about it and may even comment on it too. After all this is America and she is a berry good country allowing things like free speech.

So to all those who want to kill the messenger instead of listening to the message I offer yet more insight from Stripes. Substitute the word Army for PACS or Imaging and you get the idea. We are all different and all share the same visions - we just have different ideas of how to get there.

John Winger: Cut it out! Cut it out! Cut it out! The hell's the matter with you? Stupid! We're all very different people. We're not Watusi. We're not Spartans. We're Americans, with a capital 'A', huh? You know what that means? Do ya? That means that our forefathers were kicked out of every decent country in the world. We are the wretched refuse. We're the underdog. We're mutts! Here's proof: his nose is cold! But there's no animal that's more faithful, that's more loyal, more lovable than the mutt. Who saw "Old Yeller?" Who cried when Old Yeller got shot at the end?
[raises his hand]
John Winger: *sarcastically* Nobody cried when Old Yeller got shot? I'm sure.
[hands are reluctantly raised]
John Winger: I cried my eyes out. So we're all dogfaces, we're all very, very different, but there is one thing that we all have in common: we were all stupid enough to enlist in the Army. We're mutants. There's something wrong with us, something very, very wrong with us. Something seriously wrong with us - we're soldiers. But we're American soldiers! We've been kicking ass for 200 years! We're 10 and 1! Now we don't have to worry about whether or not we practiced. We don't have to worry about whether Captain Stillman wants to have us hung. All we have to do is to be the great American fighting soldier that is inside each one of us. Now do what I do, and say what I say. And make me proud.

“Survivor 2010: What It Takes To Make a Trade Show Make It”

2010-02-02T10:10:00.000-08:00

PACSman: The press release came out last week “Despite a weak economy, attendance at RSNA 2009 was very strong and even set two new records”. OK, I was at the 2009 Annual Meeting of the Radiological Society of North America (RSNA) just as I have been for the past 26 years in a row (and hopefully will be for the next 26 as well) so maybe I just missed something The headlines screamed “15,644 radiologists – new record!, 11,058 RSNA members – new record!, 9,060 International attendees – second highest ever!” Officially show attendance was down 4% from last year and 2008’s was down 5% from 2007’s numbers. That’s really not bad considering the economy and how travel budgets have been cut to the bone. But is it real?

RSNA is not alone creating as positive a spin on trade show numbers as it can. While attendance is only down slightly at RSNA, the makeup of those numbers varies a lot more than just 4%. While international volume is down only 3% over 2008, North American numbers are down 13.3% over the same period last year. Better than one out of three attendees (36%) were international attendees. That is great if you market overseas, but unfortunately a large percentage of the PACS companies out there don’t market outside the US. That means right off the bat 9,000 of the 26,000 professional attendees stated don’t hit the vendor’s target audience.

If you also factor out all those who aren’t decision makers, who are students, and others, the real numbers of people looking at PACS at RSNA is probably closer to 2,000, if that, with radiology executives who make up 4% of the attendees (589 attendees) a good quarter of that number as well. The numbers could be higher if you include “Radiology Support personnel” but how that is defined is anyone’s guess. Bottom line is it’s not anywhere near the 26,000 professional attendees stated. On the plus side spouses and family members were up 21% (7,881) from last year’s numbers (6,522) so shop owners on Michigan Ave need to take note. In this the Tiger era of trust it could also be a sign that momma doesn’t want daddy to go away for five days without her either (laugh).

Vendors also need to look at domestic coverage too. If a vendor has a strong presence in the Midwest, you are in luck because 35% of three RSNA attendees in the U.S. came from four states around the host state of Illinois - Indiana, Michigan, Ohio, and Wisconsin. No wonder they don’t want to move the show to Orlando (laugh). 20% came from the Northeast, 23% from 17 Southern states, about 11% from California and the Northwest. Hopefully you see what I am getting at here. From a quantity standpoint what you see isn’t always what you get…Quality, though, is another story.

Most shows promote quantity over quantity. Why they do this is anyone’s guess because it is simply wrong. As one vendor told me “I’d rather have 10 qualified leads that 1,000 whom I have to educate from the start.”

Few PACS vendors feel they can get away with not going to RSNA if for no other reason as the signal it sends to the marketplace once they have exhibited there. The same holds true with dramatically scaling a company’s booth size. But getting the attention they want and/or need with 700+ vendors in 3 different halls, especially given many attendees have limited time there makes it very rough. I’d love to think that the RSNA would create an area where PACS could be the focal point similar to an InfoRad ™ with equipment there- but then where do you draw the line? Should it also include RIS, speech recognition, DR, CR, 3D, etc.? You also know all the majors would scream loud and long to this arrangement as well.

For the most part the RSNA has proven to be a very good show for most PACS vendors despite the costs and numbers game being played. HIMSS (Healthcare Information and Management Systems Society) and SIMM (The Society for Imaging Informatics in Medicine) are different animals though. Both are IT-based shows, with SIIM the only one that is PACS-centric. Most of what is shown at both shows is IT-related so you would think both would offer a perfect venue to showcase to PACS. Unfortunately that is not the case.

HIMSS has almost completely ignored PACS and imaging for years and continues to do it this year as well. Don’t believe me? Go to the HIMSS web site http://www.himssconference.org/education/default.aspx and do a search using keywords like PACS, Imaging and Radiology. Of the half dozen or so presentations that even show up and of those only two really deal with PACS and that is stretching it. That is two out of 300 presentations- 0.7% for those who like statistics. To me what is most fascinatingly is in spite of this ongoing denial of PACS importance in the IT community PACS vendors keep attending HIMMS even though several of its own major IT vendors have bailed on the show in recent years. Why?

The dynamics of the PACS decision making has significantly changed in the past few years. Where radiology departments once stood apart from other clinical systems and with them the way decisions surrounding the vendor of choice were made, now nearly half (and in some cases more) of the final decision on the PACS vendor of choice falls to the IT department. And where does IT go to gets its information? Largely from HIMSS, who is a “comprehensive healthcare-stakeholder membership organization exclusively focused on providing global leadership for the optimal use of information technology (IT) and management systems for the betterment of healthcare...(with) 23,000 individual members, of which 73% work in patient care delivery settings. "I guess radiology/imaging doesn’t count in that definition - or at least so it seems."

SIIM should be THE preeminent show for PACS, since it is that is what SIIM is all about. But with marketing budgets cut to the bone, will others be far behind this year?

So what would be the ideal? From my perspective SIIM needs to be a subset of HIMSS where IT managers could see everything radiology/imaging related at one trade show, not two. At RSNA there should be a PACS area where attendees can easily do a compare and contrast easily without having to walk all over creation referencing a map just to get it done. And most importantly, every enterprise needs to expand their educational resources.

There is no money to travel to the dozen or more healthcare trade shows a year- one or two shows a year are most hospitals limits. Why not bring the trade show to the end user just as HIMSS is doing with its virtual conferences and expos? It may take a while to catch on for sure but it’s cheap, it’s easy, and most of all it’s effective.

Webinars educate end users in ways that no others can. At an average cost of less than $100 per attendee and oftentimes significantly less, they are cost effective, take little time -an hour at most), and most of present information to QUALIFIED end users, people who are willing to carve an hour out of their day to learn more.
The question is not so much will trade shows survive but in what form and function? With few exceptions, most notably RSNA, the days of the big trade shows are probably limited. Virtual trade shows will show a dramatic increase and information that end users need to make informed, objective decisions will come not just from those shows that survive but from Webinars and other educational opportunities as well. These will no doubt be provided by organizations like the AHRA (The Association for Medical Imaging Management, formerly the Association of Healthcare Radiology Administrators), RBMA (Radiology Business Managers Association), HIMSS, CHIME (College of Healthcare Information Management Executives) and others, bringing the message to the end user, not the other way around.

Bob Dylan was right - The Times They Are A-Changin', and if trade shows are to survive they need to change with the times as well...

Ms. PACS: One question for you PACSman. Would you rather be a big fish in a small pond or a small fish in a big sea? I don't know if you had guppy fish as a kid, but those are the first to go. Either by the larger fish or the cat grabbing a snack.

Point is, why would a radiology IT show want to get lost in a sea of general healthcare IT? I suppose some vendors might try to pawn off their PACS as an EMR, as long as you use it in a "meaningful" way? Just look for PACS or imaging in the "meaningful use" matrix issued last June. It's hard to find...I think the word "images" is tucked in there somewhere between parentheses. It took groups like the e-Ordering Coalition to form a representative voice, called the Provider Roundtable, to be heard by the ONC, and represent radiology’s views on how “meaningful use” should be defined.

At least in the latest version of the proposed "meaningful use" definition, Stage 2, it says it encourages the use of "CPOE and the electronic transmission of diagnostic test results, such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, pulmonary function tests and other such data needed to diagnose and treat disease.”

Don't get me wrong, HIMSS is worthwhile, but you have to weigh the value, and for radiology IT, it doesn't replace SIIM. Basically, you're not comparing apples to apples. That's like comparing Chicago to "Sn"Orlando. One has culture and the other is a shopping mall in the middle of a swamp...where a giant beast with enormous ears lurks...

If you click on "Education" on the HIMSS Web site, and do a search for PACS, you get 3 entries:
- Reducing Risk in Healthcare IT Purchases: Avoiding and Resolving Disputes
- Bringing the Hospital and Physician Clinical IT Together
- Integrating Medical Images and the EHR -- the Time Is Now

Now look up the "Educational Program" at SIIM:
- Using Dashboards and Business Analytics for Practice Improvement
- The Role of Imaging Informatics in the Next Generation of EMR/EHR
- Value Innovation Through Imaging Informatics
- Imaging Center PACS 24x7
- Image Sharing and Accessibility
- Automated Reporting Systems
- etc, etc, etc.....

Need I say more?

The point is, if you want to address radiology IT, SIIM is vertical, geared specifically toward radiologists' needs. Now maybe it could get a little bit more horizontal, and I think it's going in that direction. I just spoke with a GE IT guy who told me they are running a Lean Six Sigma study where they'll take a stop watch and a video of radiologists working. Wake up...I know it's not exactly Avatar. Oh, you slept through that too. But the idea is to create a value stream map that identifies workflow bottlenecks, and then find ways to make them flow faster. Because with reimbursement cuts, the only way to make up for that lost revenue is to work faster. That's a reality. Will those results be mentioned at HIMSS 2011? Maybe. But they'll definitely be heard at SIIM 2011.

I understand vendors need to watch costs, and maybe more virtual education is in order so you can become a TOTAL couch potato. But just recall back to your last date...got it...now tell me, is there any substitute for face to face encounters...oh, unless the date was virtual too:)

Wii Takes the Controls from PACS

2010-01-25T11:53:00.000-08:00

Ms. PACS: Wii may have just made it's way into medical imaging - in particular PACS. Now you can use Wii for more than just virtual bowling, tennis or any other Wii sport. The Wiimote lets you zoom, pan, scroll, and more, remotely.

The Wii remote is interfaced with GlovePIE, allowing the end user to interface with images, scroll through a CT volume data set. GlovePIE is a program that lets you turn a Wii Remote into a mouse, joystick, or even script it for unique functions in games and software.

The developer says this is where Radiology reads a case in a “Minority Report" kind of way. Check out the video demo. The developer says, "This is a simple example of me interfacing for window/level, zoom, pan & slice scrolling features on a CT set of images."

Maybe you can be a WiiPACS beta site! According to the developer, he says, "I’m open to suggestions!”

Who do service agreements really serve?

2010-01-18T06:02:00.000-08:00

PACSman: Who do service agreements really serve?

PACSman: I’ve been helping a friend buy a car the past several months - obviously a female friend since a guy would have done his homework in advance, picked out the car online, negotiated the price by phone, and been home watching the game within an hour of pulling into the dealers lot - and came to the part about service agreements. Now contrary to what many might think I am not against service agreements or anti-extended warranties or anti-female- contrary to what Ms P might think or say. It’s just the nature of the beast, Ms P, so don’t get your panties all in a wad over it. When is the last time you saw a guy spend an entire afternoon shopping and buying nothing - unless he’s with his wife or girlfriend that is? When guys have something to buy we go in and buy it - end of story - not spending months going from dealer to dealer trying to figure out what we like and don’t like. That’s why they have the Internet…Now I know - women going shopping is no different then men sitting on their fat a$$es all day watching a football game drinking beer - it’s a social bonding thing - but I’m more an ESPN Highlight Zone kinda guy anyway so I really can’t relate. You know what they say in the South “Don’t bother me with the birthin’ pains, just show me the baby” . I’m sure I’ll hear it from Ms P. for that comment as well even though her babies are the four -legged kind. Blame it on my ADD or some other reason….they are all valid…Just keep in mind that no guy would EVER scratch a car from the list because it didn’t have a lighted visor mirror on both driver and passenger sides… True story…I mean, really, can we talk?

Now I have service agreements on both mine and my son’s car, one on the flat screen TV in the living room and extended warranties on both my waters heaters I replaced a few years ago (I have two in my house, a necessity with two teens living here who take extended showers). I also am getting quotes on 10 year parts and labor warranties on a replacement for my heat pump that decided to quit last week just before the coldest week in Florida history hit, leaving me with no heat and a $399 electric bill from using space heaters from hell. After all I can’t let the Elvis the Wonder Dog get cold now can I even if he is still peeing on my bookcase? And they say God has no sense of humor. Indeed!! So no, Ms P, I am not anti-service or anti woman at all. But I do have to ask who is really served by some of these self-serving contracts?

The car dealer we went to - best known for its “We make it simple” ads in the late 70’s and early 80’s who now believes in “The power of dreams” and makes a pretty damn good lawnmower too– presented a smorgasbord of what I felt was dramatically overpriced service agreements (SA) to consider, using the assumed close “Which of these do you want?”. The cheapest SA offered was around $800.00 for five years/60,000 miles coverage (actually two years 24,000 when you factor in the 3/36 coverage that comes standard with the car). The one my friend bought ended up costing her over $2,300.00 for eight years/120,000 miles (actually 5/84) of coverage. It was her decision and her money but I did let her know there were other options she could consider that would provide her with virtually identical coverage at a fraction of the cost. She wanted the dealer’s coverage though, so being the somewhat logical person I am I told the dealer we need time to consider this before making a decision (actually to give us time to shop around) and will make a decision in a week or so. After all, the car comes with a three year 36K bumper to bumper warranty on it so everything is covered by the warranty for the next three years and 36k miles, right? The answer - “Yes you can wait a week, but if you don’t buy the warranty RIGHT NOW the purchase agreement cost goes up.” I’m like, “OK, ‘splain me that one Ricky!! The car comes with a three year 36K bumper to bumper warranty on it so shouldn’t I be able to buy the warranty anytime before then without penalty?” Not so, Mrs. Ricardo!! Turns out if she waited six months their already hyper-inflated price goes up 30%; wait one year and the price goes up 50% and wait beyond a year and it is solely t the dealer’s discretion to offer a warranty it at all.
Can it get any better (or worse) I thought to myself? “Why cointenly!!” was the answer that came back in my best Curley impression. I asked what happens if she decides to sell the car within the three year period and never gets to use the first lick of the service provided by the service agreement. Does she get her money back? Logic again dictates yes since the contract, while technically in force, was never used or billed against. Silly me again…”The agreement gets refunded on a pro rated basis” was their answer. Huh? Pro rated? We never even used it!! Basically every mile she drove cost her $.02 towards the service contract price which in plain English means she would be out $720.00 of her $2,300.00 (31%) BEFORE the contract even kicked in. My first reaction can’t be published without using a bunch of expletive deleteds (although I did keep my composure at the dealership) and then I just started to laugh. I thought to myself, yup, just like PACS, except PACS doesn’t give you a choice. Sure you have you Bronze Silver and Gold plans that put you light years above the 1-2 scumbags in all of PACS who - gasp!! - elect to go on a time and materials basis. But is a service contract really necessary? After all ,if you have a well trained PACS Systems Administrator (admittedly a big if at that) 90% of your problems can be handled in-house, 5% by the vendor’s technical staff and the remaining 5% are bug fixes that require the vendor to make changes to their software code. Of course to get these bug fixes you also MUST have a service contract as they aren’t offered without them. Once again, 'splain that to me Ricky… The evil empire at Microsoft sends me bugs fixes every week for free, most I don’t even know what they are “fixing”, on a $199 operating system and you are telling me that I just spent $1.5M on a system, 75% of that amount that is for applications software that has bugs in it (as all software does) and I need to pay you 15% of list price per year (actually closer to 20% what you actually paid) to make it run right? Yes I am, AND on top of that you also have to commit to a minimum five year service contract up front as well - again when you sign the contract to purchase and not a moment after. Otay, buhwheat!!! Yes, you heard it right…And yes, it even gets better still!!! If you had bought the hardware direct it usually comes with a three year warranty from the manufacturer but since you are buying the system from the vendor AS A SYSTEM you get the preferred one year warranty on the system - software AND hardware combined. If you want the other two years coverage that you technically paid for already, know they are part of the system service agreement price for years two and three. Now you might be saying “Didn’t I pay for a three year hardware warranty when I bought the hardware?” Yes, but that went away when we integrated the hardware and made it part of a “system” that we delivered. Arghhhhhhhhhh!!!!

PACS, cars, and ink jet printers all share one thing in common - they make their money after the sale on service. The system is the way to the service (on in the case of ink jet printers consumables). Since AMICAS went private Merge is only publicly traded PACS company remaining (outside of the majors who don’t specifically break out their numbers) yet I can tell you that at least 70% of the money that all companies bring through the door comes from service. Without those service dollars companies would be hemorrhaging worse than they are already. That is why they make you commit to along term SA when you buy - because when you see how little you actually use service and what it ends up costing you and you might actually end up saying “Why AM I spending this money anyway?”.

These three entities also get you coming and going. Ink jet cartridges are the highest priced liquids on the face of the earth running from $3,000.00-8,000.00 per gallon, and literally costing more than blood. In addition most ink jet cartridges have short expiration dates so if you buy them in bulk and don’t use them you are outta luck there as well - no deposit, no return.

With cars and PACS there are always hidden clauses as well. The dealer tried to get my friend to buy the $300.00 oil change “special” - 3 years/36K miles which would be an OK (but not great) deal if it were standard oil and she got the oil changed every 3,000 miles (12 changes total). Instead the “deal” she had was offered was 4 synthetic oil changes at $75 each (list price) although she easily could stretch out the interval from 7,500 to 10,000 miles in between changes since 90% of her driving was highway mileage. A rip off? You might say that. With PACS it’s the upgrades (not updates) that aren’t included in the service contract price - or travel time or….100 other small points the vendor neglected to tell you about.

Just like a PACS is often over-engineered, so too were the options she was told she just HAD to have. The $429.00 wheel and tire protection package (fixing a flat costs a whopping $20 - so that’s a whole lot of flats), the $399 “appearance” package (that she got for free anyway when she said no thanks to it), the $699 LoJac so she could find her totaled stolen car faster and easier (ever heard of insurance?) and the $120 GAP insurance offering that she paid her own insurance agent…drum roll please…$4.00 for.

Yessiree - Rosanne Rosannadanna was right- “It’s always something.”

Who do service agreements really serve?

Cloud Storage - More than Just Hot Air

2010-01-13T15:12:00.000-08:00

Ms. PACS: It's like, everyone catches on to a concept and it's the most incredible thing since the PACSman shaved his beard.

Seriously - cloud storage is the new BIG Idea...at least in Radiology...while the rest of the IT world has been raving about it...and we as consumers have been using it on Google and Amazon...but - with the exception of tech-savvy you - didn't realize how good we had it up there on cloud 9. In fact, the cloud computing craze has become as ubiquitous as its architecture. Did you know that there is a cloud computing magazine and trade show? Soon we'll see an action figure: Cloud Man, Cloud Ranger, or the Stormy Cloud Guy (the moodier younger brother). But first, before we cash in on the next Disney movie, let's take a step back.

When Amazon introduced its virtual computing environment, Amazon Elastic Compute Cloud or EC2, it created awareness about brought cloud computing in the consumer environment. What Amazon’s customers liked was they paid only for what they used.

The popularity of cloud computing has also reached new heights in medical imaging for its capacity to cost-effectively archive large volumes of imaging data.

How it works: Organizations pull up the image on their PACS, send it to a patient or another facility and send it to a cloud client that sits on their desktop. The image goes to an offsite server, is temporarily stored, until the receiving physician or radiologist accesses it. That provider, who is sent an e-mail notification, can choose to simply view the image on his or her desktop, burn it to a CD, or push it out to the facility’s own PACS.

As evidenced at RSNA 2009, several vendors staked their claim to cloud computing (these were off of the top of my head - i'm sure there are many more - maybe we could start a NEW Radiology in the Clouds trade show:)
- Candelis is an early adopter, leveraging cloud-based computing and storage to make its suite of medical software solutions available via cloud-hosted services.
- InSite One Inc. was also one of the first to offer, pre-RSNA, medical data storage in a cloud environment.
- DR Systems’ Electronic Medical Information Exchange called eMix is a cloud computing-based, vendor-neutral technology that eliminates the need for the provider facility to burn CDs, print films, or fax reports. It also facilitates universal access to medical imaging for a complete EMR.
- Accelerad’s software-as-a-service solution (SaaS), SeeMyRadiology.com, utilizes cloud computing architecture to store all client images on a centralized cluster of servers, providing access to medical images across the entire healthcare continuum.
- Merge Healthcare provides RIS, PACS and disaster recovery solutions in a cloud computing platform. The cloud-hosted solutions also enable rapid implementation of a RIS or PACS.
- **lifeIMAGE is a platform connecting patients and providers to medical imaging studies and reports through two core components. First, for hospitals and imaging centers, its a Local Appliance (LILA) to manage imaging exams introduced by patients on portable media such as a CD. Next lifeIMAGE.com is a cloud-based environment for image sharing and storing between patients and referring physicians.

**I have to say The Dalai of PACS tipped me off to this one. Patient power is a good thing - it should make them more responsible and better advocates for their own health care. No more baby sitting. And they have more data when insurance companies try to re-neg on reimbursing patients for just breathing in a hospital. Do you ever notice how the insurance company bills you....even when they are supposed to cover the bill? Don't get me started:)

Now, you get 10 Bonus Points if you can unravel this mystery lyric:
How do you catch a cloud and pin it down?

Is the future of PACS up in the air? You bet it is. Why? According to Mitch Goldburgh, InSite One, it's because:

1) The distinction of data storage and archiving have been blurred;
2) There are no DICOM or HL7 messages for deleting data;
3) Retention rules for digital information is about to become even more complex with the adoption of health information exchanges where retention requirements extend beyond any single institution.

That's why at HIMSS 2010 expect to see a resurgence of hosted solutions for primary applications and storage service providers. Revolving around the term ‘cloud’ are virtual services offering a lot of benefits for access to new applications, data storage, and imaging exams across the hospital.

So, do you think you got it nailed down?

PACSman: Every time someone mentions cloud computing I think of the Rolling Stones “I said hey! (hey) you! (you) get off of my cloud….” or Judy Collins from her song Both Sides Now (“I’ve looked at clouds from both sides now, from up and down and still somehow, It’s clouds illusions I recall, I really don’t know clouds…at all.”), not the Sound of Music like Ms P is fond of hyper-linking too. She is a true Maria in every sense of the word, waiting for some Austrian goober to sweep her off her feet so they can go hand in hand into the mountains singing Edelweiss together…Now I admit that the relationship that Christopher Plummer and Julia Andrews had was idyllic in every sense of the word but…it’s the movies…let’s get real….
Big idea? Since when? Like clouds, the CONCEPT of cloud computing in healthcare has been around for quite some time and got a lot of fluff at RSNA but it’s still a few years from being accepted by healthcare providers, insurance companies and others, with other areas like cloud-based archiving even further away.
Yes I know there is a cloud computing magazine Ms P- I subscribe to it actually- and if you are out in San Jose March 15-18 and have $2,000 that isn’t earmarked for anything else you can attend Cloud Connect (http://www.cloudconnectevent.com/) one of several Cloud trade shows that are popping up like…well…...clouds…
Craze? Not hardly. Most of what was shown at RSNA was either in the concept stage (RSNA= Real System Not Available) or just getting installed and at the alpha testing stage. I’d hesitate to say few vendors had that have even made it into beta testing yet….but they still were neat to look at.
There are still way more questions than there are answers about cloud computing. The first is insuring that everything you get from one PACS easily translates to another via the common viewer. This takes much more than performing a simple DICOM query/retrieve. When you convert data from one PACS to another (or to a common standard like vendor neutral archives (VNA) have) you may lose things like grey scale presentation states (GSPS) or some database information. This hasn’t quite been figured out yet completely. Then there are the patient confidentiality issues, the HIPAA conformance issues, and a host of others. Some of the papers I’ve seen from clouds supporters are claiming cost savings against sending CD’s out to primary care physicians (PCP’s) at a cost of $30 or more, but is this claim real? For them obviously yes, but for the rest of the market its more a resounding no. Very few hospitals I know send out CD’s to PCP’s. Most use image distribution via the web that is inherent to most PACS allowing PCP’s to select the studies they want to see. Most outpatient imaging centers hand the CD’s to patients to BRING to their doctors as well at a cost of maybe $0.50, with most of this for the CD case and label.
Clouds biggest claim to fame is that a PCP can do a single log and using a single viewer look at all images from multiple disparate PACS from different facilities without having to log onto several different systems saving time (and in the process, money).
So how many showed cloud computing ar RSNA? Too many and not enough.
Does cloud have potential? Cointenly…
Is it ready for prime time today? Cointenly not. I give it a couple of years to work out the bugs then we can talk about clouds like it’s Jack Johnson (aka the Great White Hope) instead of just some overweight pugilistic punching bag full of hot air who wants to overthrow the existing incumbent PACS.Cloud computing has potential but it needs to spend some time in the gym yet working on establishing it’s knockout punch before it steps into the ring against established PACS that are working already. HIMSS should be interesting for sure but the end users have to feel comfortable turning everything over to an unknown and unseen enterprise and that may take a little getting used to…So time will tell….Stay tuned…

AMICAS Sale Goes Round and Round

2009-12-28T13:08:00.000-08:00

Ms. PACS: Did you hear the news today: AMICAS has entered into a definitive agreement with an affiliate of Thoma Bravo LLC to be acquired for $217 million in cash.

This is good news for AMICAS' board since the company shelled out $39 million for Emageon Inc. this year. Time to recoup some of the green. But what does it mean for the PACS industry?

Not sure yet, but Stephen Kahane, AMICAS' chairman and chief executive, says it's great, but for whom? Kahane said the buyout will give AMICAS the "additional capital and operational expertise" that it badly needs to grow. The cash injection should help, especially after AMICAS shares hit a seven-year low late last year, reported WSJ.com. Actually, AMICAS stocks have grown steadily in 2009 thanks to rising sales and expectations. Again, what does it mean for the ailing PACS industry? Perhaps, what goes up must come down, and go up again?

Not so fast. Just 40 minutes ago, a New York law firm, Stull, Stull & Brody, opened an investigation on behalf of AMICAS shareholders over the price to be paid to AMICAS shareholders. And, they are also questioning whether AMICAS' board of directors breached its fiduciary duties to the shareholders by agreeing to sell the company at an unfair price. According to the firm: "Whereas AMICAS’ shareholders would receive $5.35 per share in cash under the terms of the proposed transaction, at least one analyst has set a price target of $6.00 per AMICAS share, representing a substantial potential discount to Thoma Bravo, LLC."

So is this something AMICAS' board should be concerned with? Only if they don't have leech powder to burn these guys off their ankles. This is just "Attorney advertising," looking for people to join a class action suit on behalf of the stockholders. It is no more than a bunch of leeches looking for a host. Every time a pending sale is made almost without exception they come out of the woodwork. Scratch your leg and another one comes up - this time its Levi & Korsinsky - making the same claim, pretty unoriginal.

PACSman: AMICAS was sold to Thoma Bravo, LLC, a private equity firm who wants to put money into a sure thing and bring the company private and out of the public eye. That, in my opinion is great news. AMICAS is also now subject a class action suits from at least two firms in the past 12 hours claiming that the stock was undervalued and someone was playing games with the stock price. That, in my opinion, is old news…Yogi Berra was right- “It’s déjà vu all over again!”

Every company who has offered stock has to deal with these legal vultures trying to make a buck for themselves. This is the latest deal:
The current investigation concerns the price to be paid to Amicas’ shareholders and the process by which Amicas’ Board of Directors is addressing the transaction, including whether the Company’s Board of Directors breached its fiduciary duties to the Company’s shareholders by agreeing to sell the Company at an unfair price.

AMICAS had to deal with this very same thing back in April, 2009 when it acquired Emageon:
The action…..alleged, among other things, that the members of the Emageon Board of Directors violated their fiduciary duties by failing to maximize value for Emageon's shareholders when negotiating and entering into the Agreement and Plan of Merger dated as of February 23, 2009 among Emageon, AMICAS and a subsidiary of AMICAS. The complaint alleged that AMICAS aided and abetted those purported breaches.

In one statement they purportedly "breached its fiduciary duties to the Company’s shareholders by agreeing to sell the Company at an unfair price" while in the other "they violated their fiduciary duties by failing to maximize value for Emageon's shareholders. Other than the words used, as Led Zeppelin once sang, the song remains the same…"

So who wins? Did the stockholders get what they wanted? No. Did the vultures get what they wanted? Yes - at least for them..

Here is part of the release from Health Imaging magazine:
On March 27, Emageon said that it and the other named defendants in a putative class action lawsuit filed by its shareholders on March 13, in connection with the proposed acquisition of Emageon by Amicas, have entered into a memorandum of understanding with counsel for the plaintiff.
Under the terms of the memorandum, the parties have agreed to settle the lawsuit, subject to court approval, at which time the lawsuit will be dismissed with prejudice. Emageon and the other defendants maintain that the lawsuit is "completely without merit." Nevertheless, to avoid costly litigation and eliminate the risk of any delay to the closing of the tender offer and subsequent merger, the defendants have agreed to the settlement contemplated in the memorandum, according to Emageon.
Source: http://www.healthimaging.com/index.php?option=com_articles&view=article&id=17000:emageon-acquired-by-amicas-settles-shareholder-suit

Now this is the part I don’t like: Nevertheless, to avoid costly litigation and eliminate the risk of any delay to the closing of the tender offer and subsequent merger, the defendants have agreed to the settlement contemplated in the memorandum, according to Emageon. Score: Vultures- 1, Stockholders- 0, AMICAS- ?

Take a look at how AMICAS stock has done over the past five years. Five years ago, on December 27, 2004 AMICAS stock traded at $4.45. It got as high as $5.54 on August 29, 2005 and never broke $5.00 a share after the week of February 6, 2006. From February 2006 to December 2009 is almost four years, for those who are mathematically challenged.

From May, 2006 to September, 2008 AMICAS stock hovered in the high $2’s to mid $3’s, with the stock taking a significant hit in the 3rd quarter of ’08, closing at $1.89 share on December 28, 2008. Again, for those who are mathematically challenged that was just 12 months ago or one whole year, whichever you prefer.

Due to some incredibly wise investments made by AMICAS corporate management as well as solid sales made by the AMICAS sales force in an incredibly challenging economy AMICAS stock closed on 12/24/09 at $4.42/share, a 177% increase in the stock price over the course of past 12 months. Thoma Bravo offered $5.35/share for the stock, a 21% premium over the closing share on the day the deal closed.

The vultures say that “The offer price is only a small premium over the $4.84 price the Company's shares traded at as recently as December 8, 2009 and below a $6.00 per share price target set by at least one analyst.” Now break down the word analyst into two words- one four and one three letter - and you’ll have a better understanding of what exactly is going on here. These “anal-ysts” are truly clueless about this market. Why not just claim that AMICAS was worth the $34.44 it traded at nine years ago on 11/24/2000 even though less than three years prior to then (on 9/8/1997) their stock only traded at $2.22? Gee, back in 1989 I weighed 125 lbs…Today I weigh…um…a bit more. Does that make me worth twice as much since I am almost twice the person I was then? No. Again, these people are completely clueless.

This is the exact same anal-yst mentality that has allowed Merge’s stock to get pumped up from $0.41/share on 11/25/2008 to a high of $4.67 of 7/7/2009. Again for those who are calendarly challenged that is over a ten-fold increase in stock price IN JUST EIGHT MONTHS. Merge has “settled back” into the low threes which is where they probably will stay until- God help us all- someone steps up and buys them as well. Of course the vultures will then say that Merge stock was undervalued too since Merge traded at $28.72 as recently as 11/28/2005, just four short years ago. Of course there was this little accounting irregularity they have dealt with since then but…why are we dwelling on minor details like that (laugh)?

The bottom line is Bravo saw a good thing and bought AMICAS, to which I say, well, bravo!! They offered a fair price, which AMICAS management smartly took. It’s good for AMICAS, and it’s good for the marketplace.

And the vultures? They always have and always will come out of the woodwork, especially since they stand to make money through something the do best - intimidation. As they have in the past AMICAS will no doubt pay, the vultures will fatten their wallets, pump up their chests and give those foolish enough to sign up for the class action suit $.03, $.06 or whatever a share, if that, and pocket the rest. I chose to ignore them and frankly you probably should too.

Celebrate that a private equity firm would chose to invest in AMICAS and keep them as they are. This is a far better alternative than the company being bought by a major PACS vendor who no doubt would totally screw up a good thing as so many before have experienced (cough - DI - cough).

Lastly, a personal note to the vultures. If you are going to show that you have the coglioni (as we Italians like to say), to sue on behalf of others, at least get the name of the company whom you are suing right. It’s AMICAS, Inc.- upper case A through S, little Inc., not – “Amicas, Inc. (“Amicas” or the “Company”) (Nasdaq: AMCS).”.

Now sing a little Zeppelin along with me:

I had a dream. Crazy dream.
Anything I wanted to know, any place I needed to go

Hear my song. People won't you listen now? Sing along.
You don't know what you're missing now.
Any little song that you know
Everything that's small has to grow.
And it has to grow!

California sunlight, sweet Calcutta rain
Honolulu starbright - the song remains the same.

Sing out Hare Hare, dance the Hoochie Koo.
City lights are oh so bright, as we go sliding... sliding... sliding through.

A Different Time and Place

2009-12-22T08:18:00.000-08:00

PACSMan: I love it when my kids ask me what my computer was like growing up. I show them a pencil. They ask about my cell phone. I told them the networks back then were very, very primitive, with our “Internet” back then known as MVR- the mom voice relay. My mom would open the door and yell for me. Another mom would hear it and relay it to yet another mom, and if you were half a mile away, you would know within 20 seconds that it was time to come home. Best of all, it was free and you never dropped a call either. Of course our town had at best 8,000 people, most of whom knew each other, and was only a mile square from end to end, but still...

It was such a simpler time. When there was a home game on Saturdays around noon the band would march through the heart of town from the high school, down Maple Avenue and over to the football fields. You’d hear them and know...The civil defense siren would test itself every Saturday as well, at 11:55, and when there was a fire our volunteers knew where to go because the system they used based on siren taps told you which intersection it was at. So where am I going with this….Oh yes, the holidays…

Back then we too had Salvation Army bell ringers, but they were actual members of the Salvation Army, and did it because they believed in collecting to help the poor, not because it was a paid position like it is today. They NEVER EVER sat down and EVERYONE was there always smiling and ringing the bells in their neatly pressed Salvation Army uniforms, not just an apron over blue jeans. Often times there would be 2-3 musicians with them, playing songs or singers singing next to the kettles as well - as the snow drifted down all around us. I tell my kids this and they look at me like I am crazy or have been looking at too many Norman Rockwell paintings…but that was the way it was...a different time and a different place…

Now I’ve seen more shrinks in my life that any six people combined - mostly for my own edification in trying to be the better person that I truly need to be - yet a large part of my childhood memories have stayed locked up behind walls that as one counselor put it “made the Great Wall of China look like a picket fence.” I remembered very, very little of my life before age 12…until recently that is...when the wall suddenly developed a leak. I have no idea what has caused this sudden flood of memories to come back, but they have. At first it scared the living hell out of me, but now it’s almost calming in its own way.

The other night in one dream I was back in kindergarten, age 6, and all the kids through 5th grade and their parents were in the playground at Oakland Street School. Dee Dee, the janitor, had moved the piano outside and Miss Broadmeyer led everyone - kids and parents alike - in singing Christmas carols as a light snow fell upon us. In my dream, I could even feel the cold air, even though mom bundled me up real well (we always walked to school, even that night). I could even taste the snowflakes on my tongue… What’s funny is everyone in the dream sang together and everyone wished each other a Merry Christmas. If there was a Jewish family or Indian family there (admittedly not that many in my white bread town of Red Bank though), we wished them happy holidays and they sang along. We didn’t need the government telling us we had to desegregate because everyone of every color and every creed all sang carols together and ate homemade cookies (I don’t think the stores even offered store made ones back then), while the milkman (yes, we had one of those too) supplied all the milk for free - poured from glass bottles. Some were Christmas carols, some Jewish songs (in the dream I recall singing “I have a little dreidel” so it musta been Jewish - and this was well before I knew the Dalai too), but all the songs had all one thing in common - they were happy songs sung by happy people. No one from the ACLU was there to monitor us because….well they probably would have been kicked out if they had been.

Political correctness? What was that? We even hugged and kissed our teachers, and they hugged and kissed us back. They truly LOVED us, and we them. There was no such thing as sexual harassment back then either…

There were no in-school or out-of-school suspensions. If the teacher called your house, you were in serious deepness. Guilty until proven innocent. Unlike our Southern counterparts, our teachers weren’t allowed to hit you - spanking was outlawed in the North by then - but it probably would have been less painful if they had. One call to home and mom and dad would be all over my case and my…... If they had a DCF back then, they too would probably join the hit force as well.

The cops never arrested you when you did something stupid because they all knew your parents and knew that it would be much better if your parents addressed it at home than through the system. So in the car you went - scared um….to death what would happen as they talked in hushed tones, laughing on the inside, but so serious on the outside. Juvie was only for the really bad kids, and we were never bad kids, just stupid kids, or shall I say typical kids. Big difference. That is why it’s so hard for me to get mad at mine own kids for being stupid. I was stupid once…and many think I still am…or at least my kids feel that way. In another decade I may get smart again though…we’ll see.

Christmas Eve we always ate an Italian feast complete with pasta fritte (fried bread dough) and suppa de peche (seafood spaghetti sauce) and all sorts of goodies, including incredible pastries from Caputtos Italian Bakery in Long Branch. Any time you traveled a whopping 10 miles to get pastries you knew they had to be good. We never knew half of what we were eating at the time, but ate it anyway - and it was delicious. Whether at our house, Mr and Mrs T’s, an aunt or uncles house, friends - anywhere, everywhere - we’d eat and eat and eat and laugh until it was time to go to midnight mass - and a high mass at that. That was another night’s dream as well - Christmas Eve - complete with midnight mass, the songs in both Italian and Latin, the incense, the stations of the Cross, and me there, sometimes in the audience, sometimes serving as an altar boy, although not until much later in life, since that was reserved for the “older” kids of 12 and up. In my dream I could actually smell the incense and hear the incense burner moving back and forth as we blessed the people.

As I looked around in my dream, I saw all our friends and neighbors - everyone knew everyone - and looked up in the balcony and saw my Aunt Mary singing with the choir- “Oh bambino mio divino…” There were maybe seats for 300 if that and the church was always packed on Christmas eve.

By comparison my kids go to my ex’s church that holds about 3,000 people and cost $46M to build, almost $10M of it on audio and video equipment alone. The worship team there consists almost totally of professional musicians – St. Anthony’s had parishioners with an average age of 67. I was proud putting my $1 in the collection basket Christmas Eve; at my kid’s church you feel like tipping the usher $20 for the magnificent Vegas-style production. Monsignor knew us all by name - my ex’s church only knows the top 1% of tithers and probably doesn’t even know half the church staff. I go to a much smaller church - maybe 600 people tops - and know most of the men and can call the pastor anytime, if I need him. That said, it’s just not the same as when I was growing up though.

The last time I was in St Anthony’s was a few years ago at my Aunt Mary’s funeral where I delivered her eulogy. Before then the last time I was there was at my dad’s funeral nearly 6 years ago and before then mom’s funeral almost two decades prior to then….Yes, I am an orphan….BUT thankfully my life doesn’t read like a Dickens novel or anywhere close…although Dad did have an Ebenezer Scrooge attitude about Christmas which I never fully understood until I was in my mid 40’s.

Even though I had been in the church just a few years before it had been over 40 years since I was last on the altar there. I just sorta froze for a moment as hundreds of memories came flashing back in rapid fire sequence. The altar always looked so much …bigger...and the priest so much more…imposing. We never had altar girls back then either - blasphemy!! - and never ever were we allowed to wear sneakers either - only polished black shoes. The church had changed immensely since I was a child - it didn’t even look the same - but I closed my eyes and could hear the songs, smell the incense, see everyone I knew…and then I had to speak. But I was speechless…my heart was broken at the loss not just of my dear Aunt Mary, but of my youth well….a time and a place that was so much better than the fast paced high tech world we live in today…

Christmas day was always reserved for relatives and friends. Like the miracle of the loaves and fishes wherever we were- our house or theirs- there was always a steady stream of people in and out- some whom we never knew who they were and it didn’t really matter either- there were never any strangers in the house at Christmas and we never ran out of food or wine either. And Uncle Louie, God love him, you’d put a bottle of Sambucca in front of him and the laughs would get louder and louder as the night progressed. God how I miss that all….

So if I happen to chat with you between now and the December 25th and wish you a Merry Christmas, please bear with me for not saying Happy Holidays instead. I’m just flashing back to much a simpler time and place, where the heart always goes at the holidays…

Have a blessed holiday season and, oh yes, Merry Christmas to you and yours!!….

PACSMan

3D is Not only Fun, It’s Coming to a PACS Near You

2009-12-15T10:48:00.000-08:00

Ms. PACS: If you’re still hemming and hawing over the uneventful technologies on display at RSNA this year, then you definitely missed the fun at the Fuji booth. It was fun and funny to see radiologists ogling over a tomosynthesis viewer, while wearing 3D glasses on top of their own spectacles.

Does that mean 3D mammography plus 3D glasses adds up to 6D? I’m not sure, but they call it 3Dimensional Stereo Digital Mammography and the images definitely popped off the screen. Actually, they were viewing 3D images acquired from a full-field digital mammography system instead of individual slices displayed in 2D from 3D data sets. The idea is to see behind overlapping structures and read breast-imaging exams faster.

McKesson also featured a 3D monitor for viewing 3D clinical images - a heart beating in the air. If this type of visual enhancement proves to be useful for diagnostic accuracy, there may already be millions of radiologists in training – but most of them busy playing AVATAR.

Since, Mitsubishi made 3D video gaming a reality earlier this year with the release of Nvidia 3D technology on one of its 3D-enabled TVs, as well as on home entertainment PCs, with a souped up graphics card of course, software now creates 3D imagery from regular video games, and some day regular 3D volume data sets.

By the way, Avatar is a new video game that uses the same 3D technology as the James Cameron sci-fi movie, also called Avatar. Talk about back to the future, it’s like 3D at the movies in the 1950s when Hollywood was losing viewers to TV and released 3D flics to regain popularity. Hmmm...sounds like Hollywood today is banking on AVATAR to do the same.

Back to reality, in a study presented at RSNA 2009, and conducted at the Mayo Clinic in Rochester, Minn., researchers used 3D stereotactic surface projection (3D-SSP) software to improve accuracy in diagnosing Alzheimer’s disease. 3D-SSP has been used in some centers and is thought to improve the accuracy of experts, said Vance Lehman, M.D., lead author of the study, which included 54 patients (23 normal and 31 cognitively impaired individuals). Two readers with less than one year of experience and two nuclear medicine experts with at least 10 years of experience viewed and rated all the PET scans. The readers ranked the scans from 1 to 5, with 1 as a normal scan and 5 as severe dementia. They also evaluated the scans for diagnostic confidence, with 1 as uncertain diagnosis and 5 as complete diagnostic certainty. During the 3 to 3.5 years of patient follow-up, no one in the normal group developed cognitive impairment, which confirmed their initial diagnosis. To my knowledge, the images were not projected on 3D-enabled monitors nor were the clinicians wearing 3D glasses, but don’t be surprised if they do in a follow-up study.

Now that it’s looking more and more likely that 3D technology will soon be a common modality to view volumetric, live images in radiology rooms and in the ORs, maybe they should hand out free 3D glasses at next year’s RSNA – and win back some its popularity.

Note: On December 3, LG Display Co. of Seoul, Korea, rolled out, the world’s first commercial launch of 3D LCD panel boasting full HD resolution. The new 23-inch 3D monitor LCD panel is used with shutter glasses that deliver full HD resolution.

PACSman: Some women are easily impressed, and so too it seems to be with Ms P. and 3D. While tomosynthesis is a relatively new technology and has only been around 20 years or so, 3D has actually been around since 1922. Three D had its Golden Era in the mid 50’s, a revival in the 60’s and 70’s and went to a new dimension in the mid 80’s with IMAX film. Today many films can be found in 3D, including the latest from PIxar Studios, Up.

I’ve seen nearly every iteration of 3D imaginable, and while it’s really cool and does have its benefits in healthcare, the costs are still fairly substantial, even though they have dropped in recent years. Processing requirements also remain fairly intense as well. Reimbursement will largely determine whether 3D thrives or dies on the vine, but for now, like its film counterpart, medical 3D is enjoying a revival of sorts.

There was a lot shown at RSNA, but very little was what I consider earth shattering or that helped me justify the $1,500 it cost me to go this year. Unlike the vendors and even Miss P who works for a company, it all comes out of my pocket. Of course with the show being in Chicago Miss P also had the option of sleeping in her own bed at night and didn’t have to spend $225 a night to call some place home, so that’s yet another inequity I had to deal with.

3D really didn’t catch my attention anywhere near as much as it did Ms. P.’s , but then I am the world’s biggest cynic as well and focused mainly on PACS. What did catch my interest was the promotion of cloud-based solutions as an alternative to image distribution via the web… We’re still a few years out from making this a widespread reality and with it commensurate pricing, but the concept is still intriguing nonetheless. So why show it if its not real? RSNA - Real System Not Available. Next question. A few vendors are doing alpha and beta testing of their cloud solutions so within the next year or two these will become more and more real…

So what exactly does a cloud-based system do? Cloud-based systems allow multiple disparate systems to upload images and reports to a central data repository, or "cloud," and then resend them out to various clients from a single site. This is crucial in making a cardiologist, orthopedists or others’ job easier, especially since the clinician typically covers multiple hospitals. Instead of having to log into four, five or six disparate systems at various hospitals or deal with CD’s that all too often don’t work properly, they simply log into the cloud and viola - instant access to all their studies that have been downloaded for them. Of course, like everything, there is a cost associated with this that the hospital pays and currently that costs is quite high, but within a year or so once, these are more than a concept, then you’ll see prices drop.

There were the obvious improvements to PACS that every vendor made a big hoopla over. VNA’s all over the place, data migration services being offered by a host of vendors, and, of course, a number of Rajivs in Ramanathapuram’s Radiology Renderings, Inc. who offered teleradiology services at a price that my dog wouldn’t even touch.

Would I go to RSNA again? I feel the same way that vendors do - you have to go because if you don’t it raises more questions than not, and once you start you can’t stop even though each year its becoming harder and harder to justify the costs. Of course, over 100 vendors out of the 700 or so who displayed at RSNA 2008 didn’t show up at RSNA 2009 - so it does happen. I just can’t let it happen to me, especially since the PACSMan Awards are among the top five stories to come from the floor of the RSNA, and people look forward to a little levity in their lives. God knows we all need some after walking all over creation and back listening to so much bull I feel like I’m in Dallas instead of Chicago. But as I’ve grown to know after more than two decades of shows, it’s all a part of the game…and next year I may even get to see to see RSNA virtual - and in 3D!!

PACSMan´s Notes From The Floor

2009-12-01T05:18:00.000-08:00

PACSman: Another year another show...the weather is nice, but oy, my feet are killing me...Part of that is due to the decision of the powers that be to expand the technical exhibits from two to three areas to make the show look bigger. I had to look and see if Dr. Scholl was a new addition the Exhibitors Circle.

Everyone IS talking about attendance at this year's show, especially since HIMMS, SIIM, and others' attendance numbers were significantly down from last year. According to RSNA published reports officially attendance is up over both 2007 and 2008, with the RSNA stating the attendance that ¨set a new record¨. Based on what most vendors saw that might be hard to believe, the RSNA registration numbers are like an NBA basketball game - paid attendance and actual attendance can sometimes vary significantly especially since most RSNA members register whether they come or not. This would be an interesting use of RFID tags that have come into play the past few years. The RSNA should publish how many people showed up on each day, how long the stayed on the floor versus attending the presentations and other areas, as well as what booths they went to...I bet the results are eye openers.

Sign of the times - at least four majors and three others decided to cancel their parties this year. Surprisingly, those having parties could also have given the Secret Service a lesson in security given they were invitation only and were strictly enforced unlike prior years where all you had to do was show up. Thankfully I had the gracious and lovely Ms P. with me who opened as many social doors for me as I did for her.

Contrary to Ms. P´s predictions, the lines in the ladies room closely mimicked the men's, which had no lines at all. This is fascinating, considering most women almost always go in groups, something I never did understand, and won´t go at all if alone, choosing instead to hold it. Maybe one guards the door or something...but there are either fewer women this year or they are drinking less...

Speaking of women, with every third booth offering so many varieties of chocolate this year there is absolutely no excuse for bitchy behavior at all.

Lots and lots of changes this year. I no longer have to squint through a bus ad covering the windows...yeah!!! And Captain Kirk is letting me name my own price on hotels for the first time in ages...There were more hotel vacancies than you can shake a stick at, with me not only able to get a great rate, but the room type I wanted AND able to check in at 10 a.m. as well. That has NEVER happened in the past. New record attendance, huh? Could have fooled me and the Chicago hoteliers as well.

Lotsa big booths from the majors, but there is definitely more dancing area for sure...less equipment means less staff...and less staff means lower show costs...

I´m beginning to wonder if I am at a radiology conference or cosmetology show. Yesterday I got my thumbnail professionally polished (and can do the other nine digits in the privacy of my hotel room for the low show special price of just $49.95), and was offered treatment for my dry skin as well. I missed the foot massagers they had last year, but haven't made it completely around yet...so let´s hope.

I did see a dark haired beauty here who significantly piqued my interest, but alas Ms. P. said that I would have to buy her a meal to have her even remotely be interested interested in me and I just don't know if there is time for that. Her name is intriguing-Lola- which reminds me of that old Kinks song. I wonder if she´s a very kinky girl as well. Time will tell...

Gotta love the overseas companies. Every year I wonder how much they paid translators to do such a wonderful job of making me laugh...

OK, gotta get to the show. More tomorrow...And if anyone knows how to get Spanish characters off my laptop, please let me know. I let my love child use my computer last to do his Spanish project, and low and behold when I type in a character expecting one thing, Bobba Louie gives me another. Maybe it´s just getting me ready for the El Grande dinner tonight when many of us from various journals get together and share a laugh or three over lousy Mexican and wonderful drinks, while talking about the vendors in ways that will never ever see the light of day...Till tomorrow - Ole...

RSNA 5-Day Forecast

2009-11-23T09:59:00.000-08:00

Ms. PACS: I was looking into my crystal ball, trying to see what to expect at RSNA 2009 next week, when I saw...a huge smudge - I needed Windex. So in my quest to seek out truth and wisdom, I turned on the TV. Clicked on the weather channel. To my surprise, standing in front of a large map, it was Willard Scott! I wondered if it was an old VCR recording…but realized it was in fact 2009. Maybe Willard’s 401K had taken a nosedive, forcing him out of retirement. In any case, despite his feeble yet rotund state, he did provide some sound data in his RSNA 5-Day Forecast.

Willard said: “You can expect to see:

1. Low res images sent from PACS to EMR: If you go to the BRIT Systems booth, you will see their new Webworks solution. Referring physicians and their patients now have access to diagnostic images with a new browser-based application for viewing patient images and reports on any computer with an Internet connection and a browser. The new application also provides access to radiologists for low volume review. The platform uses AJAX for real-time updating of patient lists and clustering technology for redundancy and load balancing.

INFINITT Accent also allows PACS-based medical images to be accessed along with all other types of medical information on any Internet-enabled terminal. A new PACS offering for EMR, HIS and practice management vendors fully integrates the complete range of medical images with EMR software of almost any kind.

2. Vendor-neutral archiving will be one of the big themes on the exhibit hall floor.
Carestream will show its vendor neutral PACS and storage/archive solutions, which brings disparate PACS and data systems into a shared, long-term data management solution that can streamline management tasks and reduce costs.

3. Bathroom breaks: The bathroom wait times on the RSNA exhibit hall floor will be approximately 3 minutes long (which is a 2 minute drop from last year)…except in the ladies room - that will remain the standard 15 minutes.

4. New PACS: Siemens will introduce the new PACS that appeared on Dalai’s PACS Blog last week (http://doctordalai.blogspot.com/)

5. RSNA unveils structured reporting templates – The RSNA has established a Radiology Reporting Committee to identify and promote "best practices" in radiology reporting. June 2008: RSNA convened a workshop to plan the future of radiology reporting. More than 50 radiologists, medical informatics specialists, and representatives of cardiology, oncology, and pathology participated. Consensus was reached on a global template for diagnostic radiology reports, including standardized radiology report headings.

December 2009: RSNA will release the first set of reporting templates, freely available for downloading and use. (http://reportingwiki.rsna.org/index.php?title=Main_Page)

Have you seen the Google “radiology-report” site with RSNA radiology structured reporting templates. It contains RELAX-NG templates for radiology-structured reports. The code is from the GNU free software operating system. Someone at Medical College of Wisconsin is developing it.

By the way, Stage 6 of the EMR Adoption Model requires structured reporting systems.

6. Fuji 86's its annual House of Blues (HOB) party – is it due to NEMA code of ethics? When did fun equate unethical behavior? Do you really think a doctor is going to buy equipment just because you buy him a beer…and it's only a buffet dinner – not an intimate candlelight engagement with a contract on the table. Granted, I have witnessed some embarrassing behavior at such events…but the moral infractions usually happen after the party, not on HOB premises. The silver lining is that like any enforced code of conduct, there’s a loophole, or a lawyer to find one for you. Some companies are keeping it ethical by throwing a charity event. At least some of the frivolity goes to those in need. It’s all about balance.

7. White flag: The CT slice wars will officially come to a stalemate as attentions focus on lowering the dose.

8. Pocket diagnostics: Ultrasound debuts as a new iPhone feature – for both diagnostic purposes and pure entertainment. Talk about consumer driven healthcare.

9. E-Ordering imaging exams: To meet with stage 4 of the EMR adoption, CPOE and CDSS (Clinical Decision Support Systems). Evidence-based medicine makes sense, but it’s hard to get physicians to actually use it. IT tools that provide decision support at the time they make decisions may help close that gap. Kind of like the little Einstein on PCs (or you can make it a cat) that alerts you when it has a suggestion or detects a potential error. I heard Bill Gates’ wife, Melinda, came up with the idea for that little alert icon – but man is it annoying. I have to use the cat icon so at least its cute and I don’t get as aggravated.

10. Last, but not least. While perusing the IHE demo exhibit, the PACSman will find his true love – she will not be a PC or a MAC this time. But one thing is for sure - she will have a pulse.

And When I'm Gone….

2009-11-10T10:17:00.000-08:00

PACSman: Like many of us in the industry I was shocked to hear of the death of Sectra North America President John Goble. I both knew John and liked John and anyone who met John couldn’t help but like him. He has this thing about him that was just…well…..likeable.

Years ago, when Philips decided to go with Stentor as their PACS solution ending a decade-long relationship with Sectra, I asked John what he thought about it all and how it would impact the company. In typical Goble fashion, instead of cursing the darkness, John lit a candle. He said it was probably a good thing that it happened finally allowing the company to come out the shadow of Philips and stand on its own merits. I was astounded that a guy who probably just lost 80% of his company’s U.S. revenue could be so upbeat and positive. In my own politically correct fashion I asked if it upset him being dumped for a younger woman. He just smiled and again with that typical Goble response said, “We had a lot of good years together and a lot of good times. They are doing what is right for them, and we will do what is right for us and our customers. We will stand behind the Sectra customers who have our products installed and continue to move ahead on our own as a stronger, more unified company.”

He never had a bad word to say about Philips, even off the record, because these were his friends and just you don’t trash friends. That is the essence of John- straight ahead, honest to a fault, open, dedicated, and focused. In a market of full of schmucks, John was the anti-schmuck. That is probably not the legacy he envisioned for himself- to be labeled the anti-schmuck- but he’d probably just laugh about it knowing how I meant it in all sincerity.

The past few years the PACS industry has lost a lot of good people. Sam Dwyer, Phil Berman, John, and others all made their mark not just on the industry but on me personally.

I can recall a conversation many many years ago that I had with Sam Dwyer, sitting on the back screened porch of my rental house in Maitland where he elected to stay for a few days while he was in town. Now Sam could have stayed at the Ritz since a company was picking up his tab but elected to stay in the guest room at my house so he could help me set up my fledgling PACS consulting business. As we sat on the porch I shared with him my fears about the future and what it would bring. His answer was very simple and very basic- “Do what you love, Mike, have a good woman by your side like I have with Marylou, and when you have kids, be there for them”. I heard his stories of starting out in years past with so little money that it was frightening but his formula- love your work, love your woman, love your kids- worked. I loved my work- still do to this day- and love my kids- always have, always will- but I guess I need to put a little more effort into the woman thing.
Phil had the same simple formula for living as well. Love your work, love your family. He would always talk about his family with whatever new project he had cooking on the back burner, right up until the time he ran out of toes to paint. Another great guy gone way too soon.

John was cut from the same genre. I didn’t get to spend as much time with John as I wanted to- I’d see him at trade shows, he’d stuff my bag full of chocolate, and we’d talk on the phone and have dinner now and then- but I did get close enough to him to hear his war stories so that was closer than many. Love your work, love your family, and make time for yourself was his mantra. All day yesterday the old Laura Nero/Blood Sweat and Tears Song “And When I Die” ran though my head:

“I'm not scared of dying,
And I don't really care.
If it's peace you find in dying,
Well then let the time be near”

John died doing what he loved best, flying helicopters. While it was a terrible and tragic way to go how many of us can say the same- that we died doing what we love best? “

“Give me my freedom for as long as I be.
All I ask of living is to have no chains on me.
All I ask of living is to have no chains on me,”

That got me to thinking - when it’s my time how do I want to go? Now I know we don’t get a choice in it and that it’s all predestined and such (or so the guys in my men’s group at church keep telling me) but if I had my druthers I’d either be at a garage sale having just scored a killer bargain, taking pictures of my youngest son’s high school marching band or my oldest son’s BPA involvement, or watching the guys I’m worked with for 10 years enjoying the fun and fellowship that comes from playing a game of soccer. The very last way I ever want to go is behind my computer typing a report that will be read once- if that- and then discarded. Also know before God gives me the thumbs up or thumbs down, He and I are going to sit down over a pitcher of beer and some wings and talk about a lot of things. I won’t question Him or His infinite wisdom- after all He is God- but I just need to know a few whys and wherefores about my life and others for my self-edification, that’s all. This has the guys in my church praying for me harder still - the arms lifted high, “Praise Jesus!!” variety - and me instead asking, “Yo, God, can we talk?” But God knows it’s coming, and I’m sure he has the answers ready to the questions I’ll be asking, and most of all He’ll be cool with it too. My God is a loving, caring God and I’d be willing to bet He’d even pick up the tab for the beer and wings if they have tabs in Heaven. Heck, He might even meet me outside the Pearly Gates as well, since as it stands now, I can go in either direction and why waste time, right?

I have had so many opportunities to get a “real” job the past few decades- ones that would pay me three to five times what I make now - and each time I came close to saying “Yes” I ended up saying “No.” The sacrifices I would have to make by leaving my kids far exceeded any financial “benefits” I would have reaped. Do I regret it? The money would have been very nice as would the chance to be a part of a team, but I’ve found I get frustrated when people don’t share the same vision and enthusiasm I have in achieving a goal and learned that money doesn’t mean anything so I’d have to say No I don’t. I also have something that few can say in our industry- I was there for my kids. Almost every event that my kids were involved in, big and small, I was there for. I’d be willing to bet Sam, Phil, and John could pretty much say the same. If my kids had something going then they were my prior commitment. That is something I couldn’t do that with a “real” job.

I’m going through a hard time in my life now because suddenly my babies aren’t babies any more. My youngest son Matt at 16 scrimped and saved and now has his own car and can take himself where he needs to go without me taking him. For all the bitching and bellyaching I did about playing Hoke in Driving Miss Daisy, I miss schlepping him all over creation. I also realize what my mom used to say about the hen never sleeping until all the chickens are back in the roost when he is out. Thankfully he can’t drive after 11 pm until he turns 17, so I got the tour of duty for 1 a.m. pickups for him and his friends at Halloween Horror Nights a few weeks back. As tired as I was, it was heaven getting them even if they all fell asleep before we were even out of the parking garage.

My oldest son Nick just turned 18, and now he is officially an adult and will be going to college next year. Thankfully he is leaning towards our local community college, which means he’ll be living with either me or my ex until he hits age 27 or graduates, whichever comes first. He’ll also be getting his car soon enough and then will be in 15 different directions as well. He is my brilliant computer genius with half a dozen certifications already and is a Web site design guru as well, but I just wish he would fix my computer when I mess it up without making me feel like the idiot I really am.

I should be celebrating my new found freedom with the kids being on their own finally but instead have a very bad case of empty nest syndrome. I thought that only affected women….Maybe its time to consider a real job again but at least Elvis the Wonder dog still needs me to clean up when he gets an attitude and pees on my couch leg or the carpet so all is not lost. And someday, somewhere, I’ll meet the woman of my dreams (probably at a garage sale) and give love a chance again - or at least some heavy duty lust. Ms. PACS - where are you when I need you most!!

And when I die, and when I'm gone,
There'll be one child born
In this world to carry on,
to carry on.

I have two children that I love dearly to carry on and I hope they leave me a legacy that I’ll be proud of. And John Goble - in addition to his family and many many friends he has - also has an entire company called Sectra North America that he considered his “children” to carry on….. and carry on they will…

What the World Needs Now…

2009-11-04T07:19:00.000-08:00

PACSman: …isn’t love, sweet love. Sorry to disappoint you, Dionne, but what we really need is fewer ego-centric individuals and companies who are looking out for themselves rather than the good of the industry or the individuals who actually have to use the systems. There, I’ve said it- sue me.

I’ve been in this industry for way too long and each day I wonder when “pro bono” actually will be “for the good of the people” and not for someone’s own good. It has always been my opinion that companies put representatives on committees not to help develop industry-wide standards like DICOM, HL-7, IHE, etc. but instead to protect their own interests. That is one reason why DICOM is the most non-standard standard that ever existed and you need a Ph.D. in reading conformance statements to understand what a company does and doesn’t adhere to relative to this “standard”.

IHE is another example. The concept of improving the way computer systems in healthcare share information is commendable, but do we really need 253 member organizations providing input, of which 177 (70%) are Healthcare IT and consulting companies? No. And how many of those 177 have adopted all or at least most if the IHE initiatives to date? Fewer than a handful. It’s all about the companies ego, being able to say “our company participates in…” .even if in reality they don’t do squat..

Now before you go off on me, yes I do have an ego although you mostly see my alter ego in print and not who I really am. The same can be said for Ms. PACS, many of my fellow editors, and even my good friend the Dalai. In print we can be anything and often are, but it’s all done in good fun. I am incredible outward and beyond bold in print but in reality I’m closer to 180 degrees from that. The same could be said for most people I know. The Dalai is one of the quietest most unassuming guys I’ve ever met yet when you read his stuff its like- “Whoa, wait a minute!! Are we talking about the same guy?” Yes I am. Opinionated? Of course. Correct? Most times. We are both Clark Kent in real life and Superman in print - individuals in search of truth, justice and the American way… trying to help out as we can even if we do resort to a bit of sarcasm now and then…And Ms. PACS - she can be like Rilke’s panther one minute and a pussycat the next…Yes it’s all a game…but a game about helping. All of the 350+ articles I’ve written on PACS have been done with the single intent to help, even if I do tend to inject a degree of sarcasm into them now and then. Most importantly, at least to me, all were also written without cost to the journals - pro bono, for the good of the people.

So what then about egos? I’ve noticed more and more that certain individuals in our industry have adopted God complexes about themselves of late, and it’s not good at all. There seems to be no place for bantering or discussion anymore, and every day I see more of the “I am the great and mighty Oz!!” syndrome showing up. Why then is this happening? The answer is ugly too. We have looked up to these certain individuals for answers and called them Gods for so long that they now they believe that they are…Pull back the curtain as Toto did and you’ll see that academia produces some of the worse cases followed closely by executives at the large companies and lastly people connected with the smaller companies and individuals. Like everything there are exceptions though. I know some individuals in academia who will do anything to help others and be perfectly content to stand in the shadows while there are others where the spotlight can never be bright enough…

To understand ego we need to get a big technical so we need to go back to Herr Sigmund Freud. According to Wikipedia, the “id” acts as according to the “pleasure principle” seeking to avoid pain or unpleasure aroused by increases in instinctual tension. OK, that explains a lot.

The ego is that part of the id which has been modified by the direct influence of the external world. The ego represents what may be called reason and common sense, in contrast to the id, which contains the passions ... in its relation to the id it is like a man on horseback, who has to hold in check the superior strength of the horse; with this difference, that the rider tries to do so with his own strength, while the ego uses borrowed forces [Freud, The Ego and the Id (1923)]

The Super-ego aims for perfection. It comprises that organized part of the personality structure, mainly but not entirely unconscious, that includes the individual’s ego ideals, spiritual goals, and the psychic agency (commonly called 'conscience') that criticizes and prohibits his or her drives, fantasies, feelings, and actions. The Super-ego can be thought of as a type of conscience that punishes misbehavior with feelings of guilt (example: having extra-marital affairs).

The Super-ego works in contradiction to the id. The Super-ego strives to act in a socially appropriate manner, whereas the id just wants instant self-gratification. The Super-ego controls our sense of right and wrong and guilt. It helps us fit into society by getting us to act in socially acceptable ways.

So is it the ego’s fault or the id’s? Where does the Super-ego come in too? Socially acceptable ways? Where? Here? Guilt? Honey, I was raised in a Roman Catholic Italian house, while the Dalai was raised a good Jewish boy. We have enough guilty for any 10 of you - on a good day…

So what’s the bottom line? Let’s go back almost 15 years ago when Michael Jackson, Bruce Springsteen, Diana Ross, Bob Dylan, Billy Joel, Stevie Wonder and over three dozen other rock and pop superstars showed up to cut a record called “We Are The World.” The song was written by Michael Jackson and Lionel Richie to help starving kids in Africa. The great producer and Motown director Quincy Jones, coordinated the entire effort. All through the night the artists recorded and worked together for the benefit of others, with the net result being a record that hit the #1 position a mere four weeks after it was released. The recording stayed in the number one spot for a month raising almost $14M in the first four months alone and has raised $63M in humanitarian aid to date.

How did he get everyone to cooperate? “Q”, as he is known in the industry, put a sign out over the entrance because he had all these huge international stars there—and with them lots of egos too. The sign said simply. “Check your ego at the door”. They listened, worked together and collaborated and raised a lot of money to do good things.

At RSNA, SIIM, HIMSS the DICOM, HL-7 and IHE meetings, and everywhere that individuals can congregate we need to make a sign that say the same - Check your ego at the door. Maybe then we’ll finally achieve the goals with PACS that we have been desperately seeking for years.

Ms. PACS: “Q” is brilliant and while the whole world acknowledges that fact, he has the insight to know people – especially celebrities - need have have some humility to work well as a team.

The funny thing is, every time I have heard the instruction: “Check your ego at the door” - it’s coming from the one’s with the biggest egos…the one’s who are telling you to check YOUR ego at the door because there’s only room for their ego.

These are the Super-ego dictators – they’re going to dictate to you in their unchecked self-righteousness what’s socially and professionally acceptable and how you should act. It’s the people in power who slide under the radar of checks and balances who are most severe with their subordinates. That’s why it’s good to be a doctor – there are few people above you to kick you around. And fear of getting kicked is what drives and reinforces the “id” – which seeks to avoid pain. So remember that the next time you are dolling out instructions.

What I like better than “Check your ego at the door” is “Let go of the ‘e’ in ego and go!” A little cheesy, but the message is the Super-ego often holds you back from learning. It blinds you from recognizing your own shortcomings and prevents you from improving. It actually operates as a shield to avoid pain – the pain of the reality that you are, to a large extent, powerless – the realization of which unearths that underlying, trembling emotion – fear. And lord knows fear is what drives countries to war and places dictators in power. As Dr. Paul Chang explained to me once, in the context of improving healthcare IT, there is the dangerous combination of ignorance and arrogance.

These Super-egos plague healthcare IT and PACS. It is hard for the IT-savvy radiologist or other doctors to recognize they don’t know everything – even about how best to run their own departments. The realization that healthcare IT is 10 years behind other industries, such as banking and finance, is an embarrassment to the erudite. The id cranks up the engine to high-gear to avoid the painful realization that we weren’t born knowing everything, and the Super-ego further buffers the id by denying the truth. Again, ignorance and arrogance.

So what if the IT guy knows more about hospital IT networks than you - isn’t that his job? I know your response - but they don’t know Radiology workflow. So tell them how it works, but listen when they tell you how it might work better.

It’s simple, if you want to improve in life - don’t let your Super-ego blind you, and ignore that wimpy little ‘id’ when it tells you to stick your head in the sand. Why? Because it’s o.k. and even satisfying sometimes to have a slice of humble pie. So maybe a better motto would be – no pain, no gain.

Adam, Eve and PACS

2009-10-26T08:26:00.001-07:00

PACSman: The very few people who know me know well know that for the past decade plus I’ve run a sports ministry. Now before you fall over yourself laughing at me being involved in either sports or a ministry know that it wasn’t my idea but God’s.

I was just minding my own business one day over a decade ago when out of the blue a voice echoed in my ears saying two simple words - “It’s time.” My immediate reaction was “Huh?” Am I late for a very important date like the rabbit in Alice in Wonderland or what? Who is this? No answer.

I said out to no one in particular out loud “Look Jack, don’t waste my time” and then fell back to sleep….

”It’s time” came the booming voice again…

I looked around expecting to see either George Burns or Morgan Freeman in my bedroom, then said ”Nah..no way….can’t be.”

Long story short, after much bantering back and forth with “the voice” aka “Him,” I caved in and took what was supposed to be a two-day job helping out at soccer camp at my old church. I thought nothing of it until I watched my role in sports ministry over the next several months and years increase dramatically.

Was that what He meant by “It’s time”? Who knows. All I know is every Friday night now I oversee 80-90 young adults playing soccer and have helped establish several sports ministries at various churches when I’m not playing PACSMan. I could care less about denominational theology - that’s for the elders to address cuz in my way of thinking it’s all one God - but it’s been a really interesting trip so far. I’m glad I came to my senses listening to the voices in my head because the reality is you can’t win with someone who knows the outcome of something before it even happens….. although God knows I sure tried.

So where am I going with all this? I have a client who calls me an “enigma.” He says that I’m a guy who could make a sailor blush with some of my comments and analogies, yet is surprised that I am one who also studies the Word. “It’s all about balance,” I said to him as we got to talking about his current bible study on Adam and Eve.

Now I’ve read Genesis more than a few times and have many of the guys in my men’s group praying for my heathen soul on a daily basis. Why? Because in my mind Adam was given a bum rap and got the blame for much more than he deserved.

My client/friend and I bantered back and forth on this. While he is a very open guy, he does tend to take the more conservative Baptist perspective that the man leads and the woman follows. Me, I’m a Billy Joel “Only the Good Die Young” ex-Catholic who goes to a PCA Presbyterian church and actually avows a more Unitarian kinder-gentler approach towards God than any specific denominational approach.

OK, back to Genesis. When I discussed the man being over the woman thing as defined in Genesis 3:16 with a very good friend of mine she said “Good luck with that (expletive deleted)!” I explained it to her that Eve had it all then blew it by listening to the serpent and then Adam blew it by listening to Eve yet somehow it always gets turned around that it’s all the guy’s fault The look I got said it all and it wasn’t one of endearing love either. Maybe I’ve been looking for love in all the wrong places but I’ve been told that “biblical wives “exist out there. I have never found one and truth be known I don’t really think I want to either. Just give me one who listens a little better than Eve did and I’ll be happy.

Most die-hard Christians say the Fall is all man’s fault but to that I say read the Word again. It never says that. The worst it says in Genesis 3:17 is "Because you listened to your wife…” with the implication “and not Me,” then we get all the curses put upon us because Adam was a dummy... Heck, that pretty much defines my life…

In my many roles I’m supposed to lead yet find people who just won’t let me. It happens in my business - Mike, you tell us what to do or how to do it, and then we’ll do it our way anyway and blame you when the outcome isn’t what we expected.

It happens in my personal life - you lead, I may or may not follow. Apparently Fred Astaire I’m not.

It even happens with the dog. “No, I want to pee here, not there, and if you lead me back there, I’ll just pee on the carpet again to spite you…”

That’s sort of the dilemma that Adam faced. God told both Adam and Eve the rules together, and while he was in the Garden with her doing God knows what she goes eating from the tree of knowledge of good and evil. Now he blew it too by listening to the lil vixen that was formed from his rib and as hard as it is to say he, too, got what he deserved. I won’t debate that. I also won’t debate that God wasn’t happy at all either. I honestly can’t say I don’t blame Him either, but was it all Adam’s fault?

Genesis 2:24 uses the words “one flesh” as in equals. It wasn’t until Genesis 3:16 did God say “Your desire will be for your husband, and he will rule over you.". So if both were equals before the Fall why did Adam take the blame for her mess up? After all, she knew the rules too, right?

Now let’s go a step further. Was Adam right next to Eve? In Genesis 3:6 it says “She also gave some to her husband, who was with her, and he ate it.” Was he right there next to her when she ate it the first time or just somewhere else in the garden and came back to find out that she blew it by disobeying God’s one and only rule? It doesn’t say. The conspiracy theorists could have a field day with this one. Was Adam mesmerized by the serpent and said nothing or had he just come back from being somewhere else in the Garden and found out what she did. I wonder what would have happened if he said “Eve- WTF!!! You dumb bunny. You knew the rules God gave us. You blew it!!. You’re outta here now babe!!.”. and didn’t cave in to her “offer” of a bite or two. Who knows who might have been her replacement. God may have even seen that maybe Adam needed all his ribs after all. Rest assured though whatever the outcome it wouldn’t have been Adam and Steve…and the sheep were safe too…

Now keep in mind in Gen 3:12 Adam even told God “..the woman you put here with me…”. This, at least to me this to me, implies that Adam really didn’t even want a mate but was he given any choice in the matter? Noooo….. God, in His infinite wisdom, decided to give him one. Adam probably could have asked for his rib back and his life would have been all well and good. Of course technically we might not all be here now were it not for Adam and Eve but…these are minor details. Did he ask for a “helper”? Nope….Some helper huh? Now you know why I’m still single…and probably will be for a long while…

OK so before I go straight to hell without collecting my $200 for passing Go, you need to know what all has to do with PACS. Several things:

1)   Be content with what you have. Adam and Eve had it all yet in true female fashion Eve wanted yet more. I know a woman can never have enough shoes or chocolate but….Eve should have left the tree of knowledge of good and evil alone. All those trees and a good life to boot and yet it still wasn’t enough… Yes, there might be something better out there but if you have you are fairly happy with what you have why bother looking for something more?

2)   Follow the rules. Most vendors don’t ask a whole lot out of end users- just that you have a PSA, do routine maintenance, load the upgrades, and report any known problems. Customers merely ask that a vendor provide responsive support and sell them a product that does indeed do what they said it would. Break the rules and there are consequences you both will face. Corollary: It only takes one person to screw it up for all the rest of us so…..

3)   If it ain’t broke don’t fix it. Adam was perfectly happy in the garden with “the livestock, the birds of the air and all the beasts of the field as well” as the “trees that were pleasing to the eye and good for food”. Heck, the livestock even had names. Did he say “Hey God, how about stealing a rib from me and making me a helper? Nope. Genesis 2:18 “The LORD God said, "It is not good for the man to be alone. I will make a helper suitable for him." My pastor always says God never make mistakes but in this instance….it does make you wonder.

4)   Not everyone is out there to help you. Just look at the serpent…..and Eve…who thought they were both helping out…I have a plaque that summarizes it all- trust in yourself- but since there are also 61 passages in the bible that tell you to trust in the Lord as well I’ll compromise and say trust in Him to help you trust in yourself…although I still wonder about His judgment with that whole creating Eve thing...

5)   Without leadership you will flounder. If Eve knew Adam was in charge she might not have risked going against his wishes or God’s, but since she considered herself an equal she did as she pleased and look where it got them both.


Now you are probably praying for me right now thinking if I’m this bad with Genesis I can only imagine what he’ll do with Revelation. Psalms and Proverbs are probably a much safer and better bet for me to address though, although if I really wanted to stir up controversy I could quote from the Gnostic Gospels (Philip, Mary Magdelan, et.al.). I can just see it now- the elders and the deacons of my church are already on their way over to my house to hold a combined prayer meeting/exorcism for me…..
Nah….. Next time I think I’ll just play it safe and hit the tried and true Song of Solomon and see if I can get Ms. PACS all worked up….in more ways than one….

Where are the Next Gen PACS features?

2009-10-22T10:11:00.001-07:00

Ms. PACS: Research. Doing research on PACS or anything related to radiology will send you in 100 hundred different directions. Which is the very opposite of the PACSman, who will send you directly to @#%^&(*), if you catch him on a bad day.

Seriously, which is the best Radiology specific search tool:

- Radiology Research

- MyPACS.net

- Yottalook.com and Yottalook app for the iPhone

- ACR Case in Point

- Dr. K. MSK Cases

- EURORAD

- Journal of Radiology Case Reports

- Pediatric Radiology

- Rad Files

- radRounds Cases

How often are these tools actually used by rads, rad techs, PACS admins, and nerdy people who like radiology IT? I know one doc, Dr. Phillip Silberberg, a pediatric radiologist, who led MyPACS.net in reads. He's a real champ because all of that work is pro bono. But most rads are not so generous with their time.

What I was looking for was:

1. the most recently tallied average on the # of cases a radiologist reads in a day (in the U.S. - had to clarify as PACSaholic has become quite international as of late - bonjour Dr. Lambert).

2. I was looking for next generation features/tools that eliminate mouse clicks and improve access to data include. After meeting with one borderline angry healthcare adminstrator, who loved to squeeze as much out of his radiologists as he could, he did make an impression with this comment on PACS: “Anytime you add a mouse click, scroll, page forward/backward, open/close, every step you add to workflow is a design defect!”

After 5 too many interviews for my article, i came across one PACS admin (lady by the way) who said: "The radiologists are going to start billing for every additional mouse click they add to PACS!" Of course they would - anything to make a few extra bucks.

The next gen tools I unearthed from the bowels of "new PACS features" were:

- touch screen

- voice commands in RIS

- voice commands to navigate PACS

- automatic registration and matching of volumetric data at different time points on

- auto-structured reporting

- auto-loading templates mapped to procedure codes

- bookmark findings/optimal image

- one click to sign reports

- critical test results management solution to delivery of critical patient findings

These are more recent innovations thanks to Apple and Microsoft:

iPhone Apps:

- 3D rendering of CT scan: app developed by Ziosoft (www.ziosoftinc.com)

- Osirix iPhone: As difficult as it may be to give driving directions to an out of towner, it’s often more challenging for a radiologist to describe a patient’s imaging findings to a colleague. The Osirix iPhone app can actually help. The application brings a small and easy to use DICOM viewer to the iPhone. (www.osirix-viewer.com/).

- eRoentgen Radiology Diagnosis: developed by Constantine Brocoum, M.D., a neuroradiologist, the application is a compendium of textual information listing recommended imaging studies for each item from a voluminous list of symptoms and diagnoses. (www.iatrossoftware.com)

Microsoft Courier: two-screened hinged tablet with multi-touch capability, designed for writing, flicking and drawing with a stylus, in addition to fingers.

Thanks MAC and Microsoft. Meanwhile, are the PACS developers in hiding? Where are the 2.0 ideas? And how many radiologists have an iPhone (your kids' doesn't count). I guess GE's Jeff Immelt, a non-radiologist carrying around radiology apps, showed off his new iPhone ultrasound system called Vscan this week at the Summit 2.0 in San Fran. He called it a "smart phone" though. I thought Web 2.0 was all about collaboration. That's what Dr. Paul Chang told me in his interview Closing the Imaging Loop. When are Rads going to really explore the social side of technology - converse with their patients and referring physicians online or via Web cam embedded in PACS?! But that would mean you can't be in pajamas.

Déjà Vu All Over Again

2009-09-25T07:18:00.000-07:00

PACSman: I was reading about yet another patent that got issued in the PACS world last week and starting thinking to myself what Yogi Berra once said: “This is like deja vu all over again.” This time a patent was issued for archives…or more specifically one that "provides for the management of clinical data using a scalable solution based on clinical business rules that logically or physically segments shared storage infrastructures.” Whatever you call it, it has me wondering what the heck is going on in DC?

Now I do not want to take away anything from any company who applies for a patent - after all, it is their right to apply for and even be granted one - but in the nearly seven years it took from the patent file date to the patent issue date it seems like an entire cottage industry sprang up around what they have patented. This seems to be endemic to our industry, a situation I have seen time and again.

Medical imaging companies have been issued patents for workstation hanging protocols, creating CD’s with embedded DICOM viewers, and now archive management. Normally this isn’t a problem if it’s something that isn’t used as part of the day-to-day operations of a PACS. The problem is most of these so called utility patents are. A utility patent is issued for the invention of a new and useful process, machine, manufacture, or composition of matter, or a new and useful improvement thereof, and generally permits its owner to exclude others from making, using, or selling the “invention” they got a patent on. In the case of many of these medical imaging patents that is tantamount to someone putting a patent on middle C of the piano, having seven years worth of music written around it, and then charging every author whose song hits middle C in it. The more you hit it, the more you pay…for the next 20 years. What sadder still is that 90% of all patents issued in the past few years by the USPTO have been design patents, those that address medical imaging.

Once a patent is issued getting it rescinded is virtually impossible. And what happens next? If typical, the patent holder sends notification to all companies who are using similar (or identical) technologies that might infringe on the patent letting them know that they may be in violation of patent infringement and will need to negotiate a licensing arrangement with them. And who ultimately pays for this? The end user.

Can you fight it? Of course you can and many of the majors have. But for many of the smaller vendors the risk of losing a patent infringement case and having to not only pay their own legal fees but that of the patent holder, plus back licenses, more often than not exceeds the value of just settling and paying the licensing fees up front.

Is this wrong? Legally no. Morally and ethically though it can be considered a gray area. Companies that apply for a patent typically have to state that a patent is pending, yet most patent applications aren’t published until at least 18 months after the filing date of the application. In the healthcare field, that length of time is an eternity - and that’s just to find out that it’s been filed.

After the patent application has been published, a member of the public may request a copy of the application file, but getting this was not an easy process. It wasn’t until late 2004 that the U.S. Patent and Trade Office (USPTO) made patent searches available via the Net, using the USPTO’s Public PAIR (Patent Application and Information Retrieval) system. Unfortunately, until the patent was actually granted, you had to know a fair amount of information about the patent to be able to search for it. This put an unfair burden of responsibility on companies who may have developed technology that was similar but perhaps not identical to that which was under review for a patent. You also never knew if the patent was going to be granted, sent back for revision, etc., until it happens, so why hold up the development of a product for three, five, or seven years or longer on a maybe? It’s also not until after the patent is issued that the application and all correspondence leading up to issuance of the patent are made available in the Files Information Unit for inspection by anyone, copies of of which may be purchased from the Office.

One source said each year nearly 50,000 patents are issued - 137 per day - yet the number of patent reviewers isn’t nearly enough to cover the number of patents being applied for, let alone granted. This creates a situation where patents are issued years after they are filed, allowing a cottage industry to spring up in the interim. If the 50,000 number is indeed correct (I’ve seen numbers anywhere from 20,000-50,000 bantered about on various sites, including the USPTO’s website), this means 350,000 patents were approved before the most recent one in medical imaging was. Even if only 20K patents per year were approved, that still leaves 140,000 who got their Golden Wonka ticket ahead of the latest medical imaging winner. And as Billy Shakespeare said about that in Act 1 of Hamlet: “Something is rotten in the state of Denmark”- or at least in Washington, DC.

The problem as I see it is fourfold. First there are not enough patent reviewers to act in a timely fashion. Seven years is way too long to take to get a patent approved. By the end of seven years, PACS is usually in the third generation of products…and so many systems have been put into place that any retroactive licensing will cause an undue financial burden on companies.

Second, and most importantly, patents are being issued by reviewers who, in my opinion, really either do not know or do not understand the medical imaging community. Adding a DICOM viewer to a CD that contains DICOM images isn’t - or at least shouldn’t have been - patentable. Both DICOM images and DICOM viewers existed separately well before this “patent” was granted. How hard can it be to add software like a viewer to a CD? Not rocket science by any means and not patentable either. And hanging protocols? People have been arranging icons since Windows 3.0 introduced the concept of a Graphical User Interface (GUI) way back in 1990. What makes this special besides this being used in medical imaging? It’s the same concept applied slightly differently. Now, admitted, I am oversimplifying what no doubt is considered a much more complex process by the patent owners, but hopefully you catch my drift here. I need to read the current archive patent a few times before it sinks in, but I’m sure I can distill it to a few simple points of relevancy and commonality as well.

Third, there needs to be a way of letting companies know in plain English when a patent has been filed, what it encompasses, and if their any technologies being in the industry impinges or infringes on it. This should be the responsibility of either the USPTO or the patent applicant, not the end user to figure out, sorta like a guy who gets ambushed on Maury - “You ARE the father…”

Fourth, patents shouldn’t be retroactive to the file date. Penalizing companies for a patent they might not have even known about just isn’t right again in my opinion.

Bottom line - we need to take a closer look at the way patents are issued. We can’t change the way things work overnight, but the input we provide just might make a difference and keep this industry from tripping all over itself as it is now…

Yogi summed up the situation best: "If you can't imitate him, don't copy him." There ya go….

So, What’s the Damage?

2009-09-16T14:21:00.000-07:00

Ms. PACS: We might finally get the bill. I’m talking about the latest proposed healthcare reform bill from Congress - this one hovers around $856 billion.

Many said the proposal still spends too much, and it does too little to cut healthcare costs. But the final details were etched out by a bipartisan group of senators so that in the end – we’re all to blame.

This latest proposition in healthcare reform does not provide for a ‘public option,’ but would require everyone in the U.S. to purchase health insurance by 2013. So what are the option for diagnostic imaging?

For starters, the bill would levy $4 billion in annual fees on medical-device manufacturers beginning in 2010. Fees would be proportioned according to each company’s market share. Some say the government believes device makers will actually benefit from an overhaul thanks to wider insurance coverage, which will bring them more customers. So, it’s sort of like paying insurance to the White House to help pay for the package.

What a more widely insured population will do is grow the volume of diagnostic imaging exams. But at what cost?

As government scrambles to cut healthcare costs, it repeatedly targets medical imaging reimbursement. Fortunately, there is some reprieve – this version of the healthcare reform bill would set the equipment utilization rate for Medicare reimbursement of imaging studies at 65 percent, significantly lower than the 90 percent level proposed in original versions of the legislation.

If this passes, it will be a relief to radiology and radiation oncology alike. In the recent Medicare physician fee schedule proposed rule, Medicare payment rates for physician services, including radiation oncology, proposed cutting radiation therapy services by nearly 20 percent.

As we all know, what is at stake is the sustainability of freestanding and community-based cancer centers, as many would be forced to close, stop accepting Medicare patients and reduce critical services to cancer patients. Obviously not a healthy prescription for anybody.

So, PACS people, how does this relate to you - but, really, you should ask, how doesn't it? One of the best healthcare plans, albeit unofficial, to surface in the ‘media’ thus far comes from a concerned radiation oncologist who got it posted on another popular PACS blog - the Daili PACS Blog. Not surprisingly, he suggests scrapping most of HR 3200 proposals.

Get More Out of Your PACS Vendor with Guilt Trips

2009-09-01T14:56:00.000-07:00

Ms. PACS: Guilt trips aren’t usually meant to hurt people but simply to get them to behave in a certain way. Let’s face it - it’s a way to manipulate someone. So, if it can work in your favor, then why not learn how to apply guilt trips, in three easy steps. (See Guilt Trips in 3 Easy Steps below)

But before you feel guilty, let me ask you this – have you ever walked into a store, and the clerk comes up to you eagerly waiting on you, unsolicited, and tries to help you make a selection. You ask yourself: Did I ask for help? Your shoulders clinch, and, for those more primal fellas, the hair on the back of your neck stands up. It’s as if someone scratched the nails on a chalkboard right in your ear. You grit your teeth in an effort to hold back from shouting in the clerk’s face: “I’m just looking – so back off!” Fortunately, before that happens, a whole subconscious dialogue transpires in a millisecond. The clerk acknowledges you’re completely irritated and grins back with a feeble smile. The very act of shrinking into a submissive pose is how the clerk plays a guilt trip on you – “Please don’t bark at me, I’m just a humble clerk trying to do my job.” Whether you like it or not, the shout softens into a whisper, and you respond: “Oh, I was just looking,” and tag on a thank you for good measure, “but thank you for your help.” So this clerk has tricked you into thanking him for pestering you. Basically, you have allowed this person to manipulate you – they provoked your sympathy by laying a guilt trip on you.

If you search guilt trips, you come across a reasonable explanation on ehow.com as to why we lay guilt trips. One big reason is manipulation. You play on someone’s sympathy to get them to do what you want. Another big reason is payback – you’re sick of someone laying a guilt trip on you, and want them to feel the same way.

Guilt trips can be very effective – take for example the “Daddy’s little girl” guilt trip. You know your beautiful smile pulls on his heartstrings. And you walk off with the car keys and the credit card. But does it work in the PACS world? Can you guilt a PACS vendor to give you added features for free, or not charge you for a service call, or to lower his asking price on a new PACS? You better know how to bat those baby blues, because if there’s not something in it for the PACS vendor, like more money, then you’ll have to know how to lay it on thick.

Assuming it’s a guy, with an ego (a novel idea) - start by getting inside his head. Does he feel important when people see him as a “good guy”? Does he take pride in being “fair” to customers? Could acquiescing to your demands be acceptable for him because it means building a long-term business relationship with you? If so, then you may have a chance.

How can you get more than the vendor bargained for? Start by breaking him down, but without nailing him to the wall. Tell him that on a few occasions the response to service was slow and/or inadequate, costing you in downtime. Dollars lost as a result of poor service is justifiable, if you can justify it - which may require proof.

Guilt Trips in 3 Easy Steps (if the first works, stop there):

Step 1
Hold your hands together and wring them lightly. Look very sad, as though you’re a bit hurt that he refuses to give you extra PACS licenses for free. Use the “you don’t care about me as a person” trip. “Haven’t we worked together for a few months now?” Add to that: “I thought we had established a working relationship?” Be as bold as to say: “Am I just another client to you?”

Step 2
Play the helpless victim. Tell him how much you are struggling financially these days –both business-wise and personally. The DRA hit you hard, and you don’t know how long you can stay in business. At this point, pull out your iPhone, mobile device, whatever, and glance at the photos of your family or significant other. Chuckle and show him pictures of your kids or your dog, so he identifies with you and internalizes your problem.

Step 3
Act indignant. This is the "Look at all the business I’ve given you” ploy. The best way to lay this guilt trip is by being indignant, such as "Don't worry, I’m not a charity-case,” even though you are in this scenario. This type of guilt trip works well for big and little jobs alike.

So give it a try…and let me know how it works.

PACSman: Guilt trips work for a lot of people. Unfortunately they don't on my kids ("Can you just do this one little thing I'm asking you?" "No."), they didn't in my dating past ("But we have so much history together." "And that's what it is now…history."), and they don't even on my dog ("Why did you pee on my leather couch again? I thought you liked it here." "I do, but the patio door was locked and I had to pee, so get over it..." )

I was raised in an Italian Roman Catholic household and made an honorary Jew by my good friend the Dalai, so I probably have enough guilt to last several lifetimes. I don't need any more. Because I'm older I also have less things to feel guilty about. I still screw up more often than I care to admit and feel guilty when I do even, if it's an inadvertent screw up, but on the whole I do OK. I haven’t been to confession in ages and can just see me going now. "Bless me Father for I have sinned. It has been way too long since my last confession - age 12 maybe- so let's do this the easy way. This is what I haven't done." And two minutes later I walk out a "free man" - after I say 124,179 Our Fathers, 36,825 Hail Marys, 11,527 Glory Be's that is. The Stations of the Cross will have to wait for another lifetime…Momma always said ain't no such thing as a free lunch…and apparently free sin falls into the category as well. Considering my past (thankfully I can’t remember most of my 20’s), I think I got off the hook pretty easily.

So let's talk about guilt, manipulation and payback...The salesperson example Ms. PACS gave has to be a female thing because most of the men I know don't go shopping just to look, unless it’s with a woman, and then it’s because they we’re guilted into it. They go shopping to shop.

Two weeks ago I went to Jacques Pennays to replace my “intimate apparel.” After five years they were finally stretched out just right and fit perfectly, but alas they had holes in strategic areas that could have been hazardous to my overall health and well being, so out they went...old friends tossed to the curb that served me so well. Still, I was in and out of the store in <10 minutes. Four of that was walking from the entrance to the men’s department (and back again), three minutes spent looking for extra-fat sized products, and the remaining three checking out and using my $10 off a $25 purchase coupon. After all, why pay $5 for a pair of britches when I can get ‘em for <$3 each, even if they do last 5 years...A buck is a buck. Did I feel guilty? Nope. And no, Ms. PACS, saving a buck on undies it’s not a guy thing either. You know you secretly raid your neighbors’ mailboxes when Vickies has their “free pair of panties” coupon specials too so…..

You really don't need guilt to buy a PACS these days - only a pulse...It’s worse than buying a car. True, you can find "Buy here, Pay here" car dealerships where you’ll pay as much for a 1998 Chevy Malibu with142,000 miles on it as you would a 2008 Mercedes SLK 250, if your FICO score wasn’t 425, but at least you got a car. So too it is with PACS.

When I went to buy my car last October. They got up and locked the doors on me as my son’s eyes got wide saying only, “We’re in trouble, Dad.” Trouble indeed - the dealership that usually sold 60 cars a month had sold 4 so far and here I was with a credit score in the very high 700’s. “We’re sorry sir, but you are not leaving until you purchase something.” Now, I loved the $35 and $40K wonders I saw, but being Mr. Pragmatic I ended up walking away with a 2003 Mitsubishi Diamante with 70K miles on it for just over $8K. But I did buy something so all was not lost.

PACS dealers are trying to do the same thing. You want a PACS? We’ll find a way to get you a PACS, even if you have a 425 FICO score. How often have you seen “Preferred customer discount” on the bottom line or something of a similar ilk. That’s subliminal guilt…even if you were a first time buyer for them. You weren’t necessarily a preferred customer but rather they preferred to have you as a customer, hence the discounts…With roughly 50% fewer deals currently being completed that last year and more competition for those deals, everyone is a preferred customer. You don’t need to try and get in the head because all they really want is to get into your wallet (and don’t make any analogies either here Ms P. It goes both ways….)

Good guys? Fair? Long-term relationships? That requires give and take on both parties and that just isn’t happening. Good guys usually finish last because most women tend to gravitate to bad guys so they can complain about how badly they get treated by men…In the meantime the good guy looks on and says “Huh?”. Just the way it is….And everyone knows good girls go to heaven but bad girls go everywhere…So much for that argument.

Fair? To whom? If you read most PACS contracts they are anything but fair and that is all that matters in a court of law. I’d dealing with a client of mine now whose system hasn’t worked right in the 10 months since he’s had it “installed” and today is dropping yet more studies. Oops. The vendor’s answer is they will de-install it and give him his money back but they never comes back with any concrete details…and limits their liability to what was paid, if that…That’s like dealing with the manufacturer of Trojan condoms- sorry it didn’t work for ya and busted and now you have a kid to raise…but we hope the $0.42 we’re giving you back for the one that got away helps offset some of your costs…

I love the three steps Ms. PACS outlined. Step one - the answers are all yes. Step two - You’ll most likely end up giving them money as they lay it on thick about them being the helpless victim too. Step three - Indignant - feeling, characterized by, or expressing strong displeasure at something considered unjust, offensive, insulting, or base: Synonyms: angry, resentful, infuriated, mad. Doesn’t work…take it from someone who has spent a large part of his life writing about PACS with indignancy.

Daddy’s little girl? Good luck with that…I have much more patience when they are growing up and formidable than when they are grown up and manipulative…but I guess if it works, then that is what matters most….

Coming up..."Guilt Trips: How to Get More Out of Your PACS Vendor "

2009-08-27T10:47:00.000-07:00

Guilt trips aren’t usually meant to hurt people but simply to get them to behave in a certain way. We'll tell you how to lay a good guilt trip on your PACS vendor - in just three easy steps!

Health IT Next on the FDA Hit List?

2009-08-14T06:43:00.000-07:00

Ms. PACS: The Wall Street Journal (WSJ) reported that “FDA Medical-Device Regulator Resigns‎”1 According to Daniel Schultz, M.D., who has worked at the FDA's Center for Devices and Radiological Health for 15 years and led it for the past five years, it was a mutual decision made between him and FDA Commissioner Margaret Hamburg, M.D., who just started in May.

After working there 15 years, was it time for Schultz to go, or was the bad press too much for Hamburg and the rest of the FDA to take? And was Schultz’s bad-wrap warranted? They say he was real ‘too friendly’ with the medical-device manufacturers. What’s wrong with making friends – as long as you know the right ones to make friends with. Apparently, Schultz made friends with the manufacturers and enemies with the FDA scientists. Hmm?

There were at least two highly publicized incidences regarding Schultz’s decisions:
Two years ago when Sen. Chuck Grassley (R., Iowa) held hearings on Dr. Schultz’s approval of a nerve stimulation device to treat depression, irrespective of objections from multiple FDA doctors. The senator again opened an investigation into a knee-surgery device made by ReGen Biologics Inc., also approved by Dr. Schultz despite numerous objections from FDA scientists and reviewers.

So, was Schultz the victim of political ambition – Grassley trying to do something ‘important’? Or was Schultz simply just breaking the rules?

We won’t know…at least not until Schultz’s ‘FDA-tell all’ novel makes the NY Times Best Seller list.

No hard feelings though – WSJ didn’t rat out any of the device manufacturers and their questionable dealings with the FDA this time around. To boot, Hamburg gave Schultz a warm adieu in a statement saying that "Dr. Schultz left a strong legacy and helped the division enhance understanding of medical-device use in children."

Now that they've cleaned house – what will happen with Schultz’s legacy? Will the FDA approval process for devices take even looooooonger? And should medical IT solutions start to fear heavy regulation in the future – especially with the new premium placed on healthcare IT by the Obama administration to save the economy (at least part of it).

As one observant blogger…blogged: “HIT is, in fact, a virtual medical device that other important countries (e.g., in the EU) are already moving towards regulating in a manner similar to physical medical devices.” (hcrenewal.blogspot.com)

So, look out PACS vendors – you may be next. Just make sure you make the right friends.

1. Mundy, A. FDA Medical-Device Regulator Resigns‎. The Wall Street Journal Online. 8.12.2009. http://online.wsj.com/article/SB125002014808123517.html

PACSman: I love it when Ahhhhnold shows up to terminate someone and then they use politically correct words like "it was a mutual decision." Why not just say, "We're not gonna pay you anymore and are giving your cubicle to some other Dilbert instead.... but you are welcome to stay if you wanna." People will leave faster than a truckload of illegals when someone yells out "Inmigracion!" My old church never terminated anyone either - instead they would "allow them to use their God-given talents in venues outside the church." At last count there were 3,927 people doing the Lord’s work there even though fewer than 50 were on payroll. Praise the Lord and pass the time cards...

OK, so maybe Sargent Schulz did "Know nothing" but that was no reason for Colonel Klink to can him even if it "would be in the best interest of the center and the agency." Maybe he was "too friendly" with medical device manufacturers. I don’t see anyone from the American College of Radiology (ACR) being canned because there were "too friendly" with vendors on the DICOM committees by allowing them to help develop industry "standards." Isn't that letting the wolf guard the hen house as well? Of course that could be why DICOM is unquestionably the most non-standard standard that ever existed- because everyone on the committee had input to it and had to be kept happy. Sure it's better than nothing.... but would we be talking about establishing vendor neutral archives (VNA) 25 years later if we just put down fast and hard rules that would have established a VNA 25 years ago and said this is the way it HAS to be instead of letting everyone do their own thing?

It's funny - a friend of mine says I micromanage my kids by asking them where they are going (in my car), what they will be doing (with the money they got from me), what time they will be coming back (to my house) and who they are with (because they are still my responsibility until they turn 18). Maybe I'm wrong, but I recall that micromanagement was a parental role in some parenting book I read - Dr. Spock maybe. Of course, it could have been Leonard Nimoy's "I Am Not Spock" book as well - or his "I Am Spock" book written 16 years later. Make up your mind Leonard will ya? No wonder why my kids are so screwed up. It's all Spock's fault. Now my friend is a great person, but our parenting styles are as different as night and day.That doesn't make one of us right and the other wrong except in our own eyes. To her I'm much too uptight and untrusting when it comes to my kids and perhaps rightfully so. I was a teen once myself and even though it was ages ago I remember how I was. Back then I knew it all and then some. Even as smart as I was though I actually enjoyed my micromanaged upbringing. I guess I'm just old school because she is a much more laid back and easy going parent than I am. Thankfully neither of us have to raise each others kids because while I interpret her style as one that allows her kids as much opportunity to express themselves as they feel they need, my kids would be expressing significant pain as they crawled into their bedrooms with two broken legs if they didn't follow rules I had set down to the letter, or at the very least to the spirit of the letter. Different strokes for different folks and all that jazz. If one of my kids- or both- turn out to be serial killers I'll know she was right but until then I'm sure I'll hear my kids saying. "If you hit me again I'll call DCF!!" "Here - speed dial 7 - tell them I said hi!" Thankfully I haven't had those issues (yet), but despite everything I ever swore would never happen, I have indeed turned into my parents - my house, my rules. "I'll leave then!!' "Don't let the door hit you in the a$$ on the way out....and make sure you shut it tight so the dog doesn't get out either please! Thank you, Love you. Be home by 11." I can just FEEL the love here...

So what did Schultz do that was so wrong? He approved a knee repair device that the FDA scientists rejected on several previous occasions as unsafe. Apparently they felt they were "pressured to approve medical devices against their professional judgment." Did the guy take any under the table money? Not that has been proven. Did he do anything else wrong? Not really, except go against the scientists "better judgment" by taking actions on his own against their pettiness for "repeatedly reject(ing)" a product between 2006 and 2008 because the scientists apparently felt "the company's device had 'an increased risk' compared with products already on the market." An increased risk of what? Failing? Are they afraid they would bear the brunt of an "I've fallen and I can't get up" commercial because of a faulty knee repair device? What's the big deal? FDA scientists recommended rejecting another application from the same company in fall 2008, saying Regen had not shown "that patients who received the device experienced any benefit." Yeah, and? What's your point?

Years ago when I was a pharmaceutical rep we marketed a drug that had a much stronger placebo effect than a pharmacological one, yet it sold like hotcakes, and yes it did have FDA approval. I didn't see that commissioner being called on the carpet...OK, so maybe the FDA did blow it with Vioxx, but shouldn't the scientists be held accountable too? After all, last time I checked, "stuff" flowed down hill and the scientists had to approve that drug too.

You want to get on the FDA's case? Have them start enforcing the GMP reviews of the PACS and RIS vendor's software. Maybe that way one of my clients won't have freaked out when the system put the wrong patient's name with the wrong report, as it did most recently, and almost allowed his referring to do a slice and dice on the wrong patient. The vendor’s response? "Oops, our bad...We fixed it. See? All better!!" Make freeware conform to the same standards that commercially available software does or don't allow it to be used, period. Now I'm all for freeware, but who gets sued if someone screws up? I'll give you a hint- it won't be me.

Create STANDARDS for PACS - not guidelines, principles, standards of practice, or whatever you want to call it, but God-fearing, Devil- bashing, "Pe-raise Jesus!!" rules that say you will do it this way or we WILL shut you down with enforceable rules on how it should be done...Just like when I say be home at 11 p.m. then by God that means 11 or sooner - not 11:03, 11:07, or 7-11. And if you are going to be late, call. That's the lil’ green button on your phone - or at least on mine. Yours is too damn fancy anyway. And if you can text 2,765 times this past month alone, you can figure out how to press it - I'm preset 6, right next to the DCF. Don’t text me either. I’m old and have near zero tolerance to learn yet another technology.

So how will all this impact healthcare IT? Sorry folks, but I hope we put MORE RULES in place, not fewer, cuz the ones we have aren't worth a hill of beans. Make standards firm and fast and revisit and revise them as often as necessary... Not only is patient safety in jeopardy, but those using the system are in jeopardy and even the companies are in jeopardy by not overseeing software development and its ultimate use. I never could "detail" any of the meds we promoted for non-indicated uses. Why then can PACS vendors sell software that might not have even had to go through the 510-k process because it was "substantially equivalent" and was never reviewed? It not only needs to be reviewed but multiple times as well...Sure the FDA is tasked with doing a pre-market review which is supposed to trigger a GMP review in turn....but does it? Just like a geriatric driver needs to have his eyes examined every so often to keep his license current, so too does PACS and RIS software need to be reviewed often as well...

The problem is the FDA just doesn't seem to understand all the intricacies and subtle nuances that go into making PACS what it is. It's so much more than just another clinical IT system. Maybe Schultzie did "know nothing," but at least he didn't have a hidden past like Hogan did. General Burkhalter may be happy that you threw the baby out with the bath water, Colonel Klink, but your problems go a lot deeper than just knees, even though almost 450,000 of them were replaced last year. Yes, that's a lot of knees, but by comparison, according to the ACR, the U.S. has approximately 30,000 post-training, professionally active radiologists. Each radiologist read about 14,900 studies annually on average. You do the math - almost 450 MILLION radiology cases read across all age spectrums vs. 450,000 knees on patients where 90% were ages 65-70. Where should the concern be????

Captain Kirk was wrong when he told Spock in "Star Trek III - The Search for Spock" that "The needs of the one outweigh the needs of the many." Instead, at least relative to PACS, it needs to be "The needs of the many outweigh the needs of the one." That should be the FDA’s legacy....and Schultz’s too...

The eBay™ Mentality in a PACS World

2009-08-04T10:12:00.000-07:00

PACSman: I used to dabble on eBay picking up some pocket change while getting rid of things I really didn’t need around here. My house still looks like a “before” episode of Clean House, but my 16-year-old has picked up my eBay torch and now is doing what I used to. So far he’s made enough to buy himself a decent car but has barely made a dent in the storage shed I call a house (or is that house I call a storage shed).

I’ve watched eBay over the past year evolve and the changes aren’t good. The first thing eBay did that was bad was to no longer allow sellers to leave negative feedback - only buyers can. Their rationale was that sellers only left negative feedback in retribution for buyers who left them negative feedback so no one wins. Take away the feedback from the sellers and you level the playing field, right? Not quite. Now what you have is sellers who are at the mercy of unscrupulous buyers who scam you left and right and leaves sellers at their mercy.

My son has had to deal with several of these recently. He left a ¼ full bag in a vacuum he sold, and the gal complained “it was dirty”. Duh! Another guy said the cable box my son sold him was “no good.” When we got it back the box had obviously been tampered with, with the buyer removing the good hard drive we sold it with, and replacing it with his busted one. He then put the box back together the wrong way, even forgetting to plug in the hard drive cable. “No good” indeed. We shipped a consumer grade cordless drill to a commercial enterprise- and a used cordless drill at that. Everything was thoroughly tested and worked before it shipped. In his initial negative feedback he said the drill needed to be completely rebuilt. Huh? Maybe did need to be rebuilt, but you aren’t buying perfection when you buy something used and at 20 percent of new cost as well. It worked well and was as advertised. And lest we forget the guy who bought yet another cable box, then complained that the software wasn’t the right version, even if it clearly said in the posting: “Make sure you check with your cable system provider to see if this box will work with your system.” Whose fault is that? The buyer or seller? The seller took the hit even though it wasn’t his fault although at least he got a neutral feedback instead of a negative. Had he gotten a negative there wasn’t anything he could do about it though anyway…

Too many buyers seem to expect perfection, while too many sellers seem to deliver anything but, and never the twain shall meet. I’ve seen way too many used car “Buy Here, Pay Here” deals where the warranty ends when you sign the paperwork, let alone when you drive it off the lot. Of course, when (not if) problems occur buyers seem to do their best to be idiots too, threatening to destroy the seller even though legally they don’t usually have a leg to stand on (unless I’ve drafted a contract for them that is). What we really need is Rodney King to stand back up and say, “Can’t we all just get along?” Unfortunately, even a $3.8M settlement from the LAPD didn’t help poor Rodney who suffered 3 more arrests after being made a multi-millionaire, and the ultimate insult, being shot with birdshot by thieves trying to steal his bicycle back in 1997.

Have we as an industry gone too far? Innocent until proven guilty has become guilty until proven innocent. It’s the user’s fault that the system won’t do what it was sold as and ostensibly designed for. It’s the seller’s fault that they never told us what we didn’t ask. We buy on price then complain it doesn’t meet the functionality we desired. We pay more yet expect features and functionality that the seller never promoted the product as having, even though sales might have danced around the line of questioning that would have exposed the real answer. Just like e-Bay, we want the best for less, yet aren’t willing to settle for anything less than that.

Over the past five years, I’ve been saying PACS has become a commodities market. One look at the company’s quarterly reports shows that as being oh so true. While gross sales might be slightly up in a down market, which is a testimony to PACS, net revenues are down significantly. Last time I checked net revenues are what keep a company alive. There has been a tremendous shift in what makes companies money. Software sales used to constitute 25-35% of a company’s net margins. Now it’s less than 10%. Hardware used to be good for 10-15% uplift - now it’s pretty much all passed through. Service used to constitute about half a companies net margins. Now 65 and 70% of all profit comes from service. Only implementation has stayed constant at 20-25%, although I’m seeing companies adding a lot more implementation “services” on than are really needed.

Buyers need to do a much better job of due diligence, knowing what they want, buying only what they need, and knowing what the market will bear. They also need to understand that, just like on eBay, if they buy from someone with a low number of sales or whose negative feedback score is high, they’ll probably get what they deserve. Of course you have to take it all with a grain of salt too. My son has probably sold over 200 items, yet just passed the 100 feedback mark with only one undeserved negative to his name. He tests everything before he lists it, does an incredible job of packing and most importantly, stands behind his product, doing whatever is necessary to keep his customers happy, even though more times than not they really didn’t deserve it. How many vendors can say that in the PACS market? I know of maybe four at most.
The customer still has the upper hand (if they have a contract that covers them that is), but the best they can ask for is a vendor who listens as well - two people who can “just get along” for the sake of everyone.

Ms. PACS: It took no more than two words - PACS eBay - to find that your good buddy, the Dalai PACS, had found a Dynamic Imaging Solutions' Centricity® PACS-IW 3.6.2.0065 for sale for the low, low price of $45,000. He posted this on Doctor Dalai this past Feb. 2009. The PACS was not too outdated and had been fairly recently upgraded. To the Dalai's point, would GE handle licensing and service for whomever bought this?

There is a something missing on eBay - and often in PACS - a blackhole that needs to be filled. Similar to garage sales, used car dealers and sales people, it's all too often take the money and run. If it's a lemon, don't even think of putting the squeeze on the seller because they're long gone. Even with responsible, entrepreneurial types who test every gadget before sending it out - that's certainly a lot more than what most eBay vendors might do - it can still break a week post-purchase. By that time, it's no one's fault. I guess that's where the 'Buyer Beware' notice should pop up on eBay - buy at your own risk.

My colleague who sells WWII military collectibles offers insurance for shipping, at the cost of the customer of course. That way you can only go postal. In cases where you buy something and it just doesn't work, and the vendor refuses to refund your money, you can always slam him/her on eBay's Reviews. At least it will feel good.

Then there are the Pirates from all ends of the earth. One non-threatening, in the bodily harm sense, is a 53-year-old Hartford, CT, resident pleaded guilty to federal charges for criminal copyright infringement, i.e., pirating movies and TV shows and selling them on eBay (Mass Cops). He made off with more than $100,000 – too bad he didn’t take off to Mexico too.

There are eBay vendors that are pretty convincing and look like they really do sell Sony Ericsson T610 cell phones for just $13 or who really offer a Sony PlayStation 2 PIRATE LGND BLCK BUCCANEER for $29.99. It even comes in the ‘real’ box with all of the packaging, and via the UK! But once you plug it in – you couldn’t charge it with a defibrillator. Go back to the vendor – and if you can trace him back to Shanghai or Shangri-La, you’ll quickly find there are no home addresses or accountability in Never Never Land. eBay may eventually identify the cons and kick them off the site to boot, but give them a week or two, and they’ll be back.

On that note, I would double check with GE before putting your credit card down on that Centricity PACS for sale on eBay.

On the bright side, where there's a need, there's an opportunity. In the case of eBay, and even PACS sold on eBay, there's a need for service. Are there any eBay product service providers out there - cuz we need one.

Will PACS and RIS qualify for reimbursement under the HITECH Act?

2009-07-24T13:54:00.000-07:00

Ms. PACS: The HITECH Act, part of the American Recovery and Reinvestment Act (ARRA), and its impact on radiology is foremost on the minds of everyone in healthcare.

Critical questions surrounding the language of the Act remain unanswered.

- Will PACS and RIS qualify for reimbursement under the "meaningful use" definition?

- How will interfacing radiology PACS and EMRs impact radiology workflow?

-Will there be a return-on-investment (ROI) through these image exchange networks?

To gain better insight on the matter, Imaging Technology News spoke with healthcare IT research and development expert Don Woodlock, vice president and global GM of GE Healthcare Integrated IT Solutions.

PACSmaker Make Me a Match

2009-07-13T13:33:00.000-07:00

PACSman: Two weekends ago eHarmony® ran a weekend special where you can communicate free with the love of your life that you didn’t know was out there waiting just for you. Now I haven’t been on eHarmony for at least 3 years ever since it started hooking me up with nothing but die-hard Christians - and that was after taking their 400+ question profile twice - and frankly I am fairly content with my “life” as it is. I have some great people in my life yet just couldn’t resist answering one person’s questions on a Sunday afternoon though that turned out to be a race against the clock before I had to actually pay to chat. She was a doctor and I a lowly PACS consultant and besides, it was free so…..

The questions and answers flew back and forth in rapid succession over the course of two hours and all seemed well. While I must have scored A’s and B’s in the first and second set of questions as well as my “must have/can’t stands,” my last set of questions just before the open communication session I must have scored an F on it because I never heard back from her after that. Bummer. Or not. There were three questions I received and I think I blew them all.

Question #1 was: I am very impressed that you have your own company. This shows me that you are very ambitious and responsible. Tell me about your background, and how you came to have this expertise. I’ve gone to your website - WOW. Have your e-mail.

My answer: I wouldn't go that far- maybe it's just that no one would hire me for the past 26+ years. LOL. The website also needs to be updated...Bottom line for me is money doesn't mean as much as having fun, which is what I do - plus working from home in gym shorts and a tee is a bonus.

Maybe she’s just jealous that I work from home in my gym shorts and a tee…or wants someone who regales in his accomplishments and achievements instead of using self- deprecating humor like I do because I really don’t feel like I am better than anyone else…but for anyone who knows me knows, this is who I am so…M.D. to me doesn’t mean most divine either…I know way too many docs to know that. And the comment of being gainfully unemployed? I’ve never missed a house payment yet…and have plenty of money to go garage saling with as well, so life is very good indeed…

By question two I knew I was in serious trouble:
Question #2: During a typical week, what sort of physical activities do you enjoy?

My answer: I wish I could say more. Does walking the dog count?..... In a few I’m going to mow my own lawn - it’s not a money issue but a pride one - I need something that provides me with instant gratification…

Wrong answer again I’m sure. While I talked about how I used to play racquetball until my buddy Steve got hurt last week and now we do bike riding, etc., I probably should have told her that I used to exercise a lot more until I blew my right knee out white water rafting three years ago (I did)…...and how I run a sports ministry overseeing 80-100 guys and gals playing soccer every week among other events….and…and…and….The truth though is while I enjoy biking and racquetball my most consistent exercise is walking the dog and shampooing the carpet after he blesses it with his holy water…Maybe she was looking for a marathon man instead. The closest I come to being a Marathon Man is that 30+ year old film where Dustin Hoffman plays a graduate history student unwittingly caught in the middle of an international conspiracy involving stolen diamonds, an exiled Nazi war criminal, and a rogue government agent. Yeah, that’s my life….NOT! Worse than anything, though, is not only do I mow my own lawn but – gasp!!- no hablo español either!! Despite all that, that probably wasn’t it either. No doubt it was my “instant gratification” (IG) comment that did me in….but to me mowing your own lawn beats many of the other IG options too (laugh).

On to Question #3: Tonight you can do anything you want, no penalties, no reprisals, and the cost is unimportant. What are you going to do?

My answer: Fix my leaking garbage disposal (laugh) …
OK, so maybe that isn’t what she wants to hear, but I was thinking maybe it was a trick question too. The reality is just when I was about to answer something completely different my son Matt came to me and asked, “Dad what’s that brown stuff coming out from underneath the sink onto the floor?” Come to find out my garbage disposal chose just then to give up the ghost and…well…..you get the picture…I think the saying goes “When you are up to you’re a$ in alligators its hard to remember your initial objective was to drain the swamp.”

As a consultant I also learn to ask a lot of questions so my next comments in my reply were: “Would I be alone or with someone? If so, would I be with someone new? Someone I’ve dated for a short time (month or so?)? Longer time? Are we casual friends or in an exclusive relationship? Is it raining out or sunny? What are our moods, desires? What has to be done, what doesn't before I could enjoy the day? (there is that responsibility thing again). Do I have work tomorrow? Those can all be answered in about 2 minutes, but everything needs to be looked at so our minds can be where they need to be and not somewhere else…Too many questions I’m sure for someone who no doubt is a runner and probably takes the Nike approach - Just Do It!! - versus being methodical, although I thought a doc might have appreciated my methodical approach…Oh well…

I would love to have said: “I’d hop on a flight and visit my relatives in Sicily!” (Rosario, oh Rosario…Wherefore art thou Rosario!!), or “Take my 1930’s wooden speedboat (that I don’t own, but would love to someday) to the middle of Lake Dora with some candles, wine and cheese and enjoy a quiet moonlit night,” or “Dinner, dancing and decadent delicacies over an entire evening,” but hey….that’s not gonna happen anytime soon either, with her or anyone else (besides there are a few others in line ahead of you anyway who won’t allow cutsies ). I’d also love to go to Jade Mountain in St. Lucia where my friend the Dalai went on his vacation, but need someone special to go with. That’s not the kinda place you go to alone to or take your kids to either. The Dalai also makes about $1.50 an hour more than me so…

“No penalties, no reprisals and cost is unimportant?” That’s gonna take some serious thought….I have two kids going to college in another year, so cost is always a consideration from the $5.34 Hungry Howie’s pizza my son and I just split for lunch on down….Besides, everything in life has penalties and reprisals attached to them…and anyone who doesn’t believe that I probably wouldn’t want to date, let alone marry…But it’s a nice thought…One day I might even think this through more and answer it properly…. although I doubt I’ll get it right then either.

So 1,200+ words later what does this all have to do with PACS? Too many customers and too many vendors have both given the wrong answers lately.

I have one client who is using both himself (a radiologist) and his business manager as their site’s PACS Systems Administrator (PSA) because in his words: “We don’t need and can’t afford a dedicated PSA.” Wrong answer. True a PSA does cost money, but when you add up the time they spend doing PSA duties plus - and this is the most important part - the ticked off customers he had because things a PSA could have done to prevent some of the issues they had weren’t being done - it actually cost them MORE money…

Here is the reality - EVERY PACS and EVERY clinical IT system implemented has issues with it every single day. That’s why every PACS needs a systems administrator to deal with these. The PSA can be someone who is already in your IT department or someone you hire from the outside, but it needs to be someone. These are not optional areas - these are MANDATORY!! The vendor should also REQUIRE you to have a PSA before they sell you the system - not an option, but a requirement. Vendors, listen up. Have a PSA or no sale…

The second set of wrong answers came from a vendor who had one of my clients’ RIS and PACS systems down for almost six hours before anyone bothered to do something to bring it back to life and over eight hours total…on a Friday…It was Abbott and Costello’s “Who’s on First” routine all over again except my client lost over $15K worth of business that walked up the street during this process. He also ended up working well past midnight on a Friday clearing up 8 hours of backlog…. all the while his wife and three-week old baby waited on him to get home… The problems still exist three days later, only now different ones in different forms…And the vendors respond? “Aside from all this I hope your weekend was a good one.” I think I've heard this put another way before - "Other than that, Mrs. Lincoln, how did you like the play?" They need to do a whole lot more than say, “Aside from all that…” and put together a serious plan of action on how to prevent it from happening again, then make damn sure the penalties surrounding circumstances are sufficient if it does happen again.

That’s like my then wife and I finding out she was with child again with a 9-month old at home. After a brief discussion we went with a very permanent plan of action, a plan that involved sitting on a bag of peas for a day and all was good…and if we did have another, we would name him after the urologist since he would be raising him, not I.

So did I lose out on eHarmony? Did she? Who knows? I want someone who doesn’t like to date or at the very most has the intention of her next date possibly being her last. Unfortunately, my potential match is someone who has “been out with several men, and has enjoyed this process...” and “…find(s) the prospect of getting to know someone thrilling.” I don’t know if I find it thrilling or not - occasionally it can be exciting, but most times the thrill becomes a nightmare that I’ll moonwalk away. You just can’t be who you are - or answer straight from the heart either. Like her I miss female companionship in many ways, but am not quite ready to take a ticket from the deli waiting my turn to order either….

I’m not sure if I have as strong a personality as she does, but do find women with that quality very exciting - as long as it’s not overpowering. Finding out I’m on a date with Dominatrix Debbie is something I’m really not into... I also am not ready for any kind of marriage relationship either – I’m looking more to spend time together, just enjoying the relationship without the pressure of "is this forever?"

Maybe I’d do better if I if found a gal with as dry - or wry- a sense of humor as I have. After all, even if you are a born again, you should be able to appreciate that I’m not totally serious when I say: “The only time I want to hear ‘Oh God!” or ‘Oh Jesus!’ is in the throes of passion,” and not be appalled. I mean if you can’t laugh at yourself, who or what can you?

Money is not a problem here either, except when I don’t have it, and I, too, just love a good deal. Thank you Dr. Warren and your eHarmony cronies for making me an offer I couldn’t refuse.

I almost never look back - maybe briefly, as a matter of learning from mistakes - but as she shared with me you just can’t haunt yourself with too much of the hand-wringing. Move on. And so I shall. After all, she has my e-mail, and the answers that I gave weren’t right or wrong but instead just me…

Ms. PACS: How am I supposed to react to this PACSman...you are actively e-dating behind my back?! I'm crushed!

Or possibly – relieved.

Yes, relieved to know that you’re finally catching on. If you want to come up with the right answer, you need to ask the right question. Whether it’s about knowing how to answer and get the attention of potential mates on eHarmony – discerning what he or she looking for? Or do you really care because it’s all about you anyway? Or whehter it's asking your PACS vendor the right questions – "Once I buy this thing, what’s it's going to cost to service it?" Or if it’s a frustrated PSA, wondering why the system continues to crash...over and over again….it’s all about asking the right questions, so that you can come up with the right answers.

But chose your words wisely when eHarmonizing. There are so many lyrics about choosing the right words. Just think of The Cure’s “Pictures of You” (You know it. The song enjoyed a revival from it’s 80’s roots in a late-90's camera commercial). Robert Smith’s voice is not only agnozingly somber…hold back the tears PACSman…but he makes you think. Because we have all probably lived these lyrics at some point in our lives:
“If only I’d thought of the right words
I could have hold onto your heart
If only I thought of the right words
I wouldn’t be breaking apart, all my pictures of you.”

The more philosophical PSAs occasionally come up with a few deep-thoughts of their own like:
1. As techonology gets better, does anyone think it could become a risk to keep data?
2. If something is missed using today's technology, but discovered years later, what are the risks?
3. What are typical refresh times for DMWL? Are there ways to tweak it?
4. If I shout in the woods, will anyone hear it? Just wondering.

So maybe a good answer to Question #3: Tonight you can do anything you want, no penalties, no reprisals, and the cost is unimportant. What are you going to do?
Should have been a question/response to your potential date, like:
What am I going to do? Whatever the doctor orders.

EMRs at Sam’s Club - Watch for Hidden Costs

2009-06-24T10:45:00.000-07:00

PACSman: I like Sam’s Club. I’ve been a member for well over a decade back when buying stuff in bulk was much more pragmatic than it is now as a single dad to two teen sons who eat out five times a week. I also like Costo and BJ’s (Wholesale Club that is- get your mind out of the gutter Ms P.). But would I buy my electronic medical records (EMR) system from them? A copy of Turbo Tax maybe, but an EMR? Ah…no…

There are limits to what most physicians can do technology-wise (with the exception of my all-knowing friend The Dalai who is both a computer guru and now plays the role of Cesar the Dog Whisperer as well) but installing an EMR probably is beyond the limits of most docs I know. Heck, just taking it out of the box and plugging it in challenges the capabilities of most docs I know.

That leads me to wonder just what is incorporated in the “on-site technical set-up”. Open up the box and plug it in? Is installation “load the DVD in the DVD player and push play?” Does training consist of a call to Billie in Bangladesh who says “Thank you for buying eClinical Works. What questions can I answer for you?” Come to think of it that sounds like many PACS company’s installation and training programs that you are given the privilege of paying 40% of system list for….but alas, I digress…

Site assessment equals “Do you have power? Cable or DSL hookup? $25K extra in your checking account? We’ll make it work!!” Integration? With what? The operating system? Whoop tee doo!! George Wallace did better with integration than they seem to do. How about integrating the system registration, billing, and financial systems? Hmmmm….

Installment payments? What a novel idea!! Rent-A-Center, Drive Time, Cort, Buddy’s and others would go in shock. Just $49.95 a week for the next 152 weeks and the EMR you could have bought for $1000.00 cash can be yours for the low, low price of just $15,584.00, tax included! Of course it’s zero interest so we can’t say we’re charging you $15,584.00 for a single $1,000.00 CD. It’s a $15,584.00 CD that is interest free for 156 months!! Momma always told me there ain’t no such thing as a free lunch, and at our house if you were hungry you generally had to make that lunch yourself too!!

Working for what you get? My God yet another novel approach!! Send me some of that Bama stimulating money please!! Our President would be so proud that we are using our healthyimagination®. God bless our Obamination and the folks over at Generous Eclectics.

Now that HHS has published the definitions on “meaningful use” will anyone find anything meaningful about it? The matrix they put out identified with these priorities:

• Improve quality, safety, efficiency, and reduce health disparities
• Engage patients and families
• Improve care coordination
• Improve population and public health
• Ensure adequate privacy and security protections for personal health information

Some of the criteria might be difficult to measure and validate, but PACS hits all of these……if you use your healthyimagination that is. So please send me my Sam’s Club coupon, Ms P. I already got my “free” cable conversion box even though my 52” flat panel 120 Mhz Sony LCD TV with 1080i, 4 HDMI ports, a 900,000:1 contrast ratio, four on the floor dual hemis and mag wheels doesn’t require it. After all Momma also told me you should never turn down anything for free…

Ms. PACS: Now that the ‘meaningful use’ definition has squeezed in imaging as “multimedia (e.g. X-rays),” it’s time to get the ball rolling – if you’ve got a roll of cash. So, how are physicians groups going to pay for the EMRs, or even large cash-strapped hospitals for that matter? Cut down on bed pans?

Here’s a more hygienic solution: You can buy an EMR at Sam’s Club! It’s true: Sam’s Club, eClinicalWorks and Dell are offering a “turnkey” electronic medical record (EMR) and practice management package for small physician practices. Dell will provide necessary hardware and site assessment, onsite technical set-up and training as well as integration of the eClinicalWorks software with the operating system, along with hardware warranty support. And it comes at the low, low price of $25,000 - for a three-provider practice - and up to $10,000 for each additional provider. What a deal – right?

But before you reach for your wallet, a PACS veteran with a Belgian accent commented to me over lunch yesterday: “You can buy an EMR in Sam’s Club. But if you try to implement it, you’re on your own.” Good point – especially if you need it to interface with all of the rest of those systems – like PACS.

While you can rely on Sam’s Club for excellent frozen wild-catch salmon, I wonder about EMRs. Here’s an alternative – pay in installments. One of the big three came up with its own EMR-finance program. They call it “Stimulus Simplicity.” Sounds a little like Obama and Philips on a date.

No, they are not dating, but GE is offering its own flavor of a stimulus package. As part of the healthymagination program: “GE’s Stimulus Simplicity program helps physician offices and hospitals that invest in GE’s electronic medical records (EMR) products, GE Centricity EMR and Centricity Enterprise solutions, maximize the potential benefits of the increased focus on EMR under President Obama’s stimulus funding bill…. GE is now offering its HITECH Warranty for Centricity EMR and Centricity Enterprise solutions and zero-interest funding with deferred payments to qualified buyers so they can have immediate access to this technology without the up-front capital costs.”

But before you take out that second mortgage, the public comment period on ‘meaningful use’ is open until Friday, June 26, and as such, we still don’t know for sure what the ‘meaningful use’ language will wind up saying in the end. So, most likely, no one will be rolling the dice on EMRs this week, at least not until they get a coupon in the mail from Sam’s Club.

All Roads Still Lead to PACS

2009-06-18T12:58:00.000-07:00

Ms. PACS: Just a quick comment for the PACS “pepes” post the SNM and SIIM shows. There are new client-server solutions for nuclear medicine invading a PACS near you. And I’ll preface it by saying: “No – this is not a commercial – just an update.” So don’t blow a gasket PACSman….just breathe.

At both SNM and SIIM, I kept seeing the integration of nuclear medicine imaging with multimodality PACS.

Just this week, Siemens showed its Symbia.net client-server solution that’s designed to work with an existing SPECT or SPECT/CT system, RIS and PACS infrastructure. Image uploads to the server database are performed automatically. Additional remote users can be added at any time and installed remotely to grow with the needs of the imaging facility.

The biggest show stopper took a step beyond PACS - a preview to the future of PACS - was 3D modeling. Often used in architecture using AutoCAD software, you can create any complex 3D model - a building, a brain or a SPECT/CT system in a nuclear medicine suite. Thanks Dominic (ala Philips) for the demo and good thing you gave me the cliffnotes.

Then there’s the one from GE Healthcare, I saw this at SIIM a week ago. GE Healthcare integrated Xeleris Suite for Nuclear Medicine into the GE PACS RA1000 workstation. The big push here is enterprise connectivity. This platform provides a single database for patient selection, reporting and archiving for multimodality review, including nuclear medicine tools and reprocessing capabilities. According to GE, the Xeleris Suite enables nuclear medicine physicians and radiologists to do nuclear image reviews together… holding holds…on the Centricity PACS RA1000 workstation.

Here’s one for the small private practices or a Nuclear Medicine or PET/CT department – a new patient scheduling and workflow manager that interfaces with the RIS. Numa made a lot of noise about its new NumaManage – “designed to replace the traditional static whiteboard with a digital, touch screen interface.” It is also a DICOM worklist provider, so the user only needs to input patient information once, and the information is distributed throughout the department.

So what does this all mean – PACS is still important and still the principal imaging management tool. While the EHRs will become the hospital image and data exchange center, offering a unified viewer for all physicians to view all images and media, there is something the enterprise viewer will not be used for – diagnosis. So, PACS maintains its position of importance because – at least for now – it’s the only platform for storing and viewing diagnostic images.

So, can anyone guess what's the next ology to integrate into PACS?

Would You Like Some Cheese With That Whine?

2009-06-10T10:20:00.000-07:00

Ms. PACS: When Radiologists, PACS admins, IT folks, students and residents hit a show like SIIM, they leave each session chattering about what peaked their interest in the discussion or they compare notes on their own workflow issues – all the while happy to know they are accumulating CME credits. Below the mumbles, gurgling hunger pains instinctively steer them toward the exhibit hall floor where the herd bee-lines for coffee and donuts or lunch boxes, depending on the time of the day. Can you blame them after enduring imaging bootcamp?

Once appetites are calmed, they meander through the exhibits, sheepishly revealing interest amidst fears that they will be roped into trying out a workstation by a charming marketing guy/lady with a big bright grin and long legs. After a 10-15 minute attention span, they regroup, check their watches/iphones/blackberries and scurry back to the sessions to listen to experts discuss "economic stimulus package funding opportunities," or to argue over "who owns imaging" – radiologists, cardiologists or IT – and to ponder the convergence of radiology and pathology PACS. Why, because that’s what they came for, and they seemed pretty content too. That's the attendees' version.

The reality is, however, it’s not just about the attendees' needs. Whether they like it or not, the trade shows have to cater to the vendors too.

Now, here’s the vendors' version. At most shows, while attendees are off the floors, the press are the ones buzzing from booth to booth, "talking shop" with vendors on the latest and greatest in PACS and IT. Inevitably, they end up talking about the status of the show. Gum cheeewing: “So, how’s the show’s going?,” i.e., "Are there any attendees?" "Did you get any new orders?"

In the last two years, the resounding response among vendors has been: “There were more people last year,” “I don’t know if we’ll be back next year,” “Why do we have to come here?” After all their moaning and groaning, a light goes off, they remember it’s a trade show – and decide what the hell, let’s have some fun. “So, where are you going tonight?” The next day, the same thing, whining…maybe it has more to do with their hangover, but let me tell you, it’s never enough. Or have they just had enough?

How effective are the trade shows for the vendors? One PACS vendor veteran noted:
“I used to go to these shows to learn about the latest in PACS innovation. Now it’s an educational session, and you can’t demo workflow on your workstation. I’d rather sponsor an educational grant than bring down 20 people.”

Well, maybe that’s a good idea. The attendees want CME credits and they seem to pay a lot more attention to the educational panels than to the vendors’ new gadgets. Ergo, educational grants may get you some attention.

SIIM just released a statement on their show (6/12/09), saying: "While attendance was less than in previous years - mostly due to a decrease in international and corporate registrants - vendors in the exhibit hall had a successful show as far as quality of interactions and ability to have substantive meetings with customers and partners....Feedback from attendees indicated that they found the educational program and sessions highly engaging and practical."

You can blame the show organizers all you want, but there were attendees, albeit less. Quality of interactions for vendors? You'll have to poll the vendors. What does seem clear is that it's time for a tactical marketing move. Here’s a suggestion to the vendors – change your approach in reaching your audience. Give the buyer what they want. If it’s education, educate them or at least sponsor popular sessions. If show attendees tend to stick around at these sessions a lot longer than the booths, if you see them high-tailing it back to imaging bootcamp mid-marketing speak, then learn to speak their language.

PACSman: I didn’t attend SIIM this year. Truth be known I haven’t attended any SIIM meeting since it was held in my hometown of Orlando a few years ago. The same holds true for HIMSS, AHRA and most other shows. If I can drive there, if I’m speaking there, or someone is paying my way I’ll go, but if not, I’ll read about it in the trade journals. The RSNA is the only exception to the rule and that is because people look forward to reading my tongue-in-cheek PACSMan Awards® and have made it one of the top read pieces from the show on another e-journal I write for.

So why don’t I go? For the same reason many don’t. How you spend your time and money is getting harder to justify. You go where you will get the most bang for your buck. Frankly the smaller shows just don’t seem to provide that any more. TEPR (Towards the Electronic Patient Record) pulled the plug this year when their crowds failed to materialize once again. I’ve been to TEPR before - I even spoke there once - and sadly its time has come and gone.

The smaller shows seem to be the most impacted by a bad economy, but no one is immune. Attendance at HIMSS, the big IT show, was down 6% this year, yet still drew nearly 27,500 attendees and 907 exhibitors. The RSNA had 58,800 attendees yet showed a 5% overall decline. Interestingly they had only a 1% drop in professional attendance, with 12% vendor declines making up the difference. Still they pulled in over 27,500 professional attendees.

So can the smaller shows survive? And will the vendors continue to pony up the bucks to exhibit at shows that bring in less than 1,000 attendees? If the bigger shows are in trouble, you know the smaller ones will be too. Meditech pulled out of HIMSS this year citing the expense for the company and attendees. Total exhibit square footage declined 4% at RSNA this year with a concomitant reduction in the number of vendors. And Fuji, one of original founders of SIIM back when it was called SCAR, pulled out from the show it helped organize, this year as well.

Most of the feedback I got from attendees at SIIM was that it was fairly good show content-wise…but the vendors weren’t so sure if they really got the bang for the buck they wanted. From a sales perspective one needs to ask: does SIIM deliver the right people? Information in the 2009 exhibitor prospectus shows indicated that 81% of the attendees are involved in the purchasing decision, 68% plan on purchasing, replacing or upgrading their equipment next year, and 65% will spend $1M or more. On the surface that sounds great, but is it reality? Seven out of 10 SIIM attendees were either PACS Systems Administrators, Researchers, Technologist, or Vendors/Consultants. Yes, they may be involved in the decision-making process, but few carry any decision making clout. The true PACS decision makers - Health Care Administrators (including C-suite level), IT managers and Physicians (I assume they mean radiologists) made up the remaining 30%. That means out of 800 total attendees only 240 were in decision-influencing positions. When you figure out booth space costs (>$3K for a 10x 10, over $12K for a 20 x 20), exhibition-related costs, personnel costs, travel and entertainment costs, etc., you are talking a minimum $20K for even the smallest booth and a six figure investment for the majors, all to reach fewer than 250 people over thee days with a mere 17 hours exhibition time (two full, one half day). Is it worth it? Many are asking that very same post-show question - are we getting the most bang for our buck.

As an industry we tend to focus on quantity over quality. Why else would more and more PACS vendors sign up to exhibit at HIMSS when the show virtually ignores PACS, at least from a presentation standpoint. Out of 300+ presentations at HIMSS this year only two – TWO – focused on PACS, and one was from a vendor. So why do PACS vendors exhibit there? Because it attracts IT people, the people who are being pinged about PACS at the C-suite level and will ultimately have a major role in the decision-making process. The same can be said about RSNA, which attracts a high percentage of radiologists. These are the primary users of PACS and will have a major role in the decision-making process, even though their time at the show might be divided among 4,000 other entities. And SIIM? It’s PACS-centric to the max, yet each year we can barely scrape together 1K attendees…

SIIM is a great organization and puts on a good show. Unfortunately, many would say it doesn’t target the right demographics for exhibitors who want to sell products. Or does it? It only takes one sale to pay for itself, but how many sales are made or even influenced by SIIM? I would venture to say very few.

I personally recommended SIIM attendance to several clients who are looking at PACS. It is the only place where you can see most of the PACS vendors’ products side by side, unimpeded by other products that might redirect your attention. But it just doesn’t seem like that’s enough to drive people to the show. Those who attended the educational seminars seem to have been PSA’s looking for CEU’s. Interactive sessions are a plus. But exhibits? Who knows…..

SIIM needs to reinvent itself as the PSA-centric organization. Perhaps the answer is piggybacking itself with other shows like HIMSS. After all, the II in SIIM does stand for imaging informatics so…. Or doing a virtual conference like HIMSS is doing….or a Webinar…Why you ask? I counter with why not?

Like many smaller standalone shows, SIIM will continue to be hard pressed to draw the right crowds year after year. I hope the show - and organization - stays alive, I truly do. To do that though SIIM needs to take a closer look in the mirror on how it is received by the market, what it’s doing right, and what needs to be changed. As a former SIIM (SCAR) member, I have some definite ideas. They can call me - my contact information hasn’t changed since I was a member years ago - or they can just look in the book under PACSMan….

GE's Big Investment

2009-05-14T13:47:00.000-07:00

PACSman: Before anyone accuses me of being anti-humanitarian I think GE investing $6B to help “lower the cost of health care and improve the quality of medical care in underserved regions of the United States and abroad,” is commendable, especially if it gets into the hands of the rural regions of the U.S. who really need financial help.

On the surface this investment looks great. Of the stated $6B donation, $3B is slated for “spending on new, lower cost medical technology,” $2B in financing and $1 billion for partnerships, patient education and other services. Now here is where it gets interesting.

The $500 million per year earmarked for Healthymagination® technologies will account for half of the $1 billion GE plans to spend on R&D in each of the next six years. Launching these 100 innovations will “lower cost, increase access and improve quality by 15 percent.” But even GE acknowledges that, “These actions will strengthen GE Healthcare’s business model.” (http://www.genewscenter.com/content/Detail.asp?ReleaseID=6760&NewsAreaID=2)

This then leads to the question: “What makes this investment so newsworthy that it generates over 35 pages of hits when you Google ‘GE $6B’?” Now $6B over six years sounds like a lot of money, and it is, but it’s all relative. GE Healthcare generated $17B in sales last year alone, so this comes out to an investment of just under 6% of the company’s total gross revenue.

Increasing R&D spending to make better products is commendable, but again what’s the big deal? Admittedly most companies spend between 12-15% of their sales on R&D and GE is now upping the ante in this area considerably in the hope that they will be able to reduce the cost of modalities by 15%. But isn’t this just making the company more competitive? And isn’t reducing health care costs the aim of the DRA and other programs that CMS has so wonderfully graced us with? It’s great to say the company will “reduce by 15 percent the cost of procedures and processes with GE technologies and services, increase by 15 percent people’s access to services and technologies essential for health, reaching 100 million more people every year, and improve quality and efficiency by 15 percent for customers through simplifying and refining health care procedures and standards of care,” but how does this really benefit the end user? If the costs of modalities are reduced 15%, will these savings also be passed on to the end users, especially when most single modality outpatient diagnostic imaging centers are struggling just to stay alive in the face of DRA cuts? “Mr. Customer, GE allowed us to save 15% therefore we are passing the savings on to you…” Um….I’m not holding my breath on that one…

I also fail to see how “expand(ing) its employee health efforts by creating new wellness and healthy worksite programs while keeping cost increases below the rate of inflation” and “increasing the “value gap” between its health spend and GE Healthcare’s earnings to drive new value for GE shareholders” affects anyone other than the GE employees. Isn’t this better served in the company newsletter than a press release?

I’d love to understand why GE plans to “expand clinics in Cambodia and provide additional funding for maternal health care programs in Bangladesh.” Now Bangladesh and Cambodia are pretty low on the totem pole in life expectancy at numbers 167 and 174, respectively out of 221 countries, yet they are still just a few years below the average life expectancy of 66 years for all countries combined at 63 and 61 years respectively. Of course ALL of Africa is much lower than these two recipients in life expectancy as are Haiti and Laos, but a Poppa Doc CT scanner probably wouldn’t be well received in most countries….. I’m figuring Bangladesh will no doubt give India a run for its money in call center technology in the ever near future and GE is just hedging its bets there. “Hello. Thank for calling GE, this is Bob in Bangladesh.” We also should not forget that GE gave a whopping $20M to Ghana, Ethiopia, Nigeria, Kenya, Rwanda, Senegal, Mali, Malawi, Tanzania and Uganda back in 2006 to “transform hospitals,” including providing health care and power generation equipment to water filtration systems, appliances and lighting. That comes out to $2M per country or less than the cost of two GE CT scanners.

As an aside, there are 44 countries that have a higher life expectancy than the U.S., which averages 78 years, including several U.S. commonwealths and the like. Maybe it’s time to move…

“GE Capital will provide $2 billion in financing to help health providers in rural and underserved areas get access to more innovation that improves health and reduces the cost of care.” Now $2 billion in financing is nice and is certainly a helluva lot more than I have in the bank, but last time I looked into it financing costs money - and the people lending the money typically make money from that as well. President Obama’s healthcare stimulus program will no doubt help. GE stated that making this money available “will focus financing to assist in the adoption of EMRs and health information exchanges (HIEs)…. GE’s financing will help healthcare systems adopt EMR and HIE before 2011 in time to qualify for federal financial incentives.” I wonder how much interest accrues on $2B in loans though – and how easy it will be to get this money as well with financial institutions all over clamping down. I wonder if GE Capital follow suit?

One billion dollars is slated for partnerships, patient education and other services, yet part of that includes GE using its NBC television networks, including NBC Universal, NBC News and MSNBC as a way to increase consumer knowledge about health, including launching a daily program devoted to health in June on MSNBC. Forgive the cynicism again, but isn’t that just taking money out of one pocket and putting it in another?

GE chairman Jeff Immelt summed it up well: “We don't run a charity at GE – we make money,” he said. “We are in business to earn profits for our investors. We think this is a growth program for the company.” And so it is…

I guess it's no...

2009-05-13T07:19:00.000-07:00

Ms. PACS: So, I guess it's no. Medicare will not pay for virtual colonoscopies.

"Evidence is inadequate to conclude" that virtual colonoscopies are an appropriate colorectal cancer screening test for Medicare patients, the Center for Medicare & Medicaid Services (CMS) said Tuesday in a statement on its website.

Considering the resounding support from the medical community for the reimbursement of virtual colonoscopy, you have got to wonder what is truly behind CMS' decision. This move certainly does NOT facilitate early screening, which saves healthcare lots of money in the long run, and CMS is well aware of the stumbling blocks involved with optical colonoscopy as a screening tool. At least CMS could throw in a few centavos for a help hotline, providing psychological support for the large percentage of people dreading a traditional colonoscopy: 888-MY-COLON.

It could be the work of a strong gastroenterologist lobby that wants to hold on to the reimbursement for optical colonoscopy. Or this could be another move by CMS to restrict the use of medical imaging as a diagnostic screening method. But that wouldn't be too smart. Nor is this final decision by CMS in the minds of many radiologists.

VCT Debate Heats Up Pre-May 12 Decision

2009-05-08T11:28:00.000-07:00

Ms. PACS: While I wait for the PACSman to respond to my email that I'm posting...he'll probably be up soon from his nap...I wanted to see if anyone is following the heated debate over virtual colonscopy.

How does it relate to PACS? First off, if it helps you get over the fear of getting a colonoscopy, it doesn't matter if it relates to PACS. The first step in overcoming this fear is to click on the image of the colon. But, also, it's about radiology imaging, which is managed on a PACS, and the question is whether the diagnostic quality of virtual colonoscopy (CT colonography or CTC) is at least equal to optical colonography, and if so, whether Medicare should reimburse for it.

As you know, virtual colonoscopy is a noninvasive colon cancer screening procedure with the potential to increase low screening rates and save lives. But to the surprise...for some shock...of many doctors, it did not receive good marks when reviewed by CMS and was subsequently denied coverag. So, now, right before CMS makes its decision on May 12, medical professionals are trying to get their voices heard by posting comments on the CMS Web site (https://www.cms.hhs.gov/mcd/viewpubliccomments.asp). But will CMS listen?

Most comments reflect a strong urging toward reimbursement for virtual colonoscopy.
Here's one from Kyle Kreinbring, M.D., of Advanced Radiology, S.C.:

“I am writing to voice my strong disagreement with Medicare’s recent denial of coverage for virtual colonoscopy. We are all aware that colon cancer is a major concern to all American’s age 50 and older, that colon cancer kills more Americans each year than breast cancer and AIDS combined, and that appropriate screening is the only way to prevent colon cancer.

"As radiologists who have reviewed the literature, we are shocked by the conclusion. Large, randomized and blinded studies have been published in well-respected journals. This includes several articles in arguably the most esteemed journal, The New England Journal of Medicine. Using updated technique and software, the results have been very clear…CTC is a valid, sensitive and safe modality for detection of polyps and cancer. The concerns over radiation and incidental findings seem to be a technique to detract from the real success of CTC. With new protocols and effective dose control the radiation dose is negligible, especially in this population of older patients....This technology has the chance to be a life-changing event for many Americans. It will encourage more patients to be screened, which is the ultimate goal,” he said.

Here's a scathing one from Mark Albright:

“History is replete with examples of governments, politicians, philosophers and businessmen making colossal blunders while clinging to mistaken ideals even in the face of significant evidence to the contrary…Any failure to approve reimbursement of CT Colonography (“CTC”) for colon cancer screening would promptly take its place as among the biggest, costliest and deadliest gaffes in the history of public health. The effect of such a decision will be that (a) more Medicare patients will die from colon cancer, and (b) the costs of Medicare will continue to escalate because Medicare will be paying for treatment and care of colon cancer patients, rather than preventative care for an extremely curable disease.”

Now, a more tempered, voice of reason from gastroenterologist, Dennis Ahnen, M.D., Denver VA Medical Center and University of Colorado Denver School of Medicine:

He starts by expressing his disappointment that “to learn of the proposal to not include CT colonography as an acceptable and reimbursable option for colon cancer screening. I think this is a mistake."

1. It is now well established that CT colonography, if done by well-trained radiologists with state of the art equipment, is a highly sensitive test for detection of both cancer and significant (>6mm in size) adenomas of the colon; studies have shown that it is as good as optical colonoscopy for detection of these lesions.

2. The concern about variable quality of CT colonography in the community is real but it is equally true or even moreso for colonoscopy. It is well established that colonoscopy quality as measured by cecal entubation rates, withdrawal times, adenoma detection rates and/or complication rates varies widely among endoscopists so that high quality screening is required for both CT colonography and optical colonoscopy.

3. The concern about the cancer risk of radiation exposure with CT colonography is appropriate but theoretical (back-extrapolated from exposure data to much higher doses or radiation) and is much less than the radiation exposure of a barium enema which is covered as a screening option by Medicare.

4. The concern about extraintestinal findings possibly leading to higher costs without better health care is also a legitimate concern, but it is uncertain whether the overall balance of these effects is harmful or beneficial nor what the magnitude of the effect would be in practice. A similar argument is not made for the unintended consequences of other screening tests like false positive fecal occult blood tests that lead to negative colonoscopies, which may be followed, by upper endoscopy and/or capsule endoscopy to look for a source of the blood in the stool. I think that issue of extraintestinal findings could be minimized by guidelines about which lesions should be followed up and which workups Medicare will pay for.

5. The inability to biopsy or remove lesions is a real disadvantage of CT colonography, so it would not be a good choice in a population that would have a high pretest probability of having a polyp seen but there are populations that have a low risk such as those with a negative previous colonoscopy where CT colonography would be a good and cost effective alternative to colonoscopy.

6. CT colonography has some distinct advantages over optical colonoscopy in that it is less expensive, associated with less of a risk of both the procedure and the sedation and is much more convenient for the patient.

Overall, it seems to me, that CT colonography is being held to a higher standard than other screening tests, and I would urge you to reconsider your proposed ruling.

To his last point, that sounds a lot like the trouble with coronary CTA - CMS is holding CCTA to a higher standard than other screening tests. I thought that Obama's plan was to encourage early detection as an effective way of cutting healthcare costs. Or is his ARRA stimulus package confined to investment in EHRs - for which PACS will probably not see a dime despite leading the way to streamlining image data in healthcare...oh well. Maybe you should have waited for the hand outs like the rest of healthcare.

The resounding message here is - "enough of this beaurocratic b.s.!" I think Mark Albright, whomever he is - maybe a 10 year-old child prodigy wearing an oversized suit? - hit the nail on the head when he said: It takes its place "among the biggest, costliest and deadliest gaffes in the history of public health."

Mamma Mia!!

2009-04-29T07:22:00.000-07:00

PACSman: A very good friend of mine sent me an e-mail that said, “I was going to do a search on "Cannavo" on AuntMinnie to find a recent article Mike wrote, but accidentally typed it into the Google search window instead. Some interesting results, especially if you search the "Images" section ...” Being the good journalist I am I had to do a little research on the subject personally. So I typed in “Cannavo” on Google under images and- Mamma Mia!!! Not only does Rosaria have the same last name as mine, but she hails from Sicily as well where all my dad’s family came from…(Note to vendors who have considered putting out a hit on me- Our gang can shoot straight, so watcha you step). The last time I heard we still had family there but it’s been a while since my brother Frank visited our cousin Vincenzo. It’s was amazing to me to hear Frank’s stories about how an Alfa Romeo mechanic can live in a mini-palace and have the townspeople treat him like he is the pope….but in situations like that its always best to ask nothing…That’s sorta like when I found out my dad knew Vito Genovese well…yes THAT Vito Genovese - and used to chat with him in Sicilian all the time. Vito used to conduct his “business” from the phone booth in the back of the paper store where dad had his second job. Decades after my dad stopped working at the store I asked him if he ever worried that he could understand what Vito was saying on the phone. Dad’s answer’ “It’s none of my business what he does. He treats his family good and treated me well and that’s all that matters.” That was dad’s diplomatic way of telling me to mind my own business, because a man who treats his family good was a good man in my father’s eyes. Now how dad defined family was anyone’s guess but…ask me no questions I’ll tell you no lies…

Now about my fellow Cannavo. Rosario bumped me off the first page of Google images where three versions of my mug and several of my fellow Gumbas used to be. The first five pages of Cannavo images are almost all Rosaria now but, oh my, what a lovely five pages they are… Heck, my mug doesn’t even show up until you get 6 pages down. On one page there is also a pope looking Cannavo (Ignazio)- I think he’s an archbishop or something- and various other Cannavos as well. I don’t even show up again till page 11. Rosario obviously bought a lot of Google Adwords that is for sure- and her photos keep right on coming right through page 25…I love her bio-

Rosaria Cannavò, a 26 year old Italian showgirl 26 year-old from Catania, Italy, is absolutely beautiful especially for her Mediterranean touch. With her simple, sweet look, the provoking brunette is a student at the university and an actress in the long run…. She has presented to the public her musical moves and ballerina skills given that her passion has always been the dance.

Yeah, that’s the ticket. I’m looking at her for her musical moves and dance skills. We Italians have great musical moves and dance skills…Uh huh…Right… I’ll also let you know if Rosaria is related to me as well. My brother says my cousin Enzo had two daughters who would be about that age by now so….who knows…From my lips to your ears, Lord….

Since Cannavo images on the Net have been overtaken by this breathtaking beauty of late I wondered what I would find looking under PACSMan. Let’s see- two PACS people holding hands, a dog in a PACSMan shirt.and, yes ladies and gentlemen, in the #5 position, Ms PACS and I….with me in my Politically Incorrect tee shirt I asked her to replace with another photo a mere two weeks ago and am still waiting on…My solo picture doesn’t even show up till the #12 position of page one and it’s a God-awful 10 year old mullet shot from Diagnostic Imaging dating back to 1999. I can’t believe I’ve been doing the PACSMan awards that long, but now it’s on AuntMinnie.com where it has been for several years…. It’s also funny in a not so comical way what shows up between page 1 and page 8 where my next mug shot is posted….

So what is the moral of the story? Buy Google Adwords by the thousands and you too can have 25 pages of photos for all to admire. Of course being drop dead gorgeous doesn’t hurt either. If I had registered my own last name as GoDaddy has been bugging me to for years, I too could have owned Cannavo.com, but alas a few days after Rosaria’s pictures started flooding the Internet someone registered it and they probably weren't even Cannavos either. As another good Italian, Rosanne Rosanadanna once said, “It’s always something!!" But I do own the PACSMan.com Web site though so….hope springs eternal….and name Cannavo will never been looked at the same again.

Ms. PACS: Mamma Mia!! Isn't that the name of an ABBA cover band...as well as a popular musical? Or does "Mamma Mia!!" mean get ready to hear the PACSman talk about the PACSman and his heritage for the whole blog. Oh, that's right, it's about Google too. Well, who hasn't Googled themselves annually to check if any of those compromising pictures somehow got in the wrong hands, got posted and are now ruining their professional future?

You're right PACSman, if I am reading through the lengthy lines correctly, you're talking about search engine optimization. Did you ever check to see on Google how many results come up for CT scans compared to CT systems? CT scans comes up with 11,600,000 results compared to 41,800,000 CT systems. Does that mean you should buy CT scans instead of CT systems, because there is more content, aka, more eyes searching CT scans? Not necessarily. Remember, it's quality, not quantity, unless you're an advertiser who bases decisions on the number of page views alone - even though it may be your Aunt Winnie who fell asleep while reading a stimulating medical imaging news Web site and keeps rolling over on the same Web page over and over again.

So, if you really wanted to talk search engine optimization, then why didn't you say so. For example, PACSman, how is a search-based keyword tool different from the keyword tool in AdWords?

Well, the main difference between the search-based keyword tool and the keyword tool in AdWords is that search-based generates keyword ideas based on your website, and tells you which ones are not being used in your AdWords account. Also, the search-based keyword tool gives you a lot more detailed info for each keyword - like category information - and suggests a bid that may place the ad in the top three spots of a search results.

So, it's the same way you chose those lucky ladies, PACSman, it's quality, not quantity.

What went down in Malvern?

2009-04-23T07:09:00.000-07:00

Ms. PACS: “Uh oh”….that’s what my niece says when she’s done something wrong. Or, when you ask, “Carrie, what are you doing?” and she answers, “Nothings.” You know she’s up to no good.

In the case of the FBI raiding one of the big three (which happens to be a major PACS vendor too) in Malvern, PA, yesterday, we don’t know what prompted the FBI to bust down the doors and haul out a lot of boxes. But I'm sure there were a lot of "Uh oh's" among the employees.

They say it's related to a U.S. military contract for radiology systems – I didn’t realize how top-secret military radiology was – move over CSI – military rads are a lot sexier – sorry PACSman, you’ll get your own show too one day;) Of course, there is always that possibility that they won’t find any weapons of mass destruction and it is a simple case corporate-giant wrongly accused - but of what, exactly? Here is how local channel 6abc.com covered it:

Agents raid Siemens Medical Solutions
Federal agents converged on a medical supply company in Malvern, Chester County late this morning. The raid began shortly after employees reported for work Wednesday morning.

Agents with the Defense Criminal Investigations Service rolled in with a rented box truck.

They swarmed into the building with a search warrant and went to work.

Nervous employees stood outside as the agents combed through files and computer records. About six hours later, they emerged with box loads of evidence.

They loaded it all onto the box truck and then left.

DCIS confirms they were looking for records in connection with a specific military contract.

Siemens says it has hundreds and hundreds of contracts with the military, but could not confirm which one is at issue.

Siemens is a multinational corporation based in Germany with satellites around the world. About 4,000 people work at the Great Valley complex.

They specialize in computer record systems and high tech medical devices.

The Pentagon says it will not identify the contract in question, but does confirm that Siemens does business with all branches of the military.

The building that was searched houses the executive offices among others at the U.S. headquarters for Siemens.

Source: http://abclocal.go.com/wpvi/story?section=news/local&id=6773715

So, Inspector Gadget, does this have anything to do with the latest version of syngo PACS? Is it a bust or a frame up? What's your take on it?

PACSman: Bust? Where? It's just you and me here Ms P and since you seem to be somewhat mammarily challenged we're just about even in the upper level department so...Thankfully I'm more a leg and butt man than a bust guy anyway so...

Wrongly accused huh? Oh yeah, well about that $2.1B slush fund back in 2007....Well you see, that wasn't our fault. We weren't supposed to get caught with that. ..but hey, $317M in fines was only 15% of th total fund so.....it's what we call the cost of doing business. Now the the $2.5M in fines we paid in the same year for a sham joint venture on a $49M deal in Chicago was a travesty. Chicago!! Of all places - one of the most non-corrupt cities in the entire country...But we did much better because that only cost us a little over 5% of the total cost of the deal...and once again, the cost of doing business...

When I read Ed Bradley was in charge I said to myself - now they are in serious deepness - 60 Minutes is on their case, but alas, tis only a special agent by the same name.

You also have to love the one and only comment Siemens made to the press - that it “will continue to cooperate fully with the government’s investigation.” Let's see - a dozen or more federal agents with guns show up at your building with a search warrant and a truck to secure records. Hmmm...what are you going to do - declare diplomatic immunity in Malvern, PA? Ah, no...

I also can't possibly imagine who would tip the Feds off to anything that was done improperly by such an upstanding company. Whomever it was probably had to have sour grapes over losing medical imaging contracts worth $267 million to supply radiology systems, subsystems and components on behalf of the U.S. Army, Navy, Air Force, Marine Corps and federal civilian agencies. Rest assured it wasn't me - I haven't done a deal over $150M in years...which is why I still drive a six year old car.

If this had anything to do with syngo PACS, it would amaze me because I don't see very many standalone syngo PACS being installed outside of those bundled with modality deals. Of course, you could say the same about the other modality vendors as well. Bundled deals happen - that's the nature of the game - it's just that Siemens seems to have the market on bundled deals that include their PACS, while the other vendors just discount heavily to make their sales happen.

For the company's part they "asked its employees who work near the area subject to the search to leave for the remainder of the day and to return tomorrow for a regular workday." So Siemens fans and detractors alike - as the little red haired girl Annie once sang, "The sun'll come out tomorrow, bet your bottom dollar that tomorrow there'll be sun! " and it will be business as usual at Ziemens...Just don't look too closely in the dark corners or listen to the whispers...

The Future of CT

2009-04-22T14:49:00.000-07:00

Ms. PACS: If you were wondering if other radiologists thought the same as you about the near future of CT, well these are the results from a group of 200 radiologists polled by The MarkeTech Group on CT in terms of usage and capital investments.

This is one interpretation of the results by an analyst:
IT News Poll 1: The majority believe that CT volumes will increase in 2009;
IT News Poll 2: Clearly most of the facilities do not plan to purchase CT scanners in the next year;
IT News Poll 3: The difference between smaller imaging systems and larger imaging systems is not statistically significant.

This is another interpretation of the results by a radiologist:
It is somewhat surprised by the overwhelming response to question #1. Despite concerns for Radiation Safety, more than 80% of respondents expect an increase in CT volumes, perhaps related to the expanded range of examinations made possible by multi-detector technology. Hopefully we will follow the ALARA principles and "Image Gently."

With the other two questions, clearly this reflects the current economic climate. But even during this crisis, fully one third of respondents plan major capital expenditures in either CT or MR, which is a testament to their value added in streamlining costs in medicine today.

Which interpretation do you think is more accurate?

Mrs. Robinson…Coo Coo ca choo

2009-04-09T09:41:00.000-07:00

Ms. PACS:

Guys love to watch coming of age movies because they are usually about how a boy becomes a man - just watch The Graduate for the 10th time to get my drift. As an adult, you reminisce about the golden days of your youth, but at the time they were really days of confusion.

Well, here’s another coming of age story – starring PACS. This is not about its adolescence but undoubtedly it is facing another stage of maturity - something the PACSman, at times, must come to grips with as well. PACS is well beyond the age of imaging silos that separated radiology and cardiology, has become an integral part of the oncology experience, continues to cross all of the ‘ologies,’ and more recently has absorbed pathology. But before medical imaging can conquer the healthcare enterprise in its entirety, PACS will be restructured as a data management solution that feeds into an image-enabled electronic medical record (EMR).

At the HIMSS 2009 annual conference, a few industry leaders spearheaded this movement toward the image-enabled EMR. Both GE and Agfa rolled out centralized image management archives for all images - DICOM and non-DICOM - as enterprise imaging solutions. These archives are standards-based and help manage patient and image data. In the words of GE’s marketing speak: “The end result is a multi-departmental imaging repository that enables an enterprise to create a longitudinal, single patient jacket for users across a region that includes multiple hospitals and imaging centers.”

The EMRs are designed to consolidate patient data from existing multivendor PACS into the EMR system. GE calls its solution “Centricity Enterprise Archive” and Agfa bequeathed the name “Enterprise Visualization” on theirs. Agfa’s is powered by both IMPAX Data Center and IMPAX Mobility, which take independent PACS and clinical data into a comprehensive enterprise solution. Plus, both the GE and Agfa systems have a single enterprise viewer. According to Agfa, this is “the foundation for the true multi-media Electronic Health Record (EHR).”

Obviously, the viewer in the EMR is not diagnostic quality, or at least not yet, so PACS will remain the specialty platform for radiology. But what does change is the workflow. In this scenario, radiology PACS will not be the train conductor but just another driver of medical images, that feeds the EMR.

I know change is hard, but these are no more than adolescent growing pains because what an image-enabled EMR can do for radiology is enhance referrals and the overall value of radiology. Now, or at least in theory, clinicians will be able to use a viewer to see the imaging exams not just as part of the final report but also at the point-of-care. The value of radiology services will augment, confirming the relevance of imaging exams as an essential element in today’s complete medical record. This will take radiology where PACS up to now has not. So, if EMR is the older mistress, then its time for PACS and EMR to jump in the sack.

PACSman:

And here’s to you, Mrs. Robinson,
Jesus loves you more than you will know.
God bless you, please Mrs. Robinson.
Heaven holds a place for those who pray,
Hey, hey, hey….

Ms. PACS likes to think that men love the fantasy of an older woman seducing a 15 year old boy, but let me tell you, I have both a 15 year old (16 this week) and 17.5 year old sons here and if Mrs. Robinson tried to seduce them they would both say “Eww. That is just so gross. She is so OLD!” Now, know that I wouldn’t have kicked Anne Bancroft out of bed for eating crackers, but when The Graduate came out in 1967 I was a mere baby of 12 and still an altar boy. Kids still think that engaging in “the act” ends at age 25 or when you have kids, whichever comes first.

Now kids do impact both the quantity and quality of coo coo ca choo moments for sure…but much to their chagrin those moments still do happen, as gross as that may seem.

We’d like to know a little bit about you for our files
We’d like to help you learn to help yourself.
Look around you all you see are sympathetic eyes,
Stroll around the grounds until you feel at home.

PACS came of age years ago, so I’m not quite sure where Ms. P is coming from. It sounds more like an evolution than a revolution to me though. PACS hasn’t aged or grown or absorbed anyone or anything. It’s gone well beyond Mrs. Robinson and evolved into Jerry McGuire - show me the money and the money is in EHR these days, not PACS. With an average $5.7M Medicare stimulus package dangling over the typical 250 bed hospital’s head to implement an EHR, who in their right mind is going to buy a standalone PACS? PACS somehow needs to be carefully gift-wrapped into the new EHR. Tie in a common archive, add an “ology” or 3 for good measure and…viola - instant EHR.

Data from the HIMSS Analytics Database, which tracks IT adoption milestones from 5,166 non-governmental U.S. hospitals, reveal that 67% of these hospitals need to add only one or two healthcare IT applications to be compliant. The applications include computerized physician order entry, clinical documentation, clinical decision support, and/or major auxiliary department information systems. Stage 7 (a paperless system and the ability to share interoperable patient data and analyze clinical data for performance, improvements and clinical decision support) is the ultimate goal yet only 2 hospital groups in the country are stage 7’s -12 Kaiser hospitals in CA and three NorthShore University Health system, based in Evanston, IL and none were there until the middle of 2008 so we have a very long way to go. Still, that’s where the money is long term so….

According to yet another HIMSS Analytics report published in December 2008, based on an eight-stage EMR implementation process:
- 31.2% of hospitals are at Stage 2 and have implemented a clinical data repository that contains and facilitates physician review of orders, lab results, radiology images and reports, and prescription drug information.
- 35.7% are at Stage 3 and have also implemented nursing documentation capabilities in at least one unit of the hospital and have clinical decision-support systems to support nursing procedures.
- 6% have advanced EMR capabilities such as computerized practitioner order entry, physician documentation, data warehousing and mining capabilities, and full radiology PACS.

Sitting on a sofa on a Sunday afternoon.
Going to the candidate’s debate.
Laugh about it, shout about it
When you’ve got to choose
Every way you look at it you lose.

So with everyone buying EHR’s will anyone be happy buying “just” PACS. Well, look on the bright side- “full radiology PACS” is considered an advanced EMR capability so…I sure hope so. It is fascinating that of the big six PACS vendors only McKesson (at 14,.4%) and Siemens (9.5%) are listed in the top five of EHR vendors with Meditech #1 at 26.6%; GE and Agfa didn’t even make the top 10.

PACS needs to be in the drivers seat when it comes to radiology operations for sure, but will it take precedence over IT’s other choices? That is the $50,000.00 question.

A 4/8/09 article in Healthcare IT news reported the following:
“The hard part is doing something with it,” said Dave Garets, the session’s moderator and president and chief executive officer of HIMSS Analytics. “At a Stage 7, you have everything, what are you going to do with it?”…..

The interfaces to legacy systems are also more numerous, complex and expensive than one might think, said Andrew Wiesenthal, M.D., SM, associate executive director of The Permanente Federation.

“You won’t have advantages until you have everyone up and running on the system,” said Thomas Smith, chief information officer of the NorthShore University Health System.
Smith said NorthShore did a few things wrong the first time. Having a backup data center is important, he said, because ongoing user engagement is a priority and order sets should be taken care of.

“Surprises” in implementing an EMR in the three organizations included the amount of training needed, complexity and cost of a truly redundant information center, whether it’s worth getting rid of all paper documents, and the legal reaction to an EMR.

“The simple stuff can bite you,” Wiesenthal said. “If you strive for perfection, you won’t get anything but.”

So yes, Ms. P, change is hard, but then hard is what Mrs. Robinson ultimately strived for wasn’t it? She gave new meaning to the term adolescent growing pains.

Is the “older woman” in the form of EMR able to do anything more for PACS than the teenage prom queen can? While she brings more to the table in terms of experience and money…that’s about all. Benjamin was merely a play toy after all. After all that teasing she did to poor, poor Benjamin, Mrs. Robinson ended up spending the next 38 years happily married to none other than….. Mel Brooks….

Photos: UA/Embassy © 1978 Bob Willoughby - Image courtesy mptvimages.com

Paybacks Are Hell

2009-04-02T08:55:00.000-07:00

PACSman: I love how all the hot potatoes get thrown at me and then when I finally say what I feel I am the one accused of being politically incorrect. It’s not just Ms. PACS who does it either. I’ve run into this problem my entire life, most recently almost 25 years ago when I last worked as an employee for one of the major PACS vendors (can you believe I’ve been on my own for that long?). They asked me a question, I gave them an answer. They said, “That’s not what we want to hear.” So I answered, “Well, why don’t you just save us both the time and trouble and tell me what you want to hear, so I can tell you that instead of what I really think.” That was the wrong answer apparently. They replied: “You have a bad attitude towards management.” “No,” I said. “I just have a bad attitude towards a$$holes which is what you are being by asking me a question then telling me you don’t value my thoughts or opinions.” OK, so maybe I was a tad strong in making my point, but it got through to them and they to me as well. I didn’t belong there. What’s funniest though was being able to come back 20 years later to the same company as a consultant and telling them ostensibly the same things I said 20 years prior, and charging them as much for two days of my time than they paid me in an entire month. Paybacks are indeed hell……which leads me to today’s topic.

I have specifically avoided talking about the entire Emageon “deal” over the past several months, especially in print, because I have too many people that I consider friends still with the company. My tongue has also been bloodied way too many times from biting it, but I did very well by saying nothing. You should be proud of me. Unfortunately the handwriting is on the wall for many of those I know, which makes me sad. There is much too much overlap between both companies, and since AMICAS is the buyer, guess who loses? The good guys in the trenches, of course. And management? Well many there will lose too, except the big cheese himself who walks away with his head high and pockets filled to the brim. This is America - it’s the way it should be, right? The stock price plummets 90%+ , the company sells for less than half it should have in a matter of two short weeks, and he gets $1.7M to say “Adios amigos!!” …That buys a lot of Taco Bells for sure.

Now, this isn’t my blog site (I sorta wish it were) but rather one I picked up from a posting my good friend the Dalai had in a comment on his post about Agfa today. I got on the site and simply roared. The site, http://dearchuckjett.blogspot.com/, is a “tribute” (and I use the term very very loosely) to the big Kahuna at Emageon from his ex-employees, current employees, those he has worked with and the like. It’s all done anonymously and such and looks like it’s been up since February 10th, after news of the HSS/ Stanford “investment” going south. That didn’t exactly take a rocket scientist to figure out either - the feds had been investigating Stanford since last July, but those are minor details…Ask me no questions, I’ll tell you no lies. Emageon took the Rod Tidwell approach to financing as outlined in the movie from Jerry McGuire - Don’t know, don’t care - just “show me the money.”

Now Chuckie really isn’t a bad guy like the Child’s Play character of the same name might imply - he really isn’t - but I think it fair to say his business acumen might leave just a little something to be desired. After all the company that he was in charge of showed a $42M loss in 2008 and he walks away with $1.7M? Um..can we talk? Reminds me of AIG on a much smaller scale - but the Emageon Board or someone approved it so...not that tax payers. Now I’ll admit market and economic circumstances did play a small role in some of what happened, but all? Nah….As I tell my kids, you have to accept responsibility when you are responsible. Harry Truman said it best when he was President, “The buck stops here.” It’s not with Congress or the Senate or the Board or the investors - the buck stops here, with the President…and last time I checked Chuckie was that plus CEO too. I can only hope that Dr. Steve Kahane at AMICAS continues to maintain the “buck stops here” attitude he has had since Peter McClennan left as President and he stepped into both roles. A ballsy move for sure, but the mark of a true leader.

AMICAS was one of the few PACS companies whose total gross revenues were actually up this year over FY 2007, albeit just under 1%, but they took a $27.3 million “goodwill impairment charge” hit that significantly impacted their bottom line profitability. Now I’m all for Goodwill- heck I even shop there frequently - but $27.3M buys a whole lotta jeans… So AMICAS - call me and let’s talk- please… The first hour, as always, is free. I’ll even give you two hours because I like ya. The last thing this industry needs is you guys going off on your own as blind as Stevie Wonder and Ray Charles combined hoping that you’ll do it right. The financial burn rate for both companies is much too great to screw this one up and I have more people I know at AMICAS than I do at Emageon. So call me….please. Now, where was I?

I was also asked today about what I thought about the Pam Pure’s departure from McKesson. I never met the woman so I can’t comment on her personally, but do know McKesson is uncharacteristically tight-lipped about it all so something has to be up. I know many many people in McKesson and have worked with the company on many projects. To the person they have all been very above board and fair to the max. That is so unusual in this industry. If they couldn’t do something they would tell me so - not BS me or try and squeak out of something on a contract technicality like a very large PACS leader did recently with a customer of mine leaving me saying nothing after? Adding insult to injury, we didn’t even get kissed either.

The bottom line is what goes around comes around….and it will…because revenge is sweet…and paybacks are hell. Just ask Chuck…and those who are doing the blogging on that site well know…

Ms. PACS: I think the expression is "Paybacks are a B#*ch"? But you wouldn't know anything about paybacks...now would you? What I like about you PACSman is that you're good at telling it like it is without getting under anyone's skin;)

But every now and then, even I, the demure Ms. PACS feels like lashing out and telling someone how full of #$&^ they really are. It is at those times I turn to a lil' book that reminds me that, indeed, "Paybacks are a B#*ch". It's called Emotional Intelligence: Why It Can Matter More Than IQ (1996) by Daniel Goleman. Goleman argues that our emotions play a much greater role in thought, decision making and individual success than is commonly acknowledged. He defines “emotional intelligence” as a trait not measured by IQ tests, but as a set of skills, including how to control one’s impulses, being self-motivated, having empathy and social competence in interpersonal relationships. Another self-help book? I think of it as confirming what we already know - don't burn bridges.

With the dearchuckjett blog you can look at it in two ways. It could reflect a certain degree of Emotional Intelligence because it might be a good way for people to vent so that they don't blow up at people who are currently relevant in their professional and personal lives. It's not complete justice, and it's definitely tied to an inferiority complex - they got kicked around on the playground - which we all undeniably struggle to overcome throughout our lives, but applied in a positive way, that may motivate many to reach their potential.

Then there is the burning your bridges part where if you even care what Emotional Intelligence dictates - it's not so smart. If Chuck makes a come back or has friends in those high-places where you want to go...you're smoked. And the odds are someone's identity on the blog is going to be revealed.

But maybe they are more like you, PACSman: tell it like it is and 20 years later, tell him how it's done - and get paid for it. You just might have some of what pop-psychology, mumbo jumbo calls emotional intelligence. But just remember what's happens when you play with fire...eventually you get burned.

Can PACS Be Politically Incorrect?

2009-03-25T10:27:00.000-07:00

Ms. PACS: If you thought it was just an iron-on T-shirt, think again. The PACSman is on a 'politically incorrect' rant again.

PACS Jr.: The PACSman sent this to me relating how PACS and school have both become extremists. I’m not sure I share in all of his sentiments about how we took something so simple and made it complex, but do agree that certain aspects of PACS have become more convoluted than they need to be, especially when it deals with standards support and such.

Anyway, even though the PACSMan is much older than I and can relate to this much better than I can, I enjoyed this and hope you will too.

Scenario:
Jack goes quail hunting before school, pulls into school parking lot with shotgun in gun rack.
1958 - Vice Principal comes over, looks at Jack's shotgun, goes to his car and gets his shotgun to show Jack.
2008 - School goes into lock down, FBI called, Jack hauled off to jail and never sees his truck or gun again. Counselors called in for traumatized students and teachers.

Scenario:
Johnny and Mark get into a fistfight after school.
1958 - Crowd gathers. Mark wins. Johnny and Mark shake hands and end up buddies.
2008 - Police called, SWAT team arrives, arrests Johnny and Mark. Charge them with assault, both expelled even though Johnny started it.

Scenario:
Jeffrey won't be still in class, disrupts other students.
1958 - Jeffrey sent to office and given a good paddling by the Principal. Returns to class, sits still and does not disrupt class again.
2008- Jeffrey given huge doses of Ritalin. Becomes a zombie. Tested for ADD. School gets extra money from state because Jeffrey has a disability.

Scenario:
Billy breaks a window in his neighbor's car and his Dad gives him a whipping with his belt.
1958 - Billy is more careful next time, grows up normal, goes to college, and becomes a successful businessman.
2008 - Billy's dad is arrested for child abuse. Billy removed to foster care and joins a gang. State psychologist tells Billy's sister that she remembers being abused herself and their dad goes to prison. Billy's mom has affair with psychologist.

Scenario:
Mark gets a headache and takes some aspirin to school.
1958 - Mark shares aspirin with Principal out on the smoking dock.
2008 - Police called, Mark expelled from school for drug violations. Car searched for drugs and weapons.

Scenario:
Johnny takes apart leftover firecrackers from 4th of July, puts them in a model airplane paint bottle, blows up a red ant bed.
1958 - Ants die.
2008- BATF, Homeland Security, FBI called. Johnny charged with domestic terrorism, FBI investigates parents, siblings removed from home, computers confiscated,
Johnny's Dad goes on a terror watch list and is never allowed to fly again.

Scenario:
Johnny falls while running during recess and scrapes his knee. He is found crying by his teacher, Mary. Mary hugs him to comfort him..
1958 - In a short time, Johnny feels better and goes on playing.
2008 - Mary is accused of being a sexual predator and loses her job. She faces 3 years in State Prison. Johnny undergoes 5 years of therapy.

Scenario:
A PACS breaks down.
1995 - PACS breaks down. PACS admin calls the vendor support person they've worked with for the past five years who diagnoses the problem and FTP's software patch. PACS is up and running in 20 minutes.
2009 - PACS breaks down at new imaging center. After confirming the service contract is current the customer is sent to Bhopal to talk to "Joe" who runs through 4 hours of online diagnostics and finds 16 reasons why it isn't the vendor's fault. After numerous back and forth discussions, the problem is finally fixed - two weeks later - using a known software patch - and the imaging center is billed $7,524 for non-covered support unrelated to the patch. Revenue losses during the downtime put the company so far in the red that the shareholders ultimately fold the business and sell the PACS on e-Bay....

Remind me again, what happened??

Riding on PACS Coattails

2009-03-18T16:16:00.000-07:00

Ms. PACS: You have probably noticed how PACS is the vehicle that pushes the rest of the software to the end-users. The goal of so many medical applications is to get integrated into a PACS - and then you’re golden.

Take CAD for example, it has been trying for years to become a 'must have' in PACS, but that’s only happened in Mammography PACS – probably because mammography is the one field it has proven truly valuable – despite the debates and backs and forths printed in the NEJM last July. “In response to the NEJM publication, the American College of Radiology (ACR) stated that the decreased accuracy of mammography when using CAD was due to increased false positives, not to fewer cancers being detected. The study was designed in such a way that it was impossible to determine how many cancers would have been missed without the use of CAD, according to ACR.”

On that note, CAD keeps getting a bad wrap – and probably for good reason – apparently, it scored poor marks and fell through the cracks of Medicare.

Another one is advanced visualization. Advanced Vis has become such an integral part of PACS that it’s not a question of if you’re using 3D software, but how you’re using it. 3D images are used in an increasing number of clinical applications and across a widening array of care settings. The PACS vendors recognized this several years ago, but got caught up securing orthopedics and mammography. Finally, by RSNA 2008, vendors showed off their in-house efforts with at least built-in basic 3D functionality (like MIP, MPR) in their PACS. Others took the OEM route and licensed the 3D technology, repackaged it, and turned around to sell it to their customers embedded in their PACS as if it were their own 3D software. The moral of the story is, 3D access has been driven via PACS.

There have been strides also with Speech Recognition (SR) in RIS/PACS. And SR is now stretching the chain of command by driving other applications like critical results, peer review, medical reference programs and data mining applications.

Next, have you heard – if you use your PACS in a ‘meaninful way,’ ie, transferring medical images and data through an EHR, and if your PACS merges with the EHR highway, then it qualifies for those BIG new incentive dollars. Just ask the guys at Certification Commission for Healthcare Information Technology (CCHIT) – they are the official EHR certifiers. Dr. Mark Leavitt told me in an interview: “If PACS is a departmental system that is separate from the core EHR, then it wouldn’t qualify for the incentive, but if it is defined as a module as part of an EHR, then it would qualify.” So, while all of the apps board the “all-on-PACS” bus, now it’s PACS’ turn to ride the coat tails of EHRs and skim a few billions from the economic stimulus package. Just make sure that when you’re using your PACS you do so in a ‘meaninful way.’

At that rate, and now that we’re feeling optimistic, there may come a day when all end-users get built into PACS their own wise-cracking, all-knowing PACSman. And you get your choice: with or without the beard.

PACSman: Getting integrated into PACS might be the first step of goldenness, but I can submit a list of at least a dozen vendors who thought their companies were golden when their products were finally included in a vendor’s PACS. Unfortunately their golden egg turned out to be 10 carat gold-plated, if not spray painted, and in several cases it cost them the company. There is something to be said about putting all their eggs in one basket…

I’ve always been a strong proponent of mammo CAD. Unfortunately CMS (the Centers for Medicare and Medicaid Services) did not agree with my sentiments and has proposed CAD reimbursement cuts of 50% by 2010. Third party payers are also denying breast MRI CAD payments as well. So has the golden goose laid an egg? Probably. Conflicting studies on the value of mammo CAD probably helped kill this one and with it probably more than a few patients as well. But hey, it’s medicine, and that’s why we call it a practice…

Advanced visualization (AV) is great, but how many AV packages do we really need in this market? And how many bells and whistles? Most importantly, with so many good third party packages out there why do vendors feel they need to reinvent the wheel by providing their own packages instead of just integrating a proven solution? True, a few of the smarter vendors just resold other’s solutions, but too many seem to have reinvented the wheel. 3D existed way before PACS as a standalone solution - at least 20 years before - so I would hesitate to say that 3D was driven by PACS. Instead increased utilization of 3D was driven by PACS mainly because the cost to implement 3D in a PACS is about 25-30% as much as a standalone 3D unit would cost.

Speech recognition (SR) has its supporters and detractors. I stand with my good friend the Dalai in being a SR detractor and find the SR can do nothing better than a well designed RIS and transcriber can. In fact, the latter can do it better faster and more accurately than SR can, but let’s not go there. Let’s also not even begin to dissect the world’s most abysmal contract of all time offered by a certain leading SR company whose contract verbiage differs much more than just subtly in its meaning, opinion or attitude than most contracts.

As for using my PACS in a “meaningful way” as part of an EHR- one has to ask who are these bozos defining these rules, and what planet have they been on the past decade or more? There are at least twenty times as many PACS in place than EMR’s, EHR’s, or anything else combined yet now all of a sudden the EHR is driving the bus and if PACS isn’t on board then it doesn’t get the big bucks. CCHIT is the right acronym here because these guys are full of it….and don’t seem to have a clue on the role PACS plays either.

Optimistic? When the times call for it. Realistic? Always. I doubt Ms PACS will ever grow a beard unless she has some overnight hormonal imbalance (and I’m not talking PMS either) and her Irish background may or may not require her to bleach her mustache like many of my great aunts had. I swear, some of them put the men to shame- along with those who had one hair that grew out of this dangling pimple on their face as well (no names please). When I reflect back I wonder why I didn’t use the quote from Uncle Buck- “Take this quarter, go downtown, and have a rat naw that thing off your face.” I guess I was just more politically correct at 13 then I am now, plus the fact that my dad would have beaten me from here to eternity and DCF didn’t exist then either- and if it did they probably would have beaten me too.

I really don’t want to be any part of a PACS- too much downtime with too many exemptions which the gal I am seeing would definitely not appreciate - but wouldn’t mind a little incentive money thrown my way just to keep things interesting and meaningful….

Get Some Bang for Your Buck!

2009-03-05T13:42:00.000-08:00

PACSman: One of the best things that our flailing economy has done is to cause both companies and individuals to think twice before spending money. Most companies now have travel restrictions in place requiring nothing short of a papal dispensation before a sales rep can leave home (either that or a 95% chance of closure). Some execs are even trading in their blue suits since amazingly fewer blue suits are now needed to close deals. Buyers are becoming much more price sensitive and would rather have an extra $10-15K off a deal than a decent post-contract signing meal and seeing 5 people who add no value to a sale whatsoever.

Unfortunately these changes are having a ripple down effect on trade shows, with the Medical Records Institutes TEPR (Towards the Electronic Patient Record) show the latest victim. TEPR closed up shop this year after a disappointing turnout, having just over 700 people show up for a show that was promoted as drawing over 2000. So how does this bode for other shows like the RSNA which drew just over 59,000 last year (although only 28,259 professional registrants) and even SIIM which barely broke 800 registrants (1,400 or so including exhibitors although they initially expected 3000)? That all depends on your perspective.”

RSNA registration in 2008 was down 5%, but the reality was much greater than that. By some estimates attendance was down by as much as 20%. Why the discrepancy? It’s just like attending a sold out basketball game - you go there expecting to see every seat filled, yet there are entire sections that look vacant. The turnstile count is really what matters, not registration numbers, especially since, in the case of RSNA, it costs nothing to attend as an RSNA member, so go ahead and register me and if I can make it, great! If not, well, no great loss. What’s funny is many vendors felt that despite the lower attendance numbers that RSNA ’08 was a much better show than in previous years. I would concur. Why? It’s the old quality versus quantity argument. Those in attendance were there for a reason, not just to kick tires, and came with a specific purpose and agenda in mind. Few people had the luxury of spending five leisurely days on the floor - it was get in, get the information that you need, and go home. Whether decisions were made or not remains to be seen, although it seems like a lot more decisions were made post-RSNA than in previous years because the decision makers were there and they were the ones doing the walking and talking.

Interestingly, HIMSS put out the following press release last week that started out this way: “Despite general economic conditions that might suggest otherwise, early registration for the 2009 Annual HIMSS Conference & Exhibition (HIMSS09) is running ahead of the 2008 trend, which ended with a record 29,174 attendees. Total registration for the conference, which will be held in Chicago in April, stands at 5 percent over this same period of time last year, with non-exhibitor attendance showing an almost 3 percent increase.” Can you imagine what their attendance would be if HIMSS actually acknowledged that PACS exists in healthcare? I, for one, am still waiting. This year, as in year’s past, fewerthan a handful of 200+ presentations being given at HIMSS address PACS (and only one that is non-commercial). But alas, I digress. Next year guys, OK? Just know I’m not holding my breath….

So what about SIIM? I like the people at SIIM and the organization - after all it is the only PACS-centric organization out there - but is SIIM the right venue for exhibitors? Several vendors are asking the same question in recent months, with FujiFilm Medical Systems pulling out of the show yesterday and others scaling back their presence. This was a huge step for Fuji considering that Fuji was the very first corporate member in SIIM (then called SCAR) when SCAR was first established 20 years ago. You can read through all the niceties in the press release, but the reality is you have to go where you get the most bang for your buck.

The targeted attendee for most larger PACS sales is the health care administrator/C-suite and, to a lesser degree, physicians. Maybe a better approach is to aim for quality not quantity. One organization which claims to pursue such an exalted mission is CHIME, which claims to have 1200 healthcare CIOs from across North America as members, but who really knows.

Companies are starting to ask in much louder voices - are there better ways than trade shows - then just going to the same shows and doing what we always have? The answer is an unqualified yes…I’m working with several vendors on ways that they can get the message to their audience without spending the GNP of Tonga doing it either. It’s called marketing 101.

So is all the economic news bad? Not at all. It is causing people to reevaluate what they are doing, how they are doing it, and what needs to be done to get the message through. If it were only that simple in life….

Radiologists Take the Wheel

2009-02-25T13:09:00.000-08:00

Ms. PACS: One of the big growth areas for PACS right now is in cardiology PACS. (Don’t cringe – cardiologists can look at images too.) So we at ITN decided to do a Webcast on it - produced by Herman Oosterwijk - entitled: 'Cardiology PACS Integration Can Be Seamless.' With the tagline: ‘Successful Integration is System Critical' - to add a little umph!

We found out that Cardiology PACS is more than just a popular theme, it is a huge undertaking that requires a lot of cooperation between the radiology department, the cardiology department and the IT people.

The way they set it up at The Heart Hospital Baylor Plano is that the RIS is the system where all report generating begins and ends - for both the radiologists and the cardiologists.

One of the problems that the cardiology staff is having with the RIS is: “The cardiology staff was not used to a radiology workflow and we are using a RIS for cardiology, and if you do not follow that process of scheduling, arriving, beginning or completing the exam in RIS, it could cause a break in downstream systems,” said Lori Crissup, RN, Cardiology IT Specialist, The Heart Hospital Baylor Plano.

I thought this was interesting, as it suggests that in the integration of PACS and CVIS, RIS drives the cardiology department's workflow...i.e., the cardiology staff needs to adopt radiology workflow.

“So the orders are placed in the RIS and from the RIS the patient order is brought over on the schedule to the hemodynamic monitors. Once that patient is selected in the schedule on the monitor, we select the case and all of that information populates. All of the hemodynamic data and all of the ACC data is transferred into the DMS servers. Then the cardiologist can go to the workstation in the cath lab and add his or comments and results directly into the report,” explained Richard Sanders RN, Cath Lab Manager, The Heart Hospital Baylor Plano.

Integrating the cath and echo labs, with all of the cardiovascular images, including cath, echo, nuclear cardiology and radiology images like CT, MR and PET- and SPECT-CT – with the rest of the enterprise is not only driving market growth in PACS, but with RIS generating the reports, the cardiology department has to reinvent its workflow…and that puts radiologists in the driver’s seat.

PACSman: When I went to high school my parents made me study French even though I begged and pleaded to study Spanish. Why? Because I could reuse my brother’s French books they invested in. Besides “French is the universal language - everyone speaks French.” Of course that the early 70’s when I had no other choice, but to accept my parents flawed logic. Living in a small white bread community in New Jersey my only exposure to Hispanics was limited to hearing Aurelio Ramos - who was probably the only Hispanic kid in all of Red Bank - yipper yap with his parents…I never did hear anyone speaking French either but by jove I did learn French - or at least enough to understand the words when Lady Marmalade sing her disco hit of the same name in the mid 70’s...

So here I am living in Orlando about 4 hours north of this side of Havana speaking high school French while my 15-year-old son Matt can easily converse with our wonderful Puerto Rican neighbor Jackie in fluent Spanish. Go figure…

So what am I getting at here? While cardiology using a radiology system at Heart Hospital Baylor Plano (HHBP) might work, it’s beyond klugey. That’s like me speaking French in a Hispanic world. The bigger question though is why does cardiology need to “adopt” radiology’s workflow when theirs is different. The ONLY real commonality these two systems have is a central archive- period. The Cardiology Information System (CIS) market is also a $100M+ market in the US alone so why try and make something work with bailing wire and chewing gum when you can have a much smoother system designed specifically for cardiology’s needs?

Looking at the bigger picture does a central archive for radiology and cardiology make sense? Absolutely, and while we are add it let’s add pathology, lab, pharmacy, financial, the HIS, and EMR on it too, provided the facility has a strong disaster recovery solution in place and an even stronger IT infrastructure to support it…Let’s also make sure the archive is truly vendor neutral archive where data migration is not necessary either.

So does using a RIS to take the place of CIS make sense? Not in my book. That’s like Israeli Prime Minister Ehud Olmert being sent an invitation to a Christmas party from the Pope. You have to ask- would he bring a gift? Sing carols? Attend mass? Would the Pope object if Olmert wore his yarmulke in church? Having cardiologist “accept” radiology’s system with “radiologists taking the wheel” was either an act of kindness or a Henry Ford moment to the cardiologists from the hospital (“You can have it in any color as long as it’s black”) The pope might have invited Olmert, but you can rest assured he was only being polite in accepting it and by no means had a “come to Jesus” moment because of it. The same I’m sure holds true for the cardiologists. Saving money by using a RIS in a CIS application may be penny-wise and may even work here, but to me at least the loss in productivity in the single biggest revenue generating department in the hospital seems at least from the surface as being pound foolish…(with apologies to the radiologists who, in this case, are Avis to cardiology’s playing Hertz - “We try harder…”)

Integration is crucial and what is being done at HHBP is a great start. Let’s just make sure though that every department is provided the tools they need to optimize efficiencies. While it is commendable to want to save money by having cardiology use radiology’s RIS, we should never compromise the longer-term vision of a department by focusing on the short-term goals like saving a buck…

Perplexing PACS Market Projections

2009-02-20T06:35:00.001-08:00

PACSman: Just like the statistically-challenged geniuses who gave us a hearty belly laugh by saying PACS had 90%+ market penetration yet another group of market prognosticators are at it again - this time projecting PACS growth to hit an astounding $4.8 billion in 2015. Did I miss K-Mart's blue light special on crystal balls or have they been tippling a wee bit too much Irish whiskey again? These are the only things that would explain these incredibly optimistic prognostications by these Nostradamus- wannabes.

Now normally prognosticators don’t do any harm when they prognosticate for prognostication’s sake. But these guys seem to have no basis whatsoever besides a dart board guesstimate for their vision of the future. They seem to be completely out of touch with what is going on not only in the U.S. but in the world PACS marketplace as well. Someone needs to play Quick Draw McGraw and say “Now youuuuuu hold on thar little buddy”. Instead when I read stuff like this it reminds me of an old episode of Huckleberry Hound “"Three and three is . . . . uhh, Seven? Nine? Fourteen? Sixteen!" An inexact science indeed…

You have to ask yourself why a company that is trying to sell market reports has no hyperlink to the report being offered in its website, none in the press release that works, and won’t even allow you access to their press releases on their web site unless you are an “approved publisher”. After all, issuing 34 press releases in 3 days is a massive undertaking for any company especially since 22 of them include the world “global” in the heading and the rest, if PACS release is any indication, have also addressed things from a global perspective…I guess when you put out 900 Global Strategic Business Reports (large multi-client research programs); 45,000+ Market Trend Reports; 95 Global Industry Outlooks; and 114,000+ Market Data Capsules and a partridge in a pear tree you have to always think big picture (laugh). It’s also telling that a company that is “strongly committed to upholding the highest standards of research integrity and diligent reporting” has three year old user satisfaction data on themselves- the results of which don’t bode well for the company either showing that just over half their clients think their work is good or above…and the rest either satisfactory or not commenting. That’s like my son asking me to get excited about him getting a C in a class when I know he is capable of at least a B if not an A. If my clients can’t give me an A then they don’t pay- it’s that simple…and as it should be.

I’m desperately trying to figure out what they mean by saying “…as the technology evolves from being a radiology-centric technology to a core data management technology for healthcare departments, pharmaceutical companies and academic institutions, the PACS market is expected to offer significant opportunities for vendors.” Now I know about radiology PACS and cardiology PACS and even orthopedic PACS but pharmacy PACS? What am I missing here? And don’t academic facilities have radiology, cardiology and orthopedic departments or did I miss this too?

Here’s another rocket scientist statement “Also, PACS in Europe, where the market is less robust compared to the U.S., there is significant potential for PACS growth due to the European healthcare community’s need to reduce healthcare costs while simultaneously providing quality patient care and services…..” As Homer Simpson would say, “NO DUH!!” The last time I checked the U.S. also had the need to reduce healthcare costs as well, hence the DRA. And while we are at it, lookie here!! “In Asia-Pacific, growth in demand for PACS is likely to be driven by the cost efficient initiatives being implemented by the hospitals in the region. Software licenses represent the largest segment, while services is the fastest growing segment.” Let’s see- “reduce healthcare costs” and “cost efficient initiatives”- can you say redundant? And in English it’s "services are", not "services is"….While software licenses may represent the largest segment (of what though, one might reasonably ask) they are also the highest discounted “segment” as well and represent a fairly low overall margin. Service, on the other hand, is a lower dollar figure but overall provides the highest net margins.

So how did they come up with this $4B+ number? As I initially stated my first guess involved a blindfold and darts. If the global market is $2B now (which is a huge stretch by any imagination unless you add in CR, DR, VR, RIS, archives and anything else that can be remotely construed as PACS) even them you are talking about an average of 20% growth per year. And let me tell you- that ain’t happenin’, Quickstraw, and even if it did that doesn’t mean the companies will be around another 7 years either. Every day I see the same press release on yet another company- sale up, net margins down- and last time I checked the bills don’t get paid based on sales alone but on net profit margin. That’s like listening to Rod Stewart singing “Tonight’s the Night” when the reality is the situation is Jackson Browne’s “Rosie”. It’s a nice try but….So even if sales do increase almost 150% in 7 years that doesn’t mean companies will still be in business…Look at the market leader, whose stock has lost nearly 300% of its value in the past year going from almost $40/share down to $11/share. But let’s be optimistic- their stock may be somewhat depressed but their sales are up…

I recall a similar study done several years ago by a company I shall not mention who predicted a $1B PACS market and it did come true - 10 years AFTER they predicted it would indeed happen. Of course they failed to factor in things like reduced hardware costs which brought the average sale price down about 20% or increased competition which did the same not just to the sale price but net margins as well… but those are just trivial details…

One day someone will offer a report that tells the truth about this market from people who really know the market instead of just throwing together a report with hyper-inflated numbers. Until then stick with those who know and live this market 24/7 like I have for the past 25+ years. Quickstraw was right - “I'll do the "thin'in'" around here! - And “don't you for-git it!”

Ms. PACS: Haven’t you ever heard of the luck of the Irish? In this case, PACS vendors will be really lucky if the world PACS market actually does reach $4.8 billion in 2015, as the report says.

To you, PACSman, the eternal and infernal pessimist, this is preposterous. And while I acknowledge your years of dedication to the PACS market and your infinite wisdom, I would like to ask you a simple question: Have you looked at the frequency and price of replacement PACS in the U.S. alone?

If you tuned into our latest Webcast “Cardiology PACS Integration Can Be Seamless,” the topic covered how PACS vendors are offering so-called integrated solutions, and how all too often this integration does not go as smoothly as expected. So, the Webcast targeted those planning on purchasing a cardiology PACS or integrating a cardiology system with an existing radiology PACS. Just to lend some credibility to my argument, the panel consisted of an Enterprise Imaging Administrator (Christopher Oropeza), a Cath Lab Manager (Richard Sanders RN), and Cardiology IT Specialist (Lori Crissup, RN) all of whom work at The Heart Hospital Baylor Plano in Texas.

According to the poll taken from the Webcast registrants, most of whom were IT people either in a cath lab or radiology department, and from the panelists, on average, the lifetime of a PACS was less than 5 years and often just 3! At $250K a pop, I would say someone’s making money somewhere.

Plus, by the questions submitted, it was revealing how much advice these hospital IT professionals need – that’s a nod to you PACSman – and good technical support they would benefit from. Knowledge is power...and money...cha-ching!

Here are some of the questions they submitted:

- Are both the radiology orders and the CathLab orders entered in the same RIS? If so, who manages the orders that aren't completed or need to be canceled?

- Are the reading workstations for cardiology different than the reading workstations for radiology? Or can they view both types of images on the reading workstations as they can on the web?

- Are your physicians still dictating and you are working on structered reporting? How did you deal with interventional caths which are so varied?

- Is a Single Sign On being used at a workstation? Or will the physician have to login into each system when they start?

- For how long have you been storing to reach the 2TB figure you gave? With how many studies?

- How are you handling the other cardiology modalities outside cath?

- Do the clinical nursing floors use the Web-based PACS to see patient images, and if so how did you train all those employees (all three shifts)?

- Here’s one for the turf wars - Who reads the cardiac CTAs and cardiac MRAs? The person was asking if it was the cardiologists or the radiologists.

As you can see, the integration between radiology and cardiology PACS and the integration of cardiology PACS with the hospital EHR and the rest of the systems not only raises a lot of questions about workflow and the hospital infrastructure in general, but cardiology PACS is the next gold rush for PACS vendors and it has only just begun. Then of course there is orthopedic and pathology PACS and so on.

So, you are probably right that the report exaggerates the prospects of the global PACS market and that PACS vendors may be chasing a leprechaun…but when they find him, he’ll be sitting on a pot of gold.

Love Me Tender, Love My PACS Vendor

2009-02-10T11:40:00.000-08:00

Ms. PACS: When you think of Valentine’s Day, you might think – it's another Hallmark holiday and I better buy another expensive gift if I want to stay out of the doghouse. Or, for the more sentimental ones, you might see it as an opportunity to rediscover the love you once shared with your mate. But lighting up that old spark is not an easy trick.

If your 'romancing' moves are a little rusty, you can always refer to the MSN Top 10 List of Valentine’s Day Gifts for suggestions. The list has some original ideas - such as a personalized acrylic wine stopper to celebrate your eternal love, a ‘bring on the bubbles’ champagne set for clean fun, and on that note how about the battery-operated massage wand to relieve all the stress you experienced trying to come up with something original. PACSman, I’m sure this will be your favorite - number three on the gift list was a good old-fashioned boardgame – “Lust! The Passionate Game for Two,” which comes with over 30,000 tantalizing endings for more of romantic and physical intimacy. Just $19.99!

While you are getting into the spirit, you can do the same with your PACS vendor, who you haven’t seen since you signed the contract. How can you rekindle that old flame? Since you're at a loss, PACSman, I’m going to give you 10 reasons to fall in love with your PACS vendor all over again.

First, look back to the where it all started. Remember the first time you met your PACS vendor, the eager handshake and fervent, “Glad to meet you!” stirred up a sense of optimism and excitement. You thought, “Maybe this is the guy who can really solve our data management problems.” Like a lot of the PACS vendors, he told you this PACS would meet your expectations and workflow requirements, it was standards based and Web-based, supported multifeatured, technologist QC applications, plus a combined virtual enterprise directory and a unified single-patient folder. But what really won you over was the IT support, programs and manpower to help you with workflow redesign and technology adoption in the referral community.

Three months later, after you initiated the installation of your new PACS, there are still interfacing and log-on issues. Everyday it seems like a physician or tech comes across a new glitch and with every tweak to your new PACS infrastructure comes another invoice. Now you’re going over budget and your neck is on line. “I thought he said it would be seamless!” Well, too late. You’re stuck. And now that friendly and helpful vendor guy is too busy drumming up new business elsewhere to even return your calls. What can you do?

It’s time to make this guy accountable. But remember, you want to get your needs met, so even though you want to tell him off, you need to find a win-win – in other words, find a way to fall in love with your PACS vendor all over again.

Go back to where it all started. You had a list of concise requirements and requests concerning the kind of support you would get, which you and your vendor agreed upon - sort of like taking vows. Call your vendor in, meet him face-to-face and go back over the list of agreed requirements. If he tries to make excuses, don’t be too quick to threaten him with a breach of contract because you’re still stuck with the system and without his help you will be royally screwed.

Just think of those 10 reasons to make you fall in love with your PACS vendor all over again. Set deadlines for meeting each item, and once your PACS vendor completes the following, you'll feel the pitter patter in your heart.

Those items include:
1. integrating all key components - RIS, PACS, and Speech workflow, document management, mammography tracking, billing and practice analysis
2. eliminating latency issues in transferring data between RIS/PACS/Speech systems
3. streamlining the interface deployment process, including managing vendor communication, document preparation, interface testing and organizing vendor work schedules.
4. providing access to relevant information and voice and image management tools with a single sign-on and integrated worklist and user interface.
5. giving you automatic access to an integrated worklist to view relevant current or prior clinical information through the native, bi-directional integration built into the RIS/PACS.
6. enabling all data to be entered once and flows through real-time across all systems.
7. improving data integrity by through automatic reconciliation of orders and studies.
8. reducing installation and user training time.
9. eliminating the need to maintain multiple, separate workstations.
10. enhancing communication and support with a single point-of-contact and
reduces vendor conflicts.

Ah, now that is love.

PACSman: I never did understand why it’s always the guys who need to stay out of the doghouse on St. Valentine’s Day and never the woman. Did you ever look at the Valentine’s Day ads? A man needs to go to stores where "every kiss begins with K" and spend hundreds of dollars on her, while she gets away with picking up a sample vial of cologne at Vickies for free, pulling a silk gown that some man no doubt bought her out of the drawer and voila- instant “gift.” And they say life is fair? Trust me, it isn’t…As for 30,000 tantalizing endings, I’d be happy with one- as long as its happy - and I can save $19.99 to go towards satisfying my lover in other ways. After all, if I can’t make whoopie like a jack rabbit any more the least I can do is get a decent substitute for just a few bucks more……

There may be 50 ways to leave your lover and 10 ways to fall in love with your vendor, but how about making the vendor fall in love with you the buyer all over again or for that matter your man with you again? Let’s start with the basics.

Don’t put on the green silk gown and perfume until you are serious about closing the deal. All too often a buyer will work out a killer deal, negotiate contract terms and conditions, and the like and then either invariably delay the deal or back out of it entirely in the 11th hour. That’s like getting some incredibly inviting ear nibbles and being taken by the hand into the bedroom for what seems to be the inevitable and then waiting while your love interest takes off her makeup, showers, dries off, blow dries her hair, rubs moisturizer all over herself, spritzes herself with cologne, puts on her gown, brushes her hair, brushes and flosses her teeth, rinses with mouthwash and 45 minutes later reenters the bedroom with a flourishing “I’m ready now, lover!!” only to be met with the sounds of silence…or worse yet, snoring….True, some things may be worth waiting for but for how long? If you are going to do the deal then by God do it. If it’s going to take a while then let someone know that so they can plan accordingly…

One also needs to come in with realistic expectations. Sure the green silk gown is a good sign ….but when it’s 11:45 p.m. and you’ve been up since 5 that morning you need to be realistic in your expectations. While the Eagles might be singing “All Night Long” that just isn’t a realistic expectation, at least at my age it’s not…More like “Life in the Fast Lane,” at least at that hour. The same hold true with PACS vendors. We need to be realistic in the time it takes to do the implementation, the interfaces, customizing the hanging protocols, and other related tasks. This typically takes days if not weeks, not hours. Of course you need to make sure that you are up to the customization required- and put aside enough time to do this as well. Things also need to work as you expect them to as well, and not just hoping for the best or assuming it does what you want it to…which leads us to the next point- know what you want and what you are willing to settle for as well, both in love and PACS.

In love and in PACS it’s never 50/50. Sometimes the vendor provides the majority of effort, sometimes the vendor, but in the end it should balance out to each party providing a fairly equal amount of effort. In love or PACS the end result is indeed the end result, but how you get there can either be very straightforward or take a long and convoluted path. Usually in the wee hours of the evening or early a.m. with limited time you want to take the straight and narrow path, but when it’s a larger implementation you may want to make sure you budget appropriate time to do it slowly and deliberately. And so, too, it goes with both PACS and in love. Deadlines need to be set but they need to be somewhat flexible and realistic as well, Rush it and you have two people who aren’t very satisfied; take too much time and the same holds true. You need to know what you want and find the right mix to get there…

Lastly, in the Bible there is a familiar verse that starts out "Love is patient; love is kind and envies no one. Love is never boastful, nor conceited, nor rude; never selfish, not quick to take offense. There is nothing love cannot face; there is no limit to its faith,
its hope, and endurance. In a word, there are three things that last forever: faith, hope, and love; but the greatest of them all is love." (1 Corinthians 13:4). Now I’m not sure I want to fall in love again with my PACS vendor as Ms. PACS suggests, and am just exploring that whole “intensely liking” someone phase after being divorced over 6 years now. That said, I do know a little patience and kindness goes a long way towards rekindling the fires and even creating the desire that both parties want and need to at least keep the embers burning if not create an all out roaring fire… Is that love? Heck, were it not for biblical admonitions to the contrary I’d settle just for a little lust…and take whatever I can get…

It’s a full moon out as I write this and love is in the air…so forget about what Ms PACS says, grab your favorite PACS vendor (or someone close to you who doesn’t mind being grabbed) and sing after me the TRUE meaning of amore:

When the moon hits you eye like a big pizza pie
That's amore
When the world seems to shine like you've had too much wine
That's amore
Bells will ring ting-a-ling-a-ling, ting-a-ling-a-ling
And you'll sing "Vita bella"
Hearts will play tippy-tippy-tay, tippy-tippy-tay
Like a gay tarantella

When the stars make you drool just like a pasta fagiole
That's amore
When you dance down the street with a cloud at your feet
You're in love
When you walk down in a dream but you know you're not
Dreaming signore
Scuzza me, but you see, back in old Napoli
That's amore…..

Held Hostage

2009-01-29T07:21:00.000-08:00

PACSman: In the past three weeks I have had three clients come to me looking for help with image archive, database and data migration-related issues. In each case the vendors have held the customers hostage. Some were semantic issues involving contract language while others simply because the client elected to go with a different vendor rather than upgrading with the incumbent.

Vendor number one wanted a ridiculous fee to do the data migration so the client could go to a competing vendor (nearly double the cost asked by data migration specialists like Acuo and DeJarnette and it didn’t include data reconciliation or data cleansing either). Vendor number two refused to sign a contract saying that they would provide a vendor-neutral archive and had nothing proprietary in their design that would require third party data migration… And the vendor number three.. well... I won’t even go there but let’s just say that what they did to their client crossed the boundaries of decency let alone good business. These weren’t the smaller fish vendors either where you might imagine vindictiveness would be a given. These were some of the biggies…and the contracts dollars ranged from $250K to a several million dollar wonder.

Why then in a world where standards reign do vendors still hold customers hostage by not supporting standards? Simply because they can…

I fought tooth and nail for my multi-million dollar client to get the vendor to put something in writing that the 40 TB+ of data they will be archiving annually (this was a huge contract) would not be subject to the cost and time constraints of data migration. After a month after various contract language proposals going back and forth each which were rejected by both myself and my client time and again as worthless, the big vendor won out on a technicality- since the client never asked for a vendor neutral archive that would not require data migration specifically in their 540 page RFP (although they did ask for this several times in a roundabout way) the vendor indicated they could not be held accountable for meeting specifications that weren’t asked for and they deserved to get the bid. True, but….

The second vendor offered free data migration from a company they just bought if the client upgraded to their (the buyers) system. Here’s the kicker though- the buying company announced that it would no longer support the system they just bought after 90 days, so you either upgrade to our new system or you are outta luck. And, knowing that there is no such thing as a free lunch, the client asked how would this migration be paid for? The vendor was almost brazen in their response- why, from the margins we make on the new system, of course. The client opted to go with a different vendor and now is being held hostage by the losing incumbent vendor who will only migrate their existing data- data the client paid a premium to archive in the first place- at double the price.

As an industry we have lost our most valuable commodity- integrity. Very few vendors seem to play by the book of common decency any more and those who do make sure they are able to write their own rules. Witness the very nature of DICOM itself, the most non-standard standard that ever existed. Standards utilization means virtually nothing because we have no true standards. DICOM, HL7, IHE and others are not only optional (contrary to what one might think nothing dictates the mandatory use of standards support except some basic HL7 support that is mandated by HIPAA) but they can also be interpreted in a plethora of ways. You can write image data in DICOM Part X file format, yet throw on proprietary compression like some vendors still do and it all goes out the window. Data tagging can be done so many ways it makes your head spin and when you talk about tag-morphing people look at you like you are speaking Greek…It’s like the doc meeting the gal at one of several cocktail parties the vendors throw at RSNA. Both enjoyed the free food, booze and music and by the time the clock strikes 12 both are in a very good mood. She asks if his marital status. “I’m currently separated” he says, and after another drink or two they both smile and walk back to his hotel for a “nightcap”….Technically he is right- his wife is home taking care of their 3 kids while he is in Chicago chasing down anything with a pulse…but his statement is accurate- he is “separated”…And so too it is any more with vendors. They say what you want to hear just to get you in between the sheets…and God forbid you ask for something in writing….No can do, soldier boy…

There are a few vendors with integrity left- damn few- but the majority still sing along with Bachman Turner Overdrive:

“….and you'll find out every trick in the book
and that's there's only one way to get things done
you'll find out the only way to the top
is looking out for number one
I mean you keep looking out for number one.”

In their quest to merely stay alive let alone make a profit vendors are selling more yet making less. To quote another BTO song they are “taking care of business” but going about it all wrong. And in doing so vendors aren’t winning. Clients aren’t winning. End users aren’t winning. Everyone in this industry and the people we serve has lost- our integrity, our focus, or desire to do what is indeed right…to “first, do no harm”….And that, IMHO, is just plain wrong…

Ms. PACS: Your point on business ethics is very timely. Especially at a time when some of the wealthiest people in the world recently discovered they were totally ripped-off by Bernard Madoff.

Yes, indeed, business ethics is all over the mainstream media as of late. Just last night on The Office (a TV show which should be required viewing for anyone with a job), guess what the theme was – you guessed it – business ethics. In the show, one of the characters that the boss, Michael, is hot after is Holly. While Holly was doing an ethics seminar, she discovers that the office is hardly an ethical place. When everyone is given immunity to confess any unethical behavior they have conducted, it is revealed that in addition to such offenses as pencil-lifting and ‘time stealing,’ Meredith is doing something very unethical…swapping carnal favors for a discount on paper supplies, oh, and for gift cards to Outback Steakhouse – you can hardly blame her. Of course, this is grounds for termination, says Holly. But Michael defended Meredith declaring that no one should ever be fired from Dunder Miflin because it is a family, and that while her actions were wrong, they were saving the company money, and in these hard times they should just turn a blind eye. His tactics, however, didn't get Holly to bend on carnal favors.

But, PACSman, as far as ethical behavior in PACS - only if it closes a deal. So maybe if PACS vendors realized that ethical conduct paid off, they might employ that strategy. For example, DICOM, HL7, IHE and other standards are just optional, and if you throw in a little proprietary compression, you strong arm the client into staying with your PACS. I understand the vendor wants to keep the client, but if you put someone in shackles, resentment will grow and there will likely be a rebellion.

Are PACS vendors so scared of the competition and have so little faith in their own product that they turn to incompatibility to latch on to clients? I understand making a buck, but how about concentrating on giving the end-user a good experience. If PACS as a product becomes leveled out in price or ‘commoditized,’ then on what basis is the user going make his/her decision on which PACS to go with? It comes down to the end-users’ experience – that is the deal breaker. Have you ever had to get your cable set up? The company gives you a four-hour window of time in which you need to wait at home for the cable guy to show up. If he doesn’t show up, you have to reschedule, and there is little recourse. Sure, there are two other cable companies available in your town, but they all pull the same B.S. – aka, bad service. In the case of PACS, there are more than enough vendors to choose from if the service is poor.

So, how do you create a good experience for the end-user – offering sound support for PACS implementation, a reliable system, flexibility and throw in 24/7 service. A good experience with PACS is as important as a good bartender, keep pouring the good stuff and they get hooked - not by holding ‘customers hostage by not supporting standards.’ And look out – because open source PACS are gaining ground, and there, compatibility is not an issue.

As for ethics in general, part of President Obama's inaugural speech touched on a few:

Our challenges may be new. The instruments with which we meet them may be new. But those values upon which our success depends - hard work and honesty, courage and fair play, tolerance and curiosity, loyalty and patriotism - these things are old. These things are true. They have been the quiet force of progress throughout our history. What is demanded then is a return to these truths.

Oh, at the end of the episode of The Office, the staff enjoyed a free meal at Outback. Can you blame them?

Can PACS Have its Cake?

2009-01-22T13:47:00.000-08:00

Ms. PACS: If you look at the entire radiology imaging cycle, according an interview I did with Paul J. Chang, M.D. last week, one of the most efficient areas, he said, is the reading room.

Dr. Chang is conducting a “Closed Loop Imaging” research trial (see video) in which his team identifies the bottlenecks and inefficiencies not just in PACS, but throughout the whole loop - from reception, to the imaging suite with setting up the injector and scanner, to post-processing images and of course getting the report in front of the right doctor in the necessary amount of time – whether urgent or not.

What surprised Dr. Chang was the efficiency of PACS. “What I noticed was that PACS companies in general along with speech recognition companies and the integration of speech recognition basically have resulted in incredibly efficient and very optimized reading rooms,” he said. “Here’s the problem, it doesn’t matter how efficient we are in the reading room if the rest of what we do in radiology is inefficient. I can be incredibly accurate in radiology in the reading room, but if the study was not acquired accurately, it’s the old garbage in, garbage out.”

So this is a good report card for PACS – or is it? Perfection leaves little to room for repair, i.e., if it’s not broken, how can you fix it? Of course we know nothing is perfect – especially not PACS – because it continues to evolve and there are always bugs with every upgrade. So what is the next step in the evolution of PACS?

According Dr. Chang once again (hey, he’s a great source) – it’s Web services. Right, Web-based PACS has existed, but it has provided rudimentary tools and thus far has not been very relevant, until now. So as the world – including healthcare – turns to service-oriented architecture (SOA), the role PACS will play will reside predominantly in Web services.

“Everything is a service. So the first step is to expose everyone of these resources: PACS, 3D, modalities, RIS, EMR, CPOE, all of these things, as services. Web-services is the spinal chord and SOA is the brain. What we are building is a workflow engine that can take as services and orchestrate this complexity…It makes no sense to have a PACS, the RIS or a modality drive this; you need to have an optimized workflow engine that uses all of these services as services,” said Chang. “That’s what closed loop imaging is based on – SOA.”

It will be a long while before they close the loop - air tight - on imaging, but if the researchers can effectively look at the entire loop and improve efficiency, quality and safety – then, according to Chang, “We will have our cake and eat it too.”

So, under the SOA umbrella, will PACS get its just desserts?