Cloud Storage - More than Just Hot Air

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…

PACSMan´s Notes From The Floor

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...

Adam, Eve and PACS

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?

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

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….

Get More Out of Your PACS Vendor with Guilt Trips

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….

Would You Like Some Cheese With That Whine?

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….

Radiologists Take the Wheel

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…