Wii Takes the Controls from PACS

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!”

What the World Needs Now…

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.

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.

So, What’s the Damage?

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

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 "

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?

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

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?

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

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

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

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?

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….

I guess it's no...

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

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."