Digital Imaging Delivers Modern Medicine to the Third World

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Need I say more?

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

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

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…

A Different Time and Place

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PACSMan

And When I'm Gone….

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What the World Needs Now…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Adam, Eve and PACS

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….
  

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….

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.