Beware of Ninjas

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

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

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

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

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

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

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

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

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

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

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

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

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

“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:)

Wii Takes the Controls from PACS

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

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

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

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

Where are the Next Gen PACS features?

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

Seriously, which is the best Radiology specific search tool:

- Radiology Research

- MyPACS.net

- Yottalook.com and Yottalook app for the iPhone

- ACR Case in Point

- Dr. K. MSK Cases

- EURORAD

- Journal of Radiology Case Reports

- Pediatric Radiology

- Rad Files

- radRounds Cases

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

What I was looking for was:

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

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

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

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

- touch screen

- voice commands in RIS

- voice commands to navigate PACS

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

- auto-structured reporting

- auto-loading templates mapped to procedure codes

- bookmark findings/optimal image

- one click to sign reports

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

These are more recent innovations thanks to Apple and Microsoft:

iPhone Apps:

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

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

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

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

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

PACSmaker Make Me a Match

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Or possibly – relieved.

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

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

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

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

Would You Like Some Cheese With That Whine?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Get Some Bang for Your Buck!

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

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

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

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

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

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

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

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

Perplexing PACS Market Projections

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

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

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

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

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

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

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

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

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

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

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

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

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

Here are some of the questions they submitted:

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

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

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

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

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

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

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

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

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

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

Dealing with Absurdity

PACSman: I am a consultant. I am paid an absurd amount of money to address questions my clients have about PAC systems they are looking at buying or contracts they are about to sign and other items of a similar ilk. If I don’t have the answers to the questions they have immediately I am expected to find these answers out within a reasonable timeframe. For being paid an absurd amount of money I also have to deal with absurdity at all levels on a daily basis…absurd sales claims, absurd systems that don’t perform as designed, absurd contracts – a Cirque du Soileil of absurdity.

I’ve also been called absurd many times before as well. Like the time I turned down a job that would have guaranteed me four times the income I make now; or when I told a potential client that they don’t need my services or anyone else’s for that matter – here is how to do it yourself for free; or when I told yet another client to walk away from a deal that seemed too good to be true. Of course the job would have required me to travel 80 percent of the time and that was a sacrifice I just wasn’t willing to make with two teenage sons still at home. There will be no Cats in The Cradle here. The “free” deal turned into a very lucrative contract years later when the client who recalled my honesty moved on to a bigger (and better) facility. And the client’s deal that was just too good to be true was, one that would have left the customer with a brand new unsupported half million dollar legacy system just a few months later had they signed it. So why am I struggling for answers tonight to a question that hasn’t been asked yet? Because I simply don’t have the answer I need and don’t think anyone else does either.

I just got back from a viewing for the mother of one of my youngest son Matt’s friends. I had never met this woman before and talked to her on the phone only once briefly. I know her oldest daughter who, at 15, is Matt’s age from his high school marching band where I see her and the 180 others every Friday night as the official photographer of the Marching Seminoles (you learn something new about the PACSman every day). I had never met her youngest daughter who is 10.

Now people live and people die every day, both younger and older than the 51 years this woman lived. That is a fact I can accept. But to die in the way she did was absurd. Police are investigating it now to determine if it was accidental or deliberate, but it involved a gun and a boyfriend at eight in the morning …yet until the facts are known we can only speculate. It’s bad enough that a mom has to die in such a horrendous way, but her two children’s last view of their mother should have been something other than her lying on the bedroom floor of her house with a gunshot wound. Which brings me to the question I haven’t been asked – yet – but for which there needs to be some answer – why?

I’ve read all the self-help books until I was blue in the face when going through some personal issues in years past – Kushner’s “Why Bad Things Happen to Good People,” Dobson’s “When God Doesn’t Make Sense,” and others of a similar ilk. Most tend to compartmentalize it all using stock answers that, at least to me, and seem to be completely trite. I’ve both heard them and tried to rationalize each and every one of them as well. “We are fallen people in a fallen world,” “It’s all part of God’s master plan.” But as a consultant I deal in facts and the fact here is this makes no sense. How does having a mother who pretty much raised her two girls alone being taken from them make any sense at all? And why now, when she recently left a lucrative career as an attorney in private practice to become a public defender just so she could spend more time with her kids? God’s master plan? Fallen people? Tell that to the kids left behind…and those of us who have to answer our own kids’ questions as well...

I dealt with this very same issue several years ago while working with St. Jude Children’s Hospital, asking the doctors there how they handled knowing a child was going to die. That too made no sense to me at all. Their answer seemed logical to me at the time – that more children leave here walking than any other way and those who don’t we learn from to help heal others – but when I got home and saw my own kids that logic just disintegrated. Faith like a mustard seed indeed…

It’s times like this I wish I wasn’t a consultant or at least not one who is so damn analytical because I know I won’t sleep tonight wondering what I’ll say if the question comes – “Why, dad?” It will be worse yet if the question never comes – not for Matt, but for me, because one of the beautiful things about being a consultant is I learn as much if not more from my clients than they ever do from me. Yet another PACS Secret revealed. Maybe if I listen to Matt, I might learn something still. Or maybe his silence says it all – his trust in what is and not questioning anything.

Some may say I’ve watched too many episodes of The X Files and their mantra “Trust no one” has been embedded in my brain. I wish it were that easy. Instead life lessons have taught me that trust is something that… well, I won’t go there. And for those who believe, know I am also very familiar with all 61 references to the words trust and God together in the Bible as well.
“The truth is out here” was another X-Files mantra. I’m sure it is….somewhere…. and I’m listening for it…but all I keep hearing are the words of Chris Rice’s song “Naïve” echoing in my head instead….…

“How long until You defend Your name and set the record right
And how far will You allow the human race to run and hide
And how much can You tolerate our weaknesses
Before You step into our sky blue and say "That’s quite enough!"

Am I naive to want a remedy for every bitter heart
Can I believe You hold an exclamation point for every question mark
And can I leave the timing of this universe in bigger hands
And may I be so bold to ask You to please hurry?

I hear that a God who’s good would never let the evil run so long
But I say it’s because You’re good You’re giving us more time, yeah
˜Cause I believe that You love to show us mercy
But when will You step into our sky blue
And say "That’s quite enough, and your time is up!"

Am I naive to want a remedy for every bitter heart
Can I believe You hold an exclamation point for every question mark
And can I leave the timing of this universe in bigger hands
And may I be so bold to ask You to please hurry?

Am I naive...
Can I believe...
And can I leave...in bigger hands
And may I be so bold to ask You, to ask You, to ask You

How long?

Ms. PACS: These tragedies are like a broken record and instead of growing more sensitive, we become desensitized. The only good that can come out of it is that times like these cause us to reflect on our own lives and reevaluate our relationships.

You may have read the article, “Top 10 Reasons to Change Your PACS Vendor - SIIM News Spring 2007” by Chris Meenan and Paul Nagy, PhD (1), where they discuss how buying a PACS is a long-term commitment. They warn that shared values between you and your vendor and your company's direction may diverge, prompting you to ask the question: “are we right for each other?”

The second most important telltale sign on Meenan and Nagy's list was the "top 10 signs it's time to consider changing your PACS vendor." This is when you find yourself “buying PACS hardware on eBay.” Almost as sad as surfing Craig’s List on the sly for that special encounter. The authors note that while “older UNIX equipment has historically had great reliability,” they warn, “don't be lulled into a false sense of security.” As equipment ages, failure rates increase - there is no Cialis for this. And if your PACS vendor is no longer available in the general market, find a new one…but not on eBay.

In PACS as in life, we tend to hold on to things, people and concepts that are in reality a false sense of security. Not to trivialize the tragic loss to the family by any means, but these types of tragedies are almost commonplace in the news and in our neighborhoods. Why? In this case, the false sense of security for the family was protecting the home from outside invaders with a handgun. Once again, the security measure backfired. The fact is, a large number of handgun related deaths occur in a domestic setting and are the result of one family member or friend killing the other.

In 2005, 76.1% of all homicide deaths in the U.S. were caused by a firearm, according to National Center for Injury Prevention and Control (2). The next item on the list of homicide deaths was a “cut” or “pierce” which weighed in at a meager 10.1% comparatively. So when will it end? Never. As long as people in this country keep clinging to a false sense of security.

I live in what unfortunately is ranked in 2008 as the number one murder capital of the nation, according to USA Today. Many of you will be attending what is known as the "largest medical show in the world" very soon in this same city. The town earned this deplorable title largely due to the spiraling rate of handgun-related homicides. This type of urban environment can be likened to a modern day Wild West. Back then, outlaws met at high noon to have a pistol slinging show down in the middle of town, while merchants, women and children, and other passers-byers, originated the gaper’s block. What’s not so funny is that when you’re walking down the mean streets of any major city and some suburbs the outlaws these days lack the courtesy of formally challenging you to a face-to-face dual. No, they take you by surprise, and unless you’re Quick Draw McGraw, your handgun is more likely the nail in your coffin than in theirs.

By the way, the number one reason to find a new PACS vendor was a “Poor understanding of your needs.” Maybe that's the first step to dealing with absurdity.

Reference:
1. http://www.scar.rad.washington.edu/index.cfm?id=2538
2. http://webapp.cdc.gov/cgi-bin/broker.exe?_service=v8prod&_server=app-v-ehip-wisq.cdc.gov&_port=5082&_sessionid=qCTHRMaxK52&_program=wisqars.details10.sas&_service=&type=H&prtfmt=STANDARD&age1=1&age2=40&agegp=1-40&deaths=12830&_debug=0&lcdfmt=custom&ethnicty=0&ranking=10&deathtle=Death

How We Vote for PACS

PACSman: I voted today – we have early voting here in Florida, home of the dangling chad – and from what I can tell the candidate I voted for President – “None of the Above” – is well in the lead…

In the past week or so I have also been inundated with e-mails, mailers, radio and TV ads, and the like about the candidates. Almost all are highly critical of the candidates they are running against. No one seems to extol their own qualifications or virtues any more. It’s easier to cut the lil’guy down than stand up for what you believe in…although W.C Fields was probably right when he said “A man’s got to believe in something. I believe I’ll have another drink…”

I look at the way people vote and the way people buy PACS and the similarities are downright scary….Vendors don’t promote their own virtues but instead cut down the competition. Heck, I can’t even go to church without having the Christian Coalition of Florida (CCF) putting out their “Voter Guide Project” to help me make one of the most important decisions I’ll make in the next four years. You might say “Well what’s wrong with a lil help?,” but misguided help is worse than no help at all. Unfortunately, that is what most of these guides are – a misguided attempt at “helping.” The Christian Coalition tries to determine a candidate’s suitability based on a few very narrow stances like abortion, school vouchers, human cloning, adding sexual orientation to the definition of hate crimes and do you want English as the official language of the U.S. Government, and other areas of a similar ilk. I mean, let's get real – English as the official language of the U.S.? Come on people!!! That said, let’s see them hold the vote on sexual orientation during Disney’s unofficially sponsored Gay Days – where Mickey will gladly take your money, but never officially acknowledge you – or what the vote is on English as the official language is in North Cuba, I mean Mijammie, and any of the other cities in the state where the Hispanic population exceeds 30% of the total population. No hablo Spanglish – sorry. We have candidates running down here who, if we are to believe even 10% of what is said about them, shouldn’t even be running, yet they got the CCF stamp of approval! Heck one candidate even had two affairs that he admitted to (and God knows how many others he didn’t) and STILL got their stamp of approval – just because he supported their platform!! Not a single word about fiscal responsibility, their background and suitability to run the city, county, state or country, their moral character and other silly little details like that. I hear that high pitched woman’s voice in the late 60’s Sly and the Family Stone’s hit “Dance to the Music” – “Vote for me and I’ll set you free!!” My God - I’m hearing voices now…

It occurred to me as I filled in my little black boxes that not only is this how we choose our leaders, this is also how we choose our PACS – on a few very narrow platforms that we are aware of. And those we aren’t aware of we just fill in a box and hope for the best.
Do we ask hard hitting questions? No way, no how? Contract negotiations? We’ll accept whatever we are given…Penalties? Just trust me….It’s no wonder why more than half of all second generation PACS selections are made with different vendors – because we filled in the lil’ black boxes without knowing what we were voting for and it came back and bit us in the backside time and again. Just ask anyone who is looking at a $250K+ data migration bill they didn’t expect when the vendor said they archived their data in a DICOM file format when they bought the system years ago. Technically we did support DICOM, however…The devil is all in the details….

Bill Clinton at least had the audacity to dance when he needed to about Monica Lewinsky as reported in the Starr report. “It depends on what the meaning of the word 'is' is. If the – if he – if 'is' means is and never has been, that is not – that is one thing. If it means there is none, that was a completely true statement....Now, if someone had asked me on that day, are you having any kind of sexual relations with Ms. Lewinsky, that is, asked me a question in the present tense, I would have said no. And it would have been completely true.” So he was innocent – technically. And so are vendors who don’t tell you everything you need to know before you make a buying decision. You never asked so…It’s the same Clintonesque logic. Besides, when you think about it, it wasn’t Bill’s fault. Monica was simply too cheap to get her dress dry-cleaned, saving it instead as some sick form of souvenir. Either that or her girlfriend’s never taught her properly how to finish what she started. Either way, Bill was innocent…

Remember that when you vote next Tuesday – and you do need to vote – that it’s all a matter of what you ask for and what your perspective is…Then carry it through when you buy your next PACS.


Ms. PACS: PACSman, you have never been characterized before as “opinionated,” have you? Wow. Well, you should have been on one of the campaign platforms because you sure do want to tell the people what you think. Do you think that is the reason people run for president – because they want to stand from the highest podium to tell the masses what they think and actually get an audience to pay attention? Your next gig, PACSman, is definitely in radio – talking about PACS, of course.

I do agree with some of your comments - at least the overall message - reminding folks to be discerning when listening to a PACS vendor and use their critical thinking skills – like when they vote.

You are also right about how narrow minded people are when they vote. The sad thing is that most people vote less based on logically drawn conclusions and more based on their emotions – fear being the number one critical factor. Let's vote against what we don’t want, as opposed to voting for what we want.

Many buyers rely on similar criteria when buying a PACS – the IT guy/gal thinks, “I don’t want this system to break down and for all of the radiologists to blame me and to ultimately lose my job. So, even if this PACS falls short of providing any additional useful features, such as: presenting information in a user-friendly manner or indicating if there was a prior or if it has an embedded solution for critical results or whether the hanging protocols can actually be set up in day-to-day practice. They won’t know what they’re missing and I would rather stick with the status quo than to take any risks and actually improve the radiologist’s workflow.” Sound familiar?

The irony is that the last time the “majority” of Americans voted based on fear they ended up in a long drawn out war. Don’t do the same with your PACS - it will cost you dearly. Do your due diligence, don’t base the final decision on price alone (penny wise, pound foolish) because PACS is not a commodity, despite what some claim, and some systems do work better than others - it's your job to find which ones work better for you. So take a chance and actually raise the bar on your radiology department’s efficiency and workflow. In PACS, as in life, if we strive to be better, we might just get there some day.

"Why Aren’t PACS Selling Like They Used To?"

Ms. PACS: Who said PACS aren’t selling? Maybe not how they used – true, the strategy has changed – but it is still estimated to be a $1 billion market, and the number of systems installed from 2008-2013 is projected to grow at double-digit rates. So, I don't know if there is still life in you PACSman, but you better bet there is in the PACS market.

No doubt the PACS sector is experiencing consolidation and companies are merging to offer a broader range of IT solutions and combining RIS with PACS. Plus, now that the big fish at the large hospitals have been fried, PACS vendors are targeting medium and small hospitals, outpatient imaging centers and individual practices. This gives smaller PACS vendors a better chance to get in the game with new opportunities in the smaller providers market. Many even credit the DRA reimbursement cuts with boosting the lower-end PACS market because it has forced these smaller facilities to cut the fat and improve efficiencies, and that means implementing a PAC system. Take GE, for example, who saw the writing on the wall and acquired Dynamic Imaging for its web-based solution, perfect for lesser processing and storage capabilities characteristic of ambulatory centers and physician’s offices.

There is also a healthy future for replacement PACS and the PACS service and maintenance business. As radiology more widely adopts advanced 3D visualization, desktop integration, dictation and voice recognition systems and critical test results management systems, these will all have to be interfaced with a current or replacement PACS, not to mention integrated with current RIS, HIS and even EMR systems. This is what typically happens when a site buys a product that is not complete and has to purchase add ons – in the end they get nickeled and dimed to death. It is no surprise that, according to iData Research, as the installed base for PACS increases, more and more of the total market revenues will come from support services. So, yes, the game has changed, but it is still 'game on.'

Here's some more insider information. I know the skeptics – like you PACSman – will say they already tried PACS for radiation therapy (RT) and failed. But I witnessed a resurgence in PACS activity at this year’s ASTRO conference. In fact, Varian showed me a very soon to be launched works-in-progress oncology PACS, and also there were several traditionally-radiology focused storage and data management providers on–hand, offering efficiency in the RT world – well known for its inefficiencies in image data management. So put that in your PACS and smoke it.

PACSman: Lies, damn lies, and statistics…you gotta love ‘em….I also love the prognosticators who still call this a $1B market. When you add anything and everything that can be remotely considered a PACS you might come close to this number…maybe But for the record it was a $1B market a decade ago as well…or so the reports said….Now would the Nostradamus’s of the imaging world sell a $6,000 report with more bar charts, pie charts, Gant charts and every other chart known to man if it said sales are flat or down 15-20% in a soft market? Of course not... So we pretend everything is still grand, picking up flowers for the wife on the way home from the airport only to learn that she moved in with the neighbor while you were away (and no, that is not an example from my life either, MP – it’s just a metaphor).

Sales are down, discounts are up and customers are scared to death to buy wondering if the vendor they want to buy from is still going to be around tomorrow let alone will they still love them tomorrow (someone cue the Shirelles, please)…Net margins on most deals being done today are thinly black or in the red, but hey, look, PACS is a $1B market so things can’t be bad can they? Not. I don’t know what fish fry you’ve been going to but 25% of today’s PACS sales are replacement systems and that is where the big boys are focusing their efforts. I’m also glad you read my article on DRA last year and how it stimulates PACS growth – it’s always a plus to see you educating yourself further.

I don’t think I’d use that vendor as an example. They don’t seem to be able to figure out what they want to be when they grow up in PACS. They bought DI a year ago yet now require a forklift to have their Centricity customers accommodate the 3.0 Linux “upgrade.”

Nickeled and dimed to death? You need kids, MP – it’s more like “Can I hold onto $10 Dad? $20…” or my favorite “It’s only $50…$100….$375.” We recently banned the word “only” in my household…

It’s so easy to say “It’s the economy, stupid” but that’s only part of a much bigger problem. Most vendors simply don’t know how to sell and end users don’t know how to buy – it’s just that simple. I’ve said time and again that PACS has become a commodities market and undifferentiated PACS are just that – a commodity. Yet look at most PACS ads – they all basically say the same thing. Vendors need to understand their own products so they can convey the specific advantages and benefits they offer to the end user, not making broad sweeping generalizations that can apply to just about anyone’s PACS. And end users need to understand what questions to ask to get the information they need to make informed objective decisions….

As for ASTRO…do you plan on buying your PACS from Spacely Sprockets? PACS embraced radiation therapy over a decade ago and RT thumbed its nose at it. There were a handful of companies who lost a small fortune offering remote block cutting via teleradiology as well as embracing other areas in RT. As a software add-on Varian and others might do OK, but sales into this market aren’t going to set the world on fire.

Know I gave up my pipe back when C. Everett Koop was the Surgeon General and advised against it, but whatever you’re smoking in yours I’ll gladly share…and even though it’s been quite a few years, know I plan on both inhaling and enjoying…

Is PACS Better the Second Time Around?

Ms. PACS: Did you ever go out to buy a PC and you knew exactly what you were looking for – 3GB shared dual channel, SDRAM, high resolution, glossy widescreen 17 inch LCD and a 2MP camera. Just when you boot it up for the first time, you get blue screen errors. You try to diagnose the problem, but finally give up and call up customer service. Now you’re on the phone with ‘Bob’ in India who tells you to unplug it again, check the keyboard and mouse and stand on your head, and in the end blame you that it’s your fault because you must have added some software. Now you are about to explode and take the PC with you. Your only recourse is to send a ‘nastygram’ to the head of customer service and “Cc” the president. A day or two later, a States-side ‘service specialist’ calls you, and in a sweet voice says your new PC is on the way and sorry for the inconvenience. You exhale a humble “Thank you” with a sigh of relief – then think, wait a minute, why didn’t you do it right in the first place?!

A similar scenario plays out for many when they buy a PACS for the first time - they submit an RFP, yet the PACS doesn’t meet their expectations. That’s pretty disappointing. So, are you going to make the same mistake twice?

It’s time to roll up your sleeves and start by asking key questions: Does the system archive other objects other than DICOM objects? Can the vendor guarantee data migration to the next PACS? Is it Web-enabled? Should you use a RIS-driven or PACS-driven work list? How is the PACS server configured?
What Data storage methodology is featured? Does the vendor possess the programs and manpower to help you with workflow redesign and technology adoption among the referral community?

Once you have done your homework, if you clearly state your PACS needs in an RFP, include market reports, site visits and peer advice, you can probably identify a good PACS that will meet your expectations and workflow requirements.

If radiology departments that are buying a replacement PACS do their due diligence - ask the right questions - most likely, they will get it right this time around. If not, as they, the second time around, PACSman is ‘shame on you.’


PACSman: Yes, Ms. PACS, I’m all too familiar with the saying that goes “Fool me once, shame on you. Fool me twice, shame on me.” And anyone who watches CSI Miami has heard The Who singing “We Won’t Be Fooled Again” (and some of us are young enough recall when that song first came out on the Who’s Next album back in 1971). But whatever version you subscribe to people are being fooled again and again expecting PACS to be better the second time around. Why? For the same reason >60% of all second marriages fail ….because they keep making the same mistakes.

Buying a PACS the second time around is actually harder than the first time, yet people feel because they have done it once it just has to be easier. It’s not. Just as a second marriage brings kids into the picture- a second PACS brings with it data migration. A second marriage brings with it preconceived notions- so does a second PACS. In a second marriage you feel confident that there is a better partner out there- while the reality is that your expectations may be set too high and need to be better managed. So too it goes with second PACS. In a second marriage you feel like you know what you are looking for since you’ve “been there, done that” but without truly knowing what was wrong (and right) with the first PACS you will probably have the same challenges all over again. Then, of course, you get into those sticky money-related issues - yours, mine or ours, or in the case of PACS whose money and system really is it - radiology’s IT’s or the hospitals? The parallels are frighteningly similar and, as such, carry the same caveats that second marriages do.

This first rule of second marriages and PACS is to make sure you REALLY know who you’re marrying. The PACS might look great at the RSNA or in the demo, but make sure that you cover yourself contractually just in case.

The second rule is to create a check list of issues that led to your last divorce. What did you like or didn’t? What could be changed? What couldn’t be changed?

The third is don’t rush into your second marriage because you’re blinded by “love.” This is primarily a radiologist caveat- they love to say we MUST have this vendor’s system or must have that ones, looking on the surface only without delving deeper. And while radiologist input is crucial to the decision making process, workstation functionality is but one part of the entire system that needs to be considered.

You also need to honestly look at what caused your last divorce. Were there problems you could have addressed, but didn’t? Was there one that was insurmountable? What could you have done differently? Or did you just outgrow your PACS and decide it was time for another?
Lastly, CLEARLY understand your expectations of each other. A replacement PACS or a replacement spouse is just that - a replacement - and doesn’t guarantee success. In PACS a well defined contract pretty much protects you from getting what you want. In life, the best protection is to combine heart and mind together - although having a pre-nup surely doesn’t hurt either.

I have a way to go before I’m ready to try and find love again just as many feel with looking for a replacement PACS. There has to be a better way in finding the right PACS just as there is in finding a better life partner. Looking over 1,275 pretty pictures and paragraphs or answering 436 questions to match 29 personality traits just doesn’t cut it for me…especially since I ended up being matched with over a dozen religious zealots (as if!!). None of them ever wrote back to me either after I said the only time I wanted to hear “Oh God!” or “Sweet Jesus!!” was in the throes of passion…..I tell ya - some people just have no sense of humor at all…