Preliminary Status

This morning, I spent an hour demonstrating Merge PACS to the residents and those attendings who were able to, well, attend. I went over some basics of the PACS, as well as a few of the more powerful tools, and everyone seemed to grasp very quickly what I had to offer. In particular, in working with several residents in CT and MRI, I found ALL were using the worklists as I had suggested. Wonderful!!! I was able to show those in the CT reading room the ease with with they could create 3D renderings. We tried this with both thin and thick data, and of course the thins gave the best result.

While watching the workflow, it became apparent that the residents aren’t the ones (generally) who mark the studies as “Read”, but rather the attending does so after review. I was able to make a button (a macro, really) that mimics the “Click study Read and go to Next” Checkmark, but marks the study as in “Preliminary” status instead. I think this fits the way things are done here. The only downside is that each individual user has to place this on the client under their own login, but that’s not too much of a problem.

Things are shaping up!

In the meantime, here are a few more shots of Korle Bu Teaching Hospital and environs:

Chest Clinic

Main Entrance (under renovation)

National Cardiothoracic Center

ATM “Farm” on Korle Bu Campus

Street scene outside the gates

via Blogger October 26, 2016 at 06:37PM

Monday, Monday…

Korle Bu Courtyard

Our first daily report from Korle Bu!

We had a very good first day! (Well, Erin was under the weather in the morning, perhaps a reaction to her anti-malarial, but she recovered quickly and joined us after lunch.) We had a significant amount of hurry-up-and-wait in the morning. Ben, Mack (PACS/IT), Brian, and I made the trip back and forth to the Nuclear Medicine department several times, waiting on those we needed to see. We finally did connect later in the day. More on that shortly.

While not in transit, Brian and I spent the morning in the reading room with Ben and Dr. B., one of the residents. We were able to solve a few problems, and at least understand several more. Brian had mentioned the problem of multiple clicks required to close a study and mark it as read, and his discovery of the “check mark” button that would do this in one click. (One of those things we AMICAS users have known for years!) When working with Dr. B, we found that his checkmark was greyed out. After some experimentation and observation, we found that the button does NOT function if the study was opened via query and not from a worklist. Which brings us to the problem of them actually USING a worklist. Merge PACS has VERY powerful worklist creation capability. Basically, if you can conceive of how a worklist should look, it can be created. The downside is that as compared to the later versions 6.x, which we are still on back home, the level of complexity in crafting the darn things has increased considerably. I need to have a word with my friends at Merge on that! However, I think I have the hang of the new approach, and I was able to create a simple worklist, “Today’s Studies” without too many glitches.

I worked with Dr. B. for about an hour, showing him some of the tools within the Merge Halo Viewer, and he caught on very quickly. I think similar sessions with one or two of the residents (and attendings, and clinicians, and anyone else) would work best rather than try to answer everyone’s questions in a larger group. I would like to concentrate particularly on creating departmental worklists and more individualized hanging protocols. That could take my entire two weeks in and of itself.

I spent some time trying to install the Merge PACS client on Dr. B’s Windows 10 laptop, but without success. I was able to download an MSI from my server back home in Columbia, and I’ll try that tomorrow. Apparently no one has had any trouble with Win 7, and I was able to load Merge 7 onto my Mac running Win10 in Parallels, so it CAN be done.

Now, Erin will tell everyone about the developments within the Radiography Department, which I think are very exciting!

Erin: Very exciting. Thanks guys for making sure I as alright this morning. I am feeling so much better. I met Dr. O who is the Radiography Program Director and we had a great discussion. I donated the textbooks I had brought with me. I will be lecturing the Radiography students tomorrow at 9am on what our Radiography program is like in the States. Also, Dr. O is charged with trying to start more Radiography programs all over Ghana. I learned a lot about the status of radiographers in Ghana and will be lucky to speak to students tomorrow. I told Dr. O that it would be nice to have both of our sets of students interact with each other in the near future. I feel that we could all learn a lot from each other. Maybe even create “sister” programs with each other. Dr. O stated that he is trying to attend the RAD-AID conference on Nov. 5, which Brian and I will be attending also. I was intrigued to learn how similar our Radiography programs actually are. Hopefully the beginning of a wonderful relationship.

Me: I’ll close with a paragraph about our meeting (finally!) with one of the Radiation Therapy Docs. The two NM physicians are out this week, I believe, but may be back next week. I’ll be giving a talk to the NM residents on Friday. We discussed connecting NM to the Merge PACS, which she generally favored, particularly after we were able to get the client up and running on a laptop and demonstrate its capabilities. She had NEVER seen the PACS in action and was most impressed. (This thing sells itself!) We will, of course, need to defer to the NM Head of Department for approval before proceeding, but the actual connection should be straightforward. (Which I say whilst crossing mhy fingers.) We discussed as well a problem RT has had with importing planning CT’s into their TDS planning system,

OK, just one more little paragraph….Never commission someone who was once paid by the word…

The topic of rapid delivery of reports arose at several junctures. Without a functioning RIS, there are very limited options. Merge PACS does have a comment field built into the order window, and a separate voice-clip property. We use the latter to provide instant gratification for the ER docs, and it could work here. There may be a way to use a “print to DICOM” program to load the resident’s typed reports into the PACS as a separate series in the exam. It’s not optimal but… More on this as we go. Tomorrow we have a meeting with the residents…I’m not sure if I am to lecture them on PACS or on one of the other topics I’ve brought with, but we’ll see. In the meantime, Me ma wo adwo!

Brian: Migaso

Ben: You want to try some Twi already yeah.😉

Me: Did I say it right???😃

Ben:: You mean, did you post it right? Yeah, you did! Will be glad to hear you say that out loud!…😊

Me: I’ll need coaching or Mack will laugh at my Southern Accented Twi!

More to come….

via Blogger October 24, 2016 at 07:05PM

A Quiet Day In Accra

Just a brief note…I spent most of the day at Dean’s Guest House, getting over jet-lag, and talking with my team members. Brian, radiologically-trained PACS administrator, has been here a week, and has had great discussions with the folks at Korle Bu. He’s made significant progress on a number of issues. Tomorrow, Erin, Radiology and NM technology educator , and I dive in and offer expertise where we can. My jobs will include working with Radiology residents, and with the Nuclear Medicine Department, primarily to get them more comfortable with their Merge PACS, and also to give a few lectures and work with them in any way the proves helpful. I’m hoping as well to be able to connect their gamma camera to PACS. Wish me luck!

Tonight, we went downtown to eat with Nathan, a former member of the Korle Bu staff Brian had come to know on a previous visit. The restaurant was fine (we had pizza of all things) but the cab ride from the ‘burbs (I think…I’m not very familiar with the town as yet) was fascinating. And frightening. And amazing. I’m reminded somewhat of Lima, Peru, where the traffic was actually much worse. There, stop-signs are treated as suggestions, and traffic-lights are ignored completely. Here in Accra, these things are obeyed, but traffic is still very wild. Merging is an exercise in combined trust, timing, and terror, but somehow between judicious use of horn and gas (and rarely the brakes), everyone gets where they are going.

Accra by night strikes me as somewhat similar to many towns in the Caribbean, but much larger, with more buildings, some very new and modern, some not so much. But what stands out to me more than anything else is the number of people on the sidewalks, on the streets, milling about. I’m sure they all have a purpose in mind, but I’ve never seen so many people just…there. It’s almost unnerving.  I’m sure I’ll understand the culture more by the time I return home.

In the meantime, may I wish you Me ma wo adwo, a good evening, in Twi, (the primary local, though unofficial, language here in Ghana.)

via Blogger October 23, 2016 at 06:31PM

Agfa F***s Up

I am on the e-mail list for Agfa’s Daily Blog Update, and it often contains interesting information. But imagine my surprise when THIS came through this morning:

I immediately clutched my pearls to my ample bosom and experienced a bad case of the vapors. Such language!

Agfa immediately sent out an apology:

Our sincere apologies are in order. The first article in our daily blog update today was not appropriate. We strive to bring you a wide selection of relevant articles from around the web to promote thought, present new ideas, and offer insights into the ever-changing world of eHealth and Digital Imaging. We messed up today and let an inappropriate article slip through. We have removed it from our blog, but unfortunately, could not remove it from your inbox.

Can we thank all those who brought this to our attention and please continue to read our blog updates on a regular basis.

Please accept our apologies.

No harm done, guys. But no doubt, someone is going to get fired. At least no one said, “Pu**y”.

via Blogger October 19, 2016 at 11:09AM


Wow. It’s been three months since I last checked in with you, my loyal readers. All 3 of you. As you might guess from reading my ranting over the past 11-plus years, I’ve been in the midst of a dilemma,  in this case trying to figure out what my future should hold. There are many directions to go, many options to consider, and many needs to satisfy. But I think I’ve got it. Finally.

To be totally honest, my basic instinct was to retire completely at the end of the year. Which was my intention last year, but somehow I stayed on. And I will indeed continue to work for another year, although I’ll cut back my weeks even more; in 2016, I will have worked 26 weeks, but in 2017, I’m planning on being in the saddle for only 22 weeks. That’s enough, I think. Rest assured, however, I’ll have my phone on and operational 24/7, so no one need worry about reaching me. No, I don’t charge for that extra service…

So why was this decision so hard? Do it or don’t, right? Well, it’s complicated, and there are many factors involved. Of all of them, the financial aspects are the most straight forward. Continuing to work keeps my (markedly lowered) salary coming in, and my health insurance is provided. Since Dalai, Jr. has a $36,000/year drug habit, that drug being Remicade, insurance is quite nice to have, and even our rather high-deductible plan would set me back almost as much as the Remicade if I were paying for it directly out of my pocket. No brainers, there.

Then there’s the mental stimulation. Being at the PACS station does keep me on my toes, with little time to squander on foolishness like blogs. Hopefully, with the downsized work-year, I’ll be a bit better. A three month hiatus is inexcusable.

And I must add that Mrs. Dalai was quite encouraging…of me getting my saffron-robed backside out of the house. “For better or worse, but not for lunch!” as she says. Quite often, in fact.

There were some negatives, of course. Here, I must be careful in my wording. If you choose to read between the lines, I cannot be responsible for what you assume I’m saying. Capisce? Much of my hesitation revolved around numbers. Mainly numbers of exams, read and unread, daily variance in consumptions of the numbers, numbers of things on exams I did not find, numbers of times I could not complete my interpretation of an exam all at once due numbers of others coming in my office, numbers of patients reading their own reports, etc., etc. Some of these problematic numbers could be cured by throwing greater numbers at them, but greater numbers come with greater costs, and in essence, this is not an option for the for the foreseeable future. So, I could either embrace the numbers or reject them. For one more (reduced) year, I’ll suck it up. After that…we’ll see.

You might recall my earlier post about Rad-Aid wherein I mentioned a chance to go to Ghana. I couldn’t make that trip, but I was given another chance to go, and so I shall! Watch this space for updates from Africa. My task (as team leader, no less, being the only physician on this particular expedition) is multifold. First and foremost, I will try to help with the local PACS, which thanks to a generous donation by IBM/Merge, is the same as our system. Actually, it’s a version ahead of ours, so I’ve had to try to learn that one a bit sooner than I had planned. Fortunately, the viewer component is pretty similar, but the worklist page is much more complex, allowing construction of some rather amazing worklists. I’ll still declare Merge PACS to be one of the more usable out there, and I’m sure the physicians in Accra can by now use it about as well as I can. But their system lacks one element, a RIS. As luck would have it, I gave this problem some thought when we put in our AMICAS PACS years ago, in this post from January, 2006, 10 (yes, TEN) years ago. My solution was to use PACSGear to scan a paper report and send the image to PACS as another series in the particular exam. One could also use one of several software apps out there (I cited Print2PACS back then) that would do the same thing with a digital document. Those ideas might work. It seems though that the residents in Ghana actually type their reports into a different computer, so I’m wondering if they could instead type into the PACS comment field. Much will become apparent when I’m on site. In the meantime, any ideas on this are welcome.

Rad-Aid is exploring a flying hospital concept, using not a 747, but an airship!

Sign me up for the first flight…

Let me end on a happy note. I had the opportunity to speak with a bunch of pre-meds at an event last week. Yes, that’s a good thing! These particular pre-meds were members of an honor-society, and were the cream of the crop. Based on some of my past experiences, remote and recent, I had expected a bunch of arrogant, socially-inept snowflakes, bleary-eyed from 20-hour days of study. I couldn’t have been more wrong. These kids (indulge me, I’m old) were enthusiastic, yes, but they were curious and introspective, well-informed, and interested in just what it is radiologists do. They had the proper balance of intelligence and humility. Their MCAT scores are no doubt high, but they maintain their humanity. In other words, they GET it. They have the instinct to be fine physicians, those to whom I would send my family and friends.

I feel more optimistic about the future of medicine than I have in a very long time.

One of those kids might become my doctor some day soon. Hopefully one of them will go into gerontology.

via Blogger October 04, 2016 at 10:45PM

She Flies Again!

Courtesy Smithsonian National Air and Space Museum

After a long restoration, the U.S.S Enterprise flies again, in a position of honor in the revamped Boeing Milestones of Flight Hall at the Smithsonian National Air and Space Museum. The new climate controlled case (the model once was hung on wires out in the open) sits amidst quite a few non-fictional aircraft and spacecraft, such as a Lunar Lander, Yeager’s Bell X-1, Sputnik I, The Spirit of St. Louis, the Apollo 11 Command Module, and some other good stuff. Why is a model of a fictional ship included here?

Yes, it’s just a model, but…

This collection of wood, vacuum-formed plastic, lights, and a bit of metal and paint carries our hopes, dreams, aspirations, and at least one vision of our future. This model IS the Starship Enterprise many of us came to know and love in our childhood. The ideals set forth in the show got at least some of us through the rough times of the 1960’s. Keep in mind, our first real reach beyond our planet, the moon landing July 20, 1969, occurred at the end of the original Star Trek run. Yes, I know one is real, and one is fantasy, but the dreams inspired by both will carry us to the stars. How poetic!

OK, back to Earth. There are quite a few videos on YouTube about the restoration, and I’ve posted just one of them below. I was quite fascinated by the computerized LED replacement lights in the warp drive nacelles. It seems the original rotating light show was created with motors and Christmas lights. The assemblies got hot enough to scorch the wood housing! How far we’ve come…

And now, I shall boldly go… back to work.

via Blogger July 10, 2016 at 12:50PM

McKesson Sells IT Division…To Dump Earlier Mistake???

You’ve all heard by now that healthcare giant McKesson will spin off its IT division. Here’s the bullet from Fortune:

Healthcare services provider McKesson said it would combine most of its information technology business with Change Healthcare Holdings to form a new company with combined pro forma annual revenue of $3.4 billion.

Change Healthcare, a provider of software and analytics, network solutions, and technology-enabled services, will contribute all of its businesses to the new company, with the exception of its pharmacy switch and prescription routing business.

Tennessee-based Change Healthcare is majority owned by Blackstone Group.

The new company will be able to offer managed care companies technologies for financial and payment solutions as well as tools for administrative and clinical management, said McKesson, which has a market value of about $39 billion. elaborates:

In a pair of June 28 announcements, McKesson said it will create a new standalone healthcare IT company in partnership with Change Healthcare Holdings, the revenue cycle management firm formerly known as Emdeon. The new entity will have estimated annual revenues of $3.4 billion, with McKesson owning 70% of the firm and Change shareholders owning the remainder.

The new firm will combine all of Change’s operations with most of McKesson’s Technology Solutions division, which includes its Imaging and Workflow Solutions unit, which offers enterprise PACS software as well as image management applications for radiology and cardiology. Other operations in the division include Health Solutions, Business Performance Services, and Connected Care and Analytics units.

In announcing the spin-off, McKesson Chairman and CEO John Hammergren said the move would “establish a more efficient suite of end-to-end payment and claims solutions, as well as clinical capabilities,” while also “unlocking the value” of the Technology Solutions business. McKesson and Change are also positioning the move as one that will help their healthcare customers navigate the transition to value-based healthcare.

Following the closing of the transaction, McKesson and Change plan to pursue an initial public offering for the new venture. McKesson will then exit its investment in the new company.

McKesson said the spin-off will not include its Enterprise Information Solutions division, which it will retain as it “explores strategic alternatives” for the division. This business includes electronic health record (EHR) software, such as McKesson’s Paragon hospital information system. McKesson’s RelayHealth Pharmacy division also is not included in the spin-off.

So the new company will have PACS and some other stuff, but NO EHR. Fortune adds, “The new company will be able to offer managed care companies technologies for financial and payment solutions as well as tools for administrative and clinical management, said McKesson, which has a market value of about $39 billion.” Doesn’t sound like a ripe market for the PACS offering.

Why would McK give birth to a partially-formed offspring like this? Good question. AuntMinnie’s Brian Casey continues:

Speculation that McKesson might be seeking a divestiture surfaced in early June, when an article in the Wall Street Journal suggested that the company might be looking at options due to pricing pressures in its core drug distribution business.

The article indicated that the Technology Solutions business had $2.9 billion in sales in its most recent fiscal year (end-March 31) and operating profit of $519 million, which is just a fraction of the $188 billion in sales and $3.6 billion in operating profit produced by McKesson’s drug distribution business.

The move is a sign that ongoing changes in the industry are affecting even some of the largest players, according to Michael Cannavo, principal of PACS consulting firm Image Management Consultants.

“It is interesting to see moves by many of the larger companies to either start refocusing their core offerings or consolidating their products with other vendors’ offerings,” Cannavo said. “End users used to be concerned about the smaller vendors not surviving, or at least the products they bought surviving. Now the larger vendors are starting to have some of these very same issues. The sad reality is no one vendor is considered a safe bet anymore.”

The Wall Street Journal elaborates:

Companies often consider separations of units whose profit margins, expected trading multiples or strategies differ dramatically from those of core businesses. It has been happening more as shareholder activists and other investors push companies to narrow their focus.

Spinoff activity peaked among U.S. companies in 2014, with a record 58 transactions worth $164 billion, according to FactSet. They have fallen off a bit since then, though in the past year several big companies have pursued such moves, including Hewlett-Packard Co., Baxter International Inc. and Xerox Corp.

McKesson has announced cost cuts and layoffs as it grapples with price pressures brought on by consolidation among its customers.

And again from Fortune:

Morningstar analysts said McKesson’s healthcare IT business never fit the firm’s overall strategy and was an impaired asset from the beginning as a result of the accounting fraud. (See below.)

“Management has not made any material investments within this business over the past several years, and to our understanding, the technology was two to three generations behind other major HCIT players,” they wrote in a note.

Let’s look at a bit of McKesson history, courtesy of the Wiki:

Founded in New York City as Olcott & McKesson by Charles Olcott and John McKesson in 1833, the business began as an importer and wholesaler of botanical drugs. A third partner, Daniel Robbins joined the enterprise as it grew, and it was renamed McKesson & Robbins following Olcott’s death in 1853.

The company successfully emerged from one of the most notorious business/accounting scandals of the 20th century—the McKesson & Robbins scandal, a watershed event that led to major changes in American auditing standards and securities regulations after being exposed in 1938. In the 1960s, McKesson & Robbins merged with Foremost Dairies of San Francisco to form Foremost-McKesson Inc.

Yes, they merged with a Dairy.

McK decided to get into informatics at the end of the last century. From Fortune again:

In 1999, McKesson entered the healthcare technology sector by purchasing a large tech company, HBO & Co., for $14.5 billion. Shortly after the deal, auditors discovered that HBO & Co. had been fraudulently boosting sales, eventually leading to a shareholder lawsuit that cost McKesson nearly $1 billion.

Oops. WSJ:

But after it was completed, auditors found evidence that HBO executives had fraudulently booked revenue and inflated the Georgia company’s profits. Several HBO officials were indicted on federal charges, and its chairman was eventually sentenced to 10 years in prison. McKesson shares didn’t recover to their pre-scandal levels for more than a decade.

In the meantime, McK did do something wise…it dumped the PACS that came with HBO and bought a much better product from ALI. Erik Ridley’s 2002 article gives an interesting glance into those primitive times:

With PACS seen increasingly as the imaging layer of an electronic patient record, it’s no surprise that healthcare information systems vendors would want a piece of the action. The bid by HIS firm McKesson Information Solutions to acquire Canadian PACS provider ALI Technologies for $340 million (U.S.) is the latest acquisition/partnership among PACS and HIS vendors.

For McKesson, the decision to reenter the PACS market reflects its desire to offer a complete electronic patient record, including support for digital image management, said Randy Spratt, senior vice president of technology and standards for McKesson Information Solutions of Alpharetta, GA.

If completed, the deal would mark McKesson’s second go-round in the PACS market. McKesson Information Solutions’ predecessor, HBOC, had acquired PACS developer Imnet Systems in 1998. McKesson later bought HBOC in early 1999, but abandoned the unit’s PACS initiative two years ago.

The architecture of the Imnet PACS technology was not sufficient for many reasons, including its lack of adherence to open standards and lack of a practical image distribution method, Spratt said.

“We probably did not fully appreciate the depth of technical expertise that was required for the viewers and workstations of medical images as opposed to document images,” he said. “Without a complete product and without the skill set and expertise, we determined that it would take more time and risk to get it to market than it would to close that product down and look for another.”

In acquiring ALI, McKesson receives a true PACS success story, an independent that was able to thrive in a market dominated by larger modality and film vendors. Focusing initially on ultrasound miniPACS, ALI became one of the leaders in the niche before electing to expand into radiology PACS.

ALI implemented that expansion in part by purchasing independent PACS firm Olicon Imaging Systems in 1999. Today, ALI has an installed base of over 500 installations worldwide. While ultrasound PACS orders still make up the majority of the vendor’s installed base, roughly 66% to 75% of the firm’s new system revenues are being generated from radiology PACS orders, said Greg Peet, ALI’s president and CEO.

Ha. I feel vindicated on several levels. I had been told for years that AMICAS was unworthy of my attention because it was a small company ready to be plucked and destroyed. But Merge bought AMICAS and IBM bought Merge, making this one of the most solid systems out there. And Big Iron McKesson is dumping its PACS. Go figure. And the McKesson PACS story itself tells us that a Big Iron (or shall we say, larGE) company can buy another PACS and make it work, rather than destroy it.

We shall see what becomes of one of the more beloved systems out there. I’m thinking it might be wise to put purchase decisions on hold for a while…

via Blogger June 30, 2016 at 10:26PM