A Note From Sectra

Dr. John Goble, President of Sectra North America, posted this on AuntMinnie.com:

Sectra has been in the US for nearly ten years, and we have a superb service and support team. In addition to Philips Medical Systems, we provide Level II support for our other partners, selected dealers and comprehensive support for our direct sales.

Our PACS products for the Orthopedics and Mammography markets are extremely well received by the US market. While Philips’ acquisition of Stentor will undeniably impact our revenue in the short term, we intend to aggressively bid for service on our products and continue to protect the investment of customers who have purchased Sectra PACS… whether under the Philips label or directly from us.

Sectra will continue to innovate and bring industry leading products to market in the US. If you have questions about support for your system, extensions to your Sectra PACS or have a new opportunity, we’d be happy to talk with you.

John Goble, Ph.D., President, Sectra North America, Inc. Call us at 800.307.4425.

Sounds pretty promising for Sectra customers. We’ll see how it works.

Farewell, Scotty

Today, we Star Trek fans say goodbye to James Doohan, who will be forever known as Scotty, the Chief Engineer of the Starship Enterprise. He died of complications from pneumonia and Alzheimer’s disease at age 85. His ashes will be rocketed into orbit later this year. (That’s not a joke, by the way; he will join Star Trek creator Gene Roddenberry, whose ashes were intered into space several years ago.) I guess we tend to forget that the characters of Star Trek are getting on up there in years. DeForest Kelly, who played Dr. McCoy, died in 1999 at age 79. Even Kirk (William Shatner) and Spock (Leonard Nimoy) are in their early seventies now. I had the chance to spend 10 seconds in their presence last summer at the Star Trek convention (yes, I admit I went), while posing with my son for this photo. I call it three old Jewish guys and a kid.

Many say Jimmy Doohan was the most beloved of all the Star Trek actors. I think we can rest assured that he was beamed up and not down to his Final Frontier.

One Brief and Shining Moment….

My apologies to the late Richard Harris….

I am really amazed at the traffic generated by the AuntMinnie.com article. Comments have been generally positive, usually something like, “I didn’t know PACS could be funny!” I seem to have the attention of a significant number of those in the PACS community, and I would like to put that to good use while it lasts.

It seems clear that there is a disconnect between the designers and (Radiologist) users of PACS interfaces. I’m not sure why this is the case, as it seems logical to consult your end users before creating a huge software product. I don’t want to indict any one particular company, but some do a better job than others of giving us the clear interface and powerful tools we need to slog through the day’s work.

For the moment, lots of users, and not a few vendors are dropping by to see what foolish thing I have posted this time. Now I’m sure you all realize that is is possible for you to post comments here, and I really, really, REALLY encourage you to do so. It’s simple; just click the word “COMMENTS” at the end of each posting. Perhaps this blog might be considered a “safer” place to post complaints or suggestions for the vendors, and for them to post answers. This happens on the AuntMinnie.com boards to some extent, but I think some are hesitant to post there. So, come here and let it all hang out. Don’t hold back, say what you really think. I certainly haven’t even begun to describe everything that would go into a perfect system, but if I can get input from as many of you as possible, maybe we can get closer to that ideal product.

Now, if you will excuse me, the boys want me to get back to the Roundtable, I mean my PACS station, and generate some revenue.

Northwest, One Last Time

Ms. Michelle Mohr
Northwest Airlines Complaint Department
Dear Ms. Mohr:

Unfortunately, Northwest was unable to live up to the earlier performance on our trip home. In brief, we were delayed leaving Minneapolis/St. Paul on our flight yesterday due to “weather over Detroit”, and we idled on the tarmac for almost an hour before taking off, burning a significant amount of expensive jet fuel. After a very late arrival at DTW, we did manage to make our connecting flight home, but all five of our bags did not. We had to sprint to the departing gate, B19, from A70, the longest possible distance at DTW, but made it with a few moments to spare. The fate agents were courteous, and even apologetic but told us we could not take even a minute to walk across the hall and buy a snack, since the gate was about to close. They asked US if WE knew of anyone else trying to make the flight. As it turns out, there were indeed two stragglers who boarded about 10 minutes after we did, and I would be surprised if your computer did not report that these people had arrived at DTW and were en route to the flight. (One of them had a leg injury and was walking with the aid of crutches.) It was very clear that having the aircraft push back from the gate on time was much more important than letting my family grab a quick snack to take onboard (we had not eaten for 8 hours, anticipating an adequate amount of time to do so at DTW, and this flight didn’t even have your now-famous $1.00 trail mix available.) This was the last flight of the day to our destination, and the aircraft had nowhere else to go that evening. Your schedule was likely already in shreds due to the “weather problem”; one more minor delay would not have mattered. As it was, the flight arrived home 10 minutes ahead of schedule. To complete the series of unfortunate events, all five of our checked bags did not make the transfer, forcing us to go through the claims process. The only person available at 12:30 AM was George S., one of the baggage handlers, who clearly was trying very hard to do a good job, but just as obviously had never been trained to use the computer system to file a missing baggage claim. Another baggage-handler finally was able to come to his aid, as did Venus R., whom I believe was a Continental agent. Hopefully, our luggage will be delivered sometime today.

Ms. Mohr, I am sad to report this experience, as I had much greater expectations after my last flight with Northwest. It seems that your people can shine if everything in the system is functioning perfectly, but a glitch, such as bad weather or mechanical failure sends everything into a tail-spin. Staffing has obviously been cut to the bone, and the goal of the airline seems to be to meet the on-time deadline of door-closure and pull-back at the expense of the comfort of the passengers. This will be my last flight on Northwest for the foreseeable future.

Thanks for your time. I know there are many good people working for Northwest; it is unfortunate that they are not allowed to perform to their potential.

Addendum: I do have to add praise where praise is due. Rick, the baggage manager for Northwest in my hometown, personally delivered our 5 bags when the local service couldn’t get around to it. I wish Northwest would allow the rest of their employees to go the extra mile as Rick did for us.

PACS preferences: How to push a radiologist’s buttons

I’ve finally made the big-time! This was published on AuntMinnie.com today! For radiology, PACS has been nothing short of a complete and total revolution; PACS now quite literally defines how I perform my job. As a nuclear radiologist, I spend at least 85% to 90% of my day with the microphone in my left hand and the mouse in my right hand. If I’m not talking into the former whilst manipulating the latter, I’m not generating revenue for my group.

My goal in life is to do my work and go home; my PACS system should facilitate this and not get in my way. So what are the elements of a usable, unobtrusive PACS according to this humble rad?

Let’s start with some general observations on PACS GUIs and their functions. First and foremost, every part of the darn thing has to work every single time, and that includes all those little buttons that you might use once a year.

The vendors will quote you “uptime” rates of 99.999%, but for some distributed systems, if just one workstation is up, well, that counts as uptime. Given that great uptime, please spare me hourly (or more) lockups and reboots. Been there, done that: we used an early form of a small PACS network that would fail literally on every other study. One of my partners (who still likes the product) determined that pressing thus-and-so button, and right-clicking just there, while holding your left hand in the air and howling at the moon would keep the program from crashing. That may be, but most of us just don’t have time for a crash-o-matic solution. The system needs to be bulletproof, and the least-technical member of your group should not be able to bring it down, even if he presses all the keys at the same time (I’ve seen it happen).

The interface must be clear, without distractions. The whole point of the process is to see the images, right? So why do some programs devote tremendous amounts of screen real estate to everything but the image? If I want the old report, or the demographic page, or the Nasdaq stock ticker, let me bring it up somewhere else, not where it invades the current image.
Some PACS systems out there seem to imitate the bridge of the Starship Enterprise up to and including the “gleeps” and “whirrs” from the controls. As a closet Trekker (we prefer that term to Trekkie, by the way), I love that idea, but not while I’m trying to work, please! Cute, but not what I really need.
Graphics on the various buttons can be a little underdone, too; that same crash-o-matic system I mentioned uses some very primitive low-resolution unintuitive icons on its various buttons, and at least one of those symbols seems to have been lifted from another famous non-PACS, but still copyrighted, source.

Make the interface clear and readable, with obvious designations. The same goes for menus. Some of the most sophisticated programs out there suffer from “right-click-orrhea” in which a right-click brings up a huge list of stuff. Now I don’t mind if the right-clicker results in a well-organized and helpful submenu, but there are those who pile everything including the kitchen sink into this otherwise hidden area. No thanks. Some systems make that right-click deluge (and about 1,000 additional settings) customizable, and all that for each modality, no less. Most of us would give up and use the default settings that came with the program. Keep it clean, clear, and simple. That’s all I ask.

Oh, and by the way, how about having all the buttons work in a consistent manner? It is a real pain if, say, the magnifier works by left-click activation, then actual manipulation with the mouse wheel, while the window/level control is toggled on and off with a left-click and manipulated with moving the mouse immediately thereafter without clicking anything else, etc., etc. See what I mean?

These expensive toys come with a vast number of tools and gadgets, all intended to help us interpret our examinations. Do they really accomplish this goal? Well, let’s see. In no particular order, here are some of my favorites (or not as the case may be):

RIS/PACS integration: The new Holy Grail. I don’t think this is quite there yet. Yes, it’s nice to get your reports brought up within the PACS window, and all systems do that with the appropriate connection. But does the PACS really need to feel the RIS and be the RIS, or could they just go out for dinner and a movie?
Worklist: The unsung hero of PACS. You need to see what you need to read, yes? Well, there’s much more to it than that. Tell me what needs reading, what is STAT, what can be put off until after lunch, is someone else reading something so I don’t have to, are there prior examinations, and maybe tell me something about the patient like age and what idiot (oops, I mean honored referring clinician) ordered this test.
Hanging protocols: I like to think I’m flexible, but in reality I am set in my ways. I like my studies to come up in the same manner every single time. Hanging protocols are supposed to accomplish this. Properly done, you should simply set up windows and other settings the way you want them for a particular type of exam, click the button, and presto, the next exam comes up in the same way. There are systems out there that require deep, dark, secret programming methods to set up, and somehow, no one ever quite knows how to do it. Hanging protocols can be totally confounded, however, if your techs are inconsistent in labeling the examinations. The PACS is stupid, after all, and can’t just look at the image, decide whether it’s the patient’s head, tail, or something in between, and place it appropriately. Wine and dine your techs and make them swear to label the same image the same way every time. Tell them your happiness is their reward.
3D: Gotta have it for CT and some MRI exams. Period. Some companies have built-in multiplanar reconstruction (MPR), volume rendering, and such, and some let you connect to 3D software (or actual added-on computers). The absolute minimum acceptable to me would be MPR with the ability to do oblique reconstruction, and the ability to MIP (create maximum intensity projections) from there. Volume rendering is really nice to have. It is very helpful to be able to push those renderings back to your PACS, which is often not available without the add-on programs. And by the way, make the included stuff intuitive, if you please. If I point to a lesion on one plane, I want the other planes to show me the same lesion. It’s called triangulation, and some of the vendors out there must have slept through that class in high school.
3D cursor: Most MRI studies are done in multiple planes, and the DICOM headers tell you lots of spatial information if you actually look there. A 3D cursor uses this information to triangulate (see above), snapping the images in all sequences to the spot you select. Believe me, this is incredibly helpful.
Spine labeling: Done the easy way using that 3D information there for the taking in multiplanar studies (CT, MRI), I can label the individual vertebral bodies and disk spaces in five seconds. Done the hard way (by another company), it would take me 10 minutes if I were willing to slog through things that way, which I’m not.
Magnification: You thought there wasn’t anything new here, right? Surprise! Several companies have figured out that image magnification should not go from the center of the image matrix itself, but should be centered where you select. It doesn’t sound like much of a philosophical difference, but it saves the panning step after you’ve magnified the abnormality off of your screen and have to drag it back.
Linking: If you read a CT or MR that by some miracle has a prior study available, you want to link them together slice by slice. Just about every system will do this based on table position, so if one CT was performed with thicker slices than the other, the images will match up better. A few companies still haven’t grasped this simple concept, however. If your potential vendor can’t do this, run, don’t walk, to the next one. It can be done with one click, especially if you want to display multiple views of the same sequence with different window and level settings, for example. The more clicks, menus, and buttons it takes to make this (or anything else, for that matter) happen, the less likely you are to actually use it. Some systems get bogged down if you link too many windows. That’s too bad, because I like to link multiple windows.
Measurement/markup: I have to keep reminding some of my partners not to write on the screens with the red crayons — that’s what the markup tools are for, guys. I like the latest versions that let you place the actual measurement somewhere other than over the thing you’re measuring. And if I want to make a hundred measurements on a single slice, I’m going to do just that; one system will only allow two measurements to appear on the screen at once, and that will never do.
Web client: Being rather set in my ways, I really prefer having the same interface at home as I do at work. The Web-based systems allow this; the older model “big-iron” approach is to add on another whole system that taps into the main PACS database (and was usually acquired from some other company anyway).

In my own humble opinion, a PACS needs to let me do my work, and not get in my way. At the same time, it needs to give me a Swiss Army knife (dare I say McGyver-esque?) set of tools to get the job done. These are not mutually exclusive criteria; rather, a properly deployed interface will make my work of interpretation much easier, and make my day much more enjoyable. Well, except for the BEs….

Northwest Redux and Other Random Musings From The North Woods

(My Temporary Shingle)

I try to be flexible when possible, and this week I am playing Pediatrician at my son’s camp in northern Wisconsin. The territory up here is nothing short of spectacular, lots of trees and lakes and clear blue skies. The camp itself is a rustic paradise, about as far from a Ritz Carlton as you can get, but still peaceful, placid, and comfortable. Maybe I’ll stay up here for a while….

Northwest redeemed itself in getting me here. There were absolutely no glitches whatsoever. Flights were ontime and smooth, and personel were friendly. Special thanks to Sergio at our originating airport, who went out of his way to help us redistribute items in an overweight bag, thus avoiding a penalty. Sergio’s behaviour compensated for that of the other Northwest employees to a very significant degree. He “got it” as they say. All I ask is that I be treated with kindness, understanding, and dignity; this is how Sergio treated me, and how I hope I treat my patients.

On the PACS front, the big news is the purchase of Stentor by Philips, for $280 Million. That’s a lot of cash, folks. The big question I have is this: What happens to all of those Sectra installs? The Sectra folks seem to be assuming the worst:

Since 1997, Sectra has had a global cooperation with Philips Medical Systems, which has sold Sectra’s software for processing digital X-ray images worldwide.

“We have several project agreements with Philips that extend up to ten years and our cooperation will successively be terminated,” relates Sectra’s President and CEO Jan-Olof Brüer. “We assess that the termination will impact on our sales and earnings in the current fiscal year. At this time, however, it is difficult to provide any reliable view of the financial effects, since this depends on how much time the termination will require.”

The change provides Sectra the opportunity to review its sales channels. Sectra’s sales of PACS are handled on a proprietary basis in Scandinavia and other selected markets as well as through partners, of which Philips was the largest. Sectra’s largest sales together with Philips have been in the US.

“Part of the sales for which Philips is currently responsible will be taken over by other partners that today are active in the same markets as Philips,” says Jan-Olof Brüer. “At the same time, we gain the opportunity to advance our positions and will increase our focus on own sales in important key markets, as we do today in Scandinavia, where we have captured more than half of the total PACS market.”

Sounds to me like Philips is dropping Sectra (or maybe it will turn out to be the other way around) like a hot potatoe, and Sectra will find some “other way” to service its sites. Uh Oh. I’ve lived through that sort of thing with our Elscint CT scanners. Elscint sold its CT division to Picker (actually happened while I was visiting their main offices in Haifa, Israel), which then was gobbled up by none other than Philips. Service was pretty good, considering, but it just isn’t an optimal situation. In this case, Sectra will have to bring in some other outfit to do its service. Perhaps they should contact Banctec, the outsourced Dell service provider, or maybe the Geek Squad from Best Buy.

I know of several sites that had purchased Philips/Sectra, or were close to doing so. Wouldn’t go there at this point, at least until the market stabilizes. If they were buying because of the Philips name, they would of course still get that, but a completely different product. To buy Sectra means diving into a very murky future. I personally wouldn’t go near either one for the time being, but that’s just me. Your milage may vary.

I had the chance to play with the Philips/Sectra system, and it isn’t bad. It was neither my most or least favorite. The team was (and I emphasize was) a formidible player in the PACS field. I’ve asked people why they liked the PS system so, and invariably I get one of the following answers:

  1. It’s made or marketed by a company that makes scanners, so it must be good.
  2. It has an easy pull-down preliminary report menu.
  3. Their embedded 3D lets you select exact slice thickness on MPR.

My answers to the above are probably predictable. First, GE and Siemens make scanners too…I don’t consider the PACS product from either company, um, great at the moment. Secondly, one should never, ever make a major purchase based upon one or two perks. Would you buy a Peugot over a Mercedes because it has, say, a prettier hood-ornament? You have to take all factors into account, not the least of which is the overall usability of the entire system. Having the hots for one specific component has the potential to send you down the completely wrong path. Pull-down preliminary report generators are dandy, and I have a rudimentary version on Agfa Impax 4.5. I rarely use it, because I can type my prelim much faster without any help. As far as MPR slice thickness, I don’t know anyone who finds knowing the exact numerical value of the thickness that valuable in actual use. Frankly, I suspect a lot of potential PACS purchasers, especially those who are new to the game, are so overwhelmed by whizbang gadgets, they don’t stop to think about how they might actually use said toys.

My advice remains this: use the product as much as you can before making a purchase. Web-based systems lend themselves very well to trial-runs in your own office or home setting. Vendors…can you accomidate this?

Anyway. For the moment, all is well in the North Woods. That is until Sick-Call, which is right after dinner………