The Latest In USB Acoutrements

I hesitate to post this, but I got a good laugh out of it, and you will, too. These adorable little pups plug into any USB port (I think they work equally well with USB 1.0 and 2.0, although perhaps they perform faster with the latter.) Just in case you don’t quite yet have the visual of exactly what it is they do, here is a movie clip of the little critters in action. I know I want one. This might be just the advertising gimick for some large companies out there to demonstrate their “loving” attitude toward their customers.

radRounds.com

I received an invitation to join a new social network from its founder, Steven Chan, MD, MS, a private practice radiologist in New York State. The idea was to create a FaceBook- or MySpace-like site to “. . . allow our natural connections with each other with the aid of the internet to foster new collaborations, idea exchange, new ventures, and job opportunities for us radiologists. We restrict membership only to invited industry leaders, radiologists, and rads recruiters (the non annoying ones).” I’ve personally never met a non-annoying recruiter, but I guess they do exist.

I went to Steve’s site, liked what I saw, and signed up. The front page fills in more details of the site’s goals:

Welcome to radRounds!

radRounds is a tool for radiologists. It was created by radiologists to help with clinical work and enriching one’s career. Some examples of uses might include:

  • Finding another radiologist who can help with an MR imaging sequence, job search, or tough case
  • Talking privately to an inside-connection about that practice you plan to join
  • Establishing a new collaboration to start a multi-center clinical trial
  • Leaving radiology and looking for an investment banking job
  • Searching for the dream job or hiring the dream candidate / future partner
  • Keeping in touch with alumni from your residency program and old friends from the RSNA
  • Discussing the latest topics and turf battles of radiology
  • Finding out the next time someone gives a lecture/CME on your area of interest
  • Starting your own (private or public) group or blog

And, above all, sharing one’s interests, expertise, and connections with others. radRounds will most rapidly improve with the help of the people who use it. Spread the word too and invite a fellow radiologist. By the way, suggestions and comments are all strongly encouraged.

OK, I’m spreading the word. radRounds is a site worthy of our participation. I think it will be complementary to several existing radiology sites such as Filmjacket.com, and of course Auntminnie.com. Check it out!

Amicas + Siemens = ???

In response to my RSNA report about Amicas and Siemens, Anonymous asks this question:

Thanks for expressing your analysis on Amicas. I couldn’t help but notice Amicas and Siemens in the same sentence. Do you think this would be a good acquisition for Siemens with the recent GE / Dynamic Imaging aquisition?

Interesting thought. The speculation on who will buy whom runs rampant, especially around RSNA time. I’ll give you some rudimentary (read: uneducated) analysis about the topic, and follow that with what I hope actually does happen.

With that large company having just acquired the smaller company as mentioned by Anonymous, there aren’t too many operations left that need a new PACS, let alone have the resources to afford one. Those that come to mind immediately are Siemens and Cerner. Philips bought Stentor a few years back, Fuji has their own, and Kodak has spun theirs off as CareStream (still sounds more like something the urologists should be dealing with than a PACS.)

Cerner had at one time a solution written by Cedara, now owned by Merge. I looked at it briefly in 2003 and wasn’t terribly impressed. Neither were many others, as there were very few ever installed. Today, Cerner’s ProVision™ PACS offering (which I didn’t bother to look at whilst at RSNA) has these features according to their web site:

The Cerner ProVision™ Workstation is a comprehensive solution for diagnostic softcopy reading of digital images. In order to provide you with increased flexibility, the workstation supports multi-monitor configurations, “set up and save” viewing protocols, global user preferences, and comprehensive MPR features eliminating the need for specialty workstations.

In addition, the Cerner ProVision Workstation allows you to:

  • Increase productivity and physician satisfaction with decreased report turnaround
  • Generate continued returns from legacy investments and compliance to DICOM standards
  • Provide increased patient safety with synchronization of patient, procedure and image information when configured with Cerner’s RadNet including voice recognition and access to the EMR

Uh, well, nothing really distinguishing there, I’m afraid. Some of our hospitals use Cerner’s Millenium RadNet, and since this is a kinder, gentler blog, let me simply say that I really, really like using Empiric’s Encompass.net. I’m not sure how Cerner feels about its latest PACS, nor if it is thinking it needs a replacement. But, it pays to keep one’s eyes open on such things.

Siemens has had a somewhat irregular history in the PACS field. SIENET Magic PACS came and went, and I don’t think anyone would consider it particularly beloved. There was much hype in recent years about SIENET® Cosmos, which was a combined RIS/PACS product using Siemens syngo® common user interface, and e.soft which Siemens in 2000 defined thusly:

“e.soft is the first medical imaging computer that will adapt itself to the way the system’s users work–and then do the work for them. . .”

So, syngo is an environment of a sort, that runs under Windows. e.soft is the programming language, although some of the definitions seem to be a little fluid.

Today, Cosmos has evolved into the syngo® Suite. The environment works something like this when integrated with the Siemens Sorian RIS:

It’s an interesting concept that attempts to place a common interface on everything from the order entry to the scanner to the PACS. This is a good idea in theory, but most rads don’t run the scanner, and most clerks don’t read the images. I use the syngo/e.soft system on my Leonardo, I mean syngo workstation on which I read my PET/CT’s. It is usable, but more than a little esoteric, and quite frankly, I would find it difficult to use as a PACS. That’s my opinion, and I’m sticking to it. Sales of Cosmos/syngo PACS have not been great. I suspect I’m not the only one who can’t quite get used to the idea. There are those who think that the Siemens back end is bullet-proof (see this thread), and I won’t dispute that per se, but I’m not sure a PACS needs to be bullet-proof in this day and age. Anyway, the bottom line to me is that Siemens really should consider a new PACS. Let the common interface idea go.

Now comes the editorial part of my answer. PACS is one tough business. Many of the small fry are either bought out or go under every year. Anonymous of course cites one of the largest PACS acquisitions, probably followed closely by Philips’ buying Stentor to create iSite. As near as I can tell, iSite is doing well under Philips’ stewardship. (And Sectra, the “jilted” product, is doing OK itself.) If Cerner or Siemens wanted to buy a company, who is left? I would leave out the much smaller players, such as eRad, and so forth, and make a rather short list of Amicas, Emageon, and Agfa. Yes, Agfa PACS is apparently for sale, as I noted earlier, although it has yet to be sold. I have no idea how many suitors have approached Agfa, but I suspect the number is quite small, as it is probably a very expensive purchase indeed. Emageon has had its troubles, but its stock price has stabilized this month, albeit at a rather low level. The last time I looked at the product, it seemed good, and I’m looking forward to seeing it again in Seattle at SIIM.

And Amicas? Well, that’s a different story. Amicas has a lot of cash in the bank, a new product in the works, and a veteran manager, Dr. Steve Kahane, at its helm. If I were giving Siemens (or Cerner) advice, I would say buy it, buy it NOW. Siemens, in my humble opinion, needs a new interface, and Amicas has a really good one. BUT, if I were giving Amicas advice, I would say, “Stay independent!” Being your own company allows a degree of lattitude that prompts development of innovative products. I know the folks at Amicas, and they know what they’re doing. Would they survive under a large company? Most likely, as long as they were given a very long leash, but a leash is still a leash, isn’t it? This is one of those “if it ain’t broke, don’t fix it” situations.

I realize that Amicas’ stock hasn’t done spectacularly well, either, and it just goes to show that the market doesn’t understand the PACS business too well. For what it’s worth, Amicas is buying back some stock:

“AMICAS chose to repurchase under Rule 10b5-1 because a 10b5-1 plan allows us to focus on the business rather than worry about timing and trading of our stock. This plan also allows us the flexibility to repurchase shares when the company may otherwise be precluded from doing so under insider trading laws,” said Stephen Kahane MD, CEO and chairman of AMICAS.

Do the Big Companies do that? I suppose so. But I’m not interested in buying the stock (sorry, Steve), but I am interested in a PACS that works. Would Amicas PACS work as well (and be as affordable) if it were Siemens Vision Series PACS? I can’t answer that. But I selfishly hope the status quo continues. It’s working for me.

Laziness, Or Something Else?

AuntMinnie user rogens50 asks if radiologists are “cutting our own throats” with laziness?” I’ve reproduced part of his post below”

This is a big pet peeve of mine. I have a group in which I think there are very good radiologists. However, I am constantly annoyed at reading reports which are basically just descriptive words and seem to make no effort to get down to the nature of the patient’s problem or try to make a diagnosis. This problem is not only unique to my group, buy almost every group in which I review studies. Since we are busier and busier these days, many people in the group treat the reading list like the old “Space Invaders” game in which the only purpose it to shoot down as many enemy spaceships (in this case, patients on the PACS reading list) as quickly as possible. I guess I may be too “anal” about this since I was trained in a residency program where my favorite mentors constantly implored me that “nothing makes you smarter than the old films”. In the old days, it was a pain to look at many of old studies and reports which were stuffed in the jacket, but now in the PACS era, all of this information is one or two mouse clicks away. I feel it is the radiologist role to give as accurate assessment as possible as to what is going on with the patient as opposed to generate some generic descriptive report. It seems that there is no academic curiosity or underlying desire to provide any real depth of information to the referring physician and thus help the patient. I can give numerous examples.

Rogens then does cite several situations illustrating his point, such as obvious instances when only the most recent chest radiograph (if that) was reviewed in comparison to the current study. He recommends:

In general, I feel you should try to approach the case is it were you or a family member. Certainly, you may not be quite as diligent as if they were your images, but this is at least a mindset you should have. If you read some of these reports and you and your family member had unnecessary procedures or imaging studies as a result of it, you would feel the radiologist is not doing his job.

And what might the consequences be if we continue?

By generating these kinds of reports, we are taking ourselves away from truly helping the patient. At some point clinicians and administrators may say, “If this is the kind of information I am getting, I might as well get cheaper dayhawks or maybe in the future, send them to India” Therefore, are we cutting our own throats by providing trivial readings?

But even rogens50 realizes that this may not be so easy…

I will admit when I am on call and drowning in studies, I reluctantly cut some, but certainly not all corners, but still try to provide as much information as possible. I try to address situations where the radiologists are overloaded with studies (call) at group meetings and try to correct this problem. Sometimes on call, I feel like I am the Lucille Ball character from the clip where she is trying to keep up on the candy production line. . .

I thought everyone would appreciate the video clip above in light of the analogy.

I’m going to assume rogens is fairly fresh from training. That is not meant in a derogatory manner, but just as a point of speculation. As an aside, my group has hired a number of new kids in the past year or so, and their training and work ethic has been phenomenal. I’ll bet rogens is at least up to their (very high) level. Now, I’m assuming he is new because his main thesis demonstrates some naivetee. No, not the part about adding diagnostic value to the reports, and reviewing as many pertinent old studies as possible. There, rogens is spot on. This is a necessary part of our interpretations, and must not be neglected.

No, rogens goes astray with the assumption that the problem is laziness. Really, I don’t think even he believes this to be the cause, but perhaps it is the first answer that comes to mind. While sloth may be the answer for some of us some of the time, and for a few of us a lot of the time, it is not the real underlying problem. Rather, the sheer volume we face each day is the biggest obstacle to providing the level of service we think optimal. Based on the “Lucy” remark, rogens understands this, too, but he only mentions “drowning in studies” on call. For most of us, that’s just the beginning.

Veteran poster MISTRAD puts it best:

Our workload as rads has so dramatically increased over the last decade, I think we are getting close to our maximum capacity to read studies. Sure, you could read more hours, but frankly for me after a 9 hour shift reading 150 or so studies, I am burned out. I agree with all of your points, but I don’t know if the solution, other than hiring more people, is easy.

But, hiring more radiologists means diluting the revenue, and that is the last thing most groups will consider. No, more and more of us are trying to replace shrinking reimbursement with even more volume. At some point, that too will fail, as we will indeed max out on how many studies we can read. Not only do we run the risk of issuing a “typical radiologist mumbo-jumbo, non-commital, uncompared” report, but the faster we push through that heavier volume, the more findings we will miss. At some point, the patients’ welfare has got to take precedence over our scramble for one last dollar.

So, rogens50, you have a very valid point. We do need to do better in the areas you outline. But I can guarantee you that in the majority of cases, the problem is emphatically not that we are lazy, nor are we playing games to get the work done and get out. We are tired, we are overworked. I won’t be so crass as to claim that we are underpaid, however, and that may be the problem. We may well be so concerned about avoiding being underpaid, that we create worse problems.

Lucy, I feel your pain.

Why Medical Care Is So Expensive

Image credit: http://www.about.com

I ran across this patient problem list the other day. This is completely real, but anonymized to protect the innocent:

    1. Probable occlusive coronary artery disease but fairly asymptomatic. Patient will return for a Persantine Cardiolite.
    2. Systolic murmurs consistent with mitral insufficiency and aortic sclerosis. She will return for an echocardiogram.
    3. Labile hypertension. We need to rule out renal artery stenosis. Patient will have a CT angiogram of her renal arteries.
    4. Historically occluded left carotid. I do not believe it with a lesion in the right. Patient will have a CT angiogram of her carotids.
    5. Chronic right-sided leg pain. She could have occlusive vascular disease in her lower extremities. We will do the CT angiogram of that as well.
    6. Ongoing tobacco abuse. I advised her not to smoke. She is not going to quit. She made that very clear to me.
    7. History of lung cancer. Treated with radiation therapy. No evidence of metastatic disease.
    8. Dizziness. Probably due to vascular disease. I do not think it is due to any significant arrhythmias. We will place a holter on her to be on the safe side, however.

At least she doesn’t have kidney stones or the heartbreak of psoriasis. I’m thinking this little workup on this 80+ year-old patient is going to cost about $15,000+ or whatever Medicare will pay. Let’s hope her kidneys hold up with all that iodinated contrast she’s about to get.

Now you know how doctors think. Test every twinge, and if the test shows something, order more tests. I wonder why some still carry stethescopes.

Voice Recognition and Value

Dr. Giles Boland has written an editorial about the value radiologists can provide with speech recognition (Dr. Boland prefers the more popular though less accurate term Voice Recognition). Dr. Boland is on the radiology staff of Mass General, and he is a member of RCG HealthCare Consulting, which provides “Complete IT & Management Consulting for Radiology Departments and Imaging Practices”. From the RCG website, we find that Dr. Boland is:

Vice Chairman of Radiology, Massachusetts General Hospital, Dr. Boland’s areas of specialty include PACS, Teleradiology, Voice Recognition, RIS, and the enterprise digital solution to PACS and RIS integration. He has conducted aproximately 40 pesentations in over 15 countries on these topics. As a practicing radiologist, his nterests lie in Abdominal Imaging and Interventional Radiology. Dr. Boland is an Advisor to the World Health Organization, Geneva Switzerland and a reviewer for multiple scientific journals including New England Journal of Medicine, Radiographics, American Journal of Roentgenology and Journal of Intensive Care Medicine.

Those are impressive credentials. Dr. Boland’s case for VRT is as follows:

Voice recognition technology cuts a swath across the process through which conventional preliminary findings metamorphose into a final report. Once a report is dictated into VRT, it is in fact a final, signed report (unless originally dictated by a radiology resident or fellow). By virtue of its electronic nature, such a report becomes available immediately across an institutional network, simultaneously to multiple caregivers. Consequently, final report turnaround times are typically drastically reduced. When VRT was introduced at the Department of Radiology at Massachusetts General Hospital in 1997, the final report turnaround time for staff dictated reports was reduced from 3 days to several hours almost immediately [11]. This efficiency was realized despite the fact that earlier VRT models were harder to use and had less efficient speech recognition software.

The implication is that the technology has improved a great deal; the closing paragraph in the editorial reads:

However, despite the real advantages to radiology customers of VRT, some radiologists would still rather promote an inferior transcription model, preferring instead to use traditional dictation methods, which delay their ability to generate final reports. Although radiologists’ customers are looking for succinct, standardized, and timely final reports, some radiologists continue to use a system that their customers find less valuable. Rather than using existing state-of-the-art technology, radiologists should take an active role in convincing their peers to adopt VRT. If necessary, they should also lobby their organizations to provide the capital required to finance the transition, which generally yields a very favorable return on investment within the first year [11]. Radiologists can then rightly claim that they have been instrumental in adding significant value to their product, a major benefit to patient care and all stakeholders.

Note the derrogatory language. Those that have not embraced VRT/SR are using an inferior model. This raises some concerns. Whilst Dr. Boland has the background to know what he is talking about, the superior attitude is not particularly endearing. We have had the VR/SR debate on AuntMinnie ad nauseum, and the majority opinion amonst radiologists (NOT administrators, IT types, etc) is that it is not ready for primetime. Maybe Dr. Boland has access to more advanced software that actually works as advertised, which would make his analysis spot on. Unfortunately, the machinery that makes it out to the boonies doesn’t seem to work well enough to justify the accolades. I think it is noteworthy that the JACR article contains no mention of Dr. Boland’s association with RCG Consulting or the fact that RCG Consulting considers voice technology one of its areas of expertise. Perhaps it is simply understood that anyone on the Mass General Radiology staff is a part of RGC. I’m sure there is no conflict of interest here. Of course not.

I’m not so much of a Luddite that I don’t appreciate what Dr. Boland is saying here. I just don’t think the machinery is quite there yet. So, I’ll stick with my inferior model for now, thank you.