Amicas PACS

My friend Mike Cannavo, the One and Only PACSMan, called me from the RSNA exhibit floor this afternoon, both to chide and congratulate me for avoiding the show this year. Apparently attendance is OK so far, but there seems to be a lot of hesitation over spending any money, given the state of the economy, as well as the uncertainties of medicine’s future.

By staying home from Chicago, I unfortunately will miss the world premier of the latest version of Amicas PACS. The program’s original code-name was”Phoenix” or more properly, Version 6, or V6 for short. A number of us users were asked about fancier titles, maybe something like Visionary PACS, X-Ray Vision PACS, I-Can-See-You-Without-Clothes PACS, or maybe NOT-Centricity PACS. But by the time the Amicas brass contacted me, they had pretty much decided on the simple, straight-forward title of “Amicas PACS“, and I had to agree it was the best choice. That’s what we call it around here anyway. (They did bow to some X-Box 360 fan and titled the viewer component “Halo Viewer,” but I’ll forgive them for that.

I played a minor role in the development of this product, and I have been running it from a test-server connected to our system. Thus, I can reveal to the rest of the radiology world, those folks that didn’t go to RSNA this year anyway, just what V6 is all about.

Amicas has come up with some new approaches to PACS, while keeping much of what has made this my favorite system. I won’t go through excruciating detail about every aspect of the system, but these screen-shots will give you an idea of how Amicas PACS functions.

Amicas‘ Real-Time Worklist (RTWL) is similar to it’s predecessors, although it has been updated a bit. It still offers at-a-glance assessment of your worklist status, something the competition hasn’t quite mastered. The new display has a twist, in that it shares space with a display of the current exam and its series as well as those of relevant priors, and it’s a nice addition:

Once the study is selected, the primary study and relevant priors are displayed based on your hanging protocols, as well as anatomic relational rules.

V6 takes a different approach to controls that affect the study, the series, and the images. You’ll notice the presence of icons above the viewport windows, as well as those above the series indicators, and even above the study itself on the worklist page. These allow easy manipulation at the study and series level. The usual buttons are found at the top of the window, similar to earlier versions. While this takes a bit of getting used to, it forms the basis of a very logical way to manipulate the studies. Notice the buttons for MIP, MPR, and cine-ing as well as linkage, image layout, and global stacking in this screen-shot of a single series viewport:

The older Amicas programs used a limited port of Voxar 3D for advanced visualization, one of the first PACS to have such functionality directly embedded. Amicas PACS (V6) goes way beyond this, adding some very powerful 3D and MPR displays that are reminiscent of Siemens InSpace:

Our old friend, spine-labelling, is here with little change, but fortunately none was needed for this module that set the standard for this sort of thing. Here is Amicas programming at its best: the module is very simple to use, and IT WORKS! I can label a spine in all views within 5 seconds.

There’s a lot of power here in V6, I mean Amicas PACS, folks. The functionality should go a long way toward smoothing out my worklist, and thus my work day. Obviously, some of the simplicity of the old program had to be sacrificed to gain that strength. Still, there is very little fluff here, nothing that doesn’t belong, and as near as I can tell, there isn’t much that was thrown in because one (and only one) site demanded it. I have long complained about GUI’s that have too many buttons and too many functions, and it was my goal as part of the advisory team to keep that from happening to the new Amicas PACS. I think you’ll find a very nice balance of usability and power when you try out Amicas PACS. It’s definitely worth your while, and it is certainly a better investment of your shrinking health-care dollar than my stock portfolio. . .

RSNA RFIDdles with RFID’s Again

I seem to have been the first to discover the use of RFID’s at last year’s RSNA, as published in my blog (the post in question has been sanitized and resurrected):

One major change I’ve seen at RSNA is literally around my neck; the badges now have RFID tags, which lets the powers that be do some sort of monitoring of the attendees. No doubt this information will be used for proper ends, such as making sure that we actually do attend the educational stuff for which we are requesting credit. Personally, I’m worried that (a larGE company) is using the tags to locate me when their snipers are in position. Nah, that would be too easy.

David Clunie noticed my post and persued the situation, eventually posting on AuntMinnie:

As I wandered about RSNA I recall seeing signs that mentioned that RFID badge tracking was in use, but I assumed that this would only be for RSNA’s own purposes to count attendance in various areas and educational sessions; I do not recall exactly what the signs said. Even so, I felt slightly uncomfortable that I had not been asked when I registered whether or not I agreed to this or not (at least not that I recall). I was truly stunned to discover on further investigation that RSNA was allowing vendors in the technical exhibit area to track attendees, and indeed encouraging this (see “” and click on “attendee tracking/exhibit analysis”). It is not clear from the information there whether or not RSNA is actually “selling” this information to the exhibitors themselves or merely allowing the providers of the tracking to sell the service without taking a cut. I am not sure how I feel about this, and whether or not I should take further action – I guess it depends a lot on whether the exhibitors were being provided with only aggregate information, or whether they were provided with my individual identity and contact details. If the latter were to be the case then I would be really pissed.

David has a new blog post that tells us RSNA is at it again.

Now, whilst I am happy for RSNA to know that I attended, and happy to know which scientific sessions I participated in to help their planning, I am not at all happy about providing that information to the vendors. So, whilst I do not yet know what their “opt out” mechanism is, I suspect it is to record your details to be excluded from the reports sent to the vendors (they did that on request last year in my case).

So this year I am going to be proactive and remove or destroy the RFID tag that is in my badge. This is actually easier side than done, because it turns out they are tough little The sticky label on the back of the badge will not peel off cleanly. Attacking the chip or antenna with a scalpel reveals that they are very hard, and without any way of confirming that the device is actually no longer working, doing a really good job (e.g., on the chip with a hammer) is going to make a mess of the badge. A Google search on the Internet (see for example, “How to kill your RFID chip“) reveals that a short time in a microwave oven does the job, though at the risk of starting a fire, which doesn’t sound cool. Also, most attendees won’t have a microwave in their hotel room. I tried it on my wife’s badge first (!), and when that didn’t catch fire, did my own, and whacked the chip with a hammer, nailed it with a punch a couple of times, and cut the antenna. That said, I would still rather peel the whole thing off if it didn’t look like the whole badge would tear apart.

Anyway, if you respect your privacy, as I do, then I suggest you find a way to deactivate the device before you go wandering around, and if you forget, make sure to go an opt out to prevent the information being disseminated.

I’m glad I’m not the only one who had a problem with this (ab)use of technology. If anyone wishes to track me, I’ll be down here in the not-so-sunny South this week.

Dalai Becomes Happy Fuji Customer

Empiric Systems is, or was, a small company that created a very straightforward and usable RIS which we have happily used for many years. Encompass.NET RIS was so well-done that Fujifilm contracted with Empiric to provide a RIS for Synapse PACS, as I reported previously.

Now, Fuji has done the logical thing in this business and purchased Empiric. From their press-release:

November 29, 2008 – Stamford, CT –


Gains further ground in health IT segment and expands breadth of Synapse® portfolio

Stamford, CT, November 29, 2008 – FUJIFILM Medical Systems USA is pleased to announce the acquisition of Empiric Systems, LLC, Morrisville, NC. Fujifilm has acquired 100 percent of the Empiric stock, making the vendor a wholly owned Fujifilm subsidiary. The acquisition is another significant step in Fujifilm’s growth strategy, and a demonstration of the company’s continued commitment to the fields of medical imaging and health information technology.

“Fujifilm is now in command of a fully integrated, Web-based solution for the entire radiology department,” said Bob Cooke, Fujifilm’s Vice President, Network Systems Management. “To meet the diagnostic workflow, efficiency and compliance challenges of today’s radiology environment, healthcare facilities need a fully integrated solution. Fujifilm has already made substantial progress in integrating the Synapse and Empiric applications, and with the acquisition we are now in a position to deliver an even deeper integration that will yield the complete imaging informatics solution that healthcare facilities are seeking.”

I’m a little concerned about the “IN COMMAND” verbage, somewhat reminsecent of Alexander Haig at the White House. Still, I have it on good authority that Fuji will let Empiric continue to function as usual, producing a web-based product (something Fuji also understands) which is usable (something Fuji doesn’t understand as well) with excellent service (from the reviews, something Fuji doesn’t understand at all).

So, as of now, I am a happy Fujifilm customer. Let’s keep it that way, guys.

iMoan, uMoan, we all Moan for iPhone

I knew from the moment I heard about the iPhone I was going to have to have one. I was able to delay my gratification for the year it took Apple to upgrade the iPhone to run on a 3G network, which is pretty good for me.

I have written about the MIMVista iPhone app, which is really the reason (should I say excuse?) for my purchase. I do have the app on my phone, with demo data as pictured below:

This part of the app shows a fused PET/CT examination, and all one has to do is drag a finger over the display to blend from the PET image to CT and back again. The app has to communicate back to the mothership program on one’s workstation to access data, but it does process the images on the iPhone itself. I have the software installed, and it is quite powerful, as I mentioned in the last post. Sadly, our hospital network has not been easy to crack for outside access as required by the MIM app, so I have yet to access “real” data. Still, the proof-of-concept provided by the demo data is spectacular in its own right. Let’s hear it for Johnny Appleseed!

There are some other radiology apps appearing. The most powerful will probably prove to be the iPhone version of Osirix:

Here’s a video preview of the operation of the Osirix iPhone app:

Osirix is the free, open-source viewer from Switzerland, which is totally Mac-based (much to the chagrin of those of us stuck in the Win-tel world). The app is a companion to the desktop version (here we go again) which allows downloading and manipulation series of images directly onthe iPhone. It can display images from most modalities in native DICOM. It uses the iPhone gesture controls for image functions, such as zooming and panning and rotation with two-finger drag and pinch, and so on. Their iPhone app is $20, and since I don’t have a Mac anyway, I haven’t downloaded it as yet.

Merge has a similar app that does work with a Windows-based server (and the app at least is free):

Merge Mobile incorporates advanced remote rendering techniques, including multi-planar reconstruction (MPR), which eliminate downloading of large data quantities to the mobile device and enable near-immediate access to images. Features include remote stack viewing using the iPhone multi-touch interface, scroll, contrast adjustment, zoom and pan. A secure communication protocol addresses privacy.

For actual use, one would need a Merge installation, but they have kindly made a test server available. Here are some screen-shots of the demo-data:

Not all companies have graced us with iPhone apps or ports or whatever, but there are still ways to see images from your pocket. From Amicas:

AMICAS Reach is a radiology EMR and portal designed specifically for referring physicians. This new solution uses common e-mail and secure messaging to deliver images, reports, and information to any e-mail-enabled device via a secure Web-based portal. This is a “zero install” application, which means the elimination of IT headaches traditionally associated with downloading and installing software for viewing images and results.

Others companies have available some more generic web-viewers that work at least partially with the Safari browser on the iPhone. ScImage’s PicomWeb viewer promises (from

. . .a zero-footprint physician portal that delivers diagnostic images, reports, waveforms and documents to web browsers. PicomWeb can be implemented as part of PicomEnterprise, as a unifying layer for multiple disparate systems, or as an embedded link in an EMR system using the ScImage Universal Interface Toolkit. The result is a single point of entry for all of your physicians’ to access image and reporting information.”

The version accessible through Internet Explorer uses an Adobe Flash display, but the more limited iPhone browser appears to show a JPEG image:

Last on my incomplete review is the eRAD browser, which can be accessed from the web. Images can be displayed as JPEG’s:

So, it seems that radiology viewers for the iPhone are diverging mostly into apps and web-based mini-versions of their adult counterparts. It’s hard to tell at this point which will win out. For the moment, none of these approaches should be used for diagnosis, so their main purpose is review of cases with referring clinicians and so forth (i.e. entertainment). Now this will change as the software gets more powerful. The iPhone’s resolution of 480 x 320 pixels is certainly adequate for viewing a slice from a digital modality (and it’s probably overkill for nuclear medicine—I can say that as a Nuclear Radiologist, but you can’t). No doubt we’ll shortly see some sort of integrated app allowing reading and dictation of cases from the iPhone. But please, no voice-recognition. Even Google can’t make that work very well on the iPhone, at least not for me.

You Are Safe From Attack In Stuart, Florida

It seems that a kid in Stuart, Florida was a really, really bad boy:

A 12-year-old Florida student was arrested earlier this month after he “deliberately passed gas to disrupt the class,” according to police. The child, who was also accused of shutting off the computers of classmates at Stuart’s Spectrum Jr./Sr. High School, was busted November 4 for disruption of a school function.

Feel free to read the police report above. The boy’s name has been blanked out to protect the innocent (or guilty). Thank Heavens the Stuart Police Department was up to this greuling task.

Toshiba Buys AVIS (but won’t be renting cars)

From comes news of an interesting acquisition: Toshiba Medical Systems has agreed to purchase Barco’s Advanced Visualization Imaging System (AVIS), which used to be Voxar, Ltd.

The acquisition, to be handled via Toshiba’s newly formed wholly owned subsidiary Toshiba Medical Visualization Systems (TMVS) Europe, allows for internal development of 3D volume rendering and advanced visualization capabilities for all Toshiba modalities, according to the Tokyo-based vendor. TMVS will be based in Edinburgh, Scotland. Terms of the deal were not disclosed.

Phew. I thought my friends at Voxar were going to have to move to Tokyo and learn to say “haggis” in Japanese. Toshiba promises “to honor all contractual obligations” and provide necessary support for current customers. But…

“The company also will evaluate all aspects of the AVIS business over the next 12 months,” the spokesperson said.

TMVS also expects longtime advanced visualization collaborator Vital Images to remain a key partner, according to the spokesperson. “Toshiba will continue development with Vital Images on clinical applications and, in fact, just signed a five-year distribution agreement with the company,” she said.

Toshiaki Nakazato, chief specialist at Toshiba Medical’s Research and Development Center, has been named president of TMVS, while former AVIS marketing director Calum Cunningham has been tapped as senior vice president and general manager.

Nothing like owning one company and fronting for another. We have to wonder which product Toshiba will push harder, the Voxar that they own or the Vital that they distribute. I get the feeling that Voxar won’t be sold as an add on (in the manner we use it with Agfa Impax) in the future, unless you buy a Toshiba scanner.

I suppose this all makes sense for Toshiba, as they are continually announing higher and higher slice-counts for their CT’s. I was going to do an April Fool’s piece on a fictional 10,000 slice scanner, but no doubt that will be available by next year anyway. Since one cannot actually read a 10,000 slice scan in one day, programs like Voxar 3D are a stict necessity.
Barco, meanwhile, will concentrate on medical displays, which they do quite well.

Product Safety Notification

I posted about the FDA’s letter of warning about Centricity on August 20, 2008. Three months later, on November 14, 2008, GE sent a letter to our site notifying us of the problems and promising repairs.

It seems that Centricity RA1000 workstation software versions 2.1.x and 3.0.x have a few problems.

Issue 1: Patient Jacket

There is a patient safety issue involving patient jacket content intermittently becoming unintentionally out of synchronization with the image(s) being displayed. This results in a mis-match between the information listed in the patient jacket and the image(s) being displayed. The Centricity PACS RA1000 provides the user with a message in the patient jacket header indicating that the patient jacket does not match the current displayed image(s).

This issue has been reported as occurring in the following workflow: While viewing images on a Centricity PACS RA1000 workstaton, the user immediately clicks on the “Show Patient Jacket Palette” button on the image titlebar or the “Show Palette” button on the taskbar. Intermittently, the patient information that gets loaded in the patient jacket, does not match the patient whose images are currently displayed. Instead, the patient jacket loads patient information for a patient whose images were previously displayed. In this condition, the user can continue to view the mismatched images in that patient jacket.

The expected operation is that when the “Show Patient Jacket Palette” button or “Show Palettes” button is clicked, the patient jacket should load the patient whose image(s) are currently displayed.

NOTE: It is still possible for the user to intentionally select an exam in the worklist that is different from currently displayed images. In such a case, the patient jacket will sync with the exam information selected in the worklist, and the PACS system will provide the user with a message in the patient jacket header that the patient jacket does not match the current exam. This specific workflow is normal behavior and is not identified as a potential patient safety concern.

SAFETY INSTRUCTIONS: The patient name/ID of the Patient Jacket content should be carefully checked, after immediately displaying an exam, to ensure it is consistent with the information for the displayed image(s).

If the patient jacket goes out of synchronization with the displayed image(s), it should be re-synchronized by re-opening the patient jacket palette (by selecting the “Show Patient Jacket” button on the image title bar). If that action does not result in appropriate re-synchronization, then the workstation application should be restarted.

Issue 2: Default Display Protocol

There is a patient safety issue involving Default Display Protocols (DDPs). DDP’s are hanging protocols used to lay out images when displaying a study.

If the user/site DDP was configured to place the current and historical studies in different regions than the system default DDP, the user may believe that the old study is the new one and vice versa. If the user does not check the Study Date and Time of the exam on the image title bar, then they may interpret the current exam as a historical and vice versa.

SAFETY INSTRUCTION: When displaying images, the user should check the following to determine if there are historical comparison exams, and in which image regions they are loaded:

1. The study date/time as displayed in the image title bars of every image region.

2. The italicized folt of the label in the image title bar. The current study will be displayed in an italicized font, whereas historical studies will display in a non-italicized font.

3. The Patient Jacket and the Comparisons Hotzone on every image title bar, which will show whether there are historical comparison exams and, if so, how many.

The user could also check the name of the applied DDP, as it appears on the Display Functions combo button, to see if the applied DDP is a user/site DDP or a system default DDP. This is helpful if a known convention is followed when naming user/site DDPs for easy recognition.

The gist of all of this engineer-speak is simply that you should confirm what you are looking at is what you think you are looking at. Probably good advice in all settings, not just those prompted by FDA warnings.

For what it’s worth, this is not the first such notification for Centricity RA2000. This link takes us to a letter that went out just under a year ago, covering a glitch in the exam notes window which likes to ignore special characters such as “greater than” or “less than” (which I think will confuse as well.) Makes it hard to post lab values and such. And here’s another one:

A potential patient safety issue involving incorrect study date and time information being displayed in the report screen and title has been identified. Incorrect study date and time displays may lead to a potential patient misdiagnosis. These date and time display inaccuracies may vary from minutes to years depending on certain circumstances and workflows.

I guess it’s really hard to test out every permutation of problems that might arise with such a complex piece of software. Personally, I can’t wait for the Dynamic Imaging revisions….

eRAD Snags "Pryor" Agfa President

The world of Radiology is pretty small, and the world of PACS is even smaller. Thus, the same people (and the same personalities for that matter) seem to reappear in different venues.

I first met Bob Pryor at RSNA 2003, and I remember his mea culpa for Agfa’s performance quite well. “We dropped the ball,” he stated, “but we’re going to pick it up and run with it.” And so they did. As you well know, the Impax 6 purchase that was prompted by this admission has been anything but trouble-free, but Agfa has been very willing to work with us, and certainly hasn’t thrown a certain blogger to the wolves over negative posts.

Mr. Pryor retired from Agfa recently, and now, he has a new spot:

Image Medical Corporation, parent of eRAD Inc., an industry leader in workflow solutions through its native Web-based RIS/PACS and Diagnostic Imaging Information Management Systems, announced today that Robert S. Pryor has been appointed to Image Medical’s Board of Directors. Pryor had recently served as President of Agfa Healthcare, Americas with responsibility for Agfa’s Imaging and Informatics business throughout the Americas. He had previously held executive positions at Sterling Diagnostic Imaging and in E.I. Dupont’s medical businesses. Roy W. Miller, Image Medical Board member and CEO of eRAD Inc. stated: “Bob Pryor is an outstanding individual with a tremendous business acumen and an extensive knowledge of the diagnostic imaging industry. We are delighted to have him join us in a position of such strategic importance.”

I would imagine that a smaller company like eRAD presents some different challenges and rewards than a big conglomerate like Agfa. I’m sure this new relationship will be beneficial to all involved.

Dalai’s Workstation Salvation!

I love Radiology, or at least I used to before the governmental bureaucracy and other joys of modern medicine crept into the field. Still, I can’t see myself doing anything else, except perhaps for retiring, and that ain’t happening any time soon. One major problem with the field, however, is that it does not encourage physical activity. With the advent of PACS, we don’t even have to lift a film-jacket, and as my group employs P.A.’s, I don’t even have to lift my carcass out of my chair to sling barium much these days.

These circumstances help radiologists fit right in with the rest of the population:

Obesity is a major health epidemic in the United States. It is estimated that more than two-thirds of the population is overweight and one-third obese. Both of these numbers have significantly increased over the past 25 years. Obesity increases the risk for many diseases, including hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, and some cancers.

But apparently not the heartbreak of psoriasis, at least.

Jeff L. Fidler, M.D., and colleagues at the Mayo (rather ironic since were talking about overfed, obese radiologists) decided to investigate ways to help our profession with this problem, which they also note to be sedentary, and their work is presented in this month’s JACR.

Fidler, et. al., note that

. . . even small repeated movements throughout the day can lead to increased caloric expenditure by a process termed nonexercise activity thermogenesis. In one study, the mean increase in energy expenditure for walking and working over sitting was 119 +/- 25 kcal/h. It was estimated that the incorporation of walking and working 2 to 3 hours per day could lead to weight loss of 20 to 30 kg/yr (44-66 lb/yr) if eating is not correspondingly increased. In addition, other studies have shown that cerebral blood flow, oxygen extraction, and brain metabolism may be increased with exercise and activity.

So what’s a radiologist to do? Walk on a treadmill while working? You betcha!

Potentially, these or otherdevices could be incorporated with image interpretation workstations, allowing radiologists to review imageswhile increasing their background activity. However, such a device has not been studied in this setting to determine if there is a negative impact on the detection of abnormalities. The purpose of this study was to evaluate the feasibility of a walk-and-work image interpretation workstation for computed tomographic (CT) image interpretation and to assess interpretation accuracy. If it can be shown that accuracy is maintained, this device could be implemented in clinical practice, allowing increased caloric expenditure and subsequent improvement in overall health for radiologists.

So, this is what they did:

A worktable was constructed that could be adjusted from a height of 38 to 52 in above the treadmill track using a hydraulic device. Thus, it could be adapted to accommodate the different heights of the radiologists (5 ft 9 in and 6 ft 1 in) in this study. This height range would be suitable for individual heights of 5 ft 7 in to 6 ft 10 in but could be revised for other heights. Because of the configuration of the table, the front support and control panel for the treadmill was not attached, and the treadmill control panel was mounted on the wall adjacent to the treadmill. The tabletop size was 4 ft wide by 2 ft 10 in deep. This allowed placement of a 2 monitor workstation, keyboard, fan, and dictating machine while still leaving ample room for note taking. The desktop was designed to have an overhang of 10 in. This allowed ample space for legs to extend forward without making contact with the support during a low rate of walking. The total cost for the worktable construction was approximately $1,500. A commercial-grade treadmill (C954i; Precor Inc., Woodinville, Washington) was used (Figures 1 and 2). The cost of the treadmill was $3,000. The retrospective review was performed in a remote location, and a computer with electronic medical record access, electronic dictating machine, and telephone were not present. Reviewers wore tennis shoes while walking on the treadmill.

The cost of the tennis shoes was not given. The researchers then interpreted 10 cases whilst walking on the treadmill at 1 mile per hour. Average interpretation time under these conditions was 9.2 minutes, a little longer than we usually spend on a case. The results are surprising:

As the study was developed, the main concern was that the use of the treadmill would cause the investigators to miss a significant number of findings because of the associated motion. It was surprising to discover that a significant number of findings were detected while on the treadmill that were not mentioned on the initial interpretations. Many (60%) were very subtle findings, and 13% likely would rarely be seen. Although it is intriguing to think that the walking technique may have led to this increased detection by increasing blood flow and alertness, there are several other issues that may have accounted for this.

Why did they have to go and spoil it? The other factors involve the fact that the images were evaluated twice, only 10 cases were read at a time, and the bloody phone wasn’t ringing off the hook during the interpretation. Then, there is the Hawthorne effect which says we perform tasks better in response to a change in environment. Sounds like we ought to at least move offices every hour or so.

The bottom line is that it is feasible to read from PACS whilst exercising, and your accuracy might even improve. This is wonderful news, of course. However, the researchers were probably in good shape and had good coordination. Get me up there on the treadmill, give me a tough case, and I’m likely to go George Jetson within 30 seconds.